Comparison of Fentanyl, Remifentanil, Sufentanil and Alfentanil in Combination with Propofol for General Anesthesia: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract

Background: Opioid analgesics are commonly used along with propofol during general anesthesia. Due to the dearth of data on the quality of anesthesia achieved with this combination, the present meta-analysis was carried out.

Methods: Electronic databases were searched for appropriate studies using a suitable search strategy. Randomized clinical trials comparing the combination of remifentanil/sufentanil/alfentanil with propofol with fentanyl and propofol, were included. The outcome measures were as follows: total propofol dose to achieve the desired general anesthesia; time of onset and duration of general anesthesia; depth of general anesthesia; and recovery time (time for eye-opening and time taken for extubation). Risk of bias was assessed and Forest plots were generated for eligible outcomes. The weighted mean difference [95% confidence intervals] was used as the effect estimate.

Results: Fourteen studies were included in the systematic review and 13 were included in the metaanalysis. Statistically significant differences were observed for remifentanil in comparison to fentanyl when combined with propofol: Propofol dose (in mg) -76.18 [-94.72, -57.64]; time of onset of anesthesia (min) -0.44 [-0.74, -0.15]; time taken for eye-opening (min) -3.95 [-4.8, -3.1]; and time for extubation (min) -3.53 [-4.37, -2.7]. No significant differences were observed for either sufentanil or alfentanil about the dose of propofol required and due to scanty data, pooling of the data could not be attempted for other outcome measures for either sufentanil or alfentanil.

Conclusion: To conclude, we found that remifentanil has a statistically significant anesthetic profile than fentanyl when combined with propofol. Scanty evidence for both alfentanil and sufentanil precludes any such confirmation.

Keywords: Opioids; alfentanil; anesthesia; fentanyl induced cough; propofol related pain; sufentanil..

Fig. (1)

Study flow diagram. A total of 2879 studies obtained with the outlined search strategy and finally 14 were included in the systematic review and 13 in the meta-analysis.

Fig. (2)

Risk of bias of the included studies. Red circle with minus symbol indicates the absence of reporting that specific element while green circle with plus symbol indicates the reporting of the same. (A higher resolution / colour version of this figure is available in the electronic copy of the article).

Fig. (3)

Forest plot of total propofol dose (mg) required to achieve general anesthesia when combined with either remifentanil and fentanyl. A statistically significant decrease in the required total dose of propofol was observed with remifentanil than fentanyl to achieve general 
anesthesia.

Fig. (4)

Forest plot of time taken for induction of anesthesia for remifentanil and fentanyl, in combination with propofol. A statistically 
significant difference was observed in the time taken for inducing anesthesia for remifentanil combination with propofol than fentanyl 
combination.

Fig. (5)

Forest plot of eye opening time (in minutes) for remifentanil compared to fentanyl with propofol. Time taken for opening eyes was found to be significantly lower with remifentanil when combined with propofol in comparison to fentanyl.

Fig. (6)

Forest plot of extubation time for remifentanil in comparison to fentanyl combination with propofol. A statistically significant reduction in the time taken for extubation was observed with remifentanil in comparison with fentanyl in combination with propofol.