Successful use of remifentanil for major head and neck surgery in a heart–lung transplant recipient

Editor—We would like to describe the successful use of remifentanil in a patient undergoing major head and neck surgery, who had previously received a heart–lung transplant. Remifentanil's unique pharmacokinetic profile may be advantageous in head and neck procedures.1 Intense intraoperative analgesia can be required for prolonged periods, but postoperative pain may not be severe, and prompt recovery is normally desired. In addition, remifentanil can help to ensure immobility in the absence of neuromuscular blocking agents. However, its suitability in the transplant recipient has not yet been established.

A 54-yr-old man was scheduled for laryngopharyngectomy with jejunal free flap, as surgical treatment for recurrence of a laryngeal tumour involving the posterior cricoid ring. Seventeen years earlier he had received a cadaveric heart–lung transplant, as treatment for histiocytosis X. He continued to have good cardiorespiratory function, and had no evidence of graft rejection, although mild renal impairment was present. The patient's airway was unobstructed, and recent anaesthesia for microlaryngoscopy had been uneventful.

Venous access, including central venous cannulation of the femoral vein, and radial arterial cannulation were achieved under local anaesthesia. A crystalloid preload was given. An isoproterenol (isoprenaline) infusion was commenced at a rate of 1 µg min–1 in anticipation of bradycardia occurring on induction. Anaesthesia was induced with propofol 140 mg, and fentanyl 200 µg, followed by atracurium 40 mg. A 7.0 mm oral tracheal tube was placed easily at direct laryngoscopy. The patient's lungs were ventilated, and anaesthesia maintained with an oxygen/air mixture and desflurane to an end-tidal concentration of 4.3%. A remifentanil infusion was then started at an initial rate of 0.05 µg kg–1 min–1, and increased during surgery to an infusion range of 0.1–0.2 µg kg–1 min–1, titrated according to arterial blood pressure and surgical stimulation. The isoproterenol infusion was continued at the same background rate. Mild, transient bradycardia was encountered on induction (65 beats min–1), but not during the administration of remifentanil. During the procedure, the patient exhibited no significant haemodynamic instability. The patient's pulse rate varied between 80–105 beats min–1, and his blood pressure was easily maintained within the range 90–120 mm Hg (systolic).

The total duration of surgery was 10 h, during which the larynx and lower pharynx were excised, and a portion of jejunum was anastomosed to reform the pharynx. At the completion of surgery, remifentanil and the volatile agent were discontinued, and the patient awoke promptly. Local anaesthetic had been infiltrated into the small incision through which the jejunal flap had been harvested, and further postoperative analgesia was provided by incremental dosages of morphine totalling 10 mg. The patient was transferred, breathing spontaneously, to the high dependency unit for overnight care, during which he required a further total of morphine 4 mg, self-administered from a PCA device. He was discharged to a general ward on the following morning, and made a full recovery.

The anaesthetic management of heart transplant recipients has been reviewed elsewhere.2 3 Metabolism of anaesthetic drugs may be altered if renal impairment is present, while the immunosuppressant drug cyclosporine has been shown to increase the MAC of isoflurane.4 However, the behaviour of the donor heart, which has been separated from its native autonomic supply, dominates anaesthetic considerations. Most anaesthetic techniques can potentially provoke bradycardia, or decrease venous return, neither of which are well tolerated by the transplanted heart. Any technique needs to anticipate these occurrences, and have the means to counteract them to hand.

To our knowledge, the use of remifentanil in a heart transplant recipient has not yet been described, nor is it mentioned in the two most recent reviews on this subject.2 3 However, it is successfully used in cardiac surgery,5 and from our experience, during the heart transplant procedure itself. The propensity of remifentanil, when administered as a bolus, to cause bradycardia and cardiovascular instability has been reported,6 and is probably related to a centrally mediated increase in vagal activity. Theoretically, the denervated heart might be less susceptible to this effect, but in practice it would remain a concern. We intended to minimize these risks by administering remifentanil as an infusion, starting at the lowest possible dose. Also, by avoiding the prolonged use of neuromuscular blocking agents, antagonism with neostigmine, which has been associated with asystole in a heart transplant recipient,7 was not required.

In this patient, remifentanil was successfully used without adverse effects. It is likely that there will be increasing numbers of transplant recipients presenting for surgery of this nature. The immunosuppressant regimens that prevent rejection so successfully, may also render patients more prone to malignancies of this type.8 Further cases involving the use of remifentanil need to be reported however, before potential problems can be identified.

A. D. M. McLeod, E. V. Barker and D. A. Carapiet

Portsmouth, UK

References

1 Michelesen LG, Hug CC, Jr. The pharmacokinetics of remifentanil. J Clin Anesth 1996; 8: 679–82[CrossRef][ISI][Medline]

2 Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesth Analg 1999; 89: 613–22[Free Full Text]

3 Ashary N, Kaye AD, Hegazi AR, M Frost EA. Anesthetic considerations in the patient with a heart transplant. Heart Dis 2002; 4: 191–8[Medline]

4 Niemann CU, Stabernack C, Serkova N, Jacobsen W, Christians U, Eger EI, II. Cyclosporine can increase isoflurane MAC. Anesth Analg 2002; 95: 930–4[Abstract/Free Full Text]

5 Möllhoff T, Herregods L, Moerman A, et al. Comparative efficacy and safety of remifentanil and fentanyl in ‘fast track’ coronary artery bypass graft surgery: a randomized, double-blind study. Br J Anaesth 2001; 87: 718–26[Abstract/Free Full Text]

6 Elliott P, O'Hare R, Bill KM, Phillips AS, Gibson FM, Mirakhur RK. Severe cardiovascular depression with remifentanil. Anesth Analg 2000; 91: 58–61[Abstract/Free Full Text]

7 Bjerke RJ, Mangione MP. Asystole after intravenous neostigmine in a heart transplant recipient. Can J Anaesth 2001; 48: 305–7[Abstract/Free Full Text]

8 Shiba N, Chan MC, Kwok BW, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant 2004; 23: 155–64[ISI][Medline]





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