To the Editor:-I read with interest the excellent clinical investigation of remifentanil and fentanyl in patients undergoing craniotomy for supratentorial space-occupying lesions, although I am troubled by the authors recommendations that “remifentanil appears to be a reasonable alternative to fentanyl” and “appears appropriate” in such cases.

The authors report that induction hemodynamics, intracranial pressure, and cerebral perfusion pressure were similar, as was the median time to extubation. There was no difference in the incidence of nausea or neurologic sequelae. Anesthetic recovery, as evaluated by anesthesiologists, was not significantly different, although one patient in the remifentanil group exhibited emergence delirium. Also, postoperative systolic blood pressure and analgesic requirements were greater in the remifentanil group. The only negative association with fentanyl was the frequency of naloxone utilization. [1]I would thus conclude that presently there is no indication to use remifentanil instead of fentanyl. This does not even consider the extensive experience that exists with fentanyl and neurosurgery patients or the issue of cost. [2,3] 

As has been discussed recently in the literature, physicians should decide whether the relationship between investigators and sponsor affected interpretation of the results. [4]This study has an acknowledged relationship with Glaxo Wellcome, Inc., which produces remifentanil, and raises this issue.

Roland R. Rizzi, M.D.

Department of Anesthesiology; Lenox Hill Hospital; 100 East 77th Street; New York, New York 10021–1883

(Accepted for publication August 6, 1997.)

Guy J, et al: Comparison of remifentanil and fentanyl in patients undergoing craniotomy for supratentorial space-occupying lesions. Anesthesiology 1997; 86:514-24.
Todd MM, et al: A prospective comparative trial of three anesthetics for supratentorial craniotomy. Anesthesiology 1993; 78:1005-20.
From RP, et al: A double-blind comparison of alfentanil, fentanyl, and sufentanil. Anesthesiology 1990; 73:896-904.
Todd MM, Saidman LJ: Academic-industrial relationships: The good, the bad, and the ugly. Anesthesiology 1997; 87:197-200.