Comparison of remifentanil-propofol and alfentanil-propofol based total intravenous anesthesia in patients undergoing panendoscopy

During combined endoscopy of the upper gastrointestinal and respiratory tracts sufficient anesthetic depth is needed but rapid recovery is desirable in patients with a compromised airway. In this unblinded, randomised trial we compared remifentanil-propofol anesthesia with alfentanil-propofol anesthesia. We compared perioperative hemodynamic responses and postoperative recovery and awakening. Forty patients were included and randomised. Blood pressure, heart rate and formal assessment of the conscious state (Maddox-wing and p-deletion tests) were used for perioperative evaluation. Recovery from anesthesia was measured using the Steward score together with the Maddox-wing test (done every 20 minutes in the postoperative period until preoperative values were reached). The p-deletion test was performed at 30, 60, and 120 minutes postoperatively. Results are presented as medians with [interquartile ranges]. Although differences were found in hemodynamic responses, these did not reach statistical significance. The remifentanil group had a significantly faster recovery compared to the alfentanil group (time (min) to extubation (7.5 [6-8.75] vs 11 [9-13]), p<0.01; time to reach a maximum Steward score (min) (3 [1-5] vs 10 [5-20]), p<0.001; time to reach the preoperative Maddox-wing values (min) 40 [20-60] vs 60 [40-80], p<0.01). The p-deletion test performance after 30 min was 67 [52-75] in the remifentanil group vs 26 [22-44] in the alfentanil group, p<0.001. After 60 minutes there was still a significant difference 84 [77-93] vs 55 [45-83] p<0.01. We conclude that compared with alfentanil-propofol, remifentanil-propofol offers a more brisk and alert post-operative patient after panendoscopy. This is associated with less cardiovascular instability.