Comparison of Different Analgesic Techniques for Pain Relief During Extracorporeal Shock Wave Lithotripsy: a Double-blind, Randomized Clinical Trial

Effects of dexamethasone on the EC50 of remifentanil combined with dexmedetomidine achieving analgesia during pancreatic extracorporeal shockwave lithotripsy: a prospective, randomized and controlled study

BACKGROUND

In addition to their classic genomic effects, glucocorticoids also manifest rapid non genomic effects. We speculate that dexamethasone has the potential prompt onset of analgesic effects. The objective of this study is to investigate the influence of a single preoperative dose of dexamethasone on the half maximal effective concentration (EC50) of remifentanil when combined with dexmedetomidine for pain relief during pancreatic extracorporeal shockwave lithotripsy (P-ESWL).

METHODS

A total of 60 patients undergoing P-ESWL were enrolled and randomized at 1:1 ratio into the dexamethasone (DXM) group and the placebo group. Before anesthesia induction, patients in DXM group received an intravenous injection of 8 mg dexamethasone, while subjects in placebo group received an equal dose of physiological saline. Monitored anesthesia care (MAC) was performed based on remifentanil in combination with dexmedetomidine. Remifentanil was administered by TCI with an initial target concentration of 2.5 µg/mL for both groups. A positive response was defined as that VAS score > 3 by the patient at any time during the procedure. Subsequent target concentrations were adjusted by Dixon up-down sequential method, where dose modifications were performed by 0.3 ng/mL intervals, based on the response of the previous patient. The EC50 of remifentanil for pain relief during P-ESWL treatment was calculated using Dixon's up-and-down method. Hemodynamic variables, oxygen saturation and adverse events were also recorded.

RESULTS

Dixon up-and-down method revealed that the EC50 of remifentanil was significantly higher in placebo group (2.65 ± 0.28 ng/mL) than in DXM group (2.02 ± 0.23 ng/ml) (P < 0.001). Hemodynamic parameter exhibited a significant decrease in mean arterial pressure (MAP) and heart rate (HR) before and after induction in placebo group; however, data of the two groups were comparable (P>0.05). Less adverse events occurred in DXM group, including the incidence of postoperative nausea and vomiting (PONV) and analgesia requirement with in the first 24 h following the procedure at ward.

CONCLUSION

Dexamethasone exerted analgesic effects with a rapid onset, and patients received dexamethasone 8 mg preoperative had a lower required EC50 of remifentanil during P-ESWL. It is also associated with reduced PONV in addition to reduced postoperative analgesic consumption in the first postoperative 24 h.

TRIAL REGISTRATION

Registered in the Chinese Clinical Trial Registry (ChiCTR2300078171) on 30/11/2023.

Strategies to maximise patient comfort during extracorporeal shockwave lithotripsy - A randomised controlled trial

BACKGROUND/PURPOSE OF STUDY

We aim to assess if distraction techniques improve patient comfort tolerability of SWL.

METHODS

We carried out a prospective randomised controlled trial of SWL-naïve patients attending for treatment. Patients were randomised into three groups and offered oral analgesia as standard of care. Group 1 (n = 19) received stress balls to squeeze during treatment. Group 2 (n = 19) listened to music during treatment. Group 3 (n = 17) received standard of care only. All patients completed a validated health anxiety inventory score prior to treatment. All patients completed a validated pain questionnaire and visual analogue scale (VAS) after treatment. Primary outcomes were completion of SWL treatment and pain score results.

RESULTS

55 patients attending for SWL were randomised. There was no difference in stone size or position, presence of a stent, height or weight between the groups. VAS scores were lower in controls compared to Group 1 (1.93 vs 3.69, p = 0.08). On subgroup analysis of non-anxious patients, pain questionnaire scores were lower in controls compared to Group 1 (2.58 vs 4.77, p = 0.06). VAS scores were lower in patients who received optional analgesia alone than in patients who received stress balls alone (1.92 vs 4.07, p = 0.05). Across all subgroups, pain scores were lower in the control group compared to the distraction groups, but did not achieve significance.

CONCLUSIONS

In conclusion, distraction techniques should not replace standard of care for analgesia during SWL. This study was registered with clinicaltrials.gov (identifier NCT03379922).

Evaluation of Preclinical and Clinical Studies Published in Medical Journals of Bosnia and Herzegovina: Methodology Issues

INTRODUCTION

Results of preclinical and clinical studies in medicine could be trusted only if their design and statistical analysis were appropriate.

AIM

The aim of our study was to investigate whether preclinical and clinical studies published in medical journals of Bosnia and Herzegovina satisfy basic requirements for appropriate design and statistical interpretation of data.

METHODS

Preclinical and clinical studies published in medical journals of Bosnia and Herzegovina were retrieved from the PubMed database, and the sample for analysis was randomly chosen from the retrieved publications. Implementation rate of basic principles of experimental design (local control, randomization and replication) and rate of the most common errors in design of clinical/observational studies was established by careful reading of the sampled publications and their checking against predefined criteria.

RESULTS

Our study showed that only a minority of experimental preclinical studies had basic principles of design completely implemented (7%), while implementation rate of single aspects of appropriate experimental design varied from as low as 12% to as high as 77%. Only one of the clinical/observational studies had none of the errors searched for (2%), and specific errors rates varied from 10% to 89%. Average impact factor of the surveyed studies was around one, and average publication date recent, less than 5 years ago.

CONCLUSION

Prevalence of preclinical studies that did not follow completely basic principles of research design, and that of clinical/observational studies with errors are high, raising suspicion to validity of their results. If incorrect and not protected against bias, results of published studies may adversely influence future research.

Remifentanil-induced postoperative hyperalgesia: current perspectives on mechanisms and therapeutic strategies

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.