Remifentanil improves left ventricular diastolic parameters in patients with impaired diastolic function: a prospective clinical study

BACKGROUND

Left ventricular diastolic dysfunction has a significant impact on perioperative morbidity and mortality, and its incidence is high in elderly individuals. Anesthetic agents may impair diastolic function, which may increase the incidence of perioperative complications. The aim of this prospective, clinical, phase 4 study was to investigate the effects of remifentanil on left ventricle (LV) diastolic function in patients with diastolic dysfunction. The study was performed on 30 spontaneously breathing subjects (aged 60-80 years) with diastolic dysfunction.

METHODS

Thirty patients (aged 60-80 years) with diastolic dysfunction scheduled for surgery were recruited between November 2019 and March 2023. Left ventricle function was evaluated once the intravenous remifentanil infusion reached a target-controlled concentration of 2 ng/ml with transthoracic echocardiography. Analysis of systolic function focused on left ventricular ejection fraction and mean mitral annular S velocity (Sm), whereas diastolic function focused on changes in transmitral peak flow (E), E/A, mitral septal and lateral e' waves, E/e' ratios and left atrial volume index following remifentanil infusion.

RESULTS

Diastolic function measures of LV (mitral E/e', septal and lateral e' waves) statistically significantly improved (E/e' from 10.6 ± 2.9 cm.sn- 1 to 9.5 ± 2.2 cm.sn- 1; p = 0.006) following remifentanil infusion. Left atrial volume index decreased following remifentanil infusion without statistical significance (from 55 ± 14.4 ml.cm- 2 to 51.6 ± 13.3 ml.cm- 2; p = 0.1). Systolic function (ejection fraction and Sm) did not change following remifentanil infusion.

CONCLUSIONS

Remifentanil improves left ventricular diastolic parameters in patients with preexisting diastolic dysfunction. Our study suggests that remifentanil at a plasma concentration of 2 ng.ml- 1 might be used safely in patients with left ventricular diastolic dysfunction.

The efficacy of prophylactic metoclopramide in preventing nausea and vomiting in patients with acute pain treated with intravenous tramadol: a randomized double-blinded, placebo-controlled trial

OBJECTIVE

To examine the clinical efficacy of prophylactic metoclopramide in reducing the incidence of nausea and vomiting in emergency department (ED) patients with acute pain who were treated with intravenous tramadol.

RESULTS

We conducted a single-center randomized, double-blinded, placebo-controlled trial. A total of 99 ED patients presented with acute pain were recruited. Sixty-four patients were randomized, 31 patients in the treatment arm and 33 in the control arm. Overall, there were no significant differences in baseline characteristics between treatment arm and control arm. Only one patient within each arm reported having nausea symptom. No patients reported vomiting episode. There was no statistically significant difference in the proportion of patients with nausea or vomiting symptoms between the two groups (3.2% in the treatment arm vs. 3.0% in the control arm, p = 1.000). The administration of prophylactic metoclopramide may not provide additional benefit in reducing the occurrence of nausea and/or vomiting episode in ED patients with acute pain treated with intravenous tramadol. Trial registration Randomized clinical trial TCTR20220525001; registration date: 21 October 2021. Retrospectively registered.

Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

PURPOSE

The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP.

RESULTS

The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups.

CONCLUSION

Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Effects of different doses of remifentanil on hemodynamic response to anesthesia induction in healthy elderly patients

OBJECTIVE

We compared the effects of three different doses of remifentanil infusion, which were performed for the induction of anesthesia in elder patients, on cardiovascular response.

RESEARCH DESIGN AND METHODS

The present study was designed as a randomized, prospective and double-blind study. A total of 90 ASA I-II patients over the age of 65 years were enrolled. The patients were randomly (by lot) assigned to receive one of the three doses of remifentanil infusion (0.1, 0.2 or 0.3 μg/kg/min) for two minutes. Subsequently, 0.5 mg/kg propofol was administered via IV route and 0.5 mg/kg rocuronium was administered via IV route at the time eyelash reflex disappeared. Intubation was performed after 2 minutes. Patients who had an allergy against opioids, were chronic substance users, were obese, expected to have difficult airway, had hypertension, or were receiving any drug influencing the cardiovascular system were excluded.

MAIN OUTCOME MEASURES

In this study after recording baseline values of heart rate (HR), systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and mean arterial pressure (MAP), these values were recorded at the 1st, 2nd, 3rd, 4th and 5th minutes of induction.

RESULTS

A significant increase was observed in heart rate at the 1st and 2nd minutes of induction versus baseline in the Remi 0.1 group and at the 2nd minute of induction versus baseline in the Remi 0.2 group, with no additional significant change in heart rate. A significant decrease was determined in the systolic, diastolic and mean arterial pressures in all groups from the 1st minute of induction of anesthesia to the pre-intubation period compared to baseline (p < .05).

CONCLUSIONS

It was determined that each dose of remifentanil used was quite high for patients of this age-group. ClinicalTrials.gov trial number: NCT02763098.