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Vitin AA, Egan TD. Remifentanil-induced hyperalgesia: the current state of affairs. Curr Opin Anaesthesiol 2024; 37:371-378. [PMID: 38841986 DOI: 10.1097/aco.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Remifentanil-induced hyperalgesia (RIH) is a part of a general opioid-induced hyperalgesia (OIH) syndrome, seemingly resulting from abrupt cessation of continuous remifentanil infusion at rates equal or exceeding 0.3 mcg/kg/min. The intricate mechanisms of its development are still not completely understood. However, hyperactivation of the N -methyl d -aspartate receptor system, descending spinal facilitation and increased concentration of dynorphin (a κ-opioid ligand) are commonly proposed as possible mechanisms. Several ways of prevention and management have been suggested, such as slow withdrawal of remifentanil infusion, the addition of propofol, pretreatment with or concomitant administration of ketamine, buprenorphine, cyclooxygenase-2 inhibitors (NSAIDs), methadone, dexmedetomidine. In clinical and animal studies, these strategies exhibited varying success, and many are still being investigated.
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Affiliation(s)
| | - Talmage D Egan
- Department of Anesthesiology, Perioperative & Pain Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Xu Z, Lang Y, Xu X, Deng L, Song H, Yin D. The ED50 and ED95 of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy: a prospective, double-blinded trial. BMC Anesthesiol 2023; 23:385. [PMID: 38001477 PMCID: PMC10675926 DOI: 10.1186/s12871-023-02357-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/22/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND This study aims to estimate the safety, efficacy, and median effective dose (ED50) of esketamine for preventing early postoperative pain in patients undergoing laparoscopic cholecystectomy. METHODS 54 patients undergoing laparoscopic cholecystectomy were prospectively randomized into two groups (group C and group E). Different doses of esketamine were intravenously administered before the skin incision in Group E. The patients in group C received the same dose of saline at the same time. General population characteristics were recorded. The median effective dose (ED50) and 95% effective dose (ED95) were calculated using Dixon's up-and-down method. Hemodynamic parameters were monitored, and pain intensity was assessed using a visual analog scale. We also recorded the condition of anesthesia recovery period and postoperative adverse reactions. RESULTS The ED50 of esketamine for preventing early postoperative pain was 0.301 mg/kg (95%CI: 0.265-0.342 mg/kg), and the ED95 was 0.379 mg/kg (95%CI: 0.340-0.618 mg/kg), calculated by probability unit regression. Heart rate (HR) was significantly lower in the esketamine group compared to the control at the skin incision (p < 0.05). The total VAS score at resting was significantly lower in the esketamine group compared to the control group during the awakening period (p < 0.05). There was no significant difference between the two groups regarding the incidence of adverse reactions (p > 0.05). CONCLUSIONS In this study, esketamine can prevent early postoperative pain effectively. The ED50 and ED95 of esketamine for controlling early postoperative pain were 0.301 mg/kg and 0.379 mg/kg, respectively. TRIAL REGISTRATION ChiCTR2200066663, 13/12/2022.
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Affiliation(s)
- Zhongling Xu
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Yantao Lang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Xiaolei Xu
- Department of Anesthesiology, Funing People's Hospital of Jiangsu, Yancheng, 224400, Jiangsu province, China
| | - Linjuan Deng
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China
| | - Hengya Song
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu province, China.
| | - Dekun Yin
- Department of Anesthesiology, Funing People's Hospital of Jiangsu, Yancheng, 224400, Jiangsu province, China.
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Zhao Y, Mu H, Zhang J, Lu Y. Efficacy and safety of flurbiprofen‑axetil combined with nalbuphine pretreatment on remifentanil‑induced postoperative hyperalgesia: A randomized clinical trial. Exp Ther Med 2023; 26:475. [PMID: 37664672 PMCID: PMC10469147 DOI: 10.3892/etm.2023.12174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/27/2023] [Indexed: 09/05/2023] Open
Abstract
Remifentanil-induced hyperalgesia (RIH) is a common and complicated issue in patients undergoing laparoscopic cholecystectomy (LC), which significantly reduces patient satisfaction. The present trial was designed to clarify the individual and combined effects of flurbiprofen-axetil and nalbuphine on remifentanil-induced hyperalgesia. This randomized double-blind clinical trial included 120 adult patients who underwent LC at The Second People's Hospital of Wuhu. The individuals were randomized into a flurbiprofen-axetil group (F group), nalbuphine group (N group), flurbiprofen-axetil combined with nalbuphine group (FN group) and saline group (S group). The four groups were given flurbiprofen-axetil (50 mg, iv.), nalbuphine (0.1 mg/kg, iv.), flurbiprofen-axetil (50 mg, iv.) combined with nalbuphine (0.1 mg/kg, iv.) or normal saline respectively prior to skin incision. The primary outcome was the postoperative mechanical pain thresholds at the inner forearm and peri-incisional area. The secondary outcomes were the visual analog scale (VAS) and Ramsay sedation scale at 0.5, 1, 4 and 24 h after surgery, and any other adverse events. The pain threshold of the medial forearm in the FN group did not differ from that in the F and N groups at 24 h after surgery (P=0.310 and P=0.910, respectively). However, the pain threshold around the incision in FN group was significantly lower than that in F and N groups 24 h after surgery (P=0.001). The VAS of the F group, N group and FN group were all significantly lower than that in the S group at 0.5, 1 and 24 h after surgery (P<0.001). No significant differences were observed in the incidence of adverse events between the four groups. Single flurbiprofen-axetil and single nalbuphine effectively prevented RIH 24 h after surgery in LC. The combination of the two analgesic drugs, with different mechanisms of action, was not superior to single therapy. The present study was registered with the Chinese Clinical Trial Registry (registration no. ChiCTR2100045347).
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Affiliation(s)
- Ying Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
- Department of Anesthesiology, The Second People's Hospital of Wuhu, Wuhu, Anhui 241001, P.R. China
| | - Hailing Mu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
- Department of Anesthesiology, The Second People's Hospital of Wuhu, Wuhu, Anhui 241001, P.R. China
| | - Jingjing Zhang
- Department of Anesthesiology, The Second People's Hospital of Wuhu, Wuhu, Anhui 241001, P.R. China
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
- Ambulatory Surgery Center, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
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Oliveira D, Fontenele R, Weleff J, Sofuoglu M, De Aquino JP. Developing non-opioid therapeutics to alleviate pain among persons with opioid use disorder: a review of the human evidence. Int Rev Psychiatry 2023; 35:377-396. [PMID: 38299655 PMCID: PMC10835074 DOI: 10.1080/09540261.2023.2229430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/20/2023] [Indexed: 02/02/2024]
Abstract
The opioid crisis remains a major public health concern, causing significant morbidity and mortality worldwide. Pain is frequently observed among individuals with opioid use disorder (OUD), and the current opioid agonist therapies (OAT) have limited efficacy in addressing the pain needs of this population. We reviewed the most promising non-opioid analgesic therapies for opioid-dependent individuals synthesising data from randomised controlled trials in the Medline database from December 2022 to March 2023. Ketamine, gabapentin, serotoninergic antidepressants, and GABAergic drugs were found to be the most extensively studied non-opioid analgesics with positive results. Additionally, we explored the potential of cannabinoids, glial activation inhibitors, psychedelics, cholecystokinin antagonists, alpha-2 adrenergic agonists, and cholinergic drugs. Methodological improvements are required to advance the development of novel analgesic strategies and establish their safety profile for opioid-dependent populations. We highlight the need for greater integration of experimental pain methods and abuse liability assessments, more granular assessments of prior opioid exposure, greater uniformity of pain types within study samples, and a particular focus on individuals with OUD receiving OAT. Finally, future research should investigate pharmacokinetic interactions between OAT and various non-opioid analgesics and perform reverse translation basic experiments, particularly with methadone and buprenorphine, which remain the standard OUD treatment.
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Affiliation(s)
- Debora Oliveira
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
| | - Rodrigo Fontenele
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Jeremy Weleff
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, 1950 E 89th St U Bldg, Cleveland, OH 44195, USA
| | - Mehmet Sofuoglu
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Joao P. De Aquino
- Yale University School of Medicine, Department of Psychiatry, 300 George Street, New Haven, CT 06511, USA
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
- Clinical Neuroscience Research Unit, Connecticut Mental Health Center, 34 Park Street, 3 Floor, New Haven, CT 06519, USA
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Xie WJ, Hong JS, Feng CF, Chen HF, Li W, Li YC. Pharmacological interventions for preventing opioid-induced hyperalgesia in adults after opioid-based anesthesia: a systematic review and network meta-analysis. Front Pharmacol 2023; 14:1199794. [PMID: 37426819 PMCID: PMC10324676 DOI: 10.3389/fphar.2023.1199794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/11/2023] Open
Abstract
Background: Opioid-induced hyperalgesia (OIH) is an adverse event of prolonged opioid use that increases pain intensity. The optimal drug to prevent these adverse effects is still unknown. We aimed to conduct a network meta-analysis to compare different pharmacological interventions for preventing the increase in postoperative pain intensity caused by OIH. Methods: Several databases were searched independently for randomized controlled trials (RCTs) comparing various pharmacological interventions to prevent OIH. The primary outcomes were postoperative pain intensity at rest after 24 h and the incidence of postoperative nausea and vomiting (PONV). Secondary outcomes included pain threshold at 24 h after surgery, total morphine consumption over 24 h, time to first postoperative analgesic requirement, and shivering incidence. Results: In total, 33 RCTs with 1711 patients were identified. In terms of postoperative pain intensity, amantadine, magnesium sulphate, pregabalin, dexmedetomidine, ibuprofen, flurbiprofen plus dexmedetomidine, parecoxib, parecoxib plus dexmedetomidine, and S (+)-ketamine plus methadone were all associated with milder pain intensity than placebo, with amantadine being the most effective (SUCRA values = 96.2). Regarding PONV incidence, intervention with dexmedetomidine or flurbiprofen plus dexmedetomidine resulted in a lower incidence than placebo, with dexmedetomidine showing the best result (SUCRA values = 90.3). Conclusion: Amantadine was identified as the best in controlling postoperative pain intensity and non-inferior to placebo in the incidence of PONV. Dexmedetomidine was the only intervention that outperformed placebo in all indicators. Clinical Trial Registration: https://www.crd.york.ac. uk/prospero/display_record.php?, CRD42021225361.
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Affiliation(s)
- Wei-Ji Xie
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ji-Shuang Hong
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Cheng-Fei Feng
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hao-Feng Chen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Li
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yong-Chun Li
- Department of Anesthesiology, State Key Laboratory of Oncology in Southern China, Sun Yat-sen University Cancer Center, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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Efune PN, Rebstock SE. Suspected opioid-induced hyperalgesia in an infant following surgery: A case report. J Clin Pharm Ther 2022; 47:1486-1489. [PMID: 35968556 DOI: 10.1111/jcpt.13756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/14/2022] [Accepted: 07/17/2022] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Opioids are commonly administered to infants having surgery. Opioid induced hyperalgesia (OIH) is a known adverse effect of opioids in adults but can be difficult to identify in infants. CASE SUMMARY A 3-month-old received high-dose fentanyl during anorectoplasty for imperforate anus. He had signs and symptoms of OIH immediately after surgery. His pain and agitation were difficult to manage but improved after he received ketamine. WHAT IS NEW AND CONCLUSION OIH should be considered in infants postoperatively when pain worsens despite administration of escalating doses of opioids. Ketamine can be an effective therapeutic for OIH.
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Affiliation(s)
- Proshad N Efune
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Sarah E Rebstock
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Evaluation of antihyperalgesic and analgesic effects of 35% nitrous oxide when combined with remifentanil: A randomised phase 1 trial in volunteers. Eur J Anaesthesiol 2021; 38:1230-1241. [PMID: 34735395 DOI: 10.1097/eja.0000000000001468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Remifentanil is an effective drug in peri-operative pain therapy, but it can also induce and aggravate hyperalgesia. Supplemental administration of N2O may help to reduce remifentanil-induced hyperalgesia. OBJECTIVE To evaluate the effect of 35 and 50% N2O on hyperalgesia and pain after remifentanil infusion. DESIGN Single site, phase 1, double-blind, placebo-controlled, randomised crossover study. SETTING University Hospital, Germany from January 2012 to April 2012. PARTICIPANTS Twenty-one healthy male volunteers. INTERVENTIONS Transcutaneous electrical stimulation induced spontaneous acute pain and stable areas of hyperalgesia. Each volunteer underwent the following four sessions in a randomised order: 50 to 50% N2-O2 and intravenous (i.v.) 0.9% saline infusion (placebo); 50 to 50% N2-O2 and i.v. remifentanil infusion at 0.1 μg kg-1 min-1 (remifentanil); 35 to 15 to 50% N2O-N2-O2 and i.v. remifentanil infusion at 0.1 μg kg-1 min-1 (tested drug) and 50 to 50% N2O-O2 and i.v. remifentanil infusion at 0.1 μg kg-1 min-1 (gas active control). Gas mixtures were inhaled for 60 min; i.v. drugs were administered for 30 min. MAIN OUTCOME MEASURES Areas of pin-prick hyperalgesia, areas of touch-evoked allodynia and pain intensity on a visual analogue scale were assessed repeatedly for 160 min. RESULTS Data from 20 volunteers were analysed. There were significant treatment and treatment-by-time effects regarding areas of hyperalgesia (P < 0.001). After the treatment period, the area of hyperalgesia was significantly reduced (P < 0.001) in the tested drug and in the gas active control (30.6 ± 9.25 and 24.4 ± 7.3 cm2, respectively) compared with remifentanil (51.0 ± 17.0 cm2). There was also a significant difference between the gas active control and the tested drug sessions (P < 0.001). For the area of allodynia and pain rating, results were consistent with the results for hyperalgesia. CONCLUSIONS Administration of 35% N2O significantly reduced hyperalgesia, allodynia and pain intensity induced after remifentanil. It might therefore be suitable in peri-operative pain relief characterised by hyperalgesia and allodynia, such as postoperative pain, and may help to reduce opioid demand. TRIAL REGISTRATION EudraCT-No.: 2011-000966-37.
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Morais VBDD, Sakata RK, Huang APS, Ferraro LHDC. Randomized, double-blind, placebo-controlled study of the analgesic effect of intraoperative esmolol for laparoscopic gastroplasty. Acta Cir Bras 2020; 35:e202000408. [PMID: 32555939 PMCID: PMC7357839 DOI: 10.1590/s0102-865020200040000008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/15/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose To evaluate the analgesic effect of esmolol in patients submitted to laparoscopic gastroplasty. Methods Forty patients aged between 18 and 50 years with American Society of Anesthesiologists (ASA) physical status scores of II and III who underwent gastric bypass were allocated to two groups. Group 1 patients received a 0.5-mg/kg bolus of esmolol in 30 mL of saline before induction of anesthesia, followed by an infusion at 15 µg/kg/min until the end of surgery. Group 2 patients received 30 mL of saline as a bolus and then an infusion of saline. Anesthesia included fentanyl (3 µg/kg), propofol (2-4 mg/kg), rocuronium (0.6 mg/kg), and 2% sevoflurane, with remifentanil if necessary. The following parameters were evaluated: pain intensity over 24h, remifentanil consumption, the first analgesic request, morphine consumption, and side effects. Results Pain intensity was lower in the esmolol group except at T0 (after extubation) and 12h postoperatively. Remifentanil supplementation, recovery time, and postoperative morphine supplementation were lower in the esmolol group. No differences in the time to the first analgesic request or side effects were found between the groups. Conclusion Intraoperative esmolol promotes reductions in pain intensity and the need for analgesic supplementation without adverse effects, thus representing an effective drug for multimodal analgesia in gastroplasty.
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Risk and protective factors for chronic pain following inguinal hernia repair: a retrospective study. J Anesth 2020; 34:330-337. [DOI: 10.1007/s00540-020-02743-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/24/2020] [Indexed: 12/16/2022]
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Rupniewska-Ladyko A, Malec-Milewska M. A High Dose of Fentanyl May Accelerate the Onset of Acute Postoperative Pain. Anesth Pain Med 2019; 9:e94498. [PMID: 31903331 PMCID: PMC6935250 DOI: 10.5812/aapm.94498] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/17/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023] Open
Abstract
Fentanyl is a popular intraoperative analgesic linked with the development of opioid tolerance (OT) or opioid-induced hyperalgesia (OIH). The development of OIH or OT may lead to several issues such as delayed healing after surgery and timely discharge. Moreover, it causes discomfort in patients with higher pain scores, greater use of analgesics, and other associated side effects. The current study aimed at determining whether the amount of intraoperatively administered fentanyl affects the onset of acute postoperative pain. The current retrospective study was conducted on 56 patients undergoing laparoscopic sleeve gastrectomy. In patients receiving relatively large doses of fentanyl intraoperatively (over 3 µg/kg body weight), the onset of acute postoperative pain accelerated significantly, in comparison with the ones receiving lower doses.
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Affiliation(s)
- Anna Rupniewska-Ladyko
- Department of Anesthesiology and Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
- Corresponding Author: Department of Anesthesiology and Intensive Care, CMKP ul. Czerniakowska, 231 00-416, Warsaw Poland.
| | - Malgorzata Malec-Milewska
- Department of Anesthesiology and Intensive Care, Centre of Postgraduate Medical Education, Warsaw, Poland
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Santiago AEQ, Leal PDC, Moura ECR, Salomão R, Brunialti MKC, Sakata RK. Effect of preoperative pregabalin on analgesia and interleukins after lumbotomy: prospective, randomized, comparative, double-blind study. J Pain Res 2019; 12:339-344. [PMID: 30666152 PMCID: PMC6333154 DOI: 10.2147/jpr.s189441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background Pregabalin is an anticonvulsant and has been used for postoperative analgesia. This study aimed to assess the effect of a single preoperative dose of pregabalin for analgesia after nephrectomy. Methods The study was prospective, randomized, comparative, and double-blinded, conducted in 40 kidney transplant donors, between 18 and 60 years, American Society of Anesthesia physical status I or II. Epidural anesthesia was performed with 15 mL of 0.5% ropivacaine single shot and general anesthesia with 3 µg/kg of fentanyl, propofol, atracurium, and sevoflurane, and 50% of oxygen without nitrous oxide. Patients in group 1 were administered 300 mg of pregabalin and those in group 2 were administered placebo, in identical capsules, 1 hour prior to surgery. Postoperative analgesia was supplemented with tramadol. The following parameters were assessed: pain intensity after 6 and 24 hours; pain threshold, from the thenar and peri-incisional region, analgesic supplementation; ILs (IL6, IL8, and IL10) prior to surgery and after 6 and 24 hours. Results The pain intensity was lower with pregabalin after 24 hours (G1: 2.5±2.4, G2: 3.0±2.6). There was no difference in the sensitivity of the thenar and peri-incisional region after 6 and 24 hours; in the number of patients requiring supplementation (G1=15%, G2=45%); concentrations of IL-6, IL-8, and IL-10; and side effects (nausea, vomiting, dizziness, and pruritus). Conclusion Pregabalin in a single preoperative dose of 300 mg reduced pain intensity 24 hours after lumbotomy.
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Affiliation(s)
| | | | - Ed Carlos Rey Moura
- Department of Anesthesia, Universidade Federal de São Paulo, São Paulo, Brazil,
| | - Reinaldo Salomão
- Department of Anesthesia, Universidade Federal de São Paulo, São Paulo, Brazil,
| | | | - Rioko Kimiko Sakata
- Department of Anesthesia, Universidade Federal de São Paulo, São Paulo, Brazil,
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Kido K, Toda S, Shindo Y, Miyashita H, Sugino S, Masaki E. Effects of low-dose ketamine infusion on remifentanil-induced acute opioid tolerance and the inflammatory response in patients undergoing orthognathic surgery. J Pain Res 2019; 12:377-385. [PMID: 30705603 PMCID: PMC6342226 DOI: 10.2147/jpr.s177098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Purpose Remifentanil is associated with acute opioid tolerance that can lead to increased postoperative consumption of opioid analgesics. The purpose of this study was to determine whether a low dose of ketamine prevents remifentanil-induced acute opioid tolerance and affects the neutrophil–lymphocyte ratio (NLR), a newly recognized biomarker of inflammation. Materials and methods Forty patients undergoing orthognathic surgery were enrolled in this prospective, randomized, double-blind study and randomly assigned to intraoperative administration of one of the following anesthetic regimens: high-dose remifentanil (0.6 µg/kg/minute); low-dose remifentanil (0.2 µg/kg/minute); or high-dose remifentanil with ketamine (remifentanil 0.6 µg/kg/minute with 0.5 mg/kg ketamine just after induction followed by an intraoperative infusion of ketamine 5 µg/kg/minute until wound closure). Fentanyl by intravenous patient-controlled analgesia was used for postoperative pain control. Visual Analog Scale pain scores and fentanyl consumption were recorded in the first 24 hours postoperatively. Perioperative serum C-reactive protein level and NLR were also determined. Results Baseline characteristics were similar in the three study groups. There were no between-group differences in Visual Analog Scale pain scores during the study period. The high-dose remifentanil group had a significantly higher requirement for fentanyl than the other two groups. Addition of ketamine did not affect the C-reactive protein level but increased the NLR; this increase was associated with decreased fentanyl consumption. Conclusion High-dose intraoperative remifentanil induced postoperative acute opioid tolerance that was prevented by infusion of low-dose ketamine. Ketamine increased the postoperative NLR associated with decreased fentanyl requirement for postoperative pain control.
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Affiliation(s)
- Kanta Kido
- Department of Dental Anesthesiology and Pain Management, Tohoku University Hospital, Sendai, Miyagi, Japan,
| | - Shinichi Toda
- Department of Dental Anesthesiology and Pain Management, Tohoku University Hospital, Sendai, Miyagi, Japan,
| | - Yuki Shindo
- Department of Dental Anesthesiology and Pain Management, Tohoku University Hospital, Sendai, Miyagi, Japan,
| | - Hitoshi Miyashita
- Department of Oral Medicine and Surgery, Division of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Tohoku University, Sendai, Miyagi, Japan
| | - Shigekazu Sugino
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Eiji Masaki
- Department of Dental Anesthesiology and Pain Management, Tohoku University Hospital, Sendai, Miyagi, Japan,
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Brinck EC, Tiippana E, Heesen M, Bell RF, Straube S, Moore RA, Kontinen V. Perioperative intravenous ketamine for acute postoperative pain in adults. Cochrane Database Syst Rev 2018; 12:CD012033. [PMID: 30570761 PMCID: PMC6360925 DOI: 10.1002/14651858.cd012033.pub4] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inadequate pain management after surgery increases the risk of postoperative complications and may predispose for chronic postsurgical pain. Perioperative ketamine may enhance conventional analgesics in the acute postoperative setting. OBJECTIVES To evaluate the efficacy and safety of perioperative intravenous ketamine in adult patients when used for the treatment or prevention of acute pain following general anaesthesia. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase to July 2018 and three trials registers (metaRegister of controlled trials, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP)) together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We sought randomised, double-blind, controlled trials of adults undergoing surgery under general anaesthesia and being treated with perioperative intravenous ketamine. Studies compared ketamine with placebo, or compared ketamine plus a basic analgesic, such as morphine or non-steroidal anti-inflammatory drug (NSAID), with a basic analgesic alone. DATA COLLECTION AND ANALYSIS Two review authors searched for studies, extracted efficacy and adverse event data, examined issues of study quality and potential bias, and performed analyses. Primary outcomes were opioid consumption and pain intensity at rest and during movement at 24 and 48 hours postoperatively. Secondary outcomes were time to first analgesic request, assessment of postoperative hyperalgesia, central nervous system (CNS) adverse effects, and postoperative nausea and vomiting. We assessed the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS We included 130 studies with 8341 participants. Ketamine was given to 4588 participants and 3753 participants served as controls. Types of surgery included ear, nose or throat surgery, wisdom tooth extraction, thoracotomy, lumbar fusion surgery, microdiscectomy, hip joint replacement surgery, knee joint replacement surgery, anterior cruciate ligament repair, knee arthroscopy, mastectomy, haemorrhoidectomy, abdominal surgery, radical prostatectomy, thyroid surgery, elective caesarean section, and laparoscopic surgery. Racemic ketamine bolus doses were predominantly 0.25 mg to 1 mg, and infusions 2 to 5 µg/kg/minute; 10 studies used only S-ketamine and one only R-ketamine. Risk of bias was generally low or uncertain, except for study size; most had fewer than 50 participants per treatment arm, resulting in high heterogeneity, as expected, for most analyses. We did not stratify the main analysis by type of surgery or any other factor, such as dose or timing of ketamine administration, and used a non-stratified analysis.Perioperative intravenous ketamine reduced postoperative opioid consumption over 24 hours by 8 mg morphine equivalents (95% CI 6 to 9; 19% from 42 mg consumed by participants given placebo, moderate-quality evidence; 65 studies, 4004 participants). Over 48 hours, opioid consumption was 13 mg lower (95% CI 10 to 15; 19% from 67 mg with placebo, moderate-quality evidence; 37 studies, 2449 participants).Perioperative intravenous ketamine reduced pain at rest at 24 hours by 5/100 mm on a visual analogue scale (95% CI 4 to 7; 19% lower from 26/100 mm with placebo, high-quality evidence; 82 studies, 5004 participants), and at 48 hours by 5/100 mm (95% CI 3 to 7; 22% lower from 23/100 mm, high-quality evidence; 49 studies, 2962 participants). Pain during movement was reduced at 24 hours (6/100 mm, 14% lower from 42/100 mm, moderate-quality evidence; 29 studies, 1806 participants), and 48 hours (6/100 mm, 16% lower from 37 mm, low-quality evidence; 23 studies, 1353 participants).Results for primary outcomes were consistent when analysed by pain at rest or on movement, operation type, and timing of administration, or sensitivity to study size and pain intensity. No analysis by dose was possible. There was no difference when nitrous oxide was used. We downgraded the quality of the evidence once if numbers of participants were large but small-study effects were present, or twice if numbers were small and small-study effects likely but testing not possible.Ketamine increased the time for the first postoperative analgesic request by 54 minutes (95% CI 37 to 71 minutes), from a mean of 39 minutes with placebo (moderate-quality evidence; 31 studies, 1678 participants). Ketamine reduced the area of postoperative hyperalgesia by 7 cm² (95% CI -11.9 to -2.2), compared with placebo (very low-quality evidence; 7 studies 333 participants). We downgraded the quality of evidence because of small-study effects or because the number of participants was below 400.CNS adverse events occurred in 52 studies, while 53 studies reported of absence of CNS adverse events. Overall, 187/3614 (5%) participants receiving ketamine and 122/2924 (4%) receiving control treatment experienced an adverse event (RR 1.2, 95% CI 0.95 to 1.4; high-quality evidence; 105 studies, 6538 participants). Ketamine reduced postoperative nausea and vomiting from 27% with placebo to 23% with ketamine (RR 0.88, 95% CI 0.81 to 0.96; the number needed to treat to prevent one episode of postoperative nausea and vomiting with perioperative intravenous ketamine administration was 24 (95% CI 16 to 54; high-quality evidence; 95 studies, 5965 participants). AUTHORS' CONCLUSIONS Perioperative intravenous ketamine probably reduces postoperative analgesic consumption and pain intensity. Results were consistent in different operation types or timing of ketamine administration, with larger and smaller studies, and by higher and lower pain intensity. CNS adverse events were little different with ketamine or control. Perioperative intravenous ketamine probably reduces postoperative nausea and vomiting by a small extent, of arguable clinical relevance.
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Affiliation(s)
- Elina Cv Brinck
- Department of Anesthesiology, Intensive Care and Pain Medicine, Division of Anesthesiology, Töölö Hospital, Helsinki University and Helsinki University Hospital, Topeliuksenkatu 5, Helsinki, Finland, PB 266 00029
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14
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García-Henares JF, Moral-Munoz JA, Salazar A, Del Pozo E. Effects of Ketamine on Postoperative Pain After Remifentanil-Based Anesthesia for Major and Minor Surgery in Adults: A Systematic Review and Meta-Analysis. Front Pharmacol 2018; 9:921. [PMID: 30174603 PMCID: PMC6107835 DOI: 10.3389/fphar.2018.00921] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/26/2018] [Indexed: 01/22/2023] Open
Abstract
Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been postulated as an adjuvant analgesic for preventing remifentanil-induced hyperalgesia after surgery. This systematic review and meta-analysis aims to assess the effectiveness of ketamine [racemic mixture and S-(+)-ketamine] in reducing morphine consumption and pain intensity scores after remifentanil-based general anesthesia. We performed a literature search of the PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases in June 2017 and selected randomized controlled trials using predefined inclusion and exclusion criteria. To minimize confounding and heterogeneity, studies of NMDA receptor antagonists other than ketamine were excluded and the selected studies were grouped into those assessing minor or major surgery. Methodological quality was evaluated with the PEDro and JADA scales. The data were extracted and meta-analyses were performed where possible. Twelve RCTs involving 156 adults who underwent minor surgery and 413 adults who underwent major surgery were included in the meta-analysis. When used as an adjuvant to morphine, ketamine reduced postoperative morphine consumption in the first 24 h and postoperative pain intensity in the first 2 h in the minor and major surgery groups. It was also associated with significantly reduced pain intensity in the first 24 h in the minor surgery group. Time to the first rescue analgesia was longer in patients who received ketamine and underwent major surgery. No significant differences in the incidence of ketamine-related adverse effects were observed among patients in the intervention group and controls. This systematic review and meta-analysis show that low-dose (≤0.5 mg/kg for iv bolus or ≤5 μg/kg/min for iv perfusion) of ketamine reduces postoperative morphine consumption and pain intensity without increasing the incidence of adverse effects.
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Affiliation(s)
| | - Jose A. Moral-Munoz
- Department of Nursing and Physiotherapy, University of Cádiz, Cádiz, Spain
- Institute of Research and Innovation in Biomedical Sciences of the Province of Cadiz (INiBICA) University of Cádiz, Cádiz, Spain
| | - Alejandro Salazar
- Institute of Research and Innovation in Biomedical Sciences of the Province of Cadiz (INiBICA) University of Cádiz, Cádiz, Spain
- Preventive Medicine and Public Health Area, University of Cádiz, Cádiz, Spain
- The Observatory of Pain (External Chair of Pain), University of Cádiz, Cádiz, Spain
| | - Esperanza Del Pozo
- Department of Pharmacology, Faculty of Medicine, Institute of Neurosciences, Biomedical Research Institute Granada, University of Granada, Granada, Spain
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Cohen SP, Bhatia A, Buvanendran A, Schwenk ES, Wasan AD, Hurley RW, Viscusi ER, Narouze S, Davis FN, Ritchie EC, Lubenow TR, Hooten WM. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med 2018; 43:521-546. [PMID: 29870458 PMCID: PMC6023575 DOI: 10.1097/aap.0000000000000808] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Over the past 2 decades, the use of intravenous ketamine infusions as a treatment for chronic pain has increased dramatically, with wide variation in patient selection, dosing, and monitoring. This has led to a chorus of calls from various sources for the development of consensus guidelines. METHODS In November 2016, the charge for developing consensus guidelines was approved by the boards of directors of the American Society of Regional Anesthesia and Pain Medicine and, shortly thereafter, the American Academy of Pain Medicine. In late 2017, the completed document was sent to the American Society of Anesthesiologists' Committees on Pain Medicine and Standards and Practice Parameters, after which additional modifications were made. Panel members were selected by the committee chair and both boards of directors based on their expertise in evaluating clinical trials, past research experience, and clinical experience in developing protocols and treating patients with ketamine. Questions were developed and refined by the committee, and the groups responsible for addressing each question consisted of modules composed of 3 to 5 panel members in addition to the committee chair. Once a preliminary consensus was achieved, sections were sent to the entire panel, and further revisions were made. In addition to consensus guidelines, a comprehensive narrative review was performed, which formed part of the basis for guidelines. RESULTS Guidelines were prepared for the following areas: indications; contraindications; whether there was evidence for a dose-response relationship, or a minimum or therapeutic dose range; whether oral ketamine or another N-methyl-D-aspartate receptor antagonist was a reasonable treatment option as a follow-up to infusions; preinfusion testing requirements; settings and personnel necessary to administer and monitor treatment; the use of preemptive and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. CONCLUSIONS Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies, with higher dosages and more frequent infusions associated with greater risks. Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of nonintravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.
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Affiliation(s)
- Steven P. Cohen
- From the Departments of Anesthesiology & Critical Care Medicine, Neurology, and Physical Medicine & Rehabilitation, Johns Hopkins School of Medicine; and
- Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Anuj Bhatia
- Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Eric S. Schwenk
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Ajay D. Wasan
- Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hurley
- Departments of Anesthesiology and Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Eugene R. Viscusi
- Department of Anesthesiology, Jefferson Medical College, Philadelphia; and
| | - Samer Narouze
- Departments of Anesthesiology and Neurosurgery, Western Reserve Hospital, Akron, OH
| | - Fred N. Davis
- Procare Pain Solutions and
- Department of Anesthesiology, Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Elspeth C. Ritchie
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Georgetown University School of Medicine, Bethesda, MD; and
- Howard University College of Medicine, Washington, DC; and
| | | | - William M. Hooten
- Departments of Anesthesiology and Psychiatry, Mayo College of Medicine, Rochester, MN
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16
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Santonocito C, Noto A, Crimi C, Sanfilippo F. Remifentanil-induced postoperative hyperalgesia: current perspectives on mechanisms and therapeutic strategies. Local Reg Anesth 2018; 11:15-23. [PMID: 29670398 PMCID: PMC5898588 DOI: 10.2147/lra.s143618] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The use of remifentanil in clinical practice offers several advantages and it is used for a wide range of procedures, ranging from day-surgery anesthesia to more complex procedures. Nonetheless, remifentanil has been consistently linked with development of opioid-induced hyperalgesia (OIH), which is described as a paradoxical increase in sensitivity to painful stimuli that develops after exposure to opioid treatment. The development of OIH may cause several issues, delaying recovery after surgery and preventing timely patient's discharge. Moreover, it causes patient's discomfort with higher pain scores, greater use of analgesics, and associated side effects. Remifentanil is the opioid most convincingly associated with OIH, and hereby we provide a review of remifentanil-induced hyperalgesia, describing both the underlying mechanisms involved and the available studies investigating experimental and clinical pharmacologic approaches aiming at reducing its incidence and degree.
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Affiliation(s)
- Cristina Santonocito
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Alberto Noto
- Department of Anesthesia and Intensive Care, Messina University, Messina, Italy
| | - Claudia Crimi
- Department of Respiratory Medicine, AOU "Policlinico-Vittorio Emanuele", University of Catania, Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Abstract
This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and CUNY Neuroscience Collaborative, Queens College, City University of New York, Flushing, NY 11367, United States.
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18
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Moro ET, Feitosa IMPSS, de Oliveira RG, Saraiva GFP, Rosalino R, Marossi VP, Bloomstone JA, Navarro LHC. Ketamine does not enhance the quality of recovery following laparoscopic cholecystectomy: a randomized controlled trial. Acta Anaesthesiol Scand 2017. [PMID: 28620916 DOI: 10.1111/aas.12919] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Ketamine has been used as part of the multimodal analgesia technique in the acute perioperative period. The effect of perioperative intravenous small-dose ketamine on the quality of recovery from the patient point-of-view has not been assessed. We hypothesized that low-dose ketamine would enhance recovery following laparoscopic cholecystectomy under total intravenous anesthesia. METHODS One hundred thirty five patients undergoing laparoscopic cholecystectomy were enrolled in this randomized, double-blind placebo-controlled trial. Subjects were randomly assigned to one of three groups: saline, ketamine 0.2 mg/kg, or ketamine 0.4 mg/kg immediately following the induction of anesthesia and before skin incision. The primary endpoint was assessed using the Quality of Recovery Questionnaire (QoR-40), a 40-item quality of recovery scoring system. In addition, early clinical recovery variables, such as time to eye opening, occurrence of nausea and vomiting, pain score, analgesic use, and length of PACU stay were assessed. RESULTS No differences were detected in the total or individual dimension scores of the QoR-40 questionnaire. The incidence of nausea, vomiting, and other complications did not differ among the three groups. CONCLUSIONS Small doses of ketamine do not improve the quality of recovery after remifentanil-based anesthesia for laparoscopic cholecystectomy.
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Affiliation(s)
- E. T. Moro
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - I. M. P. S. S. Feitosa
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - R. G. de Oliveira
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - G. F. P. Saraiva
- Department of Surgery; School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - R. Rosalino
- School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - V. P. Marossi
- School of Medical and Health Sciences; Pontifical Catholic University of São Paulo, PUC-SP; São Paulo Brazil
| | - J. A. Bloomstone
- Department of Anesthesiology; College of Medicine; University of Arizona; Phoenix AZ USA
| | - L. H. C. Navarro
- Department of Anesthesiology; Botucatu Medical School; São Paulo State University, UNESP; São Paulo Brazil
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Baarslag MA, Allegaert K, Knibbe CAJ, van Dijk M, Tibboel D. Pharmacological sedation management in the paediatric intensive care unit. J Pharm Pharmacol 2016; 69:498-513. [DOI: 10.1111/jphp.12630] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
Abstract
Objective
This review addresses sedation management on paediatric intensive care units and possible gaps in the knowledge of optimal sedation strategies. We present an overview of the commonly used sedatives and their pharmacokinetic and pharmacodynamic considerations in children, as well as the ongoing studies in this field. Also, sedation guidelines and current sedation strategies and assessment methods are addressed.
Key findings
This review shows that evidence and pharmacokinetic data are scarce, but fortunately, there is an active research scene with promising new PK and PD data of sedatives in children using new study designs with application of advanced laboratory methods and modelling. The lack of evidence is increasingly being recognized by authorities and legislative offices such as the US Food and Drug Administration (FDA) and European Medicines Agency (EMA).
Conclusion
The population in question is very heterogeneous and this overview can aid clinicians and researchers in moving from practice-based sedation management towards more evidence- or model-based practice. Still, paediatric sedation management can be improved in other ways than pharmacology only, so future research should aim on sedation assessment and implementation strategies of protocolized sedation as well.
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Affiliation(s)
- Manuel A Baarslag
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Karel Allegaert
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of development and regeneration, KU Leuven, Belgium
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Division of Pharmacology, Leiden Academic Center for Drug Research, Leiden University, Leiden, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Ge DJ, Qi B, Tang G, Li JY. Intraoperative Dexmedetomidine Promotes Postoperative Analgesia and Recovery in Patients after Abdominal Hysterectomy: a Double-Blind, Randomized Clinical Trial. Sci Rep 2016; 6:21514. [PMID: 26903197 PMCID: PMC4763240 DOI: 10.1038/srep21514] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 01/25/2016] [Indexed: 01/29/2023] Open
Abstract
Surgery-induced acute postoperative pain and stress response can lead to prolonged convalescence. The present study was designed to investigate the effects of intraoperative dexmedetomidine on postoperative analgesia and recovery following abdominal hysterectomy surgeries. Sixty-four patients scheduled for abdominal hysterectomy under general anesthesia were divided into two groups that were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS). During surgery, patients in the PRD group had a lower bispectral index (BIS) value, which indicated a deeper anesthetic state, and a higher sedation score immediately after extubation than patients in the PRS group. During the first 24 hours post-surgery, PRD patients consumed less morphine with patient-controlled analgesia (PCA) and had lower scores on a visual analogue scale (VAS) than their controls from the PRS group. The global 40-item quality of recovery questionnaire and 9-question fatigue severity score both showed higher recovery scores from day 3 after surgery in the PRD group. with the data are considered together, intraoperative administration of dexmedetomidine appeared to promote the analgesic properties of morphine-based PCA and to expedite recovery following surgery in patients undergoing abdominal hysterectomy.
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Affiliation(s)
- Dong-Jian Ge
- Department of Anaesthesiology, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu, 223300, P.R. China
| | - Bin Qi
- Department of Anaesthesiology, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu, 223300, P.R. China
| | - Gang Tang
- Department of Anaesthesiology, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu, 223300, P.R. China
| | - Jin-Yu Li
- Department of Anaesthesiology, Huai'an First People's Hospital, Nanjing Medical University, 6 Beijing Road West, Huai'an, Jiangsu, 223300, P.R. China
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