Remifentanil with morphine transitional analgesia shortens neurological recovery compared to fentanyl for supratentorial craniotomy.

PURPOSE: To compare the recovery profiles, efficacy and safety of remifentanil and morphine for transitional analgesia with fentanyl in patients undergoing elective craniotomy for supratentorial mass lesions. METHODS: Ninety-one patients were enrolled in this prospective, randomized, multicentre study. Anesthesia was induced with thiopental and remifentanil (1.0 micro g x kg(-1) bolus and a 1 micro g x kg(-1) x min(-1) infusion) or fentanyl (1 micro g x kg(-1) bolus and a 1.0 micro g x kg(-1) x min(-1) infusion). The opioid infusion continued until the level of anesthesia was deemed appropriate for intubation. Anesthesia was maintained with N(2)O/O(2), isoflurane 0.5 MAC and remifentanil 0.2 micro g x kg(-1) x min(-1) or fentanyl 0.04 micro g x kg(-1) x min(-1). At bone flap replacement, either morphine 0.08 mg x kg(-1) (remifentanil group) or saline (fentanyl group) was given. RESULTS: Systolic blood pressure was greater in those receiving fentanyl during induction (145.6 +/-17.5 mmHg vs 128.8 +/-18.3 mmHg; P = 0.006) and intubation (126.9 +/-17.1 vs 110.9 +/-16.5 mmHg; P < 0.001). Median time to tracheal extubation was similar but less variable in the remifentanil group (remifentanil = 8 min: range = 2-44 min; fentanyl = 8 min: range = 1-732 min). The fentanyl patients required a longer time to achieve the first normal neurological score (fentanyl = 38.0 min; remifentanil = 26.0 min; P = 0.035). Both the anesthesiologists and the recovery room nurses rated remifentanil better with respect to level of consciousness. Analgesics were required earlier in patients receiving remifentanil; median time 0.5 vs 1.08 hr, P < 0.001. CONCLUSIONS: Remifentanil is a suitable alternative to fentanyl in supratentorial craniotomy. Time to preoperative neurological recovery is faster and morphine provides some transitional analgesia without compromising the quality of recovery.