piperidines and Chest-Pain

Chronic thoracic pain after cardiac surgery is prevalent (11 to 56%) and may affect patients' physical and mental health status. Despite its favorable pharmacokinetic and pharmacodynamic properties, high doses of remifentanil administered during surgery are reported to cause acute postoperative pain and increased requirements for analgesics. Recently, an association between remifentanil use and the incidence of chronic thoracic pain in the long term was also reported. Our objective is to investigate the influence of the intraoperative remifentanil on chronic postoperative pain in a prospective randomized controlled trial.. In this prospective, randomized, single-blind clinical trial, all patients (N = 126) between 18 and 85 years undergoing cardiac surgery via sternotomy receive a continuous infusion of propofol together with intermittent intravenous fentanyl at predetermined times perioperatively. Patients are randomized to receive either an additional continuous infusion of remifentanil (0.15 μg(-1)kgIBW(-1) min(-1)) or additional fentanyl (200 to 500 μg) as needed during surgery.The primary end point is the prevalence of chronic thoracic pain 12 months after surgery. Secondary end points include acute postoperative pain; postoperative analgesic use; chronic thoracic pain 3 and 6 months after surgery; quality of life (SF-12) at 3, 6 and 12 months after surgery; work productivity; and use of health care. In addition, thermal detection and pain thresholds are measured preoperatively, 3 days after surgery and 12 months after surgery using quantitative sensory testing (QST). Finally, the influence of several genetic variances on the different outcomes will be measured.. Chronic thoracic pain is prevalent after cardiac surgery, and research is needed to minimize the risk of chronic persistent postoperative pain, which is an invalidating, long-term complication of surgery. The objective of this trial is to determine the influence of perioperative remifentanil on long-term pain outcomes for cardiac patients in a prospective randomized trial. The results may be used to optimize perioperative analgesia techniques and, thereby, improve quality of life after cardiac surgery.. Clinicaltrials.gov NCT02031016 on 13 December 2013.

Topics: Analgesics, Opioid; Cardiac Surgical Procedures; Chest Pain; Chronic Pain; Clinical Protocols; Drug Administration Schedule; Employment; Fentanyl; Humans; Infusions, Intravenous; Netherlands; Pain Measurement; Pain Threshold; Pain, Postoperative; Piperidines; Prospective Studies; Quality of Life; Remifentanil; Research Design; Single-Blind Method; Surveys and Questionnaires; Thermosensing; Time Factors; Treatment Outcome

To compare the effect of remifentanil and morphine after coronary artery surgery in a patient-controlled analgesia (PCA) protocol.. A prospective, randomized, double-blind clinical study.. Single institution, university hospital.. Sixty cardiac surgical patients undergoing primary coronary artery bypass graft (CABG) surgery.. After the operation, patients were allocated to 1 of 2 groups. In the first group (group R, n = 30), the following intravenous PCA protocol was programmed: remifentanil infusion, 0.05 microg/kg/min; bolus, 0.25 microg/kg; and lockout time, 5 minutes. In the second group (group M, n = 30), the intravenous PCA protocol was as follows: morphine infusion, 0.3 mg/h; bolus, 1 mg; and lockout time, 5 minutes. In addition to intravenous opioids, paracetamol was administered during the study. In both groups, tramadol was added to the regimen after PCA had been terminated at 24 hours after surgery. In addition to tramadol and paracetamol, 10 mg of morphine sulfate was administered if the numeric rating scale (NRS) score for pain was 3 or more after the first postoperative day. Pain was assessed with an NRS in each patient at rest, while coughing, and during movement for 72 hours. Sedation levels were measured with the Ramsay sedation scale. Overall effectiveness of pain relief was evaluated with a 4-stage scale ("very good," "good," "moderate," or "bad").. During coughing, the NRS values were statistically significantly lower in group R than they were in group M at 12 and 24 hours after surgery (median 1 vs 3 at 12 hours and 2 v 3.5 at 24 hours) (p < 0.05). On movement, NRS values were statistically significantly lower in group R than they were in group M at 12 hours after surgery (median 1 v 2.5) (p < 0.05). After the first 24 hours, the requirement for additional analgesia was similar in both groups. The overall effectiveness of pain relief was rated "very good" or "good"' in 87% of patients in group R and in 72% of patients in group M (p > .05).. There was no difference in patient satisfaction between the 2 groups. On the basis of the reduction of pain scores (with cough and movement) at 1 or 2 postoperative time points, PCA-remifentanil infusion is a better analgesic technique; overall, both PCA techniques provided for effective pain scores (<3). In patients in whom PCA morphine is contraindicated after CABG surgery, PCA remifentanil is a safe alternative.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Chest Pain; Coronary Artery Bypass; Endpoint Determination; Female; Follow-Up Studies; Hemodynamics; Humans; Infusions, Intravenous; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Complications; Remifentanil; Respiratory Function Tests

Topics: Adult; Aged; Anti-Ulcer Agents; Barium Sulfate; Chest Pain; Cisapride; Contrast Media; Esophagitis, Peptic; Esophagoscopy; Female; Gastrectomy; Gastric Acid; Gastroesophageal Reflux; Gastrointestinal Agents; Heartburn; Humans; Hydrogen-Ion Concentration; Lymph Node Excision; Male; Manometry; Middle Aged; Patient Selection; Piperidines; Radiography; Stomach Neoplasms; Vagotomy, Truncal

Since angina and heartburn can feel the same, excluding cardiac disease may be the first order of business. That done, clinical findings and laboratory tests can help identify the esophageal disturbance. Gastric acid reflux, motility disorders, and visceral nerve hypersensitivity--alone or in combination--can cause chest pain, and each may call for a different pharmacologic regimen.

Topics: Adrenergic Uptake Inhibitors; Algorithms; Amitriptyline; Anti-Ulcer Agents; Atropine; Chest Pain; Cisapride; Diagnosis, Differential; Esophageal Motility Disorders; Esophagitis, Peptic; Female; Humans; Male; Manometry; Middle Aged; Parasympatholytics; Piperidines; Postprandial Period