Induction with sevoflurane-remifentanil is comparable to propofol-fentanyl-rocuronium in PONV after laparoscopic surgery

  • Homer Yang
  • Peter T. -L. Choi
  • James McChesney
  • Norman Buckley
General Anesthesia



To compare sevoflurane-remifentanil induction and propofol-fentanyl-rocuronium induction with regards to the frequency of moderate to severe postoperative nausea and vomiting (PONV) in the first 24 hr after laparoscopic day surgery.


After informed consent, 156 ASA physical status class I to III patients undergoing laparoscopic cholecystectomy or tubal ligation were randomized to either induction with sevoflurane 8%, N2O 67% and iv remifentanil I to 1.5 βg · kg−1 or induction with iv fentanyl 2 to 3 μg · kg−1, propofol 2 mg · kg−1, and rocuronium 0.3 to 0.5 mg · kg−1. All patients received iv ketorolac 0.5 mg · kg−1 at induction and sevoflurane-N2O maintenance anesthesia with rocuronium as needed. PONV was treated with iv ondansetron, droperidol, or dimenhydrinate; postoperative pain was treated with opioid analgesics. Patients were followed for 24 hr with regards to PONV and pain. Intubating conditions, induction and emergence times, time to achieve fast-track discharge criteria, and drug costs were measured.


No differences were seen between the two groups in their frequencies of 24-hr moderate to severe PONV and postoperative pain, or in their intubating conditions, induction and emergence times, and time to achieve fast-track discharge criteria. Patients undergoing sevoflurane-remifentanil induction received more morphine (11 mg vs 8 mg; P < 0.001) in the postanesthetic care unit. Sevoflurane-remifentanil induction resulted in similar anesthetic and total drug costs for both procedures.


We did not demonstrate any difference in PONV pain, or anesthetic/recovery times or costs between the sevoflurane and propofol groups. Sevoflurane-remifentanil induction is a feasible technique for anesthetic induction.


Laparoscopic Cholecystectomy Sevoflurane Ondansetron Remifentanil Rocuronium 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

L’induction avec sévoflurane-rémifentanil ou propofol-fentanyl-rocuronium est similaire quant aux NVPO en chirurgie laparoscopique



Comparer l’induction avec sévoflurane-rémifentanil ou propofol-fentanyl-rocuronium quant à la fréquence de nausées et vomissements postopératoires (NVPO) de modérés à sévères pendant les 24 premières heures après une opération en chirurgie d’un jour sous laparoscopie.


Après avoir accordé leur consentement, 156 patients d’état physique ASA I à III devant subir une cholécystectomie laparoscopique ou une ligature des trompes ont été randomisés pour une induction avec du sévoflurane à 8%, N2O à 67 % et l à 1,5 μg · kg−1 de rémifentanil iv ou une induction iv avec 2 à 3 μg · kg−1 de fentanyl, 2 mg · kg−1 de propofol et 0,3 à 0,5 mg · kg−1 de rocuronium. Tous les patients ont reçu 0,5 mg · kg−1 de kétorolac iv à l’induction et un mélange de sévoflurane-N2O pour le maintien de l’anesthésie, avec rocuronium au besoin. Un traitement iv avec ondansétron, dropéridol ou dimenhydrinate a été donné pour les NVPO et la douleur postopératoire a été soulagée avec des analgésiques opioïdes. Les patients ont été suivis pendant 24 h pour les NVPO et la douleur. Ont été notés: les conditions d’intubation, les temps nécessaires à l’induction et au réveil, le temps d’atteindre les critères de congé de la chirurgie ambulatoire et le coût des médicaments.


Aucune différence intergroupe n’a été enregistrée concernant la fréquence de NVPO de modérés à sévères et la douleur postopératoire pendant 24 h, ou les conditions d’intubation, les temps d’induction et de réveil, de même que le temps nécessaire à l’atteinte des critères de congé. Les patients soumis à une induction avec un mélange de sévoflurane-rémifentanil ont demandé plus de morphine (11 mg vs 8 mg; P < 0,001) en salle de réveil. L’induction avec sévoflurane-rémifentanil a conduit à un usage d’anesthésiques et à un coût total de médicaments similaires pour les deux types d’interventions chirurgicales.


Nous n’avons trouvé aucune différence de NVPO, de douleur ou de temps liés à l’analgésie et à la récupération postopératoires entre les groupes sous sévoflurane ou propofol. Un mélange de sévoflurane-rémifentanil peut servir à l’induction de l’anesthésie.


  1. 1.
    Watcha MF, White PF. Postoperative nausea and vomiting. Its etiology, treatment, and prevention. Anesthesiology 1992; 77: 162–84.PubMedCrossRefGoogle Scholar
  2. 2.
    Hedayati B, Fear S. Hospital admission after day-case gynaecological laparoscopy. Br J Anaesth 1999; 83: 776–9.PubMedGoogle Scholar
  3. 3.
    Chung F, Mezei G. Adverse outcomes in ambulatory anesthesia. Can J Anesth 1999; 46(5 Pt II): R18–34.PubMedGoogle Scholar
  4. 4.
    Tong D, Chung F, Wong D. Predictive factors in global and anesthesia satisfaction in ambulatory surgical patients. Anesthesiology 1997; 87: 856–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Haigh CG, Kaplan LA, Durham JM, Dupeyron JP, Harmer M, Kenny GN. Nausea and vomiting after gynaecological surgery: a meta-analysis of factors affecting their incidence. Br J Anaesth 1993; 71: 517–22.PubMedCrossRefGoogle Scholar
  6. 6.
    Naguib M, El Bakry AK, Khoshim MH, et al. Prophylactic antiemetic therapy with ondansetron, tropisetron, granisetron and metoclopramide in patients undergoing laparoscopic cholecystectomy: a randomized, double-blind comparison with placebo. Can J Anaesth 1996; 43: 226–31.PubMedGoogle Scholar
  7. 7.
    Jokela R, Koivuranta M. Tropisetron or droperidol in the prevention of postoperative nausea and vomiting. A comparative, randomised, double-blind study in women undergoing laparoscopic cholecystectomy. Acta Anaesthesiol Scand 1999; 43: 645–50.PubMedCrossRefGoogle Scholar
  8. 8.
    Juckenhofel S, Feisel C, Schmitt HJ, Biedler A. TIVA with propofol-remifentanil or balanced anesthesia with sevoflurane-fentanyl in laparoscopic operations. Hemodynamics, awakening and adverse events (German). Anaesthesist 1999; 48: 807–12.PubMedCrossRefGoogle Scholar
  9. 9.
    Swiatkowski J, Goral A, Dzieciuch JA, Przesmycki K. Assessment of ondansetron and droperidol for the prevention of post-operative nausea and vomiting after cholecystectomy and minor gynaecological surgery performed by laparoscopy. Eur J Anaesthesiol 1999; 16: 766–72.PubMedCrossRefGoogle Scholar
  10. 10.
    Divatia JV, Vaidya JS, Badwe RA, Hawaldar RW. Omission of nitrous oxide during anesthesia reduces the incidence of postoperative nausea and vomiting. A meta-analysis. Anesthesiology 1996; 85: 1055–62.PubMedCrossRefGoogle Scholar
  11. 11.
    Hartung J. Twenty-four of twenty-seven studies show a greater incidence of emesis associated with nitrous oxide than with alternative anesthetics. Anesth Analg 1996; 83: 114–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Tramèr M, Moore A, McQuay H. Omitting nitrous oxide in general anaesthesia: meta-analysis of intraoperative awareness and postoperative emesis in randomized controlled trials. Br J Anaesth 1996; 76: 186–93.PubMedGoogle Scholar
  13. 13.
    Tramèr M, Moore A, McQuay H. Meta-analytic comparison of prophylactic antiemetic efficacy for postoperative nausea and vomiting: propofol anaesthesia vs omitting nitrous oxide vs total i.v. anaesthesia with propofol. Br J Anaesth 1997; 78: 256–9.PubMedGoogle Scholar
  14. 14.
    Tramèr M, Moore A, McQuay H. Propofol anaesthesia and postoperative nausea and vomiting: quantitative systematic review of randomized controlled studies. Br J Anaesth 1997; 78: 247–55.PubMedGoogle Scholar
  15. 15.
    Sneyd JR, Carr A, Byrom WD, Bilski AJ. A meta-analysis of nausea and vomiting following maintenance of anaesthesia with propofol or inhalational agents. Eur J Anaesthesiol 1998; 15: 433–45.PubMedCrossRefGoogle Scholar
  16. 16.
    Joo HS, Perks WJ. Sevoflurane versus propofol for anesthetic induction: a meta-analysis. Anesth Analg 2000; 91: 213–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Tramèr MR, Fuchs-Buder T. Omitting antagonism of neuromuscular block: effect on postoperative nausea and vomiting and risk of residual paralysis. A systematic review. Br J Anaesth 1999; 82: 379–86.PubMedGoogle Scholar
  18. 18.
    Alexander R, Booth J, Olufolabi AJ, El-Moalem HE, Glass PS. Comparison of remifentanil with alfentanil or suxamethonium following propofol anaesthesia for tracheal intubation. Anaesthesia 1999; 54: 1032–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Alexander R, Olufolabi AJ, Booth J, El-Moalem HE, Glass PS. Dosing study of remifentanil and propofol for tracheal intubation without the use of muscle relaxants. Anaesthesia 1999; 54: 1037–40.PubMedCrossRefGoogle Scholar
  20. 20.
    Grant S, Noble S, Woods A, Murdoch J, Davidson A. Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil. Br J Anaesth 1998; 81: 540–3.PubMedGoogle Scholar
  21. 21.
    Klemola UM, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in combination with propofol. Acta Anaesthesiol Scand 2000; 44: 465–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Stevens JB, Wheatley L. Tracheal intubation in ambulatory surgery patients: using remifentanil and propofol without muscle relaxants. Anesth Analg 1998; 86: 45–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Thompson JP, Hall AP, Russell J, Cagney B, Rowbotham DJ. Effect of remifentanil on the haemodynamic response to orotracheal intubation. Br J Anaesth 1998; 80: 467–9.PubMedGoogle Scholar
  24. 24.
    Woods AW, Grant S, Harten J, Noble JS, Davidson JA. Tracheal intubating conditions after induction with propofol, remifentanil and lignocaine. Eur J Anaesthesiol 1998; 15: 714–8.PubMedGoogle Scholar
  25. 25.
    Joo HS, Perks WJ, Belo SE. Sevoflurane with remifentanil allows rapid tracheal intubation without neuromuscular blocking agents. Can J Anesth 2001; 48: 646–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Peterson RG. Cardiovascular toxicity with injectable droperidol (Letter). Therapeutics Products Directorate, Health Canada; 2002 February 12.Google Scholar
  27. 27.
    White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete’s scoring system. Anesth Analg 1999; 88: 1069–72.PubMedCrossRefGoogle Scholar
  28. 28.
    Apfel CC, Läärä E, Koivuranta M, Greint CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting. Conclusions from cross-validations between two centers. Anesthesiology 1999; 91: 693–700.PubMedCrossRefGoogle Scholar
  29. 29.
    Fleischmann E, Akca O, Wallace T, et al. Onset time, recovery duration, and drug cost with four different methods of inducing general anesthesia. Anesth Analg 1999; 88: 930–5.PubMedCrossRefGoogle Scholar
  30. 30.
    Tang J, Chen L, White PF, et al. Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia. Anesthesiology 1999; 91: 253–61.PubMedCrossRefGoogle Scholar
  31. 31.
    Tramèr MR. Systematic reviews in PONV therapy.In: Tramèr M (Ed.). Evidence Based Resource in Anaesthesia and Analgesia. London: BMJ Books; 2000: 157–78.Google Scholar
  32. 32.
    Viby-Mogensen J, Engbaek J, Eriksson LI, et al. Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents. Acta Anaesthesiol Scand 1996; 40: 59–74.PubMedGoogle Scholar

Copyright information

© Canadian Anesthesiologists 2004

Authors and Affiliations

  • Homer Yang
    • 1
  • Peter T. -L. Choi
    • 2
    • 3
  • James McChesney
    • 2
  • Norman Buckley
    • 1
  1. 1.Department of Anesthesia, Hamilton Health SciencesMcMaster UniversityHamiltonCanada
  2. 2.Department of Anesthesia, St. Joseph’s HealthcareMcMaster UniversityHamiltonCanada
  3. 3.Department of Clinical Epidemiology & BiostatisticsMcMaster UniversityHamiltonCanada

Personalised recommendations