Sufentanil infusion before extubation suppresses coughing on emergence without delaying extubation time and reduces postoperative analgesic requirement without increasing nausea and vomiting after desflurane anesthesia

Opioid-free anesthesia: A systematic review and meta-analysis

STUDY OBJECTIVE

To evaluate all available evidence thus far on opioid based versus opioid-free anesthesia and its effect on acute and chronic postoperative pain.

DESIGN

Systematic review and meta-analysis of randomized clinical trials.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients undergoing general anesthesia.

INTERVENTIONS

After consulting MEDLINE, EMBASE and Cochrane database, studies which compared opioid free anesthesia (OFA) with opioid based anesthesia (OBA) were included (last search April 15th 2022).

MEASUREMENTS

Primary outcomes were acute and chronic pain scores in NRS or VAS. Secondary outcomes were quality of recovery and postoperative opioid consumption. Risk of bias was assessed using the RoB2 tool and a random effects model for the meta-analysis was conducted.

MAIN RESULTS

We identified 1245 citations, of which 38 studies met our inclusion criteria. There is moderate quality evidence showing no clinically relevant difference of Numeric Rating Scale (NRS) scores or opioid consumption in the postoperative period (pooled mean difference of 0.39 points with a CI of 0.19-0.59 and 4.02 MME with a CI of 1.73-6.30). We found only one small-sized study reporting no effect of opioid-free anesthesia on chronic pain. The quality of recovery was superior in patients with opioid-free anesthesia (mean difference of 8.26 points), however, this pooled analysis was comprised of only two studies. Postoperative nausea and vomiting (PONV) occurred less in opioid-free anesthesia, but bradycardia was more frequent.

CONCLUSIONS

We concluded that we cannot recommend one strategy over the other. Future studies could focus on quality of recovery as outcome measure and adequately powered studies on the effects of opioid-free anesthesia on chronic pain are eagerly awaited.

Postoperative airway morbidities in pediatric patients

Pediatric airway management is a huge challenge for anaesthetists, and airway-related complications should be actively addressed and focused on.

Total opioid-free general anaesthesia can improve postoperative outcomes after surgery, without evidence of adverse effects on patient safety and pain management: A systematic review and meta-analysis

BACKGROUND

Opioid-based treatment is used to manage stress responses during surgery and postoperative pain. However, opioids have both acute and long-term side effects, calling for opioid-free anaesthetic strategies. This meta-analysis compares adverse events, postoperative recovery, discharge time from post-anaesthesia care unit, and postoperative pain, nausea, vomiting, and opioid consumption between strict opioid-free and opioid-based general anaesthesia.

METHODS

We conducted a systematic review and meta-analysis. We searched PubMed, Embase, Cinahl, Cochrane Library, selected reference lists, and Google Scholar. We included randomised controlled trials (RCTs) published between January 2000 and February 2021 with at least one opioid-free study arm, i.e. no opioids administered preoperatively, during anaesthesia induction, before skin closure, or before emergence from anaesthesia.

RESULTS

The study comprised 1934 patients from 26 RCTs. Common interventions included laparoscopic gynaecological surgery, upper gastrointestinal surgery, and breast surgery. There is firm evidence that opioid-free anaesthesia significantly reduced adverse postoperative events (OR 0.32, 95% CI 0.22 to 0.46, I²  = 56%, p < 0.00001), mainly driven by decreased nausea (OR 0.27, (0.17 to 0.42), p < 0.00001) and vomiting (OR 0.22 (0.11 to 0.41), p < 0.00001). Postoperative opioid consumption was significantly lower in the opioid-free group (-6.00 mg (-8.52 to -3.48), p < 0.00001). There was no significant difference in length of post-anaesthesia care unit stay and overall postoperative pain between groups.

CONCLUSIONS

Opioid-free anaesthesia can improve postoperative outcomes in several surgical settings without evidence of adverse effects on patient safety and pain management. There is a need for more evidence-based non-opioid anaesthetic protocols for different types of surgery as well as postoperative phases.

Effects of Additional Intraoperative Administration of Sufentanil on Postoperative Pain, Stress and Inflammatory Responses in Patients Undergoing Laparoscopic Myomectomy: A Double-Blind, Randomized, Placebo-Controlled Trial

Purpose

Although pain after laparoscopic surgery is assumed to be minor, many women still suffer from unexpected postoperative pain. Thus, we aimed to assess whether additional intraoperative administration of sufentanil could help to improve postoperative pain and related agitation, stress, and inflammation response in patients undergoing laparoscopic myomectomy.

Patients and Methods

Forty female patients with uterine myoma scheduled for laparoscopic myomectomy under general anesthesia were randomized to receive sufentanil (group T, n=20) or normal saline (group C, n=20) 1h before the end of the surgery. The postoperative pain, agitation, stress, inflammation, and adverse effects were measured.

Results

As the primary outcome, the visual analog scale (VAS) pain score was significantly reduced in group T as compared with group C at each measured time point in a post-anesthesia care unit (PACU), VAS 5 min (31.5 ± 2.7 vs 40.6 ± 5.6) (P<0.001), VAS 30 min (36.5 ± 4.5 vs 46.0 ± 2.9) (P<0.001), VAS 1h (37.8 ± 4.0 vs 48.6 ± 5.5) (P<0.001). The secondary outcomes, including the sedation agitation scale (SAS) scores, plasma concentrations of epinephrine and norepinephrine, and the levels of plasma interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-α) in group T were remarkably lower than those in group C (P < 0.001). The cough cases in group T also showed a significant reduction in comparison with group C (P < 0.05). In addition, the anesthetic recovery time, including the spontaneous breathing recovery time and extubation time, were not significantly different between the two groups, as were the cases of respiratory depression and postoperative delirium (P > 0.05).

Conclusion

For patients undergoing laparoscopic myomectomy, administration of sufentanil 1 h before the end of surgery shows excellent analgesic and sedative effects, alleviated postoperative stress and inflammatory responses, reduced incidence of cough, without prolonging anesthetic recovery time and increasing adverse reactions.

Low- versus high-dose intraoperative opioids: A systematic review with meta-analyses and trial sequential analyses

BACKGROUND

Opioid-induced hyperalgesia is a state of nociceptive sensitisation secondary to opioid administration. The objective of this meta-analysis was to test the hypothesis that high-dose intraoperative opioids contribute to increased post-operative pain and hyperalgesia when compared with a low-dose regimen in patients under general anaesthesia.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and rated the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation system. Only trials investigating pain outcomes and comparing two different dosages of the same intraoperative opioid in patients under general anaesthesia were included. The primary outcome was pain score (analogue scale, 0-10) at 24 post-operative hours. Secondary outcomes included pain score and cumulative intravenous morphine equivalents (mg) consumed at 2 post-operative hours, together with mechanical pain threshold (g·mm^-2 ).

RESULTS

Twenty-seven randomised controlled trials, including 1630 patients, were identified. Pain score at rest at 24 post-operative hours was increased in the high-dose group (mean difference [95% CI]: -0.2 [-0.4, -0.1]; trial sequential analysis-adjusted CI: -0.4, -0.02; low certainty of evidence). Similarly, at 2 post-operative hours, both pain score (mean difference [95% CI]: -0.4 [-0.6, -0.2]; low certainty of evidence) and cumulative intravenous morphine equivalents consumed (mean difference [95% CI]: -1.6 mg [-2.6, -0.7]; low certainty of evidence) were significantly higher in the high-dose group. Finally, the threshold for mechanical pain was significantly lower in the high-dose group (mean difference to pressure [95% CI]: 3.8 g·mm^-2 [1.8, 5.8]; low certainty of evidence).

CONCLUSIONS

There is low certainty of evidence that high-dose intraoperative opioid administration increases pain scores in the post-operative period, when compared with a low-dose regimen.

A small dose of remifentanil pretreatment suppresses sufentanil-induced cough during general anesthesia induction: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Intravenous use of sufentanil can elicit cough. This study aimed to evaluate the inhibitory effect of pre-injection of a mall dose of remifentanil on sufentanil-induced cough during the induction of general anesthesia.

METHODS

This prospective, randomized, controlled trial was conducted from January 10, 2019 to March 01, 2019. A total of 100 patients undergoing elective surgery under general anesthesia were enrolled, and at last 84 patients were included and randomly allocated into two equal size groups (n = 42): Patients in the Remifentanil group (R group) received an intravenous infusion of remifentanil 0.3 μg/kg (diluted to 2 ml) 1 min before sufentanil injection; patients in the Control group (C group) received 2 ml of normal saline (NS) at the same time point. Injections of patients in both groups were completed within 5 s. Then, sufentanil 0.5 μg/kg was injected within 5 s and the number of coughs that occurred within 1 min after sufentanil injection were recorded. One minute after sufentanil injection, etomidate 0.3 mg/kg and cisatracurium 0.15 mg/kg were given for general anesthesia induction irrespective of the presence or absence of cough. The mean arterial pressure (MAP) and heart rate (HR) at time points just before remifentanil pretreatment administration (T0), 3 min after administration (T1), 1 min after intubation (T2), and 3 min after intubation (T3) were recorded.

RESULTS

The incidence of cough in patients in the R group and C group was 4.8 and 31%, respectively. Compared with group C, the incidence and severity of cough in group R was significantly lower (P < 0.01). No significant differences were observed in MAP and HR at the time of general anesthesia induction between the two groups (P > 0.05).

CONCLUSION

Pretreatment with a small dose of remifentanil effectively and safely reduced the incidence and severity of cough induced by sufentanil during anesthesia induction and can be used as an alternative treatment to inhibit coughing caused by sufentanil.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR1900020587, registered date: January 9, 2019), http://www.chictr.org.cn.

Comparison of recovery in pediatric patients: a retrospective study

OBJECTIVE

The recovery after general anesthesia is influenced by the choice of inhalational agent. Stimulations might make patient's agitate. However, the recovery using no touch technique might be safer. In this study, we compared the recovery time, awakening end-tidal concentration, and respiratory complications among inhalational anesthetics in pediatric patients using no touch technique, retrospectively.

MATERIAL AND METHODS

The subjects were pediatric patients aged 3 months to 11 years under general anesthesia using sevoflurane, isoflurane, or desflurane. Background, awakening end-tidal concentration, respiratory complications, the time of eye open, body movement, and extubation were recorded.

RESULTS

A total of 170 patients were included in the study. There were no respiratory complications during emergence. Awakening end-tidal concentration in desflurane was 0.98%, sevoflurane (0.39%), and isoflurane (0.25%). In patients received desflurane, the time of body movement, eye open, and extubation were significantly shorter than patients who received other anesthetics (p < 0.05).

CONCLUSIONS

The recovery from desflurane was significantly shorter among three inhalational anesthetics with no touch technique. In addition, no airway-related complication occurred.

CLINICAL RELEVANCE

The recovery from desflurane might be useful to predict emergence by end-tidal inhalational concentration.

Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations

Background and objectives

Laparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.

Strategy and selection criteria

Randomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.

Results

Of the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.

Conclusions

The baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.

Sex-related differences in effect-site concentration of remifentanil for preventing anesthetic emergence cough in elderly patients

Purpose

Cough on anesthetic emergence should be prevented considering its dangerous complications. Target-controlled infusion (TCI) of remifentanil can reduce emergence cough effectively, and sex-related differences in effect-site concentration (Ce) of remifentanil have been evaluated in young patients. In this study, we determined the Ce of remifentanil for preventing emergence cough following extubation in male and female elderly patients and evaluated the sex-related difference.

Patients and methods

Twenty-three male and 22 female elderly patients aged between 60 and 75 years were enrolled. Anesthesia was maintained with sevoflurane and remifentanil TCI. The Ce of remifentanil for preventing emergence cough was determined for each sex using isotonic regression method with a bootstrapping approach, following Dixon’s up-and-down method.

Results

The Ce of remifentanil for preventing emergence cough in 50% (EC₅₀) and 95% (EC₉₅) of the population was significantly lower in females than in males. Isotonic regression revealed the EC₅₀ (83% confidence interval [CI]) of remifentanil was 1.67 (1.55–1.83) ng/mL in females and 2.60 (2.29–2.91) ng/mL in males. The EC₉₅ (95% CI) of remifentanil was 2.30 (2.02–2.62) ng/mL in females and 3.41 (3.27–3.58) ng/mL in males. Dixon’s up-and-down method indicated that the mean EC₅₀ in females was lower than in males (1.56±0.26 ng/mL vs 2.56±0.37 ng/mL, P<0.001).

Conclusion

The remifentanil requirement for preventing emergence cough was lower in female than in male elderly patients, indicative of sex-related differences in Ce of remifentanil. Sex should be considered when using remifentanil TCI for preventing emergence cough in elderly patients.

Comparison of recovery effect for sufentanil and remifentanil anesthesia with TCI in laparoscopic radical resection during colorectal cancer

The aim of the present study was to compare the recovery of sufentanil and remifentanil anesthesia by target-controlled infusion (TCI) in elderly patients with laparoscopic-assisted radical resection of colorectal cancer. The effect of anesthesia on patient stress response and cellular immune function was also observed. Elderly patients (n=192) who underwent laparoscopic radical resection of colorectal cancer between July 2014 and October 2015 were randomly divided into the sufentanil and remifentanil groups (n=96 per group). The two groups used sufentanil- and remifentanil-based anesthesia by TCI. The wake-up time, extubation time, orientation recovery time, vital signs, stress response, distribution of T-cell subsets and incidence of adverse reactions were recorded and compared. The wake-up and extubation times of the remifentanil group were significantly shorter than those of the sufentanil group. The difference of orientation recovery time was not statistically significant. The differences in heart rate, mean arterial pressure, and arterial oxygen saturation following anesthesia and during surgery and those prior to anesthesia of the sufentanil group were not statistically significant. However, those of the remifentanil group significantly improved following anesthesia. The concentrations of glucose, cortisol (COR), and interleukin-6 and C-reactive protein were stable in the sufentanil group, whereas the indices in the remifentanil group had a tendency of increasing during the anesthesia and surgery, and had a longer postoperative recovery time. The decreasing degree of T-cell subsets in the sufentanil group was significantly lower than that in the remifentanil group, and had a short recovery of cellular immunity following surgery. The adverse reactions rate during anesthesia of the remifentanil group was significantly higher than that of the sufentanil group. In conclusion, sufentanil- and remifentanil-based anesthesia with TCI has certain advantages, including improved recovery effect, less stress response, less inhibition of cellular immunity and fewer adverse reactions. It has the potential to become the first choice of anesthetic in the clinic for elderly patients who undergo laparoscopic radical resection for colorectal cancer.

Comparison of emergence after deep extubation using desflurane or desflurane with remifentanil in patients undergoing general anesthesia: a randomized trial

STUDY OBJECTIVE

To compare recovery times and respiratory complications during emergence after deep extubation using either desflurane alone or a lower concentration of desflurane with remifentanil.

DESIGN

Prospective randomized double-blind clinical trial.

SETTING

Intraoperative.

PATIENTS

A total of 62 patients between the ages of 20 and 60 years with American Society of Anesthesiologists class I or II and who underwent low- to intermediate-risk surgery of 2- to 4-hour duration were enrolled.

INTERVENTIONS

Randomly assigned either 1.5 minimum alveolar concentration desflurane (group D; n = 31) or 1.0 minimum alveolar concentration of desflurane and 1.0 ng/mL effect-site concentration of remifentanil (group DR; n = 31).

MEASUREMENTS

Recovery times, from the time of extubation to the time when the patients could breathe without assistance, were awake enough to maintain the airway independently, and exited the recovery room, as well as respiratory complications were compared between the groups.

MAIN RESULTS

Recovery times were significantly reduced in the group DR (P < .001). The incidence of respiratory complications was also lower in group DR than in group D (48% vs 3.8%; P < .001).

CONCLUSIONS

The combined use of remifentanil while lowering the concentration of desflurane improves recovery profiles during emergence after deep extubation.

Magnesium sulfate inhibits sufentanil-induced cough during anesthetic induction

Sufentanil-induced cough is a common phenomenon during the induction of anesthesia. This double-blind, randomized, and placebo-controlled study was designed to investigate the effects of prophylactic magnesium sulfate (MgSO4) on the incidence and severity of sufentanil-induced cough. A total of 165 patients who were scheduled for elective surgery under general anesthesia were allocated into three groups (I, II, and III; n = 55 each) that were injected with either 50 ml of normal saline, 30 or 50 mg/kg of MgSO4 (diluted with normal saline into 50 ml). One minute following the injection, all patients were injected with 1.0 μg/kg of sufentanil within 5 s. The incidence and severity of cough were recorded 30 s after the sufentanil injection. The hemodynamic parameters and plasma magnesium concentration of the patients were also noted. Three patients dropped out the study due to an obvious burning sensation during the injection of 50 mg/kg of MgSO4. Although the injection of 50 mg/kg of MgSO4 increased the plasma magnesium level, the increase remained within the therapeutic range (2-4 mmol/L). The incidence of cough was much higher in group I than in groups II and III (47.1% vs. 16.4% and 7.6%, respectively, P < 0.05). Compared with group I, group III had the lowest incidence of mild cough and both groups II and III had lower incidence of moderate and severe cough (P < 0.05). There were no differences in the hemodynamic data at three timepoints among the three groups. In conclusion, sufentanil-induced cough may be suppressed effectively and safely by prophylactic use of 30 mg/kg of MgSO4 during anesthetic induction.

Replacing a double-lumen tube with a single-lumen tube or a laryngeal mask airway device to reduce coughing at emergence after thoracic surgery: a randomized controlled single-blind trial

BACKGROUND

Coughing episodes occur frequently at extubation after thoracic surgery, and this may be due in part to the double-lumen tube (DLT). In this study, the DLT was replaced with either a single-lumen endotracheal tube (ETT) or a laryngeal mask airway (LMA) device or left in place, and the incidence of coughing at emergence was compared between the three groups.

METHODS

Fifty-eight adults scheduled for thoracic surgery with a DLT were included. Exclusion criteria were an anticipated difficult airway, obesity, and contraindication to the use of an LMA ProSeal™ (LMA-P). After surgery but before emergence, patients were randomized to having the DLT (1) removed and replaced by an LMA-P (LMA-P Group), (2) removed and replaced by an ETT (ETT Group), or (3) left in place (DLT Group). The primary outcome was the number of coughing episodes at extubation.

RESULTS

Among 184 patients screened, 124 did not meet inclusion criteria, and two patients, both in the ETT Group, were excluded after randomization, leaving 20, 18, and 20 patients in the LMA-P, ETT, and DLT Groups, respectively. There were fewer coughing episodes (median [quartiles]) in the LMA-P Group than in the DLT Group (0[0-1] vs 2[1-3], respectively; P = 0.01). In the DLT Group, 90% of patients coughed at least once. This incidence was not significantly different in the ETT Group (83%; P = 0.222) but was significantly reduced in the LMA-P Group (35%; P < 0.001). No patient had oxygen desaturation during airway exchange or at extubation. The incidence and severity of hoarseness and sore throat were similar in all groups.

CONCLUSION

Coughing at extubation after thoracic surgery can be reduced if the DLT is replaced by an LMA-P before emergence. The number of patients in this trial was too small to evaluate the risks associated with exchanging the airway device. This trial was registered at ClinicalTrials.gov: NCT00925613.

Median effective effect-site concentration of sufentanil for wake-up test in adolescents undergoing surgery: a randomized trial

BACKGROUND

To determine the median effective concentration of sufentanil as an analgesic during wake-up tests after sevoflurane anesthesia during surgery for adolescent idiopathic scoliosis (AIS).

METHODS

This is a randomised controlled trial. Sixty patients aged 13-18 years scheduled for AIS surgery were randomized into six groups of 10 patients each to receive target effect-site concentrations of sufentanil of 0.19, 0.1809, 0.1723, 0.1641, 0.1563, and 0.1489 ng/ml (target concentration ratio, 1.05). Wake-up time was recorded. Median EC50 and 95% confidence interval (CI) for sufentanil target-controlled infusion (TCI) were determined using Kärber's method. The primary outcome was median EC50 for sufentanil TCI as an analgesic during the wake-up test after sevoflurane anesthesia during surgery for AIS.

RESULTS

The EC50 and 95% CI of sufentanil TCI were 0.1682 ng/ml and 0.1641 ~ 0.1724 ng/ml, respectively.

CONCLUSIONS

The EC50 of sufentanil TCI was 0.1682 ng/ml (95% CI: 0.1641 ~ 0.1724 ng/ml) during sevoflurane anesthesia in adolescents undergoing surgery for idiopathic scoliosis with intraoperative wake-up tests.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: ChiCTR-TTRCC-12002696.

The effect of sufentanil administration on remifentanil-based anaesthesia during laparoscopic gynaecological surgery: a double-blind randomized controlled trial

This study assessed the effect of sufentanil administered before conclusion of remifentanil-based anaesthesia on postoperative hyperalgesia and haemodynamic stability in patients undergoing laparoscopic gynaecological surgery. The patients were randomly allocated to a sufentanil administration group (S group) or a normal saline administration group (C group). Anaesthesia was induced and maintained with controlled administration of remifentanil at 10 ng · mL(-1) and propofol under bispectral index guidance. Once the surgical specimen was procured, sufentanil or normal saline was administered at 0.15 ng · mL(-1) and maintained until extubation. The haemodynamic status during anaesthetic emergence was evaluated. The pain and postoperative nausea and vomiting (PONV) were assessed for 72 h following postanaesthetic care unit (PACU) discharge. The S group had significantly lower mean systemic arterial blood pressure and heart rate changes between the start of drug administration and extubation. Postoperative pain was significantly lower in the S group until 24 h following PACU discharge. There were no significant differences in PONV incidence and severity 72 h after PACU discharge between the two groups. Sufentanil administration before concluding remifentanil-based anaesthesia improved postoperative hyperalgesia and achieved haemodynamic stability at extubation without delaying recovery or increasing PONV during laparoscopic gynaecological surgery. Clinical trial registration is found at KCT0000785.