The effects of epidural fentanyl on hemodynamic responses during emergence from isoflurane anesthesia and tracheal extubation: a comparison with intravenous fentanyl.

To investigate the effects of epidural fentanyl infusion on hemodynamic responses to recovery of consciousness and tracheal extubation, we studied 50 unpremedicated patients scheduled for abdominal hysterectomy. All patients underwent epidural catheterization and blind infusion of placebo and study drug. Patients were assigned randomly to three groups: Group I received epidural and intravenous (i.v.) bolus injections and infusion of saline at the rate of 0.2 mL x kg(-1) x h(-1); Group II received an i.v. injection of fentanyl 2 microg/kg for 30 s followed by 25 ng x kg(-1) x min(-1), and Group III received epidural injection and infusion using the same administration regimen as Group II. Anesthesia was induced with and maintained by isoflurane alone in an air-oxygen mixture. The study drug was administered at the start of retroperitoneal suturing. Hemodynamic variables, including systolic and diastolic arterial pressures (SAP and DAP, respectively) and heart rate (HR), were recorded every minute between the start of administration of the study and 5 min after tracheal extubation. During emergence from anesthesia and tracheal extubation, the increases in SAP, DAP, and HR in Groups II and III were significantly diminished (P < 0.05) compared with those in Group I. Arterial pressures, but not HR, were attenuated more significantly in Group III than in Group II during and after tracheal extubation, although the plasma fentanyl concentration was significantly lower (P < 0.01) in Group III (0.64 +/- 0.03 ng/ mL, [mean +/- SD]) than in Group II (1.15 +/- 0.09 ng/mL). The incidence of coughing during and after extubation was also lower with Group III. Suppression of respiratory rate prior to tracheal extubation was similar in the two groups receiving fentanyl. These findings suggest that the significant reduction in arterial pressures responses to tracheal extubation due to epidural fentanyl infusion may arise from more suppression of cough reflex than i.v. fentanyl infusion, which could be provided by the spinal action of epidural fentanyl as well as the supraspinal action.