- Email: [email protected]
Successful use of remifentanil for major head and neck surgery in a heart–lung transplant recipient
Correspondence
Drug Administration for general use. This inhalational agent has a powerful and fast vasodilating effect and can be easily titrated to control hypertensive surges. Tauzin-Fin and colleagues,1 used isoflurane or sevoflurane, which also have a vasodilating effect, although slower in onset. Lippmann’s5 paper stresses that whatever inhalational agent or other drugs are used, the main aspect that the anesthetist should be concerned with is that the patient should be well prepared before surgery by either the surgeon or endocrinologist. It is the unprepared (lack of adequate a-blockade) patient who is most at risk. Volume expansion, a-blockade and the use of metyrosine are, we think, the keys to success in the phaeochromocytoma patient going for surgery.
P. Tauzin-Fin M. Sesay P. Gosse P. Ballanger Bordeaux, France
M. Lippmann C. Kakazu Los Angeles, CA, USA
Editor—We appreciate the interest of Drs Lippmann and Kakazu in our study.1 Indeed, laparoscopic surgery for phaeochromocytoma is now widely considered to be the gold standard, and the anaesthetist should be aware of the pathophysiological repercussions from both the phaeochromocytoma and pneumoperitoneum. In an animal study, vasopressin release has been shown to be involved in haemodynamic instability.2 This situation has not been reported in humans undergoing normovolaemic anaesthesia with adequate monitoring of the depth of anaesthesia.6 Hypercapnia in relation to the carbon dioxide pneumoperitoneum induces small changes in plasma catecholamine levels.7 Hypercapnia can be of importance in patients with pre-existent cardiorespiratory disease. Close monitoring of E0CO2 and more precisely of PaCO2 avoids the consequences of hypercapnia in such patients. Helium can be used as an insufflating gas in laparoscopic surgery for phaeochromocytoma.8 However, because of its low water solubility, helium is more prone to induce gas embolism than carbon dioxode.9 10 Creation of the pneumoperitoneum is the main triggering factor for catecholamine release, even when close monitoring of intra-abdominal pressure during insufflation is performed. We agree with Dr Lippmann’s view that the key to success is pre- and intra-operative a-blockade, probably using short-acting agents. Unfortunately, the ideal short-acting a blocker has not yet been determined. Metyrosine reduces the biosynthesis of catecholamines without establishing haemodynamic stability, thereby causing possible cardiovascular collapse after tumour gland removal.11 Phenoxybenzamine, a non-selective a adrenoreceptor antagonist, has a long duration of action and a pharmacological half-life of about 24 h. Its chronotropic and inotropic effects can be controlled with b-blockers.11 Prazosin is a selective, competitive a1 adrenoreceptor blocker that, given orally, improves the management of phaeochromocytoma only in the preoperative phase.11 All these drugs may exert delayed effects that can increase the incidence of severe hypotension after tumour removal. An alternative treatment is urapidil, a competitive and selective short-acting a1 blocker, administered by continuous i.v. infusion preoperatively and throughout anaesthesia, to block a1 adrenergic receptors before any acute catecholamine release during surgery.1 Its pharmacological profile renders it effective in this situation. If severe rises in blood pressure occur, nicardipine at low doses is an effective adjuvant treatment, whose action is potentiated by sevoflurane.12 13 Desflurane should be avoided as it is associated with catecholamine release if given rapidly in high concentrations.14 We totally share Dr Lippmann’s conclusions that the unprepared patient is most at risk, and we believe that the use of urapidil represents a modern, pathophysiological approach to the perioperative management of phaeochromocytoma.
DOI: 10.1093/bja/aeh604
Successful use of remifentanil for major head and neck surgery in a heart–lung transplant recipient Editor—We would like to describe the successful use of remifentanil in a patient undergoing major head and neck surgery, who had previously received a heart–lung transplant. Remifentanil’s unique pharmacokinetic profile may be advantageous in head and neck procedures.1 Intense intraoperative analgesia can be required for prolonged periods, but postoperative pain may not be severe, and prompt recovery is normally desired. In addition, remifentanil can help to ensure immobility in the absence of neuromuscular
473
Downloaded from http://bja.oxfordjournals.org/ at North Dakota State University on May 23, 2015
1 Tauzin-Fin P, Sesay M, Gosse P, et al. Effects of perioperative a1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 2004; 92: 512–17 2 Mann C, Boccara G, Pouzeratte Y, et al. The relationship among carbon dioxide pneumoperitonium, vassopressin release and hemodynamic changes. Anesth Analg 1999; 89: 278–83 3 Leighton TA, Bongard FS, Liu SY. Comparative cardiopulmonary effects of carbon dioxide vs. helium pneumoperitoneum. Surg J 1993; 113: 527–31 4 Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991; 236: 997–1001 5 Lippmann M. Ford M, Lee CM, et al. Use of desflurane during resection of phaeochromocytoma. Br J Anaesth 1994; 72: 707–9 6 Lentschener C, Axler O, Fernandez H, et al. Haemodynamic changes and vasopressin release are not consistently associated with carbon dioxide pneumoperitoneum in humans. Acta Anaesthesiol Scand 2001; 45: 527–35 7 Myre K, Rostrup M, Buanes T, Stokland O. Plasma catecholamine and haemodynamic changes during pneumoperitoneum. Acta Anaesthesiol Scand 1998, 42: 343–7 8 Fernandez-Cruz L, Taura P, Saenz A, Benaroch G. Laparoscopic approach to pheochromocytoma: hemodynamic changes and catecholamine secretion. World J Surg 1996; 20: 762–8 9 McMahon AJ, Baxter JN, Murry W, Imrie CW, Kenny G, O’Dwyer. Helium pneumoperitonium for laparoscopic cholecystectomy: ventilatory and blood gas changes. Br J Surg 1994; 81: 1033–6 10 Junghans T, Bohm B, Meyer E. Influence of nitrous oxide anaesthesia on venous gas embolism with carbon dioxide and helium during pneumoperitonium. Surg Endoscopy 2000; 14: 1167–70 11 Prys-Robert C. Phaeochromocytoma-recent progress in its management. Br J Anaesth 2000; 85: 44–57 12 Nishiyama T, Matsukawa T, Hanaoka K, Conway C. Interactions between nicardipine and enflurane, isoflurane, and sevoflurane. Can J Anaesth 1997; 44: 707–9 13 Van de Low A, Plaud B, Debaene B. Utilisation du sevoflurane pour la chirurgie du phe´ochromocytome. Ann Fr Anesth Reanim 1998; 17: 301–5 14 Ebert TJ, Muzi M. Sympathetic activity during desflurane anesthesia in healthy volunteers. A comparison to isoflurane. Anesthesiology 1993; 78: 444–53
Correspondence
associated with asystole in a heart transplant recipient,7 was not required. In this patient, remifentanil was successfully used without adverse effects. It is likely that there will be increasing numbers of transplant recipients presenting for surgery of this nature. The immunosuppressant regimens that prevent rejection so successfully, may also render patients more prone to malignancies of this type.8 Further cases involving the use of remifentanil need to be reported however, before potential problems can be identified. A. D. M. McLeod E. V. Barker D. A. Carapiet Portsmouth, UK 1 Michelesen LG, Hug CC, Jr. The pharmacokinetics of remifentanil. J Clin Anesth 1996; 8: 679–82 2 Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesth Analg 1999; 89: 613–22 3 Ashary N, Kaye AD, Hegazi AR, M Frost EA. Anesthetic considerations in the patient with a heart transplant. Heart Dis 2002; 4: 191–8 4 Niemann CU, Stabernack C, Serkova N, Jacobsen W, Christians U, Eger EI, II. Cyclosporine can increase isoflurane MAC. Anesth Analg 2002; 95: 930–4 5 Mo¨llhoff T, Herregods L, Moerman A, et al. Comparative efficacy and safety of remifentanil and fentanyl in ‘fast track’ coronary artery bypass graft surgery: a randomized, double-blind study. Br J Anaesth 2001; 87: 718–26 6 Elliott P, O’Hare R, Bill KM, Phillips AS, Gibson FM, Mirakhur RK. Severe cardiovascular depression with remifentanil. Anesth Analg 2000; 91: 58–61 7 Bjerke RJ, Mangione MP. Asystole after intravenous neostigmine in a heart transplant recipient. Can J Anaesth 2001; 48: 305–7 8 Shiba N, Chan MC, Kwok BW, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant 2004; 23: 155–64
DOI: 10.1093/bja/aeh605
Hyperventilation-induced transient spastic quadraparesis Editor—We would like to report a case of transient spastic quadraparesis in a parturient presenting with extreme hyperventilation during active labour. During such conditions of extreme pain, patients hyperventilate, overriding their involuntary brainstem respiratory centre control.1 An otherwise healthy 21-yr-old, G3P1 full-term parturient, presented to our labour and delivery unit. She reported a successful labour epidural followed by 6 months of lower back pain, after her previous delivery. Following rapid progress of her current labour, the patient requested neuraxial analgesia after initial refusal, reporting unbearable contraction pain. Before neuraxial analgesia had been established, however, and after a period of hyperventilation, the patient was found lying supine with both arms and legs extended, and both wrists in extreme flexion (carpopedal spasm), looking upwards and breathing vigorously (60–80 bpm). The patient had experienced sudden spastic paresis involving both upper and lower extremities 5 min earlier, with loss of passive
474
Downloaded from http://bja.oxfordjournals.org/ at North Dakota State University on May 23, 2015
blocking agents. However, its suitability in the transplant recipient has not yet been established. A 54-yr-old man was scheduled for laryngopharyngectomy with jejunal free flap, as surgical treatment for recurrence of a laryngeal tumour involving the posterior cricoid ring. Seventeen years earlier he had received a cadaveric heart–lung transplant, as treatment for histiocytosis X. He continued to have good cardiorespiratory function, and had no evidence of graft rejection, although mild renal impairment was present. The patient’s airway was unobstructed, and recent anaesthesia for microlaryngoscopy had been uneventful. Venous access, including central venous cannulation of the femoral vein, and radial arterial cannulation were achieved under local anaesthesia. A crystalloid preload was given. An isoproterenol (isoprenaline) infusion was commenced at a rate of 1 mg min1 in anticipation of bradycardia occurring on induction. Anaesthesia was induced with propofol 140 mg, and fentanyl 200 mg, followed by atracurium 40 mg. A 7.0 mm oral tracheal tube was placed easily at direct laryngoscopy. The patient’s lungs were ventilated, and anaesthesia maintained with an oxygen=air mixture and desflurane to an end-tidal concentration of 4.3%. A remifentanil infusion was then started at an initial rate of 0.05 mg kg1 min1, and increased during surgery to an infusion range of 0.1–0.2 mg kg1 min1, titrated according to arterial blood pressure and surgical stimulation. The isoproterenol infusion was continued at the same background rate. Mild, transient bradycardia was encountered on induction (65 beats min1), but not during the administration of remifentanil. During the procedure, the patient exhibited no significant haemodynamic instability. The patient’s pulse rate varied between 80–105 beats min1, and his blood pressure was easily maintained within the range 90–120 mm Hg (systolic). The total duration of surgery was 10 h, during which the larynx and lower pharynx were excised, and a portion of jejunum was anastomosed to reform the pharynx. At the completion of surgery, remifentanil and the volatile agent were discontinued, and the patient awoke promptly. Local anaesthetic had been infiltrated into the small incision through which the jejunal flap had been harvested, and further postoperative analgesia was provided by incremental dosages of morphine totalling 10 mg. The patient was transferred, breathing spontaneously, to the high dependency unit for overnight care, during which he required a further total of morphine 4 mg, self-administered from a PCA device. He was discharged to a general ward on the following morning, and made a full recovery. The anaesthetic management of heart transplant recipients has been reviewed elsewhere.2 3 Metabolism of anaesthetic drugs may be altered if renal impairment is present, while the immunosuppressant drug cyclosporine has been shown to increase the MAC of isoflurane.4 However, the behaviour of the donor heart, which has been separated from its native autonomic supply, dominates anaesthetic considerations. Most anaesthetic techniques can potentially provoke bradycardia, or decrease venous return, neither of which are well tolerated by the transplanted heart. Any technique needs to anticipate these occurrences, and have the means to counteract them to hand. To our knowledge, the use of remifentanil in a heart transplant recipient has not yet been described, nor is it mentioned in the two most recent reviews on this subject.2 3 However, it is successfully used in cardiac surgery,5 and from our experience, during the heart transplant procedure itself. The propensity of remifentanil, when administered as a bolus, to cause bradycardia and cardiovascular instability has been reported,6 and is probably related to a centrally mediated increase in vagal activity. Theoretically, the denervated heart might be less susceptible to this effect, but in practice it would remain a concern. We intended to minimize these risks by administering remifentanil as an infusion, starting at the lowest possible dose. Also, by avoiding the prolonged use of neuromuscular blocking agents, antagonism with neostigmine, which has been
Drug Administration for general use. This inhalational agent has a powerful and fast vasodilating effect and can be easily titrated to control hypertensive surges. Tauzin-Fin and colleagues,1 used isoflurane or sevoflurane, which also have a vasodilating effect, although slower in onset. Lippmann’s5 paper stresses that whatever inhalational agent or other drugs are used, the main aspect that the anesthetist should be concerned with is that the patient should be well prepared before surgery by either the surgeon or endocrinologist. It is the unprepared (lack of adequate a-blockade) patient who is most at risk. Volume expansion, a-blockade and the use of metyrosine are, we think, the keys to success in the phaeochromocytoma patient going for surgery.
P. Tauzin-Fin M. Sesay P. Gosse P. Ballanger Bordeaux, France
M. Lippmann C. Kakazu Los Angeles, CA, USA
Editor—We appreciate the interest of Drs Lippmann and Kakazu in our study.1 Indeed, laparoscopic surgery for phaeochromocytoma is now widely considered to be the gold standard, and the anaesthetist should be aware of the pathophysiological repercussions from both the phaeochromocytoma and pneumoperitoneum. In an animal study, vasopressin release has been shown to be involved in haemodynamic instability.2 This situation has not been reported in humans undergoing normovolaemic anaesthesia with adequate monitoring of the depth of anaesthesia.6 Hypercapnia in relation to the carbon dioxide pneumoperitoneum induces small changes in plasma catecholamine levels.7 Hypercapnia can be of importance in patients with pre-existent cardiorespiratory disease. Close monitoring of E0CO2 and more precisely of PaCO2 avoids the consequences of hypercapnia in such patients. Helium can be used as an insufflating gas in laparoscopic surgery for phaeochromocytoma.8 However, because of its low water solubility, helium is more prone to induce gas embolism than carbon dioxode.9 10 Creation of the pneumoperitoneum is the main triggering factor for catecholamine release, even when close monitoring of intra-abdominal pressure during insufflation is performed. We agree with Dr Lippmann’s view that the key to success is pre- and intra-operative a-blockade, probably using short-acting agents. Unfortunately, the ideal short-acting a blocker has not yet been determined. Metyrosine reduces the biosynthesis of catecholamines without establishing haemodynamic stability, thereby causing possible cardiovascular collapse after tumour gland removal.11 Phenoxybenzamine, a non-selective a adrenoreceptor antagonist, has a long duration of action and a pharmacological half-life of about 24 h. Its chronotropic and inotropic effects can be controlled with b-blockers.11 Prazosin is a selective, competitive a1 adrenoreceptor blocker that, given orally, improves the management of phaeochromocytoma only in the preoperative phase.11 All these drugs may exert delayed effects that can increase the incidence of severe hypotension after tumour removal. An alternative treatment is urapidil, a competitive and selective short-acting a1 blocker, administered by continuous i.v. infusion preoperatively and throughout anaesthesia, to block a1 adrenergic receptors before any acute catecholamine release during surgery.1 Its pharmacological profile renders it effective in this situation. If severe rises in blood pressure occur, nicardipine at low doses is an effective adjuvant treatment, whose action is potentiated by sevoflurane.12 13 Desflurane should be avoided as it is associated with catecholamine release if given rapidly in high concentrations.14 We totally share Dr Lippmann’s conclusions that the unprepared patient is most at risk, and we believe that the use of urapidil represents a modern, pathophysiological approach to the perioperative management of phaeochromocytoma.
DOI: 10.1093/bja/aeh604
Successful use of remifentanil for major head and neck surgery in a heart–lung transplant recipient Editor—We would like to describe the successful use of remifentanil in a patient undergoing major head and neck surgery, who had previously received a heart–lung transplant. Remifentanil’s unique pharmacokinetic profile may be advantageous in head and neck procedures.1 Intense intraoperative analgesia can be required for prolonged periods, but postoperative pain may not be severe, and prompt recovery is normally desired. In addition, remifentanil can help to ensure immobility in the absence of neuromuscular
473
Downloaded from http://bja.oxfordjournals.org/ at North Dakota State University on May 23, 2015
1 Tauzin-Fin P, Sesay M, Gosse P, et al. Effects of perioperative a1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 2004; 92: 512–17 2 Mann C, Boccara G, Pouzeratte Y, et al. The relationship among carbon dioxide pneumoperitonium, vassopressin release and hemodynamic changes. Anesth Analg 1999; 89: 278–83 3 Leighton TA, Bongard FS, Liu SY. Comparative cardiopulmonary effects of carbon dioxide vs. helium pneumoperitoneum. Surg J 1993; 113: 527–31 4 Wittgen CM, Andrus CH, Fitzgerald SD, et al. Analysis of hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991; 236: 997–1001 5 Lippmann M. Ford M, Lee CM, et al. Use of desflurane during resection of phaeochromocytoma. Br J Anaesth 1994; 72: 707–9 6 Lentschener C, Axler O, Fernandez H, et al. Haemodynamic changes and vasopressin release are not consistently associated with carbon dioxide pneumoperitoneum in humans. Acta Anaesthesiol Scand 2001; 45: 527–35 7 Myre K, Rostrup M, Buanes T, Stokland O. Plasma catecholamine and haemodynamic changes during pneumoperitoneum. Acta Anaesthesiol Scand 1998, 42: 343–7 8 Fernandez-Cruz L, Taura P, Saenz A, Benaroch G. Laparoscopic approach to pheochromocytoma: hemodynamic changes and catecholamine secretion. World J Surg 1996; 20: 762–8 9 McMahon AJ, Baxter JN, Murry W, Imrie CW, Kenny G, O’Dwyer. Helium pneumoperitonium for laparoscopic cholecystectomy: ventilatory and blood gas changes. Br J Surg 1994; 81: 1033–6 10 Junghans T, Bohm B, Meyer E. Influence of nitrous oxide anaesthesia on venous gas embolism with carbon dioxide and helium during pneumoperitonium. Surg Endoscopy 2000; 14: 1167–70 11 Prys-Robert C. Phaeochromocytoma-recent progress in its management. Br J Anaesth 2000; 85: 44–57 12 Nishiyama T, Matsukawa T, Hanaoka K, Conway C. Interactions between nicardipine and enflurane, isoflurane, and sevoflurane. Can J Anaesth 1997; 44: 707–9 13 Van de Low A, Plaud B, Debaene B. Utilisation du sevoflurane pour la chirurgie du phe´ochromocytome. Ann Fr Anesth Reanim 1998; 17: 301–5 14 Ebert TJ, Muzi M. Sympathetic activity during desflurane anesthesia in healthy volunteers. A comparison to isoflurane. Anesthesiology 1993; 78: 444–53
Correspondence
associated with asystole in a heart transplant recipient,7 was not required. In this patient, remifentanil was successfully used without adverse effects. It is likely that there will be increasing numbers of transplant recipients presenting for surgery of this nature. The immunosuppressant regimens that prevent rejection so successfully, may also render patients more prone to malignancies of this type.8 Further cases involving the use of remifentanil need to be reported however, before potential problems can be identified. A. D. M. McLeod E. V. Barker D. A. Carapiet Portsmouth, UK 1 Michelesen LG, Hug CC, Jr. The pharmacokinetics of remifentanil. J Clin Anesth 1996; 8: 679–82 2 Kostopanagiotou G, Smyrniotis V, Arkadopoulos N, Theodoraki K, Papadimitriou L, Papadimitriou J. Anesthetic and perioperative management of adult transplant recipients in nontransplant surgery. Anesth Analg 1999; 89: 613–22 3 Ashary N, Kaye AD, Hegazi AR, M Frost EA. Anesthetic considerations in the patient with a heart transplant. Heart Dis 2002; 4: 191–8 4 Niemann CU, Stabernack C, Serkova N, Jacobsen W, Christians U, Eger EI, II. Cyclosporine can increase isoflurane MAC. Anesth Analg 2002; 95: 930–4 5 Mo¨llhoff T, Herregods L, Moerman A, et al. Comparative efficacy and safety of remifentanil and fentanyl in ‘fast track’ coronary artery bypass graft surgery: a randomized, double-blind study. Br J Anaesth 2001; 87: 718–26 6 Elliott P, O’Hare R, Bill KM, Phillips AS, Gibson FM, Mirakhur RK. Severe cardiovascular depression with remifentanil. Anesth Analg 2000; 91: 58–61 7 Bjerke RJ, Mangione MP. Asystole after intravenous neostigmine in a heart transplant recipient. Can J Anaesth 2001; 48: 305–7 8 Shiba N, Chan MC, Kwok BW, Valantine HA, Robbins RC, Hunt SA. Analysis of survivors more than 10 years after heart transplantation in the cyclosporine era: Stanford experience. J Heart Lung Transplant 2004; 23: 155–64
DOI: 10.1093/bja/aeh605
Hyperventilation-induced transient spastic quadraparesis Editor—We would like to report a case of transient spastic quadraparesis in a parturient presenting with extreme hyperventilation during active labour. During such conditions of extreme pain, patients hyperventilate, overriding their involuntary brainstem respiratory centre control.1 An otherwise healthy 21-yr-old, G3P1 full-term parturient, presented to our labour and delivery unit. She reported a successful labour epidural followed by 6 months of lower back pain, after her previous delivery. Following rapid progress of her current labour, the patient requested neuraxial analgesia after initial refusal, reporting unbearable contraction pain. Before neuraxial analgesia had been established, however, and after a period of hyperventilation, the patient was found lying supine with both arms and legs extended, and both wrists in extreme flexion (carpopedal spasm), looking upwards and breathing vigorously (60–80 bpm). The patient had experienced sudden spastic paresis involving both upper and lower extremities 5 min earlier, with loss of passive
474
Downloaded from http://bja.oxfordjournals.org/ at North Dakota State University on May 23, 2015
blocking agents. However, its suitability in the transplant recipient has not yet been established. A 54-yr-old man was scheduled for laryngopharyngectomy with jejunal free flap, as surgical treatment for recurrence of a laryngeal tumour involving the posterior cricoid ring. Seventeen years earlier he had received a cadaveric heart–lung transplant, as treatment for histiocytosis X. He continued to have good cardiorespiratory function, and had no evidence of graft rejection, although mild renal impairment was present. The patient’s airway was unobstructed, and recent anaesthesia for microlaryngoscopy had been uneventful. Venous access, including central venous cannulation of the femoral vein, and radial arterial cannulation were achieved under local anaesthesia. A crystalloid preload was given. An isoproterenol (isoprenaline) infusion was commenced at a rate of 1 mg min1 in anticipation of bradycardia occurring on induction. Anaesthesia was induced with propofol 140 mg, and fentanyl 200 mg, followed by atracurium 40 mg. A 7.0 mm oral tracheal tube was placed easily at direct laryngoscopy. The patient’s lungs were ventilated, and anaesthesia maintained with an oxygen=air mixture and desflurane to an end-tidal concentration of 4.3%. A remifentanil infusion was then started at an initial rate of 0.05 mg kg1 min1, and increased during surgery to an infusion range of 0.1–0.2 mg kg1 min1, titrated according to arterial blood pressure and surgical stimulation. The isoproterenol infusion was continued at the same background rate. Mild, transient bradycardia was encountered on induction (65 beats min1), but not during the administration of remifentanil. During the procedure, the patient exhibited no significant haemodynamic instability. The patient’s pulse rate varied between 80–105 beats min1, and his blood pressure was easily maintained within the range 90–120 mm Hg (systolic). The total duration of surgery was 10 h, during which the larynx and lower pharynx were excised, and a portion of jejunum was anastomosed to reform the pharynx. At the completion of surgery, remifentanil and the volatile agent were discontinued, and the patient awoke promptly. Local anaesthetic had been infiltrated into the small incision through which the jejunal flap had been harvested, and further postoperative analgesia was provided by incremental dosages of morphine totalling 10 mg. The patient was transferred, breathing spontaneously, to the high dependency unit for overnight care, during which he required a further total of morphine 4 mg, self-administered from a PCA device. He was discharged to a general ward on the following morning, and made a full recovery. The anaesthetic management of heart transplant recipients has been reviewed elsewhere.2 3 Metabolism of anaesthetic drugs may be altered if renal impairment is present, while the immunosuppressant drug cyclosporine has been shown to increase the MAC of isoflurane.4 However, the behaviour of the donor heart, which has been separated from its native autonomic supply, dominates anaesthetic considerations. Most anaesthetic techniques can potentially provoke bradycardia, or decrease venous return, neither of which are well tolerated by the transplanted heart. Any technique needs to anticipate these occurrences, and have the means to counteract them to hand. To our knowledge, the use of remifentanil in a heart transplant recipient has not yet been described, nor is it mentioned in the two most recent reviews on this subject.2 3 However, it is successfully used in cardiac surgery,5 and from our experience, during the heart transplant procedure itself. The propensity of remifentanil, when administered as a bolus, to cause bradycardia and cardiovascular instability has been reported,6 and is probably related to a centrally mediated increase in vagal activity. Theoretically, the denervated heart might be less susceptible to this effect, but in practice it would remain a concern. We intended to minimize these risks by administering remifentanil as an infusion, starting at the lowest possible dose. Also, by avoiding the prolonged use of neuromuscular blocking agents, antagonism with neostigmine, which has been