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Vitin AA, Egan TD. Remifentanil-induced hyperalgesia: the current state of affairs. Curr Opin Anaesthesiol 2024:00001503-990000000-00200. [PMID: 38841986 DOI: 10.1097/aco.0000000000001400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Dello Russo C, Di Franco V, Tabolacci E, Cappoli N, Navarra P, Sollazzi L, Rapido F, Aceto P. Remifentanil-induced hyperalgesia in healthy volunteers: a systematic review and meta-analysis of randomized controlled trials. Pain 2024; 165:972-982. [PMID: 38047761 PMCID: PMC11017745 DOI: 10.1097/j.pain.0000000000003119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/05/2023]
Abstract
ABSTRACT Recent literature suggests that the withdrawal of remifentanil (RF) infusion can be associated with hyperalgesia in clinical and nonclinical settings. We performed a systematic review and a meta-analysis of randomized controlled trials with cross-over design, to assess the effect of discontinuing RF infusion on pain intensity and areas of hyperalgesia and allodynia in healthy volunteers. Nine studies were included. The intervention treatment consisted in RF infusion that was compared with placebo (saline solution). The primary outcome was pain intensity assessment at 30 ± 15 minutes after RF or placebo discontinuation, assessed by any pain scale and using any quantitative sensory testing. Moreover, postwithdrawal pain scores were compared with baseline scores in each treatment. Secondary outcomes included the areas (% of basal values) of hyperalgesia and allodynia. Subjects during RF treatment reported higher pain scores after discontinuation than during treatment with placebo [standardized mean difference (SMD): 0.50, 95% confidence interval (CI): 0.03-0.97; P = 0.04, I 2 = 71%]. A significant decrease in pain scores, compared with baseline values, was found in the placebo treatment (SMD: -0.87, 95% CI: -1.61 to -0.13; P = 0.02, I 2 = 87%), but not in the RF treatment (SMD: -0.28, 95% CI: -1.18 to 0.62; P = 0.54, I 2 = 91%). The area of hyperalgesia was larger after RF withdrawal (SMD: 0.55; 95% CI: 0.27-0.84; P = 0.001; I 2 = 0%). The area of allodynia did not vary between treatments. These findings suggest that the withdrawal of RF induces a mild but nonclinically relevant degree of hyperalgesia in HVs, likely linked to a reduced pain threshold.
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Affiliation(s)
- Cinzia Dello Russo
- Dipartimento di Sicurezza e Bioetica, Sezione di Farmacologia, Università Cattolica Del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Pharmacology & Therapeutics, Institute of Systems Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, United Kingdom
| | - Valeria Di Franco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisabetta Tabolacci
- Dipartimento di Scienze della Vita e Sanità Pubblica, Sezione di Medicina Genomica, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Natalia Cappoli
- Dipartimento di Sicurezza e Bioetica, Sezione di Farmacologia, Università Cattolica Del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierluigi Navarra
- Dipartimento di Sicurezza e Bioetica, Sezione di Farmacologia, Università Cattolica Del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesca Rapido
- Department of Anesthesia & Critical Care Medicine, Gui de Chauliac Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, Unité Mixtes de Recherche (UMR) 5203 Centre National de la Recherche Scientifique (CNRS)-Unité 1191 INSERM, University of Montpellier, Montpellier, France
| | - Paola Aceto
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
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Zhang G, Li Q, Wang P. The analgesic efficacy of ketamine for septorhinoplasty: a meta-analysis study. Eur Arch Otorhinolaryngol 2023; 280:4083-4089. [PMID: 37027028 DOI: 10.1007/s00405-023-07933-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/14/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND The analgesic efficacy of ketamine supplementation was not well-established for septorhinoplasty and this meta-analysis aimed to compare ketamine supplementation with placebo for the postoperative pain control of septorhinoplasty. METHODS We systematically searched several databases, including PubMed, EMbase, Web of science, EBSCO and Cochrane library databases, and included randomized controlled trials (RCTs) regarding the effect of ketamine supplementation versus placebo for pain control after septorhinoplasty. This meta-analysis was conducted by random effect model. RESULTS Five RCTs were included in this meta-analysis. In comparison with control group for septorhinoplasty, ketamine supplementation was associated with significantly decreased pain scores at 30 min (SMD = - 3.84; 95% CI = - 6.73 to - 0.96; P = 0.009), pain scores at 1 h (SMD = - 2.70; 95% CI = - 3.79 to - 1.61; P < 0.00001), pain scores at 2 h (SMD = - 1.83; 95% CI = - 3.01 to - 0.64; P = 0.003), rescue analgesics (OR = 0.08; 95% CI = 0.04 to 0.17; P < 0.00001), but unraveled no obvious impact on pain scores at 4 h (SMD = - 1.13; 95% CI = - 3.37 to 1.12; P = 0.32) or the incidence of nausea and vomiting (OR = 0.71; 95% CI = 0.30 to 1.72; P = 0.45). CONCLUSIONS Ketamine supplementation was effective to improve pain relief after septorhinoplasty.
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Affiliation(s)
- Guofen Zhang
- Department of Otorhinolaryngologic, Chongqing Liang Jiang New Area Traditional Chinese Medicine Hospital, Chongqing, China
| | - Quli Li
- Department of Otorhinolaryngologic, Liangjiang New District People's Hospital, Chongqing, China
| | - Ping Wang
- Department of Otorhinolaryngologic, Liangjiang New District People's Hospital, Chongqing, China.
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Liang Z, Xu Y, Xue Z. The analgesic efficacy of pregabalin versus placebo for septorhinoplasty: A meta-analysis. Medicine (Baltimore) 2023; 102:e33259. [PMID: 37058015 PMCID: PMC10101281 DOI: 10.1097/md.0000000000033259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/22/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND The analgesic efficacy of pregabalin supplementation for septorhinoplasty remains elusive. This meta-analysis was conducted to compare pregabalin supplementation with placebo for the postoperative pain control of septorhinoplasty. METHODS We systematically searched several databases including PubMed, EMbase, Web of Science, EBSCO and Cochrane library databases, and included randomized controlled trials (RCTs) regarding the effect of pregabalin supplementation versus placebo for pain control after septorhinoplasty. This meta-analysis was conducted by fixed or random-effect model based on the heterogeneity. RESULTS Seven RCTs were included in this meta-analysis. In comparison with control group for septorhinoplasty, pregabalin supplementation was associated with significantly decreased pain scores at 1 h (standard mean difference [SMD] = -1.45; 95% confidence interval [CI] = -2.43 to -0.47; P = .004), pain scores at 2 hours (SMD = -1.01; 95% CI = -1.83 to -0.20; P = .02), pain scores at 6 hours (SMD = -1.00; 95% CI = -1.47 to -0.54; P < .0001), number of rescue analgesics (odd ratio [OR] = 0.18; 95% CI = 0.08-0.39; P < .0001) and analgesic consumption (SMD = -2.78; 95% CI = -5.05 to -0.51; P = .02), but unraveled no obvious impact on the incidence of nausea and vomiting (OR = 0.55; 95% CI = 0.24-1.27; P = .16). CONCLUSIONS Pregabalin supplementation was effective to improve pain relief after septorhinoplasty.
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Affiliation(s)
- Zanmei Liang
- Wenzhou PanHealth International Medica, Wenzhou, China
| | - Yang Xu
- Wenzhou PanHealth International Medica, Wenzhou, China
| | - Zhihui Xue
- Wenzhou PanHealth International Medica, Wenzhou, China
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Hadavi SMR, Eghbal MH, Kaboodkhani R, Alizadeh N, Sahmeddini MA. Comparison of pregabalin with magnesium sulfate in the prevention of remifentanil‐induced hyperalgesia in patients undergoing rhinoplasty: A randomized clinical trial. Laryngoscope Investig Otolaryngol 2022; 7:1360-1366. [PMID: 36258848 PMCID: PMC9575120 DOI: 10.1002/lio2.905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/28/2022] [Accepted: 08/15/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Seyed Mohammad Reza Hadavi
- Shiraz Anesthesiology and Intensive Care Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Mohammad Hossein Eghbal
- Shiraz Anesthesiology and Intensive Care Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Reza Kaboodkhani
- Otorhinolaryngology Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Narges Alizadeh
- Shiraz Anesthesiology and Intensive Care Research Center Shiraz University of Medical Sciences Shiraz Iran
| | - Mohammad Ali Sahmeddini
- Shiraz Anesthesiology and Intensive Care Research Center Shiraz University of Medical Sciences Shiraz Iran
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:479-483. [DOI: 10.1093/ijpp/riac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 03/23/2022] [Indexed: 11/14/2022]
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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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Guichard L, Hirve A, Demiri M, Martinez V. Opioid-induced Hyperalgesia in Patients With Chronic Pain: A Systematic Review of Published Cases. Clin J Pain 2021; 38:49-57. [PMID: 34699405 DOI: 10.1097/ajp.0000000000000994] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 09/28/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Opioid-induced hyperalgesia (OIH) remains an issue in patients with chronic pain. Multiple cases of OIH in patients with chronic pain exposed to opioids have been reported worldwide. The objective of this systematic review was to summarize the evidence of OIH from clinical reports. METHODS We searched the PubMed, Cochrane, EMBASE, and LILACS databases for case reports and case series of OIH published up to December 2020, with the aim to summarize the evidence for OIH in patients with chronic pain from clinical reports and to discuss issues relevant to the clinical diagnosis and management of OIH. RESULTS We retrieved and reviewed 41 articles describing 72 cases. Clinical features of OIH were observed in patients of both sexes, all ages, and with various types of pain treated with different classes of opioids. OIH was reported at all doses, but most published studies reported a pattern of OIH following treatment with very high daily doses of opioids (median oral morphine equivalent dose of 850 mg). OIH was diagnosed clinically in all cases. Three different strategies for OIH management were described: opioid rotation, opioid cessation, and the use of adjuvant pharmacotherapies. All had statistically similar success rates for OIH treatment: 72%, 57%, and 79%, respectively. The decrease in pain was achieved rapidly (mean: 8 d; range: 1 to 28 d). Adjuvant therapies resulted in the largest decrease in dose. Ketamine and dexmedetomidine were the most widely used adjuvant drugs. CONCLUSION The key finding is that clinical symptoms of OIH can be resolved when this condition is diagnosed and managed.
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Affiliation(s)
- Leah Guichard
- Department of Anesthesiology, Hospital Raymond Poincaré, Assistance Publique Hôpitaux de Paris, Garches
| | - Axel Hirve
- Department of Anesthesiology, Hospital Raymond Poincaré, Assistance Publique Hôpitaux de Paris, Garches
| | - Migena Demiri
- Department of anesthesiology, Institute Gustave Roussy, Villejuif
| | - Valeria Martinez
- Department of Anesthesiology, Hospital Raymond Poincaré, Assistance Publique Hôpitaux de Paris, Garches
- INSERM, U-987, Hospital Ambroise Paré, University of Versailles Saint-Quentin, Versailles, France
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Huang YH, Lee MS, Lin YT, Huang NC, Kao J, Lai HC, Lin BF, Cheng KI, Wu ZF. Postoperative Drip-Infusion of Remifentanil Reduces Postoperative Pain-A Retrospective Observative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179225. [PMID: 34501814 PMCID: PMC8431451 DOI: 10.3390/ijerph18179225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/20/2022]
Abstract
Development of remifentanil-induced hyperalgesia (RIH) postoperatively is an unpleasant experience that requires further treatment. This study assessed the effects of gradual withdrawal combined with drip infusion of remifentanil on postoperative pain and the requirement for rescue analgesics. A total of 559 patients receiving total intravenous anesthesia with propofol and remifentanil were enrolled. All patients either underwent gradual withdrawal of remifentanil (GWR) or gradual withdrawal combined with drip infusion (GWDR) with a dose of 1 mcg·kg−1 for 30 min after extubation. The numeric rating scale (NRS) and the requirement of rescue analgesics were assessed. The requirement for rescue analgesics was significantly lower in the GWDR group than in the GWR group (13.2% vs. 35.7%; p < 0.001). At the post-anesthetic care unit (PACU), patients in the GWDR group had a lower NRS pain score (p < 0.001). In addition, in the postoperative 2nd hour, patients in the GWDR group had a significantly lower NRS than the GWR group (beta, −0.31; p = 0.003). No remifentanil-related adverse effects were observed. We found that gradual withdrawal combined with drip infusion of remifentanil required less rescue analgesics and reduced pain scores. The new way of remifentanil administration may be effective to prevent RIH.
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Affiliation(s)
- Yi-Hsuan Huang
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Meei-Shyuan Lee
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan 71004, Taiwan
- Department of Food Science and Technology, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Nian-Cih Huang
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Jing Kao
- School of Public Health, National Defense Medical Center, Taipei 11490, Taiwan
| | - Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Bo-Feng Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Zhi-Fu Wu
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80756, Taiwan
- Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
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De Aquino JP, Flores JM, Avila-Quintero VJ, Compton P, Sofuoglu M. Pharmacological treatment of pain among persons with opioid addiction: A systematic review and meta-analysis with implications for drug development. Addict Biol 2021; 26:e12964. [PMID: 32974993 DOI: 10.1111/adb.12964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/17/2020] [Accepted: 08/23/2020] [Indexed: 01/17/2023]
Abstract
The clinical features and neurobiology of pain and opioid use disorder (OUD) are inextricably linked. Despite emerging evidence supporting the negative impact of ongoing pain in the treatment of OUD, the pharmacological management of pain in the presence of OUD has received limited attention. We sought to systematically review the studies investigating pharmacotherapies for pain among persons with OUD. Eligible studies had participants with OUD and outcomes including evoked or spontaneous pain. We searched Scopus, Cochrane Database of Systematic Reviews, Medline, and Embase. Out of 1,097 studies that met the search criteria, 12 studies provided data relevant to the research question-five laboratory studies and seven clinical trials. Random effects pooled estimates suggested no significant difference between groups at baseline but a response favoring the active treatment group over placebo, with nonsignificant heterogeneity between studies. Findings from these studies provide preliminary evidence for analgesic and antihyperalgesic effects of gabapentin, GABA agonists, and NMDA antagonists among persons with OUD. To establish the tradeoffs between the analgesic effects and abuse liability of these compounds, further well-controlled clinical trials are required among persons with OUD. This review also underscores the need for methodological enhancement in drug development for pain in OUD. Future research should address the clinical and neurobiological overlap between pain- and addiction-related phenomena. Transdisciplinary approaches may identify biomarkers of these shared phenomena and their neural substrates. The development of novel therapeutics for pain in OUD may be accelerated by such integration of pain and addiction research.
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Affiliation(s)
- Joao P De Aquino
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - José M Flores
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Peggy Compton
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mehmet Sofuoglu
- VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
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Association Between Intraoperative Remifentanil Dosage and Postoperative Opioid Consumption in Adolescent Idiopathic Spine Surgery: A Retrospective Cohort Study. Anesth Analg 2021; 133:984-990. [PMID: 33555691 DOI: 10.1213/ane.0000000000005395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adolescent idiopathic scoliosis (AIS) surgery is associated with significant postoperative pain. Remifentanil is a short-acting opioid that is often used as a component of total intravenous anesthesia. Remifentanil has been implicated in acute opioid tolerance and opioid-induced hyperalgesia, resulting in increased postoperative pain and opioid consumption. This retrospective study sought to investigate the relationship between the dose of intraoperative remifentanil and cumulative postoperative opioid consumption through 72 hours following surgery for pediatric AIS patients. METHODS We performed a retrospective chart review of adolescent patients undergoing posterior spine instrumentation under total intravenous general anesthesia at a single major pediatric center between January 2015 and October 2017. The relationship between intraoperative cumulative weight-adjusted remifentanil dose and logarithmic transformation of cumulative weight-adjusted opioid consumption through 72 hours following surgery was examined by regression analysis. A priori determined potential confounding variables were collected, including demographic data, perioperative analgesic agents (ie, ketamine, dexmedetomidine, and acetaminophen), surgical duration, vertebrae instrumented, and blood transfusion. Multivariable linear regression analysis was used to adjust for these possible confounding variables. RESULTS Eighty-nine patients met inclusion criteria, of which 78 had complete data for analysis. Univariable linear regression analysis revealed no association between remifentanil dose and opioid consumption through 72 hours following surgery (slope = 0.79 [95% confidence interval [CI], 0.61-0.98; R2 = 0.0039; P = .588]). After adjustment for possible confounding factors, no relationship between remifentanil dose (regression coefficient (coeff.) -0.08; 95% CI, -1.59 to 1.43; P = .912) and opioid consumption through 72 hours was found (slope =0.90 [95% CI, -0.65 to 2.46]; R2 = 0.1634). Similar results were obtained when the model was repeated for opioid consumption in postanesthesia care unit (PACU). CONCLUSIONS In this study examining adolescent patients undergoing surgery for idiopathic scoliosis, no association was found between the dose of intraoperative remifentanil and postoperative opioid consumption in the context of a propofol-based total intravenous anesthetic and multimodal analgesia. These results provide direction for future prospective controlled studies to further evaluate this relationship.
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12
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Cobo AA, Margallo FMS, Díaz CB, Blázquez VB, Bueno IG, Crisóstomo V. Anesthesia Protocols used to Create Ischemia Reperfusion Myocardial Infarcts in Swine. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE 2020; 59:478-487. [PMID: 32709259 DOI: 10.30802/aalas-jaalas-19-000137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The porcine ischemia-reperfusion model is one of the most commonly used for cardiology research and for testing interventions for myocardial regeneration. In creating ischemic reperfusion injury, the anesthetic protocol is important for assuring hemodynamic stability of the animal during the induction of the experimental lesion and may affect its postoperative survival. This paper reviews the many drugs and anesthetic protocols used in recent studies involving porcine models of ischemiareperfusion injury. The paper also summarizes the most important characteristics of some commonly used anesthetic drugs. Literature was selected for inclusion in this review if the authors described the anesthetic protocol used and also reported the mortality rate attributed to the creation of the model. This information is an important consideration because the anesthetic protocol can influence hemodynamic stability during the experimental induction of an acute myocardial infarction, thereby impacting the survival rate and affecting the number of animals needed for each study.
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Affiliation(s)
- Ana Abad Cobo
- Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain;,
| | | | - Claudia Báez Díaz
- Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain; CIBERCV, Madrid, Spain
| | | | | | - Verónica Crisóstomo
- Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain; CIBERCV, Madrid, Spain
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13
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Kim DH, Yun HJ, Park S, Leem JG, Karm MH, Choi SS. Comparison between total intravenous anesthesia and balanced anesthesia on postoperative opioid consumption in patients who underwent laparoscopic-assisted distal gastrectomy. Medicine (Baltimore) 2020; 99:e20224. [PMID: 32384519 PMCID: PMC7220423 DOI: 10.1097/md.0000000000020224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Remifentanil is the most frequently prescribed opioid for total intravenous anesthesia (TIVA) or balanced anesthesia (BA), due to its favorable pharmacological properties. However, several studies have reported opioid-induced hyperalgesia and/or acute tolerance after intraoperatively using remifentanil. In addition, it is imperative to control postoperative pain with lower doses of opioid anesthetic agents. Therefore, we compared the amount of opioid consumption between TIVA with propofol-remifentanil and BA with desflurane-remifentanil, to control postoperative pain in patients who underwent laparoscopic-assisted distal gastrectomy (LADG) with gastroduodenostomy.We retrospectively evaluated demographic variables (age, gender, height, weight, and smoking habits), the duration of general anesthesia (GA), and intraoperatively administered remifentanil consumption through the electronic medical records of patients who underwent LADG with gastroduodenostomy due to early stomach cancer. The primary outcome was postoperative opioid consumption during postoperative day (POD) 2. The secondary outcomes were the incidence of any rescue opioid analgesics administered, numeric rating scale, and various adverse effects during POD 2. We categorized the data in 2 patient groups to compare TIVA with propofol-remifentanil (TIVA group) to BA with desflurane-remifentanil (BA group) on the postoperative opioid analgesic consumption.We divided 114 patients into the TIVA (46 patients) and BA (68 patients) groups. Opioid consumption as a primary outcome was significantly higher in the BA group than in the TIVA group during POD 2 except in the post-anesthesia care unit. The cumulative opioid consumption was significantly higher in the BA than in the TIVA group. The incidence of rescue analgesic at POD 2 was higher in the BA than in the TIVA group. In the TIVA group, remifentanil consumption was higher, and the duration of GA was shorter than that in the BA group. No statistically significant differences were observed when comparing other variables.Our results indicated that the maintenance of GA with TIVA (propofol-remifentanil) reduces opioid consumption for postoperative pain control compared to BA (desflurane-remifentanil) in patients undergoing LADG with gastroduodenostomy.
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Affiliation(s)
- Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Hye Joo Yun
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea
| | - Sooin Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Jeong-Gil Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine
| | - Myong-Hwan Karm
- Department of Dental Anesthesiology, Seoul National University Dental Hospital, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine
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Martinez V, Lansaman T, Guichard L. Spastic Cerebral Palsy Pain Improvement With Propofol: A Case Report. A A Pract 2020; 14:e01217. [DOI: 10.1213/xaa.0000000000001217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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15
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The Effect of Intraoperative Dexmedetomidine Versus Morphine on Postoperative Morphine Requirements After Laparoscopic Bariatric Surgery. Obes Surg 2019; 29:3800-3808. [DOI: 10.1007/s11695-019-04074-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia-when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet 2019; 393:1558-1568. [PMID: 30983591 DOI: 10.1016/s0140-6736(19)30430-1] [Citation(s) in RCA: 261] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/21/2018] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
Abstract
Opioids are a mainstay of acute pain management but can have many adverse effects, contributing to problematic long-term use. Opioid tolerance (increased dose needed for analgesia) and opioid-induced hyperalgesia (paradoxical increase in pain with opioid administration) can contribute to both poorly controlled pain and dose escalation. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile. The mechanisms of opioid tolerance and hyperalgesia are complex, involving μ opioid receptor signalling pathways that offer opportunities for novel analgesic alternatives. The intracellular scaffold protein β-arrestin-2 is implicated in tolerance, hyperalgesia, and other opioid side-effects. Development of agonists biased against recruitment of β-arrestin-2 could provide analgesic efficacy with fewer side-effects. Alternative approaches include inhibition of peripheral μ opioid receptors and blockade of downstream signalling mechanisms, such as the non-receptor tyrosine kinase Src or N-methyl-D-aspartate receptors. Furthermore, it is prudent to use multimodal analgesic regimens to reduce reliance on opioids during the perioperative period. In the third paper in this Series we focus on clinical and mechanism-based understanding of tolerance and opioid-induced hyperalgesia, and discuss current and future strategies for pain management.
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Affiliation(s)
- Lesley A Colvin
- Division of Population Health and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Fiona Bull
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - Tim G Hales
- Institute for Academic Anaesthesia, Division of Systems Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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Richebé P, Brulotte V. Anaesthesia maintenance with propofol versus sevoflurane to reduce postoperative pain: Still too early for recommendations? Eur J Pain 2019; 23:847-848. [PMID: 30801920 DOI: 10.1002/ejp.1385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/19/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Philippe Richebé
- Department of Anaesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada.,Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, University of Montreal, Montreal, Quebec, Canada
| | - Véronique Brulotte
- Department of Anaesthesiology and Pain Medicine, University of Montreal, Montreal, Quebec, Canada.,Maisonneuve-Rosemont Hospital, CIUSSS de l'Est de l'Ile de Montreal, University of Montreal, Montreal, Quebec, Canada
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18
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Grandhi RK, Abd-Elsayed A. Propofol Infusion Therapy. INFUSION THERAPY 2019:27-38. [DOI: 10.1007/978-3-030-17478-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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19
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Wong SSC, Leung MYY, Cheung CW. The effect of total intravenous anaesthesia with propofol on postoperative pain after third molar surgery: A double-blind randomized controlled trial. Eur J Pain 2018; 23:884-893. [PMID: 30592344 DOI: 10.1002/ejp.1354] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Total intravenous anaesthesia (TIVA) with propofol may reduce pain after surgery compared with inhalational anaesthetic techniques. Whether propofol provides analgesic benefit may be influenced by the surgical procedure and anaesthetic/analgesic regime. Third molar surgery is a consistent and fairly standard surgical technique that provides a good model for postoperative pain. We investigated whether propofol TIVA or sevoflurane (SEVO) inhalational anaesthesia would produce better quality pain relief after third molar surgery. METHODS In this double-blind, randomized controlled trial, patients scheduled for bilateral third molar surgery received propofol TIVA or SEVO inhalational anaesthesia. Postoperative numerical rating pain scores, analgesic consumption, adverse effects and global pain satisfaction were assessed. RESULTS Data from 48 patients in each group were analysed. The area under curves for numerical rating scale pain scores were significantly lower in the propofol TIVA group at rest and during mouth opening between 1 and 72 hr after surgery (p = 0.013 at rest, p = 0.021 with mouth opening). There was no difference in postoperative analgesic consumption. Propofol TIVA was associated with less postoperative headache (p = 0.041 in the postoperative anaesthetic care unit, p = 0.036 in ward). There were no differences in other adverse effects including postoperative nausea and vomiting. Global pain satisfaction and level of postoperative discomfort at 24 hr after surgery were significantly better in the propofol TIVA group (p = 0.008 and p = 0.009, respectively). CONCLUSION Propofol TIVA was associated with reduced postoperative pain after bilateral third molar surgery, but did not reduce postoperative analgesic consumption. SIGNIFICANCE Choice of general anaesthetic technique can affect postoperative analgesia. The results of this study suggest that propofol TIVA improves postoperative pain and patient satisfaction after third molar surgery compared to inhalational anaesthesia.
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Affiliation(s)
- Stanley Sau Ching Wong
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Mike Yiu Yan Leung
- Department of Oral and Maxillofacial Surgery, The University of Hong Kong, Hong Kong, China
| | - Chi Wai Cheung
- Laboratory and Clinical Research Institute for Pain, Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
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Lee HC, Ryu HG, Kim HJ, Park Y, Yoon SB, Yang SM, Oh HW, Jung CW. Excessive remifentanil during total intravenous anesthesia is associated with increased risk of pain after robotic thyroid surgery. PLoS One 2018; 13:e0209078. [PMID: 30550587 PMCID: PMC6294434 DOI: 10.1371/journal.pone.0209078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/29/2018] [Indexed: 01/16/2023] Open
Abstract
The widespread use of remifentanil during total intravenous anesthesia (TIVA) has raised concerns about the risk of postoperative remifentanil-associated pain. Although a recent meta-analysis suggests that remifentanil-associated pain is unlikely to occur in patients with TIVA because of the protective effect of co-administered propofol, the evidence is not conclusive. We retrospectively assessed 635 patients who received robotic thyroid surgery under TIVA to evaluate the risk of remifentanil-associated pain. Postoperative pain was evaluated using 11-point numeric rating scale (NRS). Time dependent Cox proportional hazards regression analysis was used to determine the risk factors of treatment-requiring pain (NRS > 4) during the first 48 postoperative hours. Postoperative pain rapidly decreased, and treatment-requiring pain remained in 12.8% (81 out of 635) of patients at 48 hours postoperatively. After adjusting for the time-dependent analgesic consumption, intraoperative use of remifentanil > 0.2 mcg/kg/min was a positive predictor of postoperative pain with a hazard ratio of 1.296 (95% C.I., 1.014–1.656, P = 0.039) during 48 hours after surgery. In conclusion, excessive use of remifentanil during TIVA was associated with increased risk of pain after robotic thyroid surgery. Prospective trials are required to confirm these results and determine whether decreasing remifentanil consumption below the threshold can reduce postoperative pain.
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Affiliation(s)
- Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho-Geol Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Jun Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoonsang Park
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soo Bin Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seong Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Won Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Chul-Woo Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail:
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21
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Suhitharan T, Subramani S, Win MTM, Sulaiman WB, Johar NB, Chi OB. Effect of remifentanil on the recovery profile after head and neck surgeries: A prospective study. J Anaesthesiol Clin Pharmacol 2018; 34:307-313. [PMID: 30386011 PMCID: PMC6194847 DOI: 10.4103/joacp.joacp_337_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and Aims: Development of opioid tolerance in the perioperative period due to remifentanil remains controversial. We evaluated occurrence of opioid tolerance and other adverse effects due to remifentanil in patients undergoing head and neck surgery. Material and Methods: We recruited adult participants with ASA status I to III who received general anesthesia for approximately 2 h for elective head and neck procedures. Remifentanil infusion was used in one group and intermittent boluses of morphine or fentanyl were administered in another group. Postoperative pain was treated with intermittent boluses of morphine and fentanyl in post-anaesthesia care unit (PACU) to achieve a numerical rating scale score of 3. Opioid requirement was assessed as an indicator of opioid tolerance. Patients were also evaluated for time to discharge from PACU. Results: We studied 222 adults aged between 21 and 80 years. One hundred and eleven patients received a combination of remifentanil infusion and morphine boluses, and another 111 patients received only fentanyl and/or morphine boluses intraoperatively. Fifty-one patients in the remifentanil group and 25 in the fentanyl/morphine group required opioids in the PACU. Opioid requirement were significantly more (mean ± SD, 44.98 ± 59.7 Vs 20.23 ± 46.66 mcg.kg−1; P = 0.001) and required longer time to discharge from PACU in the remifentanil group compared to the fentanyl/morphine group (Mean ± SD, 88.6 ± 39.5 min Vs 73.1 ± 38.4 min; P < 0.001). No difference in the incidence of adverse effects in two groups was noted. Conclusion: At clinically relevant doses, intraoperative remifentanil infusion appears to increase opioid consumption in the immediate postoperative period. This can result in delayed discharge from PACU for patients undergoing elective head and neck procedures.
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Affiliation(s)
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa, USA
| | - Ma Thin Mar Win
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Ong Biauw Chi
- Department of Anesthesiology, Singapore General Hospital, Singapore
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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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23
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Wong SSC, Choi SW, Lee Y, Irwin MG, Cheung CW. The analgesic effects of intraoperative total intravenous anesthesia (TIVA) with propofol versus sevoflurane after colorectal surgery. Medicine (Baltimore) 2018; 97:e11615. [PMID: 30075537 PMCID: PMC6081200 DOI: 10.1097/md.0000000000011615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Clinical studies have shown that total intravenous anesthesia (TIVA) with propofol is associated with better postoperative pain control compared with inhalational anesthesia, while other studies have not shown any benefit. The analgesic effect of TIVA with propofol in colorectal surgery has not been studied. The aim of this study is to evaluate the postoperative analgesic effects of TIVA with propofol versus inhalational sevoflurane in colorectal surgery.This is a retrospective case-control study. Records of patients undergoing colorectal surgery from 2014 to 2016 (36 months) were retrieved. Ninety-five patients who received TIVA with propofol were matched against 95 patients who received inhalational sevoflurane. Acute postoperative numerical rating scale (NRS) pain scores, postoperative morphine consumption, patient satisfaction, and side effects were compared and analyzed for differences between TIVA with propofol and sevoflurane.There were no significant differences in NRS pain scores, incidence of side effects, and patient satisfaction between the 2 groups. Patients receiving TIVA with propofol had significantly reduced total morphine consumption (P < .001), and daily morphine consumption on postoperative days 1 (P = .031), 2 (P = .002), and 3 (P = .031) compared with those receiving sevoflurane.TIVA with propofol was not associated with improved postoperative analgesia, better patient satisfaction, or reduced side effects. It may reduce postoperative opioid consumption after colorectal surgery.
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Opioid-induced hyperalgesia in clinical anesthesia practice: what has remained from theoretical concepts and experimental studies? Curr Opin Anaesthesiol 2018; 30:458-465. [PMID: 28590258 DOI: 10.1097/aco.0000000000000485] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the phenomenon of opioid-induced hyperalgesia (OIH) and its implications for clinical anesthesia. The goal of this review is to give an update on perioperative prevention and treatment strategies, based on findings in preclinical and clinical research. RECENT FINDINGS Several systems have been suggested to be involved in the pathophysiology of OIH with a focus on the glutaminergic system. Very recently preclinical data revealed that peripheral μ-opioid receptors (MORs) are key players in the development of OIH and acute opioid tolerance (AOT). Peripheral MOR antagonists could, thus, become a new prevention/treatment option of OIH in the perioperative setting. Although the impact of OIH on postoperative pain seems to be moderate, recent evidence suggests that increased hyperalgesia following opioid treatment correlates with the risk of developing persistent pain after surgery. In clinical practice, distinction among OIH, AOT and acute opioid withdrawal remains difficult, especially because a specific quantitative sensory test to diagnose OIH has not been validated yet. SUMMARY Since the immediate postoperative period is not ideal to initiate long-term treatment for OIH, the best strategy is to prevent its occurrence. A multimodal approach, including choice of opioid, dose limitations and addition of nonopioid analgesics, is recommended.
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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: 64] [Impact Index Per Article: 10.7] [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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Sabourdin N, Peretout JB, Khalil E, Guye ML, Louvet N, Constant I. Influence of Depth of Hypnosis on Pupillary Reactivity to a Standardized Tetanic Stimulus in Patients Under Propofol-Remifentanil Target-Controlled Infusion: A Crossover Randomized Pilot Study. Anesth Analg 2018; 126:70-77. [PMID: 28107273 DOI: 10.1213/ane.0000000000001802] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pupillometry allows the measurement of pupillary diameter variations in response to nociceptive stimuli. This technique has been used to monitor the balance between analgesia and nociception. Under general anesthesia, the amplitude of pupillary dilation is related to the amount of administered opioids. The objective of this study was to determine whether at a constant infusion rate of opioids, the pupillary response was influenced by depth of hypnosis assessed by the bispectral index (BIS). METHODS Twelve patients (14-20 years) anesthetized for orthopedic surgery were included. Under propofol-remifentanil target-controlled infusion, remifentanil effect site target concentration was fixed at 1 ng/mL. Two measures of pupillary reflex dilation were performed on each patient in a randomized order: one at BIS 55 and one at BIS 25. These levels of BIS were obtained by adjusting propofol target concentration and maintained for 10 minutes before each measure. For each measure, we applied a standardized tetanic stimulation on the patient's forearm (60 mA, 100 Hz, 5 seconds). All measures were performed before the beginning of surgery. RESULTS Pupillary dilation was significantly greater at BIS 55 than at BIS 25: 32.1% ± 5.3% vs 10.4% ± 2.5% (mean difference estimate [95% confidence interval]: 21.8% [12.9-30.6], P < .001), without carryover effect (P = .30) nor period effect (P = .52). Hemodynamic parameters and BIS were not modified by the stimulation. CONCLUSIONS In patients receiving a constant infusion of remifentanil at a target concentration of 1 ng/mL, pupillary dilation after a standardized tetanic stimulation was influenced by depth of hypnosis assessed by the BIS.
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Affiliation(s)
- Nada Sabourdin
- From the Département d'anesthésiologie, Hôpital Armand Trousseau, Paris, France
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Peng K, Liu HY, Wu SR, Liu H, Zhang ZC, Ji FH. Does Propofol Anesthesia Lead to Less Postoperative Pain Compared With Inhalational Anesthesia?: A Systematic Review and Meta-analysis. Anesth Analg 2017; 123:846-58. [PMID: 27636574 DOI: 10.1213/ane.0000000000001504] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Many studies have compared propofol-based anesthesia with inhalational anesthesia. Results from several studies have shown improved postoperative analgesia after propofol anesthesia, but other studies showed contradictory results. There are no large prospective studies that compare postoperative pain after propofol versus inhalational anesthesia. This meta-analysis was designed to focus on this question. METHODS A systematic literature search for randomized controlled trials that compared propofol-based anesthesia with volatile agents-based anesthesia in adults undergoing surgery was conducted. Published data were pooled for the meta-analysis with Review Manager (ie, RevMan). The main outcomes included postoperative pain intensity, opioid consumption, need for rescue analgesics, and time to first analgesia. RESULTS Thirty-nine clinical trials with a combined subject population of 4520 patients came within the purview of this meta-analysis. The investigated volatile agents included isoflurane, sevoflurane, and desflurane. Compared with inhalational anesthetics, the propofol use was associated with a reduced postoperative pain intensity at rest at 30 minutes, 1 hour, and 12 hours (mean difference in pain scores, 30 minutes, -0.48 [visual analog scale, 0-10]; 99% confidence interval [CI], -1.07 to 0.12, P = 0.04) and reduced morphine-equivalent consumption 0 to 24 hours postoperatively (mean difference in morphine-equivalent consumption, -2.68 mg; 99% CI, -6.17 to 0.82; P = 0.05). Fewer patients required postoperative rescue analgesics during 0 to 24 hours after surgery under propofol anesthesia (risk ratio, 0.87; 99% CI, 0.74-1.03; P = 0.04). In addition, patients anesthetized with propofol required administration of postoperative analgesia later than those anesthetized with volatiles (mean difference in time to first analgesic administration, 6.12 minutes; 99% CI, 0.02-12.21; P = 0.01). Considering that Z statistic in RevMan 5.3 does not perform optimally in highly heterogeneous samples among groups or many combinations of groups with small sample sizes, a P value of <.01 was considered statistically significant. On the basis of this threshold, none of the aforementioned results are statistically significant. CONCLUSIONS The current results are affected by substantial heterogeneity, which makes it difficult to predict significant differences in postoperative pain control between propofol anesthesia and inhalational anesthesia. Further large, randomized controlled trials are needed to corroborate these results and to detect differences (if any) between propofol and inhalational anesthesia on postoperative pain.
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Affiliation(s)
- Ke Peng
- From the *Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China; †Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California; and ‡Department of Intensive Care Medicine, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Weinbroum AA. Postoperative hyperalgesia—A clinically applicable narrative review. Pharmacol Res 2017; 120:188-205. [DOI: 10.1016/j.phrs.2017.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 02/08/2023]
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Prolonged Perioperative Low-Dose Ketamine Does Not Improve Short and Long-term Outcomes After Pediatric Idiopathic Scoliosis Surgery. Spine (Phila Pa 1976) 2017; 42:E304-E312. [PMID: 27398889 DOI: 10.1097/brs.0000000000001772] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A randomized, double-blind, placebo-controlled study, with a six-month follow-up period. OBJECTIVES The aim of this study was to test the hypothesis that a 72-hour dose of subanesthetic ketamine in this surgical procedure reduces postoperative morphine use and to assess whether there are fewer adverse effects, if postoperative recovery is faster, if there is less peri-incisional hyperalgesia, or if there is lower incidence of persistent postsurgical pain. SUMMARY OF BACKGROUND DATA Tissue injury and high opioid requirements following posterior spinal fusion surgery produce central sensitization, which can in turn be associated with hyperalgesia and chronic pain. Clinical trials involving this type of procedure using subanesthetic ketamine doses have assessed pain and morphine requirements with contradictory results. The effects of prolonged subanesthetic ketamine doses on postoperative recovery, mechanical hyperalgesia, and the incidence of chronic pain are unknown. METHODS A total of 48 pediatric patients between 10 and 18 years diagnosed with idiopathic scoliosis were randomized to receive perioperative low-dose ketamine or placebo for 72 hours. They received general anesthesia, intraoperative remifentanil, and morphine postoperatively (patient-controlled analgesia). We measured morphine consumption, pain at rest and during movement (coughing), undesirable effects, and sedation during morphine treatment. The onset of oral intake, ambulation, and hospital stay were recorded. The extent of the peri-incisional hyperalgesia was measured at 72 hours and pain controls were conducted postsurgery. RESULTS Primary endpoint results (total cumulative morphine consumption while admitted) were obtained in 44 patients. Results were 2.72 (SD 1.13) in the placebo group and 3.13 (SD 1.13) in the study group (P = 0.2903), with no significant differences. Moreover, differences were not found between the experimental group and the placebo group in the secondary endpoints analyzed. CONCLUSION Our findings do not support the routine combining of prolonged subanesthetic ketamine doses with opioids in posterior fusion surgery in children with idiopathic scoliosis. LEVEL OF EVIDENCE 2.
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Gu W, Zhang W, Lei Y, Cui Y, Chu S, Gu X, Ma Z. Activation of spinal alpha-7 nicotinic acetylcholine receptor shortens the duration of remifentanil-induced postoperative hyperalgesia by upregulating KCC2 in the spinal dorsal horn in rats. Mol Pain 2017; 13:1744806917704769. [PMID: 28425312 PMCID: PMC6997724 DOI: 10.1177/1744806917704769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 02/28/2017] [Accepted: 03/15/2017] [Indexed: 12/15/2022] Open
Abstract
Background Accumulating evidence has shown that the signal from spinal brain-derived neurotrophic factor/tyrosine receptor kinase B-K+-Cl- cotransporter-2 plays a critical role in the process of pain hypersensitivity. The activation of alpha-7 nicotinic acetylcholine receptors could have an analgesic effect on remifentanil-induced postoperative hyperalgesia. Nevertheless, whether intrathecal administration of PNU-120596, an alpha-7 nicotinic acetylcholine receptors selective type II positive allosteric modulator, before surgery could affect the duration of remifentanil-induced postoperative hyperalgesia remains unknown, and the effects of alpha-7 nicotinic acetylcholine receptors activation on the brain-derived neurotrophic factor/tyrosine receptor kinase B-K+-Cl- cotransporter-2 signal in the spinal dorsal horn of rats with remifentanil-induced postoperative hyperalgesia is still enigmatic. Results We demonstrated that the brain-derived neurotrophic factor/tyrosine receptor kinase B-K+-Cl- cotransporter-2 signal played a critical role in the development of remifentanil-induced postoperative hyperalgesia. Intrathecal administration of PNU-120596 (8 µg/kg, 15 min before surgery) was associated with earlier signs of recovery from remifentanil-induced postoperative hyperalgesia. Simultaneously, remifentanil-induced postoperative hyperalgesia-induced K+-Cl- cotransporter-2 downregulation was partly reversed and coincided with a decreased expression of brain-derived neurotrophic factor/tyrosine receptor kinase B in the spinal dorsal horn, approximately correlating with the time course of the nociceptive behavior. Moreover, intrathecal administration of the K+-Cl- cotransporter-2 inhibitor VU0240551 significantly reduced the analgesic effect of PNU-120596 on remifentanil-induced postoperative hyperalgesia. Conclusions The activation of alpha-7 nicotinic acetylcholine receptors induced a shorter duration of remifentanil-induced postoperative hyperalgesia by restoring the brain-derived neurotrophic factor/tyrosine receptor kinase B-K+-Cl- cotransporter-2 signal in the spinal dorsal horn of rats, which provides new insight into treatment in clinical postoperative pain management.
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Affiliation(s)
- Wei Gu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Wei Zhang
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Yishan Lei
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yin Cui
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Shuaishuai Chu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Zhengliang Ma
- Department of Anesthesiology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
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Total Intravenous Anaesthesia (TIVA) for Ambulatory Surgery: An Update. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0179-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yu Z, Wu W, Wu X, Lei H, Gong C, Xu S. Protective effects of dexmedetomidine combined with flurbiprofen axetil on remifentanil-induced hyperalgesia: A randomized controlled trial. Exp Ther Med 2016; 12:2622-2628. [PMID: 27698764 PMCID: PMC5038600 DOI: 10.3892/etm.2016.3687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/23/2016] [Indexed: 12/17/2022] Open
Abstract
High dosages of intra-operative remifentanil are associated with opioid-induced hyperalgesia (OIH). The aim of the present study was to investigate the effect of combined dexmedetomidine and flurbiprofen axetil treatment on remifentanil-induced hyperalgesia. Patients with an American Society of Anesthesiologists physical status of I-II who were diagnosed with hysteromyoma and scheduled for laparoscopic assisted vaginal hysterectomy (LAVH) were randomly divided into three groups. Group hyperalgesia (Group H, n=29) received intra-operative remifentanil, Group hyperalgesia and dexmedetomidine (Group HD, n=28) received remifentanil and a continuous infusion of dexmedetomidine, and Group hyperalgesia, dexmedetomidine and flurbiprofen axetil (Group HDF, n=29) received remifentanil, flurbiprofen axetil and dexmedetomidine. Mechanical pain thresholds were measured during the preoperative visit and postoperatively at 1, 6 and 24-h time points. Visual analog scale (VAS) scores, time to analgesic requirement, total sufentanil consumption and side effects were assessed postoperatively. Mechanical pain threshold at the incision site was significantly lower in Group H compared with Groups HD and HDF (both P<0.05), and significantly higher in Group HDF than in Group HD (P<0.05). The area of secondary hyperalgesia at the incision site was greater in Group H than in the other two groups (both P<0.05), and significantly smaller in Group HDF compared with Group HD (P<0.05). VAS scores and total sufentanil consumption were significantly higher in Group H compared with the other two groups (both P<0.05), and were significantly lower in Group HDF compared with Group HD (P<0.05). Dexmedetomidine combined with flurbiprofen axetil exhibits synergetic effects in the prevention of remifentanil-induced hyperalgesia in patients undergoing LAVH.
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Affiliation(s)
- Zenggui Yu
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong 510280, P.R. China; Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian 350001, P.R. China
| | - Weilan Wu
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian 350001, P.R. China
| | - Xiaodan Wu
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian 350001, P.R. China
| | - Hongyi Lei
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
| | - Cansheng Gong
- Department of Anesthesiology, Fujian Provincial Hospital, Fuzhou, Fujian 350001, P.R. China
| | - Shiyuan Xu
- Department of Anesthesiology, Zhujiang Hospital of Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
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Remifentanil and worse patient-reported outcomes regarding postoperative pain management after thyroidectomy. J Clin Anesth 2016; 31:27-33. [DOI: 10.1016/j.jclinane.2015.12.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/06/2015] [Accepted: 12/21/2015] [Indexed: 11/22/2022]
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Hyperalgesia and increased sevoflurane minimum alveolar concentration induced by opioids in the rat: a randomised experimental study. Eur J Anaesthesiol 2016; 32:232-41. [PMID: 25485881 DOI: 10.1097/eja.0000000000000188] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perioperative opioids reduce inhalational anaesthetic requirements. The initial hypoalgesia may, however, be followed by a rebound hyperalgesia. OBJECTIVES To determine whether prior opioid administration influences inhalational anaesthetic requirements, which might be associated with opioid-induced hyperalgesia. DESIGN A prospective, randomised, experimental study. SETTING Experimental Surgery, La Paz University Hospital, Madrid, Spain. ANIMALS Seventy-nine adult male Wistar rats. INTERVENTIONS Sevoflurane minimum alveolar concentration (MAC) and mechanical nociceptive thresholds (MNTs) were assessed at baseline and 7 days later following opioid treatment with remifentanil 120 μg kg-1 h-1, buprenorphine 150 μg kg-1, methadone 8 mg kg-1 or morphine 10 mg kg-1 The duration of the effect of remifentanil on MAC and MNT was evaluated in addition to the preventive effect of ketamine 10 mg kg-1 on remifentanil-induced hyperalgesia. MAIN OUTCOME MEASURES The effect of different opioid treatments on MAC and MNT was evaluated using analysis of variance (ANOVA). RESULTS All studied opioids produced an immediate reduction in sevoflurane MAC, followed by an increase (16%) in baseline MAC 7 days later (P < 0.05), although the immediate MAC reduction produced by these opioids at that time was not different. Remifentanil produced a decrease in MNT (P < 0.05), which was associated with an increase in the MAC (P < 0.05) that persisted at 21 days. The effect of remifentanil on MNT and MAC was blocked by ketamine. CONCLUSION Opioid-induced hyperalgesia was associated with an increase in the MAC in normal rats who had not undergone surgery. Both effects lasted 21 days and were prevented by ketamine.
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Steyaert A, Forget P, Dubois V, Lavand'homme P, De Kock M. Does the perioperative analgesic/anesthetic regimen influence the prevalence of long-term chronic pain after mastectomy? J Clin Anesth 2016; 33:20-5. [PMID: 27555127 DOI: 10.1016/j.jclinane.2015.07.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 11/11/2014] [Accepted: 07/14/2015] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE To investigate if the anesthetic/analgesic regimen is associated with the risk of reporting long-term chronic postmastectomy pain (CPMP). DESIGN Cross-sectional survey SETTING Academic hospital PATIENTS A total of 267 women having undergone mastectomy with axillary lymph node dissection between 2003 and 2008 INTERVENTIONS: All patients were contacted between October and December 2012, with a questionnaire asking for persistent pain after surgery and its characteristics. MEASUREMENTS Besides demographical data, tumor characteristics, and adjuvant treatment, we recorded type and doses of intraoperative anesthetics/analgesics (sufentanil, ketamine, clonidine, nonsteroidal anti-inflammatory drugs, MgSO4, propofol, or halogenated agents). RESULTS Of the 128 patients returning analyzable questionnaires, 43.8% reported chronic pain (48.2% with neuropathic characteristics). Multivariate logistic/linear regression model showed 4 factors independently associated with persistent pain: recall of preoperative pain (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.09-1.48), chemotherapy (OR, 1.32; 95% CI, 1.13-1.55), need for strong opioids in postanesthesia care unit (OR, 1.30; 95% CI, 1.11-1.53), and halogenated agent anesthesia (OR, 0.81; 95% CI, 0.70-0.95). CONCLUSION In conclusion, our study confirms the high prevalence of CPMP, 4 to 9 years after surgery. Recall of preoperative pain, chemotherapy, and need for strong opioids in the postanesthesia care unit were all associated with the presence of chronic pain. Of the intraoperative analgesics/anesthetics studied, only use of halogenated agents was associated with a lower prevalence of CPMP.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium.
| | - Patrice Forget
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Virginie Dubois
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - Marc De Kock
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Institute of Neuroscience, Université catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
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Abstract
The use of opioids may seem to be a double-edged sword; they provide straight analgesic and antihyperalgesic effects initially, but subsequently are associated with the expression of acute opioid tolerance (AOT) and opioid-induced hyperalgesia (OIH) that have been reported in experimental studies and clinical observations. It has been suggested that opioids can induce an acute tolerance and hyperalgesia in dose- and/or time-dependent manners even when used within the clinically accepted doses. Recently, remifentanil has been used for pain management in clinical anesthesia and in the intensive care units because of its rapid onset and offset. We reviewed articles analyzing AOT and/or OIH by remifentanil and focused on the following issues: (1) evidence of remifentanil inducing AOT and/or OIH and (2) importance of AOT and/or OIH in considering the reduction of remifentanil dosage or adopting preventive modulations. Twenty-four experimental and clinical studies were identified using electronic searches of MEDLINE (PubMed, Ovid, Springer, and Elsevier). However, the development of AOT and OIH by remifentanil administration remains controversial. There is no sufficient evidence to support or refute the existence of OIH in humans.
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Minoshima R, Kosugi S, Nishimura D, Ihara N, Seki H, Yamada T, Watanabe K, Katori N, Hashiguchi S, Morisaki H. Intra- and postoperative low-dose ketamine for adolescent idiopathic scoliosis surgery: a randomized controlled trial. Acta Anaesthesiol Scand 2015; 59:1260-8. [PMID: 26079533 DOI: 10.1111/aas.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 05/09/2015] [Accepted: 05/17/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND In this randomized controlled trial, we examined whether intra- and postoperative infusion of low-dose ketamine decreased postoperative morphine requirement and morphine-related adverse effects as nausea and vomiting after scoliosis surgery. METHODS After IRB approval and informed consent, 36 patients, aged 10-19 years, undergoing posterior correction surgery for adolescent idiopathic scoliosis, were randomly allocated into two groups: intra- and postoperative ketamine infusion at a rate of 2 μg/kg/min until 48 h after surgery (ketamine group, n = 17) or infusion of an equal volume of saline (placebo group, n = 19). All patients were administered total intravenous anesthesia with propofol and remifentanil during surgery and intravenous morphine using a patient-controlled analgesia device after surgery. The primary outcome was cumulative morphine consumption in the initial 48 h after surgery. Pain scores (Numerical Rating Scale, NRS, 0-10), sedation scales, incidence of postoperative nausea and vomiting (PONV), and antiemetic consumption were recorded by nurses blinded to the study protocol for 48 h after surgery. RESULTS Patient characteristics did not differ between the two groups. Cumulative morphine consumption for 48 h after surgery was significantly lower in the ketamine group compared to the placebo group (0.89 ± 0.08 mg/kg vs. 1.16 ± 0.07 mg/kg, 95% confidence interval for difference between the means, 0.03-0.48 mg/kg, P = 0.019). NRS pain, sedation scales, and incidence of PONV did not differ between the two groups. Antiemetic consumption was significantly smaller in ketamine group. CONCLUSIONS Intra- and postoperative infusion of low-dose ketamine reduced cumulative morphine consumption and antiemetic requirement for 48 h after surgery.
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Affiliation(s)
- R. Minoshima
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - S. Kosugi
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - D. Nishimura
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - N. Ihara
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - H. Seki
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - T. Yamada
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - K. Watanabe
- Department of Orthopaedic Surgery; Keio University School of Medicine; Tokyo Japan
| | - N. Katori
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - S. Hashiguchi
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
| | - H. Morisaki
- Department of Anesthesiology; Keio University School of Medicine; Tokyo Japan
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General anaesthetic agents do not influence persistent pain after breast cancer surgery. Eur J Anaesthesiol 2015; 32:697-704. [DOI: 10.1097/eja.0000000000000215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tripi PA, Kuestner ME, Poe-Kochert CS, Rubin K, Son-Hing JP, Thompson GH, Tobias JD. Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents. J Pain Res 2015; 8:637-40. [PMID: 26445559 PMCID: PMC4590583 DOI: 10.2147/jpr.s88687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion. Methods We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong–Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours. Results The demographics of the two study groups were similar. There were no differences in the Wong–Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively). Conclusion In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.
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Affiliation(s)
- Paul A Tripi
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Matthew E Kuestner
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Connie S Poe-Kochert
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Kasia Rubin
- Division of Pediatric Anesthesiology, Case Western Reserve University, Cleveland, OH, USA
| | - Jochen P Son-Hing
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - George H Thompson
- Division of Pediatric Orthopaedic Surgery, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Nickel FT, Ott S, Möhringer S, Münster T, Rieß S, Filitz J, Koppert W, Maihöfner C. Effects of Different Anesthetics on Pain Processing in an Experimental Human Pain Model. Pain Pract 2015; 16:820-30. [PMID: 26179561 DOI: 10.1111/papr.12326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/14/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE After surgical procedures, anesthesia itself may affect pain perception. Particularly, there is increasing evidence that opioids not only have analgesic effects but also provoke pronociceptive changes, that is, opioid-induced hyperalgesia. We investigated the effect of different anesthetic regimens on pain processing in volunteers using a transdermal electrical pain model. In this model, stimulation of epidermal nerve fibers representing mainly peptidergic C-nociceptors leads to secondary hyperalgesia and habituation to the stimulus. METHODS Forty-eight healthy volunteers underwent conditioning noxious stimulation (CS) over 5 days. On day 2, the volunteers were randomized into 4 groups: control group (no anesthesia) and 3 groups receiving anesthesia before CS in anesthetic doses: propofol (P), propofol/remifentanil (PR), and propofol/remifentanil/S-ketamine (PRK). Quantitative sensory testing was performed on days 1 through 5 and on day 22. RESULTS In every group, CS was associated with short- and long-term habituation to the electrical stimulus. Repetitive CS resulted in unmodified short-term sensitization with stable areas of hyperalgesia. Although the PR group showed a trend toward increased areas of hyperalgesia on day 2, no significant differences were detectable between the groups. In contrast, anesthesia resulted in decreased intensity of the electrically evoked pain on day 2. Finally, the mechanical pain threshold before CS on day 5 was increased in all groups and remained elevated 3 weeks after the first CS, consistent with a long-term antinociceptive effect after CS. CONCLUSIONS The results suggest a short-term analgesic effect of general anesthesia. Furthermore, the conditioning stimulation over several days induced differential modulation of pro- and antinociceptive systems.
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Affiliation(s)
- Florian T Nickel
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neurology, General Fürth Hospital, Fürth, Germany
| | - Stephan Ott
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Susanne Möhringer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tino Münster
- Department of Anesthesiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Simon Rieß
- Department of Anesthesiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jörg Filitz
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
| | - Wolfgang Koppert
- Department of Anesthesiology, Hannover Medical School, Hannover, Germany
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Abstract
Propofol is an intravenous agent used commonly for the induction and maintenance of anesthesia, procedural, and critical care sedation in children. The mechanisms of action on the central nervous system involve interactions at various neurotransmitter receptors, especially the gamma-aminobutyric acid A receptor. Approved for use in the USA by the Food and Drug Administration in 1989, its use for induction of anesthesia in children less than 3 years of age still remains off-label. Despite its wide use in pediatric anesthesia, there is conflicting literature about its safety and serious adverse effects in particular subsets of children. Particularly as children are not "little adults", in this review, we emphasize the maturational aspects of propofol pharmacokinetics. Despite the myriad of propofol pharmacokinetic-pharmacodynamic studies and the ability to use allometrical scaling to smooth out differences due to size and age, there is no optimal model that can be used in target controlled infusion pumps for providing closed loop total intravenous anesthesia in children. As the commercial formulation of propofol is a nutrient-rich emulsion, the risk for bacterial contamination exists despite the Food and Drug Administration mandating addition of antimicrobial preservative, calling for manufacturers' directions to discard open vials after 6 h. While propofol has advantages over inhalation anesthesia such as less postoperative nausea and emergence delirium in children, pain on injection remains a problem even with newer formulations. Propofol is known to depress mitochondrial function by its action as an uncoupling agent in oxidative phosphorylation. This has implications for children with mitochondrial diseases and the occurrence of propofol-related infusion syndrome, a rare but seriously life-threatening complication of propofol. At the time of this review, there is no direct evidence in humans for propofol-induced neurotoxicity to the infant brain; however, current concerns of neuroapoptosis in developing brains induced by propofol persist and continue to be a focus of research.
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Affiliation(s)
- Vidya Chidambaran
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2001, Cincinnati, OH, 45229, USA,
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Jiang M, Zhang W, Cheng C, Ma Z, Gu X. Intrathecal injection of KN93 attenuates paradoxical remifentanil-induced postoperative hyperalgesia by inhibiting spinal CaMKII phosphorylation in rats. Pharmacol Biochem Behav 2015; 134:35-41. [PMID: 25937575 DOI: 10.1016/j.pbb.2015.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 04/08/2015] [Accepted: 04/17/2015] [Indexed: 10/23/2022]
Abstract
AIMS Remifentanil is a short-acting and highly selective mu opiate agonist that is used in many clinical surgical situations for intraoperative pain relief. Under certain conditions, remifentanil can produce "paradoxical" hyperalgesia. This study aims to investigate mechanisms of actions mediating this "paradoxical" effect. METHODS Sprague-Dawley rats were divided into 6 groups including control and treatment groups. The paw withdrawal mechanical threshold and the paw withdrawal thermal latency of the rats were tested. The changes of rat behaviors were measured at 24h before intrathecal injection and at 2h, 6h, 24h, and 48h after operation. According to the changes in behavioral indicators of pain, the specimens of all groups were collected at 2h, 6h, 24h, and 48h after the operation. The level of calcium/calmodulin-dependent protein kinase II (CaMKII) phosphorylation in the spinal dorsal horn was analyzed by Western blotting. RESULTS Intraoperative infusion of remifentanil induced postoperative hyperalgesia in the rats. Intrathecal KN93 injection increased nociceptive thresholds of paw withdrawal mechanical threshold and paw withdrawal thermal latency in a dose-dependent manner. Western blotting results showed that CaMKII phosphorylation in the spinal dorsal horn was increased significantly by remifentanil. Inhibition of CaMKII phosphorylation relieved the hyperalgesia pain state. CONCLUSIONS Intrathecal injection of KN93 attenuates postoperative hyperalgesia induced by intraoperative infusion of remifentanil in rats through inhibiting spinal CaMKII phosphorylation.
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Affiliation(s)
- Ming Jiang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, PR China
| | - Wei Zhang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, PR China
| | - Chongxue Cheng
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, PR China
| | - Zhengliang Ma
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, PR China.
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, PR China.
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Lee HJ, Yeomans DC. Opioid induced hyperalgesia in anesthetic settings. Korean J Anesthesiol 2014; 67:299-304. [PMID: 25473457 PMCID: PMC4252340 DOI: 10.4097/kjae.2014.67.5.299] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 10/04/2014] [Accepted: 10/10/2014] [Indexed: 11/10/2022] Open
Abstract
Pain is difficult to investigate and difficult to treat, in part, because of problems in quantification and assessment. The use of opioids, combined with classic anesthetics to maintain hemodynamic stability by controlling responses to intraoperative painful events has gained significant popularity in the anesthetic field. However, several side effects profiles concerning perioperative use of opioid have been published. Over the past two decades, many concerns have arisen with respect to opioid-induced hyperalgesia (OIH), which is the paradoxical effect wherein opioid usage may decrease pain thresholds and increase atypical pain unrelated to the original, preexisting pain. This brief review focuses on the evidence, mechanisms, and modulatory and pharmacologic management of OIH in order to elaborate on the clinical implication of OIH.
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Affiliation(s)
- Hyeon Jeong Lee
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA. ; Department of Anesthesia, Pusan National University School of Medicine, Busan, Korea
| | - David C Yeomans
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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POKKINEN SM, YLI-HANKALA A, KALLIOMÄKI ML. The effects of propofol vs. sevoflurane on post-operative pain and need of opioid. Acta Anaesthesiol Scand 2014; 58:980-5. [PMID: 25039403 DOI: 10.1111/aas.12366] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Post-operative pain continues to be a major problem. Some previous studies have suggested that patients anaesthetised with propofol have less pain after surgery than those anesthetised with volatiles. However, the results of previous studies are conflicting. We designed a large-scale trial to study, whether propofol or sevoflurane is more analgesic than the other. We measured opioid consumption in the acute post-operative phase after laparoscopic hysterectomy. METHODS In a randomised, prospective single-blind trial, we evaluated the consumption of oxycodone and pain intensity in 148 women for 20 h after laparoscopic hysterectomy under propofol or sevoflurane anaesthesia. The primary endpoint was the cumulative amount of oxycodone consumed. Secondary endpoints were pain scores [numeric rating scale (NRS)] at rest and with coughing, severity of nausea and state of sedation. RESULTS The consumption of oxycodone and the NRS pain scores did not differ between the groups. The oxycodone consumed during first 20 h after surgery was 42.5 (95% confidence interval 38.3-46.6) mg and 42.8 (37.3-48.4) mg in propofol- and sevoflurane-anaesthetised patients, respectively (P = 0.919). NRS scores for nausea were higher in the patients receiving sevoflurane during the first 60 min in the post-anaesthesia care unit, leading to higher consumption of rescue antiemetics. Sedation scores differed in favour of sevoflurane only at 4 h time point after anaesthesia. Patient characteristics did not differ. CONCLUSIONS In this study, comparing sevoflurane with propofol for maintenance of general anaesthesia, the choice of anaesthetic had no effect on the requirement of oxycodone or intensity of pain after surgery.
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Affiliation(s)
- S. M. POKKINEN
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
| | - A. YLI-HANKALA
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
- Medical School; University of Tampere; Tampere Finland
| | - M.-L. KALLIOMÄKI
- Department of Anaesthesia; Tampere University Hospital; Tampere Finland
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Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. Br J Anaesth 2014; 112:991-1004. [DOI: 10.1093/bja/aeu137] [Citation(s) in RCA: 354] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Kim SH, Stoicea N, Soghomonyan S, Bergese SD. Intraoperative use of remifentanil and opioid induced hyperalgesia/acute opioid tolerance: systematic review. Front Pharmacol 2014; 5:108. [PMID: 24847273 PMCID: PMC4021143 DOI: 10.3389/fphar.2014.00108] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/23/2014] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The use of opioids has been increasing in operating room and intensive care unit to provide perioperative analgesia as well as stable hemodynamics. However, many authors have suggested that the use of opioids is associated with the expression of acute opioid tolerance (AOT) and opioid-induced hyperalgesia (OIH) in experimental studies and clinical observations in dose and/or time dependent exposure even when used within the clinically accepted doses. Recently, remifentanil has been used for pain management during anesthesia as well as in the intensive care units because of its rapid onset and offset. OBJECTIVES Search of the available literature to assess remifentanil AOT and OIH based on available published data. METHODS We reviewed articles analyzing remifentanil AOT and OIH, and focused our literature search on evidence based information. Experimental and clinical studies were identified using electronic searches of Medline (PubMed, Ovid, Springer, and Elsevier, ClinicalKey). RESULTS Our results showed that the development of remifentanil AOT and OIH is a clinically significant phenomenon requiring further research. DISCUSSIONS AND CONCLUSIONS AOT - defined as an increase in the required opioid dose to maintain adequate analgesia, and OIH - defined as decreased pain threshold after chronic opioid treatment, should be suspected with any unexplained pain report unassociated with the disease progression. The clinical significance of these findings was evaluated taking into account multiple methodological issues including the dose and duration of opioids administration, the different infusion mode, the co-administrated anesthetic drug's effect, method assessing pain sensitivity, and the repetitive and potentially tissue damaging nature of the stimuli used to determine the threshold during opioid infusion. Future studies need to investigate the contribution of remifentanil induced hyperalgesia to chronic pain and the role of pharmacological modulation to reverse this process.
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Affiliation(s)
- Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Chosun University Gwangju, South Korea
| | - Nicoleta Stoicea
- Department of Anesthesiology, Ohio State University Wexner Medical Center Columbus, OH, USA
| | - Suren Soghomonyan
- Department of Anesthesiology, Ohio State University Wexner Medical Center Columbus, OH, USA
| | - Sergio D Bergese
- Department of Anesthesiology, Ohio State University Wexner Medical Center Columbus, OH, USA ; Department of Neurological Surgery, Ohio State University Wexner Medical Center Columbus, OH, USA
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Liu X, Liu Y, Zhang J, Zhang W, Sun YE, Gu X, Ma Z. Intrathecal administration of roscovitine prevents remifentanil-induced postoperative hyperalgesia and decreases the phosphorylation of N-methyl-D-aspartate receptor and metabotropic glutamate receptor 5 in spinal cord. Brain Res Bull 2014; 106:9-16. [PMID: 24769228 DOI: 10.1016/j.brainresbull.2014.04.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Revised: 04/10/2014] [Accepted: 04/11/2014] [Indexed: 11/27/2022]
Abstract
N-methyl-D-aspartate receptor (NMDAR) and metabotropic glutamate receptor 5 (mGluR5) play an important role in nociceptive processing and central sensitization. Our previous study showed that tyrosine phosphorylation of NMDAR subunit 2B (NR2B) at Tyr1472 in spinal dorsal horn contributes to the postoperative hyperalgesia induced by remifentanil. Cyclin-dependent kinase 5 (Cdk5) has been implicated in synaptic plasticity, learning, memory and pain signaling via regulating the phosphorylation of NMDAR and mGluR5. In the present study, a rat model of postoperative pain was used to investigate the role of Cdk5 in spinal dorsal horn in remifentanil-induced hyperalgesia and the intervention of pretreatment with Cdk5 inhibitor roscovitine. Intraoperative infusion of remifentanil (0.04 mg/kg, subcutaneous) significantly enhanced mechanical allodynia and thermal hyperalgesia induced by plantar incision during the postoperative period (each lasting between 2 h and 48 h), which were attenuated by pretreatment with roscovitine. Correlated with the pain behavior changes, Western blotting revealed that there was a significant increase in the expression of Cdk5 and its activator p35/p25, and further the kinase activity of Cdk5 in spinal dorsal horn after intraoperative infusion of remifentanil. The phosphorylation of NR2A at Ser1232, the phosphorylation of NR2B at Tyr1472 and the phosphorylation of mGluR5 at Ser1167 were also significantly up-regulated. Furthermore, these increases were attenuated by pretreatment with roscovitine. These results suggested that Cdk5 may contribute to remifentanil-induced postoperative hyperalgesia via regulating the phosphorylation of NMDAR and mGluR5 in spinal dorsal horn. These findings provide experimental evidence for the further application of Cdk5 inhibitor in preventing remifentanil-induced hyperalgesia.
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Affiliation(s)
- Xiaojie Liu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Yue Liu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Juan Zhang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Wei Zhang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Yu-E Sun
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
| | - Zhengliang Ma
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
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Rivosecchi RM, Rice MJ, Smithburger PL, Buckley MS, Coons JC, Kane-Gill SL. An evidence based systematic review of remifentanil associated opioid-induced hyperalgesia. Expert Opin Drug Saf 2014; 13:587-603. [DOI: 10.1517/14740338.2014.902931] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Zhang YL, Ou P, Lu XH, Chen YP, Xu JM, Dai RP. Effect of intraoperative high-dose remifentanil on postoperative pain: a prospective, double blind, randomized clinical trial. PLoS One 2014; 9:e91454. [PMID: 24667391 PMCID: PMC3965388 DOI: 10.1371/journal.pone.0091454] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 02/10/2014] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Remifentanil, an ultra-short-acting opioid, is widely used for pain control during surgery. However, regular dose (RD) remifentanil exacerbates postoperative pain in a dose-dependent manner. Recent studies suggest that high-dose (HD) remifentanil offers sustained analgesia in experimental studies. We thus hypothesized that intraoperative administration of high-dose remifentanil may attenuate postoperative pain. METHODS In this prospective, randomized, double blind, controlled clinical study, sixty patients undergoing thyroidectomy (18-60 years-of-age) received an intraoperative infusion of 0.2 (RD group) or 1.2 μg kg(-1) min(-1) (HD group) remifentanil during thyroidectomy. A visual analogue scale (VAS) was used to measure pain intensity. Mechanical pain threshold on the forearm was assessed using von Frey filaments before surgery (baseline), 2 h postoperatively and 18-24 h postoperatively. The primary outcome was to compare the difference of VAS score at different time points after operation and morphine consumption 24 h postoperatively between RD and HD groups. The second outcome was to compare the difference of mechanical pain thresholds in the forearm postoperatively between RD and the HD groups. RESULTS VAS scores were lower 30 min postoperatively in the HD group (1.29 ± 1.67, 95% CI 0.64-1.94) compared with the RD group (2.21 ± 1.67, 95% CI 1.57-2.84) (t = 3.427, p = 0.0043, RD group vs. HD group). Postoperative morphine consumption was much lower in the HD group compared with the RD group (1.27 ± 1.88 mg vs. 0.35 ± 1.25 mg, p = 0.033). In both groups, mechanical pain threshold was decreased 18-24 h postoperatively (2.93 ± 0.209 Ln(g) vs. 3.454 ± 2.072 Ln(g), p = 0.032 in RD group; 2.910 ± 0.196 Ln(g) vs. 3.621 ± 0.198 Ln(g), p = 0.006 in HD group, 18-24 h postoperatively vs baseline). CONCLUSIONS Intraoperative administration of high-dose remifentanil decreased VAS scores and morphine consumption postoperatively. Thus, modulation of intraoperative opiates may be a simple and effective method of postoperative pain management. TRIAL REGISTRATION This trial is registered in ClinicalTrials.gov, with the Name: Effect of Higher Doses of Remifentanil on Postoperative Pain in Patients Undergoing Thyroidectomy, and ID number: NCT01761149.
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Affiliation(s)
- Yan-Ling Zhang
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Peng Ou
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Xiang-Hang Lu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Yan-Ping Chen
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Jun-Mei Xu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
| | - Ru-Ping Dai
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan Province, China
- * E-mail:
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Xu J, Xu P, Li Z, Xiao L, Yang Z. The role of glycogen synthase kinase-3β in glioma cell apoptosis induced by remifentanil. Cell Mol Biol Lett 2013; 18:494-506. [PMID: 23990403 PMCID: PMC6275801 DOI: 10.2478/s11658-013-0102-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 08/21/2013] [Indexed: 02/04/2023] Open
Abstract
The aim of malignant glioma treatment is to inhibit tumor cell proliferation and induce tumor cell apoptosis. Remifentanil is a clinical anesthetic drug that can activate the N-methyl-D-aspartate (NMDA) receptor. NMDA receptor signaling activates glycogen synthase kinase-3β (GSK-3β). Discovered some 32 years ago, GSK-3β was only recently considered as a therapeutic target in cancer treatment. The purpose of this study was to assess whether remifentanil can induce the apoptosis of C6 cells through GSK-3β activation. 3-(4,5-Dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) was used to detect cell viability. Hoechst 33342 staining and flow cytometry were used to detect cell apoptosis. The effect of GSK-3β activation was detected using a GSK-3β activation assay kit and 4-benzyl-2-methyl-1,2,4-thiadiazolidine-3,5-dione (TDZD-8), a potent and selective small molecule inhibitor of GSK-3β. The MTT assay indicated that remifentanil induced C6 cell death in a concentration- and time-dependent manner. Hoechst 33342 staining and flow cytometry showed that remifentanil significantly induced C6 cell apoptosis. The measurement of GSK-3β activation showed that remifentanil increased the cellular level of GSK-3β. All of these toxic effects can be attenuated by treatment with TDZD-8. These results suggest that remifentanil is able to induce C6 cell apoptosis through GSK-3β activation, which provides a basis for its potential use in the treatment of malignant gliomas.
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Affiliation(s)
- Jing Xu
- College of Medicine, Nankai University, Tianjin, 300071 China
| | - Pengjuan Xu
- College of Medicine, Nankai University, Tianjin, 300071 China
| | - Zhigui Li
- College of Medicine, Nankai University, Tianjin, 300071 China
| | - Lu Xiao
- College of Medicine, Nankai University, Tianjin, 300071 China
| | - Zhuo Yang
- College of Medicine, Nankai University, Tianjin, 300071 China
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