British Journal of Anaesthesia 88 (3): 430±3 (2002)

SHORT COMMUNICATION
Effects of remifentanil and alfentanil on the cardiovascular
responses to induction of anaesthesia and tracheal intubation in
the elderly
A. S. Habib, J. L. Parker, A. M. Maguire, D. J. Rowbotham and J. P. Thompson*

University Department of Anaesthesia, Critical Care and Pain Management, University Hospitals of
Leicester, Leicester Royal In®rmary, Leicester LE1 5WW, UK
*Corresponding author

Background. We compared the effects of remifentanil and alfentanil on arterial pressure and
heart rate at induction of anaesthesia and tracheal intubation in 40 ASA I±III patients aged
greater than 65 yr, in a randomized double-blind study.
Methods. Patients received either remifentanil 0.5 mg kg±1 over 30 s, followed by an infusion
of 0.1 mg kg min±1 (group R) or alfentanil 10 mg kg±1 over 30 s, followed by an infusion of saline
(group A). Anaesthesia was then induced with propofol, rocuronium, and 1% iso¯urane with
66% nitrous oxide in oxygen.
Results. Systolic arterial pressure (SAP) and mean arterial pressure (MAP) decreased after the
induction of anaesthesia (P<0.05) and increased for 3 min after intubation in both groups
(P<0.05), but remained below baseline values throughout. Heart rate remained stable after
induction of anaesthesia but increased signi®cantly from baseline after intubation for 1 and 4
min in groups R and A, respectively (P<0.05). There were no signi®cant between-group differ-
ences in SAP, MAP, and heart rate. Diastolic pressure was signi®cantly higher in group A than
group R at 4 and 5 min after intubation (P<0.05). Hypotension (SAP <100 mm Hg) occurred in
four patients in group R and three patients in group A.
Conclusions. Remifentanil and alfentanil similarly attenuate the pressor response to laryngo-
scopy and intubation, but the incidence of hypotension con®rms that both drugs should be
used with caution in elderly patients.
Br J Anaesth 2002; 88: 430±3
Keywords: age factors, cardiovascular responses; analgesics opioid, remifentanil; analgesics
opoid, alfentanil; intubation tracheal, responses; heart, heart rate; arterial pressure
Accepted for publication: November 13, 2001

The cardiovascular responses to laryngoscopy and tracheal Few studies of the haemodynamic responses to
intubation have been well documented, and a number of intubation have been performed in the elderly, and
methods may be used to modify them, including alfentanil none have used remifentanil. The aim of this study was
and remifentanil.1 2 The elderly, who comprise an increas- to compare the effects of remifentanil and alfentanil in
ing proportion of patients presenting for surgery, have a modifying the haemodynamic response to intubation in
diminished physiological reserve, alterations in autonomic elderly patients.
function, an increased incidence of coexisting cardiovas-
cular disease,3 and increased sensitivity to opioids and
anaesthetic drugs.4 5 These factors may combine to increase Methods and results
cardiovascular lability during induction of anaesthesia, with With hospital ethics committee approval and informed
the attendant risks of myocardial ischaemia, stroke, cardiac consent, we recruited 40 normotensive, non-premedicated
arrhythmias, or sudden death.6 ASA I±III patients aged 65±85 yr undergoing elective

Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2002
 Induction of anaesthesia and tracheal intubation in the elderly

surgery and requiring tracheal intubation. Exclusions were: and 66% nitrous oxide in oxygen, to an end-tidal carbon
concurrent vasoactive medication, risk of gastroesophageal dioxide tension of 4.0±4.5 kPa. Neuromuscular block was
re¯ux, obesity (BMI >30), anticipated dif®cult airway, or con®rmed with a nerve stimulator and laryngoscopy, and
evidence of cardiac disease. Patients were randomized to tracheal intubation were then performed 3 min after loss of
two groups (group R=remifentanil, group A=alfentanil) in a verbal contact.
double-blind manner by the sealed envelope technique. Ephedrine (3 mg increments) was administered for
All patients received i.v. Hartmann's solution 5 ml kg±1 hypotension (systolic arterial pressure (SAP) <100 mm
over 5±10 min before the induction of anaesthesia. Routine Hg, or a decrease of >30% from baseline values for >60 s)
monitoring was instigated and heart rate and arterial and atropine, in 300 mg increments, for bradycardia (heart
pressure were recorded at 1 min intervals throughout the rate <45 beats min±1). For hypertension (SAP >200 mm Hg,
study. Arterial pressure was measured non-invasively using or an increase of >30% above baseline for >60 s) or
an automatic oscillometer (Datex Cardiocap II) and ECG tachycardia (heart rate >130 beats min±1 for >60 s), the
was monitored with electrodes in the CM5 position. Three inspired iso¯urane concentration was increased in incre-
readings of heart rate and arterial pressure were taken before ments of 0.5%. Power calculations based on previous data,7
the start of the study and the mean of these three values suggested that 20 patients per group would detect a 15%
de®ned as each individual's baseline data. All patients difference in SAP or heart rate between the groups after
received i.v. glycopyrrolate 0.2 mg immediately followed intubation (a=0.05, b=0.2).
by a bolus of either remifentanil (0.5 mg kg±1 in 10 ml saline Statistical analysis was performed using a general linear
over 30 s) followed by a remifentanil infusion at 0.1 mg kg±1 model analysis of variance for repeated measures for
min±1 (group R), or a bolus of alfentanil (10 mg kg±1 in 20 ml continuous variables (with treatment group and time as
saline over 30 s) followed by an infusion of saline (group between- and within-group factors, and Bonferroni adjust-
A). Immediately after the study drug, anaesthesia was ment for multiple comparisons). All analyses were per-
induced with propofol (0.5 mg kg±1 followed by 10 mg formed using SPSS for Windows computer software
every 10 s until loss of verbal contact) and rocuronium 0.6 (release 9.0).
mg kg±1 was administered to produce neuromuscular block. One patient in the remifentanil group was excluded
Patients' lungs were ventilated manually with 1% iso¯urane because of a procedural violation (unanticipated dif®cult
tracheal intubation with duration of laryngoscopy >2 min).
Patient characteristics are given in Table 1. Baseline arterial
Table 1 Patient characteristics, view and duration of laryngoscopy: mean pressure and heart rate were similar in both groups (Table
(SD, or range), or number. There were no signi®cant differences between
groups
2). Mean arterial pressure (MAP) decreased signi®cantly
after induction of anaesthesia in both groups (P<0.05
Group R Group A compared with baseline values) and increased for 3 min
(n=19) (n=20)
after intubation (P<0.05 compared with pre-intubation), but
Age (yr) 73.1 (65±83) 74.0 (65±85) remained below baseline throughout the study period. It was
Sex (M:F) 9/10 11/9 signi®cantly lower than baseline at 4±5 min after intubation
Weight (kg) 68.8 (15.3) 69.8 (13.5)
ASA grade (I/II/III) 6/11/2 7/12/1 in both groups (P<0.05). Changes in SAP and diastolic
Propofol dose (mg) 76.7 (25.0) 76.1 (23.9) arterial pressure (DAP) followed a similar pattern but DAP
Grade of anaesthetist intubating 3/12/4 2/16/2 was signi®cantly higher in group A at 4 and 5 min post-
(SHO/SpR/Consultant)
Duration of laryngoscopy (s) 14.7 (9.8) 13.4 (8.7) intubation (P<0.05). However, there were no differences
View at laryngoscopy (1/2/3) 12/6/1 17/2/1 between groups in MAP or SAP at any time point.

Table 2 Mean (SD) SAP, DAP, and MAP and heart rate at baseline, after induction of anaesthesia (Ind) and after tracheal intubation (Int) in groups R and A.
*P<0.05 compared with baseline, **P<0.05 compared with pre-intubation (Ind+3 min), ***P<0.05 between groups. Baseline values are the mean of three
readings

Baseline Ind+1 min Ind+2 min Ind+3 min Int+1 min Int+2 min Int+3 min Int+4 min Int+5 min

Group R
SAP (mm Hg) 159 (17) 134 (30)* 121 (29)* 104 (23)* 133 (27)** 141 (26)** 129 (30)** 118 (21)* 109 (19)*
DAP (mm Hg) 79 (11) 68 (17) 63 (20) 54 (15)* 77 (18)** 77 (22)** 69 (18)** 60 (15)*, *** 57 (11)*, **
MAP (mm Hg) 103 (11) 82 (21)* 79 (21)* 68 (19)* 96 (18)** 97 (25)** 88 (21)** 78 (20)* 73 (14)*
Heart rate (beats min±1) 77 (14) 75 (19) 74 (20) 74 (20) 92 (18)*, ** 89 (18)** 82 (19) 79 (18) 77 (17)
Group A
SAP (mm Hg) 153 (23) 130 (28)* 115 (24)* 105 (19)* 132 (28)** 143 (34)** 135 (32)** 127 (29)* 119 (25)*
DAP (mm Hg) 83 (11) 73 (15) 65 (13) 60 (10)* 84 (16)** 86 (20)** 80 (19)** 74 (17)*, *** 69 (13)*, **
MAP (mm Hg) 106 (15) 90 (18)* 82 (17)* 74 (12)* 101 (23)** 105 (24)** 98 (24)** 89 (20)* 83 (17)*
HR (min±1) 77 (10) 78 (10) 77 (12) 77 (12) 97 (15)*, ** 94 (15)*, ** 91 (17)*, ** 88 (16)*, ** 86 (15)**

431
 Habib et al.

Heart rate increased signi®cantly after intubation in both 20:1,8 which corresponds to the remifentanil dose of 0.5 mg
groups to exceed baseline values. Heart rate remained kg±1 used here. A previous study showed these dose
elevated, compared with pre-intubation values, for 2 min in regimens to have similar cardiovascular effects in hyper-
group R (P<0.05) and for 5 min in group A (P<0.05). Values tensive patients.9
after intubation were signi®cantly higher than baseline for 1 In another study in elderly patients, the cardiovascular
min in group R and for 4 min in group A (P<0.05). response to tracheal intubation was attenuated by
However, there were no between-group differences in heart fentanyl 3 mg kg±1 but with a 35% incidence of marked
rate throughout the study. hypotension (SAP <80 mm Hg).10 The incidence of
One patient in group R and two patients in group A hypotension in the present study may also have
experienced marked hypotension (SAP <80 mm Hg for >1 stemmed from the use of propofol, despite careful
min). Four patients in group R and three in group A required titration of dose to effect. The elderly are known to be
ephedrine for hypotension. However, nine patients in group sensitive to the effects of propofol,11 but it has been
R and eight in group A had transient hypotension (SAP suggested to be the preferred i.v. anaesthetic agent to
<100 mm Hg for <1 min) which did not require ephedrine. attenuate the cardiovascular response to intubation.12
One patient in group R and two in group A received an However, severe hypotension was rare in this study.
increased inspired concentration of iso¯urane to treat Although the drug combinations and doses were
hypertension. There were no incidences of bradycardia, reasonable in this group of elderly patients, no patients
tachycardia, arrhythmias, ST segment, or other ECG in this study had signi®cant cardiovascular disease. Few
changes observed during the study. data are available on the effects of remifentanil in
patients with impaired cardiac function, although hypo-
tension is more likely to occur, and further studies
Comment should investigate the optimum dose of remifentanil in
In this study, the cardiovascular effects of remifentanil these high-risk patients.
and alfentanil at induction of anaesthesia and intubation In summary, remifentanil 0.5 mg kg±1 over 30 s
were similar. Although observed increases in MAP and followed by an infusion of 0.1 mg kg±1 min±1 was as
heart rate at intubation were statistically signi®cant, they effective as alfentanil 10 mg kg±1 in attenuating the
were modest and clinically acceptable. MAP remained pressor response to tracheal intubation in elderly
below baseline values throughout the study, whereas HR patients. It is an acceptable alternative to alfentanil at
exceeded baseline values for 1 (group R) and 4 min induction of anaesthesia when a remifentanil infusion is
(group A) after intubation. DAP was signi®cantly higher used during surgery.
in group A than group R at 4 and 5 min after
intubation, probably because an infusion of remifentanil
was used (group R), whereas the effects of alfentanil
would be diminishing by this time (group A). References
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