piperidines and Pain--Postoperative

Remifentanil is a short-acting opioid of high analgetic potency and superior controllability. It is widely used in day-case surgery, procedural sedation, for reduction of recovery-times and obstetrics and whenever excellent controllability of opioid effects is needed. Especially in combination with Propofol it is used for target-controlled infusion (TCI). The first part of the article provides readers with information about historical aspects, pharmacological characteristics, effects and side effects of remifentanil.. Remifentanil ist ein kurzwirksames, potentes Opioid mit guter Steuerbarkeit – und vor allem in der ambulanten Anästhesiologie nahezu unverzichtbar. Umso härter trifft uns die seit 2016 eingeschränkte Verfügbarkeit und Kontingentierung. Dieser Beitrag liefert einen Überblick über die Substanz, ihre Geschichte und pharmakologischen Eigenschaften.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Drug Interactions; Female; Humans; Infusions, Intravenous; Pain, Postoperative; Piperidines; Pregnancy; Remifentanil

Remifentanil is an ultra-short-acting opioid that is used commonly during both short-term and prolonged surgery. This review investigated associations of intraoperative remifentanil administration with acute postoperative pain, hyperalgesia, and chronic postoperative pain, with emphasis on the perioperative coanesthetic drug regimen used.. Medline and Embase databases were searched for randomized studies, evaluating the intraoperative use of remifentanil (>2 h) versus another analgesic or a different dosage of remifentanil, and reporting acute postoperative pain parameters such as postoperative pain scores, hyperalgesia, acute opioid tolerance, or analgesics requirements. Furthermore, all studies in which remifentanil was used intraoperatively and parameters for chronic postoperative pain were measured were included (pain levels after a prolonged period of time after surgery).. From the 21 studies that were identified, less than half of the studies found higher acute postoperative pain, higher postoperative analgesic requirements after intraoperative remifentanil use, or both. Coanesthetics to some extent determined this incidence, with mainly studies using volatile agents reporting increased pain levels. There was less evidence when remifentanil was combined with total intravenous anesthesia or a combination of anesthetics. The limited number of studies (n=4) evaluating chronic pain suggested a potential association with the intraoperative use of remifentanil.. Although studies are diverse and sample sizes small, coanesthetics used in combination with remifentanil may influence the occurrence of postoperative hyperalgesia. No firm conclusions could be made regarding acute and chronic pain, indicating that further research with the goal to investigate the effect of volatile or intravenous anesthetics along with simultaneous remifentanil infusion on acute and chronic postoperative pain is needed.

Topics: Analgesics, Opioid; Chronic Pain; Humans; Intraoperative Care; Pain, Postoperative; Piperidines; Remifentanil

Topics: Analgesics, Opioid; Drug Administration Schedule; Drug Tolerance; Humans; Hyperalgesia; Intraoperative Care; Pain, Postoperative; Piperidines; Receptors, N-Methyl-D-Aspartate; Remifentanil

Remifentanil could induce opioid-induced hyperalgesia and tolerance, which would increase pain intensity after the operation. N-methyl-d-aspartate (NMDA) receptor antagonists have been used to prevent these adverse effects while the efficacy is still controversial. We evaluated the effectiveness of NMDA receptor antagonists in reducing postoperative pain and analgesic consumption after remifentanil-based anesthesia.. Full published reports of randomized controlled trials on adults investigating the effects of intravenous administration of NMDA receptor antagonists compared with placebo for preventing remifentanil-induced postoperative hyperalgesia and tolerance were searched in PubMed, Embase, Springer, and the Cochrane Central Register of Controlled Trials. Postoperative pain scores, analgesic consumption, time to first analgesic request, satisfaction scores, and opioid-related and other adverse effects have been evaluated. Results were combined using fix or random-effects model when appropriate.. A total of 14 randomized controlled trials with 729 patients were included in the final analysis. Compared with placebo, NMDA receptor antagonists reduced the pain scores at 0, 4, 6, 8, 12, and 24 hours postoperatively (P < .05), reduced the cumulative analgesic consumption of 0-6, 0-24, and 0-48 hours after the operation (P < .05), prolonged the first time to request analgesic (P < .05), and promoted the satisfaction scores (P < .05). There was no difference in the incidence of postoperative nausea and vomiting, psychological adverse effects, and shivering. Subgroup analysis was conducted on different interventions (ketamine and magnesium); the results are in line with general results.. N-methyl-d-aspartate receptor antagonists can prevent the increase of analgesic consumption and pain intensity induced by remifentanil, and it can improve the postoperative satisfaction of patients.

Topics: Analgesics; Analgesics, Opioid; Humans; Pain, Postoperative; Patient Satisfaction; Piperidines; Randomized Controlled Trials as Topic; Receptors, N-Methyl-D-Aspartate; Remifentanil

Topics: Analgesics, Opioid; Anesthetics, Inhalation; Drug Delivery Systems; Drug Tolerance; Humans; Hyperalgesia; Pain, Postoperative; Piperidines; Propofol; Remifentanil

Opioids can increase sensitivity to noxious stimuli and cause opioid-induced hyperalgesia. We performed a systematic review to evaluate the clinical consequences of intra-operative doses of opioid.. We identified randomized controlled trials which compared intra-operative opioid to lower doses or placebo in adult patients undergoing surgery from MEDLINE, EMBASE, LILAC, Cochrane, and hand searches of trial registries. We pooled data of postoperative pain intensity, morphine consumption, incidence of opioid-related side-effects, primary and secondary hyperalgesia. For dichotomous outcomes relative risks [95% confidence intervals (CIs)] and for continuous outcomes mean differences (MDs) or standardized mean difference (SMD; 95% CI) were calculated.. Twenty-seven studies involving 1494 patients were included in the analysis. Patients treated with high intra-operative doses of opioid reported higher postoperative pain intensity than the reference groups (MD: 9.4 cm; 95% CI: 4.4, 14.5) at 1 h, (MD: 7.1 cm; 95% CI: 2.8, 11.3) at 4 h, and (MD: 3 cm; 95% CI: 0.4, 5.6) at 24 h on a 100 cm visual analogue scale. They also showed higher postoperative morphine use after 24 h (SMD: 0.7; 95% CI: 0.37, 1.02). There was no difference in the incidences of nausea, vomiting, and drowsiness. These results were mainly associated with the use of remifentanil. The impact of other opioids is less clear because of limited data.. This review suggests that high intra-operative doses of remifentanil are associated with small but significant increases in acute pain after surgery.

Topics: Analgesics, Opioid; Dose-Response Relationship, Drug; Humans; Hyperalgesia; Pain Measurement; Pain, Postoperative; Piperidines; Randomized Controlled Trials as Topic; Remifentanil

Although post-liver transplantation pain is not as severe as expected from the size of the surgical incision, optimal pain control becomes crucial to aid compliance with the ventilator, improve respiratory function, and facilitate an early weaning from mechanical ventilation.. Because the majority of analgesics are primarily metabolized and excreted by the hepatobiliary system, a poor recovery of graft function will result in a decrease in clearance and reduced elimination of the drug. On the other hand, if the liver is working well, the metabolism of analgesics improves significantly with minimal accumulation. Morphine-based analgesia has been associated with a higher risk of sedation and respiratory depression compared with major abdominal surgical procedures. Fentanyl and sufentanil in continuous intravenous infusion may be preferred in the presence of hemodynamic instability or bronchospasm. Sufentanil produces shorter-lasting respiratory depression and long-lasting analgesia than does fentanyl.. The provision of potent continuous analgesia, independent of the duration of infusion, and the unique pharmacokinetics, not significantly affected by the functional status of the graft, make remifentanil appropriate for the majority of liver-transplanted patients. Unlike for patients with very severe pain after major abdominal surgery, liver transplant recipients usually benefit from tramadol, either in repeated intravenous boluses or continuous intravenous infusion. Paracetamol has been included as adjuvant (or sole agent, rarely) in the analgesic treatment of mild to moderate postoperative pain. The combination treatment (paracetamol plus tramadol) is a reasonable, safe option with improved analgesia and concurrent reduction in the incidence of some opioid-related side effects.. Frequent review of the patient's response is mandatory when potent opioids are used because dose-dependent respiratory depression is a serious and potentially life-threatening adverse effect. The benefits provided by epidural analgesia in this particular setting should be weighed against the risks because in the presence of markedly deranged perioperative blood clotting, the development of epidural hematoma represents a disastrous complication.

Topics: Acetaminophen; Analgesia, Epidural; Analgesics; Analgesics, Opioid; Drug Therapy, Combination; Fentanyl; Humans; Infusions, Intravenous; Injections, Intravenous; Liver Transplantation; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Care; Remifentanil; Tramadol; Treatment Outcome

Meta-analysis was performed to evaluate the preventive effects of N-methyl-D-aspartate (NMDA) receptor antagonists on remifentanil-induced increase in postoperative pain and analgesic requirement in patients.. Pubmed, EMBase, Springer and the Cochrane Controlled Trials Register were searched to identify all randomized controlled trials (RCTs) published to November 2010 which investigated the preventive effects of NMDA receptor antagonists on remifentanil-induced postoperative hyperalgesia and/or tolerance. The studies listed at the end of these articles as reference were also searched. Two authors independently assessed the quality of each study met the inclusion criteria and extracted data. Then Meta-analysis was perfomed using RevMan 5.0 software. The outcomes analyzed were the postoperative analgesic consumption, pain intensity scores, time to first analgesic request, and the incidence of adverse effects.. A total of 623 patients (223 in the ketamine group, 87 in the magnesium group and 313 in the control group) from 14 prospective RCTs were included in the Meta-analysis. Administration of NMDA receptor antagonists reduced the pain scores at 4 hr after operation (P<0.05), and the standardized mean differences (SMD) was -0.21 (95% confidence interval was -0.41 to -0.01). There were no significant differences in postoperative analgesic consumption, pain scores at other time points, time to first analgesic request and the incidence of adverse effects (P>0.05). Further subgroup analyses based on the type of intervention showed that the results were almost the same.. These data do not support the use of NMDA receptor antagonists, ketamine and magnesium sulfate to prevent the development of remifentanil-induced postoperative hyperalgesia and tolerance.

Topics: Analgesia; Analgesics, Opioid; Humans; Pain, Postoperative; Piperidines; Receptors, N-Methyl-D-Aspartate; Remifentanil

Remifentanil is a synthetic opioid, first introduced into clinical practice in 1996. Its unique pharmacokinetic profile has resulted in a gradual increase in its popularity in paediatric anaesthesia. It is an opioid of high potency and rapid clearance, consequently lacking problems of accumulation. These characteristics give it a high degree of predictability and it has become an attractive choice for a wide variety of anaesthetic challenges, from premature neonates to the elderly. Neonates and infants have a higher clearance than older children and, as a result, remifentanil has additional benefits in this group. Remifentanil can be described as the only consistently predictable opioid in paediatric practice.

Topics: Analgesics, Opioid; Child; Hemodynamics; Humans; Infant; Infant, Newborn; Neurosurgical Procedures; Pain, Postoperative; Piperidines; Remifentanil; Respiratory System

Alvimopan, a trans-3,4-dimethyl-4-(3-hydroxy-phenyl) piperidine, is a selective, peripherally acting micro-opioid receptor antagonist that is available for short-term use in hospitalized patients who have undergone bowel resection. The efficacy of alvimopan in the management of postoperative ileus has been evaluated in five phase III trials; four conducted in North America and one conducted in Europe/Australasia. Patients who had undergone partial large or small bowel resection surgery with primary anastomosis were randomized to receive alvimopan 12 mg or placebo as a single oral pre-operative dose followed by twice-daily administration for up to 7 days postoperatively. In the five phase III trials, alvimopan was significantly more effective than placebo in reducing the time to recovery of upper and lower gastrointestinal (GI) function, as assessed using a two-component endpoint (GI2) comprising time to tolerance of solid food and first bowel movement. The mean time to reach the GI2 endpoint was 11-26 hours sooner with alvimopan than with placebo. In the phase III trials conducted in North America, the time to writing the hospital discharge order was 13-21 hours sooner with alvimopan than with placebo. Alvimopan did not reduce opioid-induced analgesia and/or increase the amount of opioids administered postoperatively. Short-term alvimopan was generally well tolerated in adults undergoing bowel resection.

Topics: Analgesics, Opioid; Animals; Digestive System Surgical Procedures; Gastrointestinal Agents; Gastrointestinal Diseases; Gastrointestinal Motility; Half-Life; Humans; Pain, Postoperative; Piperidines; Receptors, Opioid, mu

Most opioids used in anaesthesia are of the anilidopiperidine family, including fentanyl, alfentanil, sufentanil and remifentanil. While all share similar pharmacological properties, remifentanil, the newest one, is probably the most original, which is the reason this review focusses especially on this drug. Remifentanil is a potent mu-agonist that retains all the pharmacodynamic characteristics of its class (regarding analgesia, respiratory depression, muscle rigidity, nausea and vomiting, pruritus, etc.) but with a unique pharmacokinetic profile that combines a short onset and the fastest offset, independent of the infusion duration. Consequently, it offers a unique titratability when its effects need to be quickly achieved or suppressed, but it requires specific drug delivery schemes such as continuous infusion, target-controlled infusion and anticipated postoperative pain treatment. Kinetic differences between opioids used in anaesthesia and some clinical uses of remifentanil are reviewed in this chapter.

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Animals; Central Nervous System; Dose-Response Relationship, Drug; Humans; Pain, Postoperative; Piperidines; Receptors, Opioid, mu; Remifentanil

Pain is among the worst possible experiences for the critically ill. Therefore, nearly all intensive care patients receive some kind of pain relief, and opioids are most frequently administered. Morphine has a number of important adverse effects, including histamine release, pruritus, constipation, and, in particular, accumulation of morphine-6-glucuronide in patients with renal impairment. Hence, it is not an ideal analgesic for use in critically ill patients. Although the synthetic opioids fentanyl, alfentanil, and sufentanil have better profiles, they undergo hepatic metabolism and their continuous infusion also leads to accumulation and prolonged drug effects. Various attempts have been made to limit these adverse effects, including daily interruption of infusion of sedatives and analgesics, intermittent bolus injections rather than continuous infusions, and selection of a ventilatory support pattern that allows more spontaneous ventilation. However, these techniques at best only limit the effects of drug accumulation, but they do not solve the problem. Another type of approach is to use remifentanil in critically ill patients. Remifentanil is metabolized by unspecific blood and tissue esterases and undergoes rapid metabolism, independent of the duration of infusion or any organ insufficiency. There are data indicating that remifentanil can be used for analgesia and sedation in all kinds of adult intensive care unit patients, and that its use will result in rapid and predictable offset of effect. This may permit both a significant reduction in weaning and extubation times, and clear differentiation between over-sedation and brain dysfunction. This article provides an overview of the use of short-acting opioids in the intensive care unit, with special emphasis on remifentanil. It summarizes the currently available study data regarding remifentanil and provides recommendations for clinical use of this agent.

Topics: Analgesics, Opioid; Drug Tolerance; Humans; Hypnotics and Sedatives; Intensive Care Units; Pain, Postoperative; Piperidines; Remifentanil

Remifentanil is a synthetic opioid derivate with an agonist activity at mu-opioid receptors. The pharmacokinetic profile differs from other synthetic opioids. Remifentanil is rapidly metabolised by unspecific blood and tissue esterases and the metabolites have almost no intrinsic activity. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia might be associated with a high level of postoperative pain, therefore, an appropriate postoperative pain management is an import aspect. In addition, remifentanil withdrawal induces a compensatory up-regulation of secondary messenger pathways, inducing hyperalgesia. This review provides a comprehensive summary of basic and clinical research concerning the intraoperative use of remifentanil and postoperative pain therapy. The relative contribution of rapid degradation and withdrawal-induced hyperalgesia to postoperative pain will be discussed. In addition, this review attempts to identify potential clinical implications and treatment strategies.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Humans; Hyperalgesia; Pain, Postoperative; Piperidines; Remifentanil; Substance Withdrawal Syndrome

Remifentanil (Ultiva), a 4-anilidopiperidine derivative of fentanyl, is an ultra-short-acting micro-opioid receptor agonist indicated to provide analgesia and sedation in mechanically ventilated intensive care unit (ICU) patients.Analgesia-based sedation with remifentanil is a useful option for mechanically ventilated patients in the ICU setting. Its unique properties (e.g. organ-independent metabolism, lack of accumulation, rapid offset of action) set it apart from other opioid agents. Remifentanil is at least as effective as comparator opioids such as fentanyl, morphine and sufentanil in providing pain relief and sedation in mechanically ventilated ICU patients. Moreover, it allows fast and predictable extubation, as well as being associated with a shorter duration of mechanical ventilation and quicker ICU discharge than comparators in some studies. In addition, remifentanil is generally well tolerated in this patient population. Thus, remifentanil is a welcome addition to the currently available pharmacological agents employed in the management of mechanically ventilated ICU patients.

Topics: Age Factors; Analgesics, Opioid; Drug Administration Schedule; Fentanyl; Humans; Hypnotics and Sedatives; Intensive Care Units; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Remifentanil; Respiration, Artificial

The adverse effects of opioids are well documented. Because opioid receptors have a wide-ranging anatomic distribution, the effects subsequent to opioid binding, both good and bad, occur centrally and in the periphery. Postoperative strategies to reduce opioid burden, therefore, are in the patient's best interest. Multimodal analgesia is the key towards balancing the need for opioids while simultaneously reducing their burden. Alternative anesthesia and analgesia options such as regional anesthesia, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 enzyme inhibitors should be considered part of multimodal protocols. Familiarity of where these drugs are active in the body and how they can be employed is imperative for all surgical team members. Optimal implementation of multimodal approaches can reduce hospital stay and improve clinical outcomes, including patient satisfaction. Finally, strategies that may help reduce rates of hospital readmission also contribute to overall improved outcome. New peripherally acting mu-opioid-receptor antagonists represent significant progress in the ability of perianesthesia nurses to play an even greater role in achieving these goals. In contrast to older opioid-receptor antagonists, these agents specifically target an important aspect of the multifactorial etiology of postoperative ileus (POI), mu-opioid-receptor-mediated activity in the GI tract. In addition, they do not pass the blood-brain barrier or diminish opioid-mediated analgesia. Advanced clinical trials have already demonstrated the ability of one of these agents, alvimopan, to reduce POI and improve other postoperative outcomes while maintaining adequate analgesia. Combined with other options aimed at reducing opioid burden, alvimopan and similar drugs in development hold promise as part of multimodal protocols to optimize pain management while minimizing postoperative morbidities.

Topics: Analgesia; Analgesics, Opioid; Anesthesia; Anesthesiology; Anti-Inflammatory Agents, Non-Steroidal; Attitude of Health Personnel; Blood-Brain Barrier; Clinical Trials, Phase III as Topic; Humans; Ileus; Length of Stay; Naltrexone; Narcotic Antagonists; Nurse's Role; Outcome Assessment, Health Care; Pain, Postoperative; Patient Satisfaction; Piperidines; Postanesthesia Nursing; Postoperative Care; Postoperative Complications; Quaternary Ammonium Compounds; Receptors, Opioid, mu; Risk Factors

Postoperative ileus (POI) is defined as the impairment of bowel motility that occurs almost universally after major open abdominal procedures, as well as other abdominal and nonabdominal procedures. For the majority of affected patients, POI generally lasts approximately three to five days, but longer duration is not uncommon. The causes of POI are multifactorial, but can be broadly categorized into two groups: those related to the surgical procedure and those related to pharmacologic interventions (opioids). The fact that POI is generally transient and therefore self-limited should not deter the surgical team from seeking improved ways to mitigate its associated adverse effects, which can be substantial and immensely uncomfortable for the patient, and can have far-reaching implications regarding overall hospitalization costs for many types of surgeries. Optimization of POI management and prevention efforts is a responsibility of all members of the surgical team and can drastically affect the overall clinical outcome of major abdominal surgery. Depending on the individual team member's role, different perspectives and strategies may be used to achieve improved outcomes, including but not limited to hospitalization costs related to care and length of stay, resource utilization, and, perhaps most critically, patient quality of life not only immediately after surgery but also after discharge. The ability to reliably and significantly decrease the duration of POI should be readily recognized as an important objective in the management of this condition. Opioids will continue to be a mainstay of postoperative care regimens, but new agents such as peripherally acting mu-opioid-receptor antagonists may offer a unique clinical advantage by helping to reduce the adverse gastrointestinal effects of opioids while preserving their desired benefits for postoperative analgesia.

Topics: Analgesics, Opioid; Causality; Cost of Illness; Hospital Costs; Humans; Ileus; Incidence; Laparotomy; Length of Stay; Naltrexone; Narcotic Antagonists; Nurse's Role; Outcome Assessment, Health Care; Pain, Postoperative; Patient Care Team; Patient Satisfaction; Piperidines; Postanesthesia Nursing; Postoperative Care; Postoperative Complications; Professional Role; Quaternary Ammonium Compounds; Time Factors; Total Quality Management

The current use of multimodal analgesia for the management of postoperative pain has resulted in reduced side effects and improved pain relief. Limitations of the technology associated with current pump- or catheter-based systems have prompted the development of continuous delivery systems and extended-duration techniques for pain relief. Among these are morphine sulfate sustained-release liposome injection (Morphine SR, DepoMorphine) and the patient-controlled transdermal system (PCTS, E-TRANS). Morphine SR utilizes the novel DepoFoam technology, a novel delivery system that allows the drug to be gradually released into the surrounding epidural space. Morphine SR is compatible with anticoagulation therapy and eliminates interference from pump and intravenous (IV) equipment. Administration of Morphine SR during hip arthroplasty significantly reduced patients' postoperative consumption of fentanyl. E-TRANS fentanyl PCTS is a transdermal system attached to the patient's arm or upper chest; a button on the device is controlled by the patient to deliver doses of fentanyl. In a study comparing fentanyl HCl PCTS with conventional IV-patient-controlled analgesia (PCA) morphine, PCTS was found to be as safe and effective as PCA for the treatment of postoperative pain. Novel delivery systems that are less invasive, that are compatible with anticoagulation regimens, and that provide continuous delivery, thus preventing analgesic gaps, will facilitate rehabilitation and recovery and ultimately improve patient outcomes.

Topics: Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Drug Therapy, Combination; Fentanyl; Humans; Length of Stay; Liposomes; Morphine; Orthopedic Procedures; Pain, Postoperative; Piperidines

The anilidopiperidine opioid remifentanil has pharmacodynamic properties similar to all opioids; however, its pharmacokinetic characteristics are unique. Favourable pharmacokinetic properties, minimally altered by extremes of age or renal or hepatic dysfunction, enable easy titration and rapid dissipation of clinical effect of this agent, even after prolonged infusion. Remifentanil is metabolised by esterases that are widespread throughout the plasma, red blood cells, and interstitial tissues, whereas other anilidopiperidine opioids (e.g. fentanyl, alfentanil and sufentanil) depend upon hepatic biotransformation and renal excretion for elimination. Consequently, remifentanil is cleared considerably more rapidly than other anilidopiperidine opioids. In addition, its pKa (the pH at which the drug is 50% ionised) is less than physiological pH; thus, remifentanil circulates primarily in the non-ionised moiety, which quickly penetrates the lipid blood-brain barrier and rapidly equilibrates across the plasma/effect site interface. By virtue of these distinctive pharmacokinetic properties, the context-sensitive half-time (i.e. the time required for the drug's plasma concentration to decrease by 50% after cessation of an infusion) of remifentanil remains consistently short (3.2 minutes), even following an infusion of long duration (> or =8 hours). Remifentanil, a clinically versatile opioid, is useful for intravenous analgesia and sedation in spontaneously breathing patients undergoing painful procedures. Profound analgesia may be achieved with minimal effect on cognitive function. Remifentanil may also provide sedation and analgesia during placement of regional anaesthetic blocks, and in conjunction with topical anaesthesia and airway nerve blocks, it may be useful for blunting reflex responses and facilitating 'awake' fibreoptic intubation. Compared with fentanyl and alfentanil in a day-surgery setting, remifentanil supplementation of general anaesthesia may improve intraoperative haemodynamic control. Both emergence time and the incidence of respiratory depression during post-anaesthetic recovery may be reduced. However, outcomes such as home discharge time, post-emergence adverse effect profile, and patient and provider satisfaction are not significantly improved, and the incidence of intraoperative hypotension and bradycardia is greater. In addition, drug acquisition costs for remifentanil are higher and clinicians may need extra time to familiarise themselv

Topics: Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Clinical Trials as Topic; Dose-Response Relationship, Drug; Drug Interactions; Humans; Hypnotics and Sedatives; Pain, Postoperative; Piperidines; Remifentanil

Remifentanil is a 4-anilidopiperidine mu-opioid analgesic which is rapidly metabolized by unspecific blood and tissue esterases. According to its unique pharmacokinetic profile, remifentanil-based anaesthesia combines high-dosage opioid analgesia intraoperatively with a rapid and predictable postoperative awakening. When compared with a standard fentanyl-based technique, the use of remifentanil has changed our present anaesthetic regimens. This includes the anaesthesia induction sequence, the choice and dosage of anaesthetics when used as adjuncts to remifentanil, and even more, the proper planning of postoperative pain management. The present paper was designed to review the current knowledge on remifentanil and all aspects of its use in anaesthesiology. In addition, present data on the use of remifentanil for analgesia and sedation of the critically ill patient are summarized.

Topics: Aging; Analgesics, Opioid; Anesthetics, Intravenous; Animals; Contraindications; Critical Care; Humans; Kidney Diseases; Liver Diseases; Pain, Postoperative; Piperidines; Remifentanil

A "fast track" approach to cardiac surgery can be defined as a perioperative process involving rapid progress from preoperative preparation through surgery and discharge from the hospital. Although highly individualized among the various heart surgery centers, the fast-track process is a team activity. It requires a team of health care providers to interact with the patient at various phases, from admission to discharge. The necessary elements of the fast-track program are choice and the titration of short-acting anesthetic drugs, standardized surgical procedures, early extubation, rewarming and sustained postoperative normothermia, postoperative pain control, early ambulation, alimentation and discharge, and follow-up after discharge. We review the current approaches to some of these aspects of patient care.

Topics: Analgesics, Opioid; Anesthesia; Body Temperature; Cardiac Surgical Procedures; Coronary Care Units; Early Ambulation; Humans; Intubation, Intratracheal; Length of Stay; Pain, Postoperative; Patient Admission; Patient Discharge; Piperidines; Postoperative Care; Preoperative Care; Remifentanil

Topics: Anesthesia, Conduction; Anesthetics, Intravenous; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Heart Diseases; Humans; Pain, Postoperative; Piperidines; Remifentanil

Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Animals; Biotransformation; Central Nervous System; Drug Interactions; Hemodynamics; Humans; Hypnotics and Sedatives; Pain, Postoperative; Piperidines; Receptors, Drug; Remifentanil

The contributions of remifentanil to anesthesia for heart surgery is described. The pharmacokinetic properties are described along with our clinical experience with the various modes and doses of perfusion for induction as well as during and after surgery.

Topics: Analgesics; Anesthesia, Conduction; Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Cardiac Surgical Procedures; Extracorporeal Circulation; Half-Life; Hemodynamics; Humans; Methyl Ethers; Myocardial Infarction; Myocardium; Neuromuscular Nondepolarizing Agents; Oxygen Consumption; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Remifentanil; Sevoflurane; Stress, Physiological; Sympathetic Nervous System

Remifentanil is a new opioid in the fentanyl family. Developed and marketed by Glaxo Wellcome Inc., it was approved by the U.S. Food and Drug Administration in July 1996 and has been available for use in Spain since the end of 1997. Remifentanil is an analog of fentanyl (4-piperidyl anilide) with a methyl-ester group that allows the molecule to be hydrolyzed by esterases in plasma and tissues. Rapid onset and metabolism make it an easy drug to control for achieving the desired depth of anesthesia, although these aspects are also the drug's main drawbacks given that the anesthesiologist must plan and initiate postoperative analgesia before surgery ends. Rapid onset and potency also mean that the use of this drug for either postoperative analgesia or monitored sedation in awake state with spontaneous breathing needs further study to assess safety.

Topics: Analgesics, Opioid; Anesthesia, Obstetrical; Anesthetics, Intravenous; Cardiac Surgical Procedures; Child; Conscious Sedation; Female; Humans; Male; Neurosurgery; Pain, Postoperative; Piperidines; Pregnancy; Remifentanil; Safety

Topics: Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Humans; Intraoperative Care; Pain, Postoperative; Piperidines; Randomized Controlled Trials as Topic; Remifentanil

The unique features of remifentanil are its rapid clearance and rapid ke0, resulting in a rapid onset and offset of drug effect. It is tempting to speculate that these characteristics will make remifentanil an easy drug to titrate, and that clinicians will not need to consider patient covariates such as advanced age when choosing a dosing regimen. However, the rapid onset of drug effect may be accompanied by rapid onset of adverse events such as apnea and muscle rigidity. The rapid offset of drug effect can result in patients who are in severe pain at a time when the anesthesiologist is ill equipped to deal the problem, for example when the patient is in transit to the recovery room. It is thus important that when treating elderly patients anesthesiologists understand the proper dose adjustment required for the elderly. By adjusting the bolus and infusion doses, the anesthesiologist can hope to avoid the peaks and valleys that might expose these patients to risk. When the proper adjustment is made, the variability in remifentanil pharmacokinetics is considerably less than for any other intravenous opioid. This makes remifentanil the most predictable opioid for treatment of the elderly.

Topics: Adult; Aged; Aged, 80 and over; Aging; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Apnea; Female; Forecasting; Half-Life; Humans; Infusions, Intravenous; Male; Metabolic Clearance Rate; Middle Aged; Muscle Rigidity; Pain, Postoperative; Piperidines; Remifentanil; Risk Factors; Titrimetry

Remifentanil is a new potent mu-agonist with a unique pharmacokinetic profile due to a rapid metabolism by non-specific tissue esterases. As a consequence, remifentanil pharmacokinetics are not modified by severe renal or hepatic dysfunction. During general anaesthesia, any dosage of remifentanil may be used without undue lengthening of emergence times. In cardiac surgery, remifentanil combines the requirement for intra-operative control of stress responses and rapid recovery. The rapid termination of remifentanil action warrants modifications of the current practice concerning early postoperative pain control. Remifentanil may be used as a sedative during monitored analgesia, or as a postoperative analgesic in spontaneously breathing patients, provided bolus doses are avoided. Remifentanil may increase patients' safety by eliminating the risk of delayed respiratory depression, but its correct use requires major changes in our prescribing habits.

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Cardiac Surgical Procedures; Humans; Pain, Postoperative; Piperidines; Remifentanil

Topics: Analgesics; Analgesics, Opioid; Anesthesia, Conduction; Anesthesia, General; Anesthetics, Intravenous; Fentanyl; Humans; Pain, Postoperative; Piperidines; Remifentanil; Tetrazoles; Tramadol

We hope to have inspired an interest in approaching the pain management issues in this challenging group of patients. Despite significant progress in understanding the pathophysiology of pain, the development of therapeutic options, and the publication and dissemination of guidelines, this progress does not seem to have been adopted into clinical practice. Bonica has stated "for many years I have studied the reasons for inadequate management of postoperative pain, and they remain the same.... Inadequate or improper application of available information and therapies is certainly the most important reason". Let us accept the challenge to re-evaluate pain management in the postoperative neurosurgical patient. Future development may provide enhanced multimodal analgesia with the development of enantioselective NSAIDs and peripherally acting opioids that do not cross the blood-brain barrier. Targeted inhibition of the central neuroplasticity that underlies sensitization, rather than attempts to use pre-emptive analgesics, may be more fruitful. Inhibition of excitatory amino acids may prove beneficial for perioperative neuroprotection and pain management. In addition, longer-acting local anesthetics show significant promise. The importance of understanding the specific benefits available and matching these characteristics to the particular patient is emphasized. Evaluation of outcomes, including morbidity and patient satisfaction, will determine if effective and rational provision of analgesia may indeed be safer than withholding analgesia. However, it is clear that re-evaluation and refinement of conventional therapy is necessary.

Topics: Analgesia; Analgesics, Opioid; Anti-Inflammatory Agents, Non-Steroidal; Humans; Neurosurgery; Pain, Postoperative; Piperidines; Remifentanil

Opioids decrease the sympathetic and somatic responses to noxious stimulation and can be given in high doses without negative inotropic effects, even in patients with impaired cardiac function. With currently available opioids, precise titration of dose to effect is difficult, and high doses result in drug accumulation and prolonged respiratory depression. Remifentanil is a new synthetic opioid with direct action on mu-opioid receptors. It has a rapid onset and short latency to peak effect. It is rapidly inactivated by esterases in both blood and tissues, resulting in a very short duration of action. The context-sensitive half-life remains very short (3 to 4 minutes), independent of the duration of infusion. These characteristics facilitate titration of dose to effect and also allow the use of very high doses (ED99) without prolonging recovery from its effects. The duration of action of remifentanil has been found to be short, even in patients with renal or hepatic failure, although only low doses have been used in the studies published to date. The hydrolysis of remifentanil produces a metabolite with very weak opioid receptor activity that does not contribute to the effects of remifentanil. Possible disadvantages of the drug include (1) the need to mix the lyophilized drug with a diluent, (2) administration as a continuous infusion, (3) risk of rapid loss of analgesic and anesthetic effects if the infusion is interrupted accidentally, and (4) difficulty in judging the dose of another, longer lasting opioid that will be required to control postoperative pain without producing excessive ventilatory depression. Remifentanil is likely to be more expensive than other opioids, but its use may reduce overall costs if prompt recovery from its effects results in shorter stays in the operating room and recovery units.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Costs and Cost Analysis; Dose-Response Relationship, Drug; Half-Life; Humans; Hydrolysis; Infusions, Intravenous; Myocardial Contraction; Nociceptors; Pain, Postoperative; Piperidines; Reaction Time; Receptors, Opioid, mu; Remifentanil; Respiration; Sympathetic Nervous System

The aim of this paper was to explore pupillary monitoring for determining remifentanil consumption during general anesthesia and evaluating postoperative recovery quality.. Eighty patients undergoing elective laparoscopic uterine surgery were randomly divided into pupillary monitoring group (Group P) and control group (Group C). In Group P, remifentanil dosage during general anesthesia was determined according to pupil dilation reflex; in Group C, it was adjusted according to hemodynamic changes. Intraoperative remifentanil consumption and endotracheal tube extraction time were recorded. The Numerical Rating Scale (NRS) Score, hemodynamic changes, and opioid-related adverse reactions in the post-anesthesia care unit were also recorded. The parameters of pupil light reflex from extubation to 30 min after extubation were analyzed in Group P, and the responsiveness of these parameters and hemodynamic changes to NRS was determined by ROC curve analyses.. Compared with Group C, in Group P, intraoperative remifentanil consumption, the NRS Score at 20 minutes after extubation, extubation time, and the incidence of nausea, vomiting, and respiratory amnesia were all significantly decreased (all, P<0.05). In Group P, ∆HR and ∆MAP had no value in judging the change of NRS. The ROC values and diagnostic cutoff values of ΔInit, ΔACV, and ΔMCV responding to NRS variation were 0.775 (95% CI: 0.582-0.968), 0.734(95% CI: 0.537-0.930), and 0.822 (95% CI: 0.648-0.997) and 0.21 (sensitivity, 92.3%; specificity, 23.1%), -1.3 (sensitivity, 92.3%; specificity, 18.3%), and -1.0 (sensitivity, 84.6%; specificity, 17.7%), respectively.. Intraoperative pupil dilation reflex monitoring can reduce remifentanil consumption and improve postoperative recovery quality. Furthermore, postoperative pupil light reflex monitoring can help evaluate pain degree with high sensitivity.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Humans; Laparoscopy; Pain, Postoperative; Piperidines; Pupil; Remifentanil

Although ketamine, a NMDA-receptor antagonist, tends to increase the bispectral index (BIS), it remains a widely used analgesic whenever administered in low doses during major surgery.. The objective of this study was to compare the impact of intravenous ketamine (given either as a continuous infusion or as a bolus) on BIS and to compare desflurane administration and postoperative outcomes between the groups.. Prospective, randomised, parallel-group, open-label study.. University hospital, operating room.. Fifty patients, scheduled for major abdominal surgery.. Patients were randomised into two groups: ketamine by intravenous continuous infusion - group (KI) and ketamine by i.v. bolus - group (KB). In the KI group, ketamine at a rate of 0.25 mg kg-1 h-1 was commenced at skin incision (T0) and maintained at this rate for the duration of surgery. In group KB, a ketamine bolus of 0.25 mg kg-1was administered at T0 and repeated every hour. The difference in BIS between the groups was compared from T0 onwards. The amount of desflurane administered to keep BIS within the usual recommended range (40-60) was compared, as were the doses of phenylephrine and remifentanil. Postoperative pain and recovery outcomes were also assessed.. After T0, the BIS increased significantly from baseline in group KB compared with group KI: the rise in BIS was 20 ± 8 vs. 11 ± 6, respectively (P = 0.0001). The between-group mean difference (95% confidence interval (CI), was 9 (5 to 13). In group KB, desflurane administration significantly increased for the first 15 min after T0: 6.3 ± 1.8 vs. 3.8 ± 1.3 ml (P < 0.0001) with a mean intergroup group difference (95% CI) of 2.4 (1.5 to 3.4) ml. There was no difference in desflurane administration when considering the full hour from T0 to T60 min: 16 ± 9 vs. 15 ± 5 ml (P = 0.63) with a mean intergroup difference (95% CI) of 1 (-3 to 5) ml. After surgery, pain scores, opioid consumption, incidence of nausea and vomiting and recovery scores were similar between groups.. Compared with a continuous ketamine infusion, a ketamine bolus significantly increased the BIS after T0. In order to keep the BIS below 60, significantly more desflurane was administered from T0 to T15 min in group KB. To prevent such higher desflurane administration and its related atmospheric pollution, our results suggest administering intra-operative intravenous ketamine as an infusion rather than a bolus.. Clinicaltrials.gov registration identifier: NCT03781635.

Topics: Desflurane; Double-Blind Method; Humans; Ketamine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil

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.. To evaluate the effect of 35 and 50% N2O on hyperalgesia and pain after remifentanil infusion.. Single site, phase 1, double-blind, placebo-controlled, randomised crossover study.. University Hospital, Germany from January 2012 to April 2012.. Twenty-one healthy male volunteers.. 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.. Areas of pin-prick hyperalgesia, areas of touch-evoked allodynia and pain intensity on a visual analogue scale were assessed repeatedly for 160 min.. 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.. 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.. EudraCT-No.: 2011-000966-37.

Topics: Analgesics, Opioid; Double-Blind Method; Healthy Volunteers; Humans; Hyperalgesia; Male; Nitrous Oxide; Pain, Postoperative; Piperidines; Remifentanil

Topics: Adult; Analgesics, Opioid; Female; Humans; Hyperalgesia; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Young Adult

Esmolol an ultrashort acting cardioselective β1-adrenergic receptor antagonist), has been successfully employed for perioperative sympatholysis. In this study, we tested the hypothesis that perioperative esmolol administration resulted in decreased postoperative pain and improves the hemodynamic balance in patients with rhinoplasty.. In this clinical trial study, fifty-six patients (56) undergoing rhinoplasty surgery were randomly distributed into two groups (Group E and Group C). Patients in the Group E were administered 5-10 µg/kg/min of esmolol in combination with propofol and remifentanil titrated to hemodynamic response. Patients in the Group C were administered normal saline, having same volume as the esmolol in addition to propofol and remifentanil. The mean blood pressure, opioid requirement, pain score, and heart rate were evaluated 30 min, 1 h and 3 h, respectively, after surgery.. Postoperative pain was reduced significantly in the first 3 postoperative hours, and the need to use morphine was decreased in the group receiving esmolol. Group E patients had significantly less variations in blood pressure and heart rate postoperatively.. Intraoperative esmolol infusion is a valid method to reduce postoperative pain, it provide lesser need to analgesics and hemodynamic stability in first 3 hours of post rhinoplasty surgery.

Topics: Adrenergic beta-1 Receptor Antagonists; Adult; Analgesics, Opioid; Anesthetics, Intravenous; Blood Pressure; Double-Blind Method; Drug Therapy, Combination; Female; Heart Rate; Humans; Infusions, Intravenous; Intraoperative Care; Male; Pain Measurement; Pain, Postoperative; Piperidines; Propanolamines; Propofol; Prospective Studies; Remifentanil; Rhinoplasty; Treatment Outcome; Young Adult

To determine the efficacy of 2 different doses (150-300mg) of preoperative pregabalin on propofol and remifentanil doses for total intravenous anesthesia in laparoscopic cholecystectomy.. Prospective, randomized, placebo-controlled, double-blinded study.. Training and research hospital.. Forty-eight adult, American Society of Anesthesiologists physical status 1 and 2 patients.. Patients were randomly assigned to 3 groups to receive orally 1hour before surgery, a placebo group (group 1), pregabalin 150mg (group 2), or pregabalin 300mg (group 3).. In the operating room, heart rate, systolic and diastolic blood pressures, SpO. The remifentanil doses used in the pregabalin groups at minutes 10, 15, 20, 25, and 30 and propofol doses at minutes 15, 20, 25, and 30 were statistically significantly lower in comparison to the placebo group.. The observations provide preliminary evidence that preoperative pregabalin may decrease anesthetic agent requirement in total intravenous anesthesia patients.

Topics: Administration, Oral; Adult; Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Double-Blind Method; Female; Humans; Hypnotics and Sedatives; Male; Middle Aged; Pain, Postoperative; Piperidines; Placebos; Pregabalin; Preoperative Care; Propofol; Prospective Studies; Remifentanil; Treatment Outcome

Topics: Aconitine; Aged; Analgesics, Opioid; Anesthesia, General; Female; Humans; Hyperalgesia; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil

Endotracheal extubation is a painful and stressful procedure. The authors hypothesized that the prophylactic use of remifentanil would attenuate the pain intensity and stress responses resulting from extubation in neurosurgical patients.. In this prospective, randomized, double-blinded, controlled trial, 160 patients with planned delay extubation after elective intracranial operation were randomized 1:1 to receive either remifentanil or normal saline (control) before their extubation. The dose regime of remifentanil was a bolus of 0.5 μg/kg over 1 minute, followed by a continuous infusion of 0.05 μg/kg/min for 20 minutes. The primary outcome was the incidence of severe pain during the periextubation period. Secondary outcomes included changes in the pain intensity and vital signs, failing to pass an extubation evaluation after the study drug infusion, severe adverse events, postextubation complications, and clinical outcomes.. Two patients in the remifentanil group did not pass the extubation evaluation. The incidence of severe pain during the periextubation period was significantly lower in the remifentanil group compared with the control group (25.0% vs. 41.3%, P=0.029). Compared with the control group, the visual analog scale in the remifentanil group was significantly lower after the bolus of remifentanil (12±18 vs. 25±27, P=0.001) and immediately after extubation (19±25 vs. 34±30, P=0.001). There were no significant differences in the vital signs immediately after extubation between the 2 groups (P>0.05).. The prophylactic use of remifentanil decreases the incidence of severe pain. Our preliminary findings merit a larger trial to clarify the effect of the prophylactic use of remifentanil on clinical outcomes and adverse events.

Topics: Adult; Aged; Airway Extubation; Analgesics, Opioid; Brain; Craniotomy; Double-Blind Method; Female; Humans; Incidence; Infusions, Intravenous; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Treatment Outcome

To compare the effects of premedication with intravenous paracetamol versus ketorolac, in decreasing intraoperative anaesthetic and postoperative opioid analgesics requirements in patients undergoing laparoscopic cholecystectomy.. An experimental, prospective, comparative, double blind, and randomised clinical trial was conducted to determine intraoperative opioid requirements, and pain and analgesic requirements in the postoperative period in 100 healthy patients undergoing laparoscopic cholecystectomy. They were randomised into 2 groups: Group 1: pre-medicated with paracetamol 1g, and Group 2: with ketorolac 30mg (both administered intravenously 30minutes prior to surgery).. There were no statistically significant differences between groups as regards intraoperative remifentanil use (Group 1: 0.0739±0.016μg/kg/min, Group 2: 0.0741±0.018μg/kg/min). The number of patients in Group 2 that had values of VAS>4 points (22.4%) was lower than in Group 1 (28.6%), but with no statistically significant difference. Of the patients who needed postoperative opioid rescue, most required a single rescue and application of analgesics during hospitalisation, that prevailed between 3 and 12hours, without any significant differences between groups. No adverse effects were observed in the study sample.. Paracetamol 1g IV given preoperatively decreased anaesthetic requirements and the need for postoperative analgesics similar to the preoperative administration of ketorolac 30mg IV.

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthetics, Inhalation; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Dose-Response Relationship, Drug; Double-Blind Method; Female; Humans; Infusions, Intravenous; Intraoperative Complications; Isoflurane; Ketorolac; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Postoperative Period; Preanesthetic Medication; Prospective Studies; Remifentanil

A randomized, double-blind, placebo-controlled study, with a six-month follow-up period.. 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.. 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.. 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.. 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.. Our findings do not support the routine combining of prolonged subanesthetic ketamine doses with opioids in posterior fusion surgery in children with idiopathic scoliosis.. 2.

Topics: Analgesia, Patient-Controlled; Child; Double-Blind Method; Female; Humans; Ketamine; Male; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Scoliosis; Time Factors

Acute remifentanil exposure during intraoperative analgesia might enhance sensitivity to noxious stimuli and nociceptive responses to innocuous irritation. Cyclooxygenase inhibition was demonstrated to attenuate experimental remifentanil-induced hyperalgesia (RIH) in rodents and human volunteers. The study aimed to compare the effects of preoperative and postoperative flurbiprofen axetil (FA) on RIH after surgery.. Ninety patients undergoing elective laparoscopic gynecologic surgery were randomly assigned to receive either intravenous placebo before anesthesia induction (Group C); or intravenous FA (1.0 mg/kg) before anesthesia induction (Group F1) or before skin closure (Group F2). Anesthesia consisted off sevoflurane and remifentanil (0.30 μg/kg/min). Postoperative pain was managed by sufentanil titration in the postanesthetic care unit, followed by sufentanil infusion via patient-controlled analgesia. Mechanical pain threshold (primary outcome), pain scores, sufentanil consumption, and side-effects were documented for 24 hours postoperatively.. Postoperative pain score in Group F1 was lower than Group C. Time of first postoperative sufentanil titration was prolonged in Group F1 than Group C (P=0.021). Cumulative sufentanil consumption in Group F1 was lower than Group C (P<0.001), with a mean difference of 8.75 (95% confidence interval, 5.21-12.29) μg. Mechanical pain threshold on the dominant inner forearm was more elevated in Group F1 than Group C (P=0.005), with a mean difference of 17.7 (95% confidence interval, 5.4-30.0) g. Normalized hyperalgesia area was decreased in Group F1 compared to Group C (P=0.007). No statistically significant difference was observed between Group F2 and Group C.. Preoperative FA reduces postoperative RIH in patients undergoing laparoscopic gynecologic surgery under sevoflurane-remifentanil anesthesia.

Topics: Adult; Analgesics, Opioid; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Female; Flurbiprofen; Forearm; Gynecologic Surgical Procedures; Humans; Hyperalgesia; Laparoscopy; Methyl Ethers; Middle Aged; Pain Threshold; Pain, Postoperative; Piperidines; Postoperative Care; Preoperative Care; Remifentanil; Sevoflurane; Sufentanil; Touch; Treatment Outcome

Inadequate analgesia following abdominal surgery may affect outcome. Data in patients undergoing liver surgery suggested that postoperative coagulopathy might delay epidural catheter removal. Thus, alternative analgesic techniques should be evaluated.. We compared the analgesic efficacy of intraoperative intrathecal morphine [single injection 4 µg/kg before skin incision (ITM group, n = 23)] to intravenous opioids [iv remifentanil infusion during surgery followed by i.v. bolus of morphine, 0.15 mg/kg before the end of surgery (IVO group, n = 26)]. Forty-nine adult patients undergoing elective open resection of liver or pancreas lesions in the Tel Aviv Medical Center were randomized into the two analgesic protocols. Postoperatively both groups received i.v. morphine via a patient-controlled analgesia pump. Follow-up was till the 3rd postoperative day (POD).. There was no significant difference in demographics and intraoperative data between groups. The primary outcome, pain scores on movement, was significantly worse in the IVO group when compared with the ITM group at various time points till POD3. In the secondary outcomes - need for rescue drugs - the IVO group required significantly more rescue morphine boluses. Complication related to the analgesia and recovery parameters were similar between groups.. The findings suggest that a single dose of ITM before hepatic/pancreatic surgery may offer better postoperative pain control than i.v. opioid administration during surgery. This beneficial effect is maintained throughout the first three PODs and is not associated with a higher complication rate; neither did it influence recovery parameters. ITM provides an appropriate alternative to i.v. morphine during major abdominal surgery.

Topics: Abdomen; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Elective Surgical Procedures; Female; Humans; Infusions, Intravenous; Liver; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil

The effectiveness of surgical pleth index (SPI) for managing nociception-antinociception balance during general anesthesia with vasodilators, including nicardipine has not been demonstrated. We aimed to compare the time course during surgery in SPI values in patients receiving nicardipine or remifentanil infusion during thyroidectomy.. Forty patients undergoing thyroidectomy were randomly assigned to receive nicardipine (group N; n = 19) or remifentanil (group R; n = 21) along with induction (propofol, fentanyl, and rocuronium) and maintenance (50% desflurane/nitrous oxide in oxygen) anesthesia (goal bispectral index [BIS] ∼50). The infusion of nicardipine or remifentanil was started before the 1st incision and adjusted to keep mean blood pressure (MBP) within ±20% of the preoperative value. SPI, BIS, end-tidal desflurane concentration (EtDes), MBP, and heart rate were recorded at 2.5 minute intervals from the 1st incision to the end of surgery. Extubation and recovery times, pain score/rescue ketorolac consumption, and adverse events in postanesthesia care unit (PACU) were recorded.. The trend of SPI during surgery was comparable between the 2 groups (P = 0.804), although the heart rates in group N were significantly higher than those in group R (P = 0.040). The patient characteristics, trends of BIS, EtDes, and MBP during surgery, extubation and recovery times, and incidence of nausea/vomiting were comparable between the groups. Group N had significantly lower pain scores and rescue ketorolac consumption at PACU.. SPI was comparable between patients receiving nicardipine or remifentanil infusion during thyroidectomy under general anesthesia, which suggests that the administration of nicardipine may confound the interpretation of SPI values during general anesthesia.. This trial was registered in the UMIN clinical trials registry (unique trial number: UMIN000019058; registration number: R000022028; principal investigator's name: Young Ju Won; date of registration: September 17, 2015).

Topics: Analgesics, Opioid; Anesthesia, General; Double-Blind Method; Female; Heart Rate; Humans; Male; Nicardipine; Pain, Postoperative; Photoplethysmography; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Thyroidectomy; Vasodilator Agents

Preoperative anxiety is known to be related with the postoperative outcomes, although it remains unclear whether pharmacologic anxiolysis preoperatively leads to better postanesthesia recovery. Hence, the purpose of this study was to assess whether midazolam premedication would result in improved Quality of Recovery-40 survey scores, as a postoperative recovery parameter, in female patients undergoing mastectomy.. This randomized double-blind study was performed at Severance Hospital, Yonsei University Health System, Seoul, Republic of Korea. Eighty-two females undergoing breast cancer surgery with propofol-remifentanil anesthesia were enrolled and randomized to receive midazolam 0.02 mg kg (group M) or saline (group C). Anesthesia was conducted with total intravenous anesthesia using propofol and remifentanil. On postoperative day 1, the Quality of Recovery-40 survey scores were surveyed.. The global Quality of Recovery-40 survey scores on postoperative day 1 did not significantly differ between groups M and C (183 vs 181, P = 0.568). However, the induction time was significantly shorter in group M (3.2 vs 4.5 min, P < 0.001), as was the total intraoperative propofol consumption (705 vs 1004 mg; P = 0.022).. Midazolam premedication does not seem to improve the postoperative quality of recovery, though group M showed faster induction and less propofol consumption.

Topics: Adult; Aged; Anesthetics, Intravenous; Anxiety; Breast Neoplasms; Double-Blind Method; Emotions; Female; Health Status; Humans; Hypnotics and Sedatives; Mastectomy; Mental Health; Midazolam; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Quality of Life; Remifentanil; Republic of Korea; Young Adult

To determine the efficacy of ultrasound-guided thoracic paravertebral block intraoperatively and 24 hours postoperatively in patients undergoing donor nephrectomy.. Prospective randomized controlled study.. Private foundation university hospital; November 2014 to June 2015.. Thirty-two patients undergoing donor nephrectomy (exclusion criteria: coagulation disorders, allergy to local anesthetics, and unwillingness to participate). The final study population comprised 30 patients (15 male, 15 female) randomly assigned to either Group P (paravertebral block, n=14) or Group M (morphine, n=16).. In Group P, a unilateral paravertebral catheter was inserted 1 day preoperatively; on the day of surgery, a single-level unilateral paravertebral block was administered through the catheter before general anesthesia. Infusion of bupivacaine continued intraoperatively and postoperatively. Patients in Group M received only general anesthesia, and morphine patient-controlled analgesia was begun postoperatively.. Intraoperative analgesic and anesthetic requirement, postoperative numerical rating scale pain scores, additional analgesic consumption during the postoperative period, and incidence of complications related to thoracic paravertebral block (TPVB) like pleural puncture, pneumothorax, epidural spread, injection into the subarachnoid space, intravascular injection, and Horner's syndrome and rate of opioid related adverse reactions like nausea and vomiting, itching, constipation, and respiratory depression.. Intraoperative remifentanil consumption was significantly higher in Group M, and postoperative morphine consumption was significantly lower in Group P (P<.001). During the first 24 hours postoperatively, the mean numerical rating scale pain scores were similar and there were no significant differences between the 2 groups. There were no statistically significant differences in the additional analgesic consumption and rate of adverse reactions between the 2 groups. We didn't detect any complication related to TPVB in group P.. Continuous thoracic paravertebral block provides good intraoperative stability with a low anesthetic requirement and reduces postoperative morphine consumption for up to 24 hours. Ultrasound guided technique enhanced the safety of TPVB and provides analgesia without major complications.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anatomic Landmarks; Anesthesia, General; Anesthetics, Local; Bupivacaine; Female; Humans; Intraoperative Care; Living Donors; Male; Middle Aged; Morphine; Nephrectomy; Nerve Block; Pain Management; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Thoracic Nerves; Thoracic Vertebrae; Tissue and Organ Harvesting; Treatment Outcome; Ultrasonography, Interventional

To investigate the effect of a single dose of ropivacaine combined with sufentanilfor thoracic paravertebral block (TPVB) on pain and enhanced recovery after surgery (ERAS) in patients undergoing video-assisted thoracosopic surgery.. Sixty patients undergoing video-assisted thoracosopic surgery were randomly divided into three groups to receive intravenous combined general anesthesia (group C), a single dose of ropivacainefor thoracic paravertebral block before surgery combined with intravenous and general anesthesia(group T. Compared with those in group C, the intravenous sufentanildose, total sufentanildose, intravenous remifentanildose during operation, NRS scores at 4 and 6, 24 h, and ICU stay and hospital stay after the surgery were significantly decreased in groups T. A single dose of ropivacaine combined with sufentanilfor thoracic paravertebral blockbefore surgery can reduce the total dose opioids, produce the optimal analgesic effect, and promote postoperative recovery of the patients.

Topics: Amides; Analgesics, Opioid; Anesthesia, General; Anesthetics, Intravenous; Humans; Injections; Nerve Block; Pain Management; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Period; Remifentanil; Ropivacaine; Sufentanil; Thoracic Surgery, Video-Assisted

Surgery-induced acute postoperative pain and stress response can lead to prolonged convalescence. The present study was designed to investigate the effects of intraoperative dexmedetomidine on postoperative analgesia and recovery following abdominal hysterectomy surgeries. Sixty-four patients scheduled for abdominal hysterectomy under general anesthesia were divided into two groups that were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS). During surgery, patients in the PRD group had a lower bispectral index (BIS) value, which indicated a deeper anesthetic state, and a higher sedation score immediately after extubation than patients in the PRS group. During the first 24 hours post-surgery, PRD patients consumed less morphine with patient-controlled analgesia (PCA) and had lower scores on a visual analogue scale (VAS) than their controls from the PRS group. The global 40-item quality of recovery questionnaire and 9-question fatigue severity score both showed higher recovery scores from day 3 after surgery in the PRD group. with the data are considered together, intraoperative administration of dexmedetomidine appeared to promote the analgesic properties of morphine-based PCA and to expedite recovery following surgery in patients undergoing abdominal hysterectomy.

Topics: Analgesia, Patient-Controlled; Anesthesia, General; Anesthetics, Intravenous; Dexmedetomidine; Double-Blind Method; Fatigue; Female; Humans; Hysterectomy; Intraoperative Care; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Surveys and Questionnaires

The aim of this study was to examine if gradual withdrawal of remifentanil infusion prevented opioid-induced hyperalgesia (OIH) as opposed to abrupt withdrawal. OIH duration was also evaluated.. Nineteen volunteers were enrolled in this randomized, double-blinded, placebo-controlled, crossover study. All went through three sessions: abrupt or gradual withdrawal of remifentanil infusion and placebo. Remifentanil was administered at 2.5 ng ml(-1) for 30 min before abrupt withdrawal or gradual withdrawal by 0.6 ng ml(-1) every five min. Pain was assessed at baseline, during infusion, 45-50 min and 105-110 min after end of infusions using the heat pain test (HPT) and the cold pressor test (CPT).. The HPT 45 min after infusion indicated OIH development in the abrupt withdrawal session with higher pain scores compared with the gradual withdrawal and placebo sessions (both P<0.01. Marginal mean scores: placebo 2.90; abrupt 3.39; gradual 2.88), but no OIH after gradual withdrawal compared with placebo (P=0.93). In the CPT 50 min after end of infusion there was OIH in both remifentanil sessions compared with placebo (gradual P=0.01, abrupt P<0.01. Marginal mean scores: placebo 4.56; abrupt 5.25; gradual 5.04). There were no differences between the three sessions 105-110 min after infusion.. We found no development of OIH after gradual withdrawal of remifentanil infusion in the HPT. After abrupt withdrawal OIH was present in the HPT. In the CPT there was OIH after both gradual and abrupt withdrawal of infusion. The duration of OIH was less than 105 min for both pain modalities.. NCT 01702389. EudraCT number 2011-002734-39.

Topics: Adolescent; Adult; Analgesics, Opioid; Cold Temperature; Cross-Over Studies; Double-Blind Method; Hot Temperature; Humans; Hyperalgesia; Infusions, Intravenous; Male; Pain Measurement; Pain, Postoperative; Piperidines; Pressure; Remifentanil; Young Adult

This study investigated the effects of indexes of consciousness (IoC1 and IoC2) monitoring on remifentanil dosage.. In this randomized, single-blinded, prospective study, 120 patients undergoing unilateral modified radical mastectomy were randomly assigned to the treatment group (T group, n = 60) or control group (C group, n = 60). In the T group, patients received both IoC1 (sedation) and IoC2 (analgesia) monitoring, and remifentanil dosages were adjusted by anesthetists according to IoC2. In the C group, remifentanil dosages were adjusted based on the anesthetists' judgment according to the patients' vital signs. Remifentanil dose, adjustment frequency, infusion duration, intraoperative adverse events, and quality of anesthetic recovery were compared between the two groups. The primary outcome was the dose of remifentanil.. Compared with the C group, mean remifentanil dosage was significantly higher in the T group (3.8 ± 1.9 versus 3.2 ± 1.2 μg kg(-1) h(-1), P < 0.05) during the anesthetic period, as was the adjustment frequency of target-controlled infusion (2.9 ± 1.9 versus 2.0 ± 1.2 times/surgery, P < 0.05), but there was no difference in infusion duration. Voluntary eye opening, extubation time, and recovery score were not significantly different between the two groups (P > 0.05). Total adverse events were significantly reduced in the T group (P < 0.05).. IoC1-targeted propofol dosing does not seem to be significantly different to hemodynamic-based monitoring, whereas IoC2 monitoring can increase remifentanil dosage during modified radical mastectomy, but the anesthetic process is more controllable and total adverse events are reduced, which improves the controllability of anesthesia.. ChiCTR-TRC-13004101 , registered on 27 November 2013.

Topics: Adult; Analgesics, Opioid; Blood Pressure; China; Consciousness; Female; Heart Rate; Humans; Mastectomy, Modified Radical; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Recovery of Function; Remifentanil; Single-Blind Method; Time Factors; Treatment Outcome

Previous studies have reported that intraoperative dexmedetomidine has morphine-sparing effects in patient-controlled analgesia (PCA). The present study was designed to investigate the possible sex differences in the morphine-sparing effects of intraoperative dexmedetomidine following general anesthesia. A total of 223 patients scheduled for surgeries under general anesthesia were divided into female and male groups. Each group was then subdivided into 2 subgroups that were maintained using propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS). During the first 24 hours postsurgery, both female and male PRD patients had lower scores on a visual analog scale (VAS) (fPRS vs fPRD, P < 0.05 or P < 0.01; mPRS mPRD, P < 0.05, P < 0.01, or P < 0.001) and consumed less morphine than their controls from the PRS group (fPRS vs fPRD, P = 0.0392; mPRS vs mPRD, P = 0.0041). Interestingly, the female PRD patients had similar VAS scores (fPRD vs mPRD, P > 0.05) and consumed comparable morphine compared to the male PRD patients (fPRD vs mPRD, P = 0.4238). However, when normalized to body weight, they consumed much more morphine than male PRD patients (fPRD vs mPRD, P < 0.001), and this effect was not seen in the PRS patients. Intraoperative administration of dexmedetomidine appeared to have a stronger morphine-sparing effect in controlling postoperative acute pain in male patients than in female patients.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, General; Anesthetics, Intravenous; Dexmedetomidine; Female; Humans; Intraoperative Care; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Sex Factors

To evaluate whether intraoperative high-dose remifentanil infusion increased local anesthetic consumption in postoperative epidural analgesia and postoperative pain scores compared with low-dose remifentanil infusion.. Prospective, randomized controlled study.. Operating room, university hospital.. Thirty female patients scheduled for elective gynecological abdominal surgery.. After epidural catheter placement and induction of general anesthesia, patients were randomly assigned to 2 anesthetic regimens. In the first group (high-dose remifentanil group), sevoflurane concentration was held constant at 1.2%, and the remifentanil infusion rate was titrated to maintain systolic blood pressure within 20% of baseline. In the second group (low-dose remifentanil group), the remifentanil infusion rate was held constant at 0.1μg/(kg min), and the sevoflurane concentration was titrated to maintain systolic blood pressure within 20% of baseline. As abdominal wall closure began, 6mL of 0.2% ropivacaine was administrated via epidural catheter; a patient-controlled analgesia device was set to deliver 4mL/h of 0.2% ropivacaine with 3μg/mL of fentanyl, with 2-mL incremental doses and a 15-minute lockout time.. Local anesthetic consumption via postoperative epidural catheter and pain intensity with the Prince Henry pain scale were assessed for 48hours after surgery.. The mean remifentanil infusion rate was 0.23μg/(kg min) in the high-dose remifentanil group, 2.3 times the rate used in the low-dose remifentanil group. The cumulative amount of local anesthetic used within 48hours of surgery was significant greater in the high-dose remifentanil group than in the low-dose remifentanil group (212±25mL vs. 181±35mL, respectively; P<.05), but postoperative pain scores were similar in each group.. Intraoperative high-dose remifentanil infusion increased local anesthetic consumption in postoperative epidural analgesia relative to low-dose remifentanil.

Topics: Abdomen; Adult; Aged; Analgesia, Epidural; Analgesics, Opioid; Dose-Response Relationship, Drug; Female; Gynecologic Surgical Procedures; Humans; Intraoperative Care; Middle Aged; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Treatment Outcome; Young Adult

The clinical relevance of pro- and hyperalgesic effects of opioids is still a matter of debate. Particularly for remifentanil, an increased postoperative need for analgesics has been demonstrated suggesting opioid-induced hyperalgesia as a possible cause. The aim of the study was therefore to investigate the effect of intraoperatively applied remifentanil compared to sufentanil on somatosensory thresholds investigated with the quantitative sensory testing (QST) battery of the German Research Network on Neuropathic Pain (DFNS).. The study was registered at the German registry for clinical studies (DRKS00009002).. Comparison of somatosensory thresholds before versus after surgery and application of intraoperative remifentanil or sufentanil.. Sixteen patients could be finally included in the analysis. No differences of mechanical or thermal detection or pain thresholds were observed between pre- and postoperative testing or between remifentanil and sufentanil.. A change of somatosensory thresholds or a clinically relevant opioid-induced hyperalgesia in the selected small patient sample (segmental resections or mastectomy with or without sentinel lymph node biopsy, surgery length <90 minutes, sufficient postoperative pain medication with paracetamol due to rather low postoperative pain intensities) with remifentanil or sufentanil was not detected 20 h after surgery.

Topics: Adult; Aged; Analgesics, Opioid; Double-Blind Method; Female; Humans; Male; Middle Aged; Pain Threshold; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Sufentanil

We aimed to compare fentanyl, remifentanil and dexmedetomidine with respect to hemodynamic stability, postoperative pain control and achievement of sedation at the postanesthetic care unit (PACU). In this randomized double-blind study, 90 consecutive total laparoscopic hysterectomy patients scheduled for elective surgery were randomly assigned to receive fentanyl (1.0 μg/kg) over 1 minute followed by a 0.4 μg/kg/hr infusion (FK group, n = 30), or remifentanil (1.0 μg/kg) over 1 minute followed by a 0.08 μg/kg/min infusion (RK group, n = 30), or dexmedetomidine (1 μg/kg) over 10 minutes followed by a 0.5 μg/kg/hr infusion (DK group, n = 30) initiating at the end of main procedures of the operation to the time in the PACU. A single dose of intravenous ketorolac (30 mg) was given to all patients at the end of surgery. We respectively evaluated the pain VAS scores, the modified OAA/S scores, the BIS, the vital signs and the perioperative side effects to compare the efficacy of fentanyl, remifentanil and dexmedetomidine. Compared with other groups, the modified OAA/S scores were significantly lower in DK group at 0, 5 and 10 minutes after arrival at the PACU (P < 0.05), whereas the pain VAS and BIS were not significantly different from other groups. The blood pressure and heart rate in the DK group were significantly lower than those of other groups at the PACU (P < 0.05). DK group, at sedative doses, had the better postoperative hemodynamic stability than RK group or FK group and demonstrated a similar effect of pain control as RK group and FK group with patient awareness during sedation in the PACU. (World Health Organization registry, KCT0001524).

Topics: Adolescent; Adult; Analgesics, Opioid; Blood Pressure; Dexmedetomidine; Double-Blind Method; Female; Fentanyl; Heart Rate; Hemodynamics; Humans; Hypotension; Laparoscopy; Male; Middle Aged; Nausea; Pain Management; Pain, Postoperative; Piperidines; Remifentanil; Young Adult

Postoperative cognitive dysfunction (POCD) is a well-known complication after cardiac surgery and may cause permanent disabilities with severe consequences for quality of life. The objectives of this study were, first, to estimate the frequency of POCD after on-pump cardiac surgery in patients randomized to remifentanil- or sufentanil-based anesthesia and, second, to evaluate the association between POCD and quality of recovery and perioperative hemodynamics, respectively.. Randomized study.. Postoperative cardiac recovery unit, University Hospital.. Sixty patients with ischemic heart disease scheduled for elective coronary artery bypass grafting ± aortic valve replacement.. Randomized to either remifentanil or sufentanil anesthesia as basis opioid. Postoperative pain management consisted of morphine in both groups.. Cognitive functioning evaluated preoperatively and on the 1st, 4th, and 30th postoperative day using the cognitive test from the Palo Alto Veterans Affairs Hospital. Perioperative invasive hemodynamics and the quality of recovery was evaluated by means of invasive measurements and an intensive care unit discharge score.. No difference between opioids in POCD at any time. A negative correlation was found between preoperative cognitive function and POCD on the first postoperative day (r=-0.47; P=.0002). The fraction of patients with POCD on the first postoperative day was statistically greater in patients with more than 15minutes of Svo2 <60 (P=.037; χ(2) test). Among patients with postoperative ventilation time exceeding 300minutes, more patients had POCD on postoperative day 4 (P=.002).. We could not demonstrate differences in POCD between remifentanil and sufentanil based anaesthesia, but in general, the fraction of patients with POCD seemed smaller than previously reported. We found an association between POCD and both perioperative low Svo2 and postoperative ventilation time, underlining the importance of perioperative stable hemodynamics and possible fast-track protocols with short ventilation times to attenuate POCD.

Topics: Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Cardiac Surgical Procedures; Cognition; Cognition Disorders; Coronary Artery Bypass; Female; Humans; Male; Neuropsychological Tests; Pain Management; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil

This study aimed to determine whether muscle relaxants facilitates insertion efficacy of the i-gel supraglottic device (i-gel) by novice doctors in anesthetized patients.. Randomized clinical trial.. Operating room.. Seventy adult patients scheduled for elective surgery under general anesthesia.. Seventy adult patients were assigned to the rocuronium (MR group; 35 patients) or control group (C group; 35 patients). Anesthesia was induced with propofol and remifentanil, and 0.9mgkg(-1) rocuronium was administered in the MR group.. The number of attempts to successful insertion, sealing pressure, and subjective difficulty of insertion were compared between the groups.. The total number of insertion attempts were as follows: one (MR group, 17 cases; C group, 4 cases), two (MR group, 13 cases; C group, 14 cases), three (MR group, 4 cases; C group, 14 cases), and failure (MR group, 1 case; C group, 3 cases), which was significantly different (P<.001). Sealing pressure was significantly higher in the MR group than in the C group (MR group, 22.1±5.4 cmH2O; C group, 18.7±3.2 cmH2O, P<.001). Subjective difficulty of insertion was significantly lower in the MR group than in the C group (C group, 72.4±19.0mm; MR group, 29.4±18.3mm; P<.001).. Our randomized clinical trial suggests that muscle relaxation facilitates i-gel insertion efficacy in anesthetized patients, as assessed by successful insertion rate, sealing pressure, and subjective difficulty of insertion.

Topics: Adult; Aged; Aged, 80 and over; Airway Management; Androstanols; Anesthesia, Intravenous; Anesthesiologists; Anesthetics, Intravenous; Clinical Competence; Female; Hoarseness; Humans; Intubation, Intratracheal; Male; Middle Aged; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil; Respiration, Artificial; Rocuronium; Young Adult

To evaluate the effects of low-dose butorphanol on hyperalgesia induced by high-dose remifetanil in patients undergoing laparoscopic cholecystectomy.. Randomized double-blind clinical trial.. Intraoperative.. Seventy-five patients scheduled for laparoscopic cholecystectomy were enrolled.. Randomly allocated into 3 groups, low dose of remifentanil (LR) group and high dose of remifentanil (HR) group received low (0.1μg kg(-1) min(-1)) or high (0.3μg kg(-1) min(-1)) doses of remifentanil, respectively, and butorphanol combined with remifentanil (BR) group received remifentanil (0.3μg kg(-1) min(-1)) and butorphanol (0.2μg/kg).. The visual analog scale scores and cumulative consumption of fentanyl were recorded.. Visual analog scale scores were significantly higher in the HR group than in the LR and BR groups (P<.001). The dose of intravenously given fentanyl was significantly higher in the HR group than in the LR and BR groups (P<.001). In addition, the HR group showed a significantly higher cumulative consumption of fentanyl during 5 to 8 hours after the operation (P<.001).. A high dose of remifentanil induces postoperative hyperalgesia, which could be prevented by a continuous intravenous administration of a low dose of butorphanol.

Topics: Adult; Analgesics, Opioid; Anesthesia, General; Butorphanol; Cholecystectomy, Laparoscopic; Double-Blind Method; Female; Fentanyl; Humans; Hyperalgesia; Male; Middle Aged; Narcotic Antagonists; Pain Measurement; Pain, Postoperative; Piperidines; Receptors, Opioid, kappa; Receptors, Opioid, mu; Remifentanil

To evaluate and compare intercostal-iliac transversus abdominis plane (TAP) and oblique subcostal TAP (OSTAP) blocks for multimodal analgesia in patients receiving laparoscopic cholecystectomy.. A prospective, randomized, double-blinded clinical study.. Operating room, postoperative recovery area, and ward.. In total, 60 laparoscopic cholecystectomy patients (43 women, 17 men, American Society of Anesthesiologists grades I-II) were enrolled from the general surgery department of our tertiary care center.. The patients were assigned to 1 of the 3 groups. Group 1 received TAP blocks (n=20), group 2 received OSTAP blocks (n=20), and group 3 patients were used as controls and received patient-controlled analgesia (PCA) only (n=20). After the induction of anesthesia, blocks were performed bilaterally in study groups 1 and 2, using 20mL of lidocaine (5mg/mL). PCA with intravenous tramadol was routinely provided for all patients during the first 24hours.. The intraoperative use of remifentanil, postoperative visual analog scale (VAS) scores, demand for PCA, and total analgesic consumption were recorded.. The patients in the control group had greater analgesic demands and analgesic consumption than did those in groups 1 and 2. However, patients in the OSTAP group had lower VAS scores than did those in groups 1 and 3.. The demand for analgesia was greater in the control group than in groups 1 and 2. Moreover, lower VAS scores were recorded in the OSTAP group than in groups 1 and 3 and were positively correlated with total PCA consumption among all patients. However, postoperative VAS scores were negatively correlated with the total intraoperative consumption of remifentanil at 24hours.. TAP and OSTAP blocks improved postoperative analgesia in patients receiving laparoscopic cholecystectomy, which resulted in lower VAS scores and reduction in total analgesic consumption.

Topics: Abdominal Muscles; Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Local; Cholecystectomy, Laparoscopic; Double-Blind Method; Female; Humans; Lidocaine; Male; Middle Aged; Nerve Block; Pain Management; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Tramadol; Ultrasonography, Interventional; Young Adult

High-dose remifentanil during surgery paradoxically increases postoperative pain intensity and morphine consumption. Cyclooxygenase inhibitors decrease prostaglandin synthesis, thereby antagonizing N-methyl-d-aspartate receptor activation, and may reduce hyperalgesia. This study was performed to evaluate whether postoperative morphine consumption increased following intraoperative continuous remifentanil infusion and whether this could be prevented by intravenous ibuprofen pretreatment.. A randomized controlled study.. Single university hospital, study period from September 2014 to March 2015.. One hundred and twenty patients undergoing pancreaticoduodenectomy.. After induction of anesthesia, patients received remifentanil target-controlled infusion (effect site concentration of 4 ng/mL or 1 ng/mL) with or without intravenous ibuprofen (800 mg).. Postoperative cumulative total morphine consumption and pain intensity were assessed.. Intraoperative remifentanil use in patients receiving high-dose remifentanil was more than 3-fold higher than that in patients receiving low-dose remifentanil (2666.8 ± 858.4 vs 872.0 ± 233.3 μg, respectively; P< .001). However, cumulative total morphine consumption at postoperative 1, 3, 6, 12, 24, and 48 hours did not differ among the groups. There were no differences among the groups in the self-administered analgesic dose by the patients using a controlled analgesia device, number of self-administration attempts, numerical rating scale for pain, or analgesic side effects.. We found no influence on postoperative pain after high-dose remifentanil in patients undergoing pancreaticoduodenectomy. Addition of intravenous ibuprofen did not reduce postoperative morphine consumption or pain intensity.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Cyclooxygenase Inhibitors; Female; Humans; Hyperalgesia; Ibuprofen; Infusions, Intravenous; Intraoperative Care; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Pancreaticoduodenectomy; Piperidines; Postoperative Period; Receptors, N-Methyl-D-Aspartate; Remifentanil

In this double-blind, randomized study, the authors compared the effects of a patient-controlled remifentanil and morphine combination with morphine alone on post-thoracotomy pain, analgesic consumption, and side effects.. A prospective, randomized, double-blind clinical study.. University hospital.. Volunteer patients at a university hospital undergoing elective thoracotomy surgery.. Patients were allocated randomly into 2 groups to receive patient-controlled analgesia: the morphine (M) group or the morphine plus remifentanil (MR) group. Pain, discomfort, sedation scores, cumulative patient-controlled morphine consumption, rescue analgesic (meperidine) requirement and side effects were recorded for 24 hours.. Sixty patients were allocated randomly to receive intravenous patient-controlled analgesia with morphine alone (M) or morphine plus remifentanil (MR) in a double-blind manner. Patients were allowed to use bolus doses of morphine (0.02 mg/kg) or the same dose of a morphine plus remifentanil (0.2 µg/kg) mixture every 10 minutes without a background infusion. VAS scores were lower in the MR group than in the M group at 30 minutes (p = 0.04), 1 hour (p = 0.03), and 2 hours (p = 0.04). Mean cumulative doses of morphine were not significantly different at 27.8±15 mg for the M group and 21.9±10.5 mg for the MR group. Significantly more patients needed meperidine in the M group (p = 0.039); these also experienced more nausea (p = 0.01).. Coadministration of PCA remifentanil with morphine for the treatment of post-thoracotomy pain did not reduce morphine consumption but provided superior analgesia, less use of rescue analgesics, and fewer side effects compared to morphine alone.

Topics: Administration, Intravenous; Adult; Analgesics, Opioid; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Thoracotomy

Total intravenous anesthesia (TIVA) is used widely in spinal surgery because inhalational anesthetics are known to decrease the amplitude of motor evoked potentials. Presently, dexmedetomidine is used as an adjuvant for propofol-based TIVA. We compared the effects of remifentanil and dexmedetomidine on pain intensity as well as the analgesic requirements after post-anesthesia care unit (PACU) discharge in patients undergoing spinal surgery.. Forty patients scheduled for posterior lumbar interbody fusion (PLIF) surgery under general anesthesia were enrolled. Anesthesia was maintained using propofol at 3-12 mg/kg/h and remifentanil at 0.01-0.2 μg/kg/min in Remifentanil group or dexmedetomidine at 0.01-0.02 μg/kg/min in Dexmedetomidine group, keeping the bispectral index between 40 and 60. Patient-controlled analgesia (PCA) made of hydromophone was applied once the patients opened their eyes in the PACU. The visual analog scale (VAS) score, PCA dosage administered, and postoperative nausea and vomiting (PONV) were recorded at the time of discharge from the PACU (T1) and at 2 (T2), 8 (T3), 24 (T4), and 48 hours (T5) after surgery.. The VAS score in Remifentanil group was significantly higher than that in Dexmedetomidine group at immediate and late postoperative period (4.1 ± 2.0 vs. 2.3 ± 2.2 at T1, and 4.0 ± 2.2 vs. 2.6 ± 1.7 at T5; P < 0.05). Dexmedtomidine group had a statistically significantly lower PCA requirement at every time point after surgery except directly before discharge from the PACU (3.0 ± 1.2 ml vs. 2.3 ± 1.4 ml at T1; P > 0.05, but 69.7 ± 21.4 ml vs. 52.8 ± 10.8 ml at T5; P < 0.05). Patients in Remifentanil group displayed more PONV until 24 hours post-surgery.. Dexmedetomidine displayed superior efficacy in alleviating pain and in postoperative pain management for 48 hours after PLIF. Therefore, dexmedetomidine may be used instead of remifentanil as an adjuvant in propofol-based TIVA.. Clinical Research Information Service (CRiS) Identifier: KCT0001041.

Topics: Aged; Analgesics, Non-Narcotic; Anesthetics, Intravenous; Dexmedetomidine; Female; Humans; Male; Middle Aged; Pain Management; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil; Spinal Cord

Opioids are the cornerstone therapy for the optimal pain management. Perioperative opioid infusion is accused of causing acute opioid tolerance, especially as the postoperative opioid requirement increases in time to provide efficient analgesia. It is debatable whether there is a difference between opioid agents regarding tolerance development. We aim to compare the effects of morphine, remifentanil and alfentanil when infused intravenously during the perioperative period.. Sixty patients undergoing elective major abdominal surgery were randomized into four groups. The four groups obtained the following treatments: saline 5 cc iv bolus and 10 cc/h infusion for induction and maintenance in Group C, remifentanil infusion 0.25 µg/kg/min following 1 µg/kg iv bolus in Group R, alfentanil infusion 0.50 µg/kg/min following 10 µg/kg iv bolus in Group A, and morphine infusion 0.02 mg/kg/h after 0.1 mg/kg iv bolus in Group M. Meperidine 10 mg/cc iv patient-controlled analgesia was used postoperatively, and total meperidine consumptions were recorded. VAS scores and side effects were recorded during postoperative 48 hours.. VAS scores in Group M were found to be significantly lower than in Group C at the 1st postoperative hour. Twenty-four hour total meperidine consumption in Group R and Group M were significantly lower than in Group C. No statistical difference was found between groups regarding the incidence of nausea and vomiting.. Our study indicated that infusions of morphine, alfentanil and remifentanil administered to patients undergoing major abdominal surgery did not cause acute opioid tolerance. In contrast, infusion of morphine and remifentanil reduced postoperative opioid requirement.

Topics: Abdomen; Alfentanil; Analgesia, Patient-Controlled; Analgesics, Opioid; Double-Blind Method; Female; Humans; Infusions, Intravenous; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Perioperative Period; Piperidines; Prospective Studies; Remifentanil; Treatment Outcome

Remifentanil, an ultra-short-acting opioid, provides intensive analgesia without prolonged respiratory depression and is widely used in cardiac surgery. Diminished dosing may also offer stable hemodynamics, even during sternotomy and sternal retraction. However, increased postoperative pain and induced opioid tolerance after remifentanil dosing during abdominal surgery was reported. We tested whether remifentanil 0.3 μg/kg/min infusion increased postoperative opioid consumption and pain compared to 0.1 μg/kg/min dosing.. Ninety coronary artery bypass grafting or heart valve surgery patients were randomized to remifentanil 0.1 μg/kg/min or 0.3 μg/kg/min infusions during surgery. All patients received oxycodone bolus 0.15 μg/kg postoperatively, and patient-controlled analgesia (PCA) with oxycodone thereafter. Postoperative pain was estimated thrice daily by visual analogue scale, and 48-h opioid consumption was recorded from the PCA-device.. Total remifentanil dosing was 64 μg/kg in the higher and 22 μg/kg in the lower dosing group during the 3-h cardiac operations. Mean postoperative opioid consumption was 107 (SD 36) mg in the lower and 104 (SD 33) mg in the higher dose remifentanil groups. Postoperative pain did not differ between groups, at rest or during deep breathing, at any time (P = 0.110 and 0.941, respectively).. Remifentanil 0.3 μg/kg/min infusion did not increase postoperative pain or opioid consumption after cardiac surgery compared to the 0.1 μg/kg/min infusion. Remifentanil infusion 0.1-0.3 μg/kg/min during cardiac surgery was safe, with no exaggerated postoperative pain or opioid consumption.

Topics: Analgesics, Opioid; Cardiac Surgical Procedures; Dose-Response Relationship, Drug; Female; Humans; Hypnotics and Sedatives; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

Opioids are associated with hyperalgesia that can reduce their analgesic effect. The aim of this study was to determine whether the addition of ketamine reduces remifentanil-induced hyperalgesia; improves its analgesic effect; and alters interleukin 6 (IL-6), IL-8, and IL-10 levels.. This is a prospective, randomized, double-blind study.. The setting is in a operating room and ward in a university hospital.. There are 56 patients, aged ≥18 years, American Society of Anesthesiologists I or II, who underwent laparoscopic cholecystectomy.. Anesthesia was induced with remifentanil, 50% oxygen, and isoflurane. Patients randomized to group 1 received remifentanil (0.4 μg/kg per minute) and ketamine (5 μg/kg per minute), and patients randomized to group 2 received remifentanil (0.4 μg/kg per minute) and saline solution. Postoperative analgesia was achieved using morphine via patient-controlled analgesia.. The measurements were postoperative pain intensity during 24 hours; morphine consumption; time to first morphine supplementation; hyperalgesia (using monofilaments and an algometer) and allodynia (using a soft brush) in the thenar eminence of the nondominant hand and in the periumbilical region 24 hours after surgery; extent of hyperalgesia using a 300-g monofilament near the periumbilical region 24 hours after surgery; and serum levels of IL-6, IL-8, and IL-10.. Groups were similar for baseline characteristics. There were no differences in pain intensity, time to first request of morphine, and total 24 hours dose of morphine between groups. There was a difference in hyperalgesia using monofilaments 24 hours after the surgery in the thenar eminence of the nondominant hand, with a better profile for the experimental group. However, there were no differences in hyperalgesia using an algometer, in allodynia using a soft brush; in extent of hyperalgesia; or in levels of IL-6, IL-8, and IL-10.. It was not possible to demonstrate that the addition of ketamine (5 μg/kg per minute) is effective in preventing or reducing remifentanil-induced postoperative hyperalgesia in laparoscopic cholecystectomy.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics; Analgesics, Opioid; Cholecystectomy, Laparoscopic; Double-Blind Method; Female; Humans; Hyperalgesia; Ketamine; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Treatment Outcome

This study was designed to investigate whether stepwise tapering of remifentanil at the end of surgery could decrease postoperative pain scores and requirements of rescue analgesics after remifentanil-desflurane anesthesia in patients with thyroidectomy.. Sixty two patients undergoing thyroidectomy under general anesthesia were randomly allocated into two groups. All patients were anesthetised with desflurane and high-dose remifentanil. Remifentnail was infused at the rate of 0.3 μg/kg/min until the end of surgery in patients of the control group (group A) whereas remifentanil was tapered gradually from 0.3 to 0.1 μg/kg/min until the end of surgery for at least 30 minutes in patients with group B. Pain scores (0-100 numerical rating scale, NRS), rescue analgesic requirements and adverse events were assessed at 30 min, 2 h, 6 h, 12 h, and 24 h after operation.. There was a significant decrease in pain scores at 30 min (20 [0-80] vs. 50 [0-100], P = 0.002) and 2 h (30 [10-60] vs. 40 [20-80], P = 0.018) after surgery in group B compared with group A. In addition, rescue analgesics are less required in group B than in group A postoperatively (2 [1-3] vs. 3 [2,3], P = 0.039). There were no significant differences in adverse events between the two groups.. Tapering of remifentanil at the end of surgery decreased postoperative pain scores immediately after thyroidectomy with desflurane and high-dose remifentanil anesthesia.. Clinical Research information Service (CRiS, registration number KCT0000589).

Topics: Adult; Aged; Analgesics; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Female; Humans; Infusions, Intravenous; Isoflurane; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Single-Blind Method; Thyroid Neoplasms; Thyroid Nodule; Thyroidectomy; Young Adult

Association between postoperative nausea and vomiting (PONV) and µ-opioid receptor A118G single nucleotide polymorphism (SNP) is undefined and might underlie inconsistent results of studies on PONV occurrence in patients undergoing general anesthesia with the opioid, remifentanil. Four hundred and sixteen Korean women undergoing breast surgery with general anesthesia were randomized to receive remifentanil 10 ng/mL (plasma-site, Minto model) using a target-controlled infusion device and either propofol for total intravenous anesthesia (T group) or sevoflurane for inhalation anesthesia (I group) with bispectral index values maintained between 40 and 60. Blood specimens were collected after anesthesia induction for A118G SNP analysis. PONV and postoperative pain were evaluated. A118G SNP type distribution among Korean female adults studied was AG (n=195)>AA (n=158)>GG (n=63). Regardless of anesthetic technique, patients with GG types had lower PONV scale on arrival at postoperative care unit (PACU) (P=0.002), while T group showed lower PONV scale than I group up to 6 hr after PACU discharge in AA and AG types. No differences were apparent for postoperative pain among opioid receptor polymorphism. PONV occurrence differs according to opioid receptor polymorphism and anesthetic technique in patients undergoing general anesthesia with remifentanil.

Topics: Adult; Analgesics, Opioid; Anesthesia, General; Breast Diseases; Demography; Double-Blind Method; Female; Humans; Methyl Ethers; Pain, Postoperative; Piperidines; Polymorphism, Single Nucleotide; Postoperative Nausea and Vomiting; Receptors, Opioid, mu; Remifentanil; Sevoflurane

Extracorporeal Shock Wave Lithotripsy is usually performed in day surgery setting, consequently people who undergo to this procedure need a safe and fast recovery. Conscious sedation with remifentanil can relieve from pain and keep patients in touch with anaesthesiologists. Few publications tell about infusion rates administered to perform this procedure7. The aim of this study is to assess which is the most appropriate infusion rate.. Patients were randomly assigned to two groups. Two different infusion rates were compared: 0,05 mcg/kg/min, GROUP A (N.=114), vs. 0.1 µg/kg/min, GROUP B (N.=114). Patients' vital signs, additional analgesic requests, PONV (postoperative nausea and vomiting) and other side effects were registered. The deepness of sedation and patient's satisfaction were evaluated referring to Obsever's Assessment of Alertness and Sedation scale (O/ASS) and using a Likert's scale respectively. Pain intensity was assessed with a 11-points VAS (visual analogue scale). Differences between groups were analyzed using Student t test for independent variables. The χ2 test was used to analyze categorical variables.. The study enrolled 228 patients and assigned them to two groups (N.=114). No significant differences were found regarding Likert's scale values (P=0.20), additional analgesic request (P=0.30) and mean VAS values (P>0.05) between the two groups. The difference between the two groups about PONV, hypotension, oxygen desaturation and respiratory depression was statistically significant (P<0.05), as a matter of fact in group A these side effects occurred less frequently. The fifth degree of O/ASS was estimated in about 1.61±0.19 min and 2.987±0.20 min in group A and in group B respectively (P<0.05).. According with previous results remifentanil at the infusion rate of 0.05 µg/kg/min provides an effective analgesia, causing a lower incidence of side effect than 0.1 µg/kg/min, granting a fast and safe recovery.

Topics: Analgesia; Anesthesia, Intravenous; Anesthetics, Intravenous; Conscious Sedation; Dose-Response Relationship, Drug; Double-Blind Method; Female; Hemodynamics; Humans; Hypotension; Hypoxia; Incidence; Infusions, Intravenous; Lithotripsy; Male; Middle Aged; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Complications; Postoperative Nausea and Vomiting; Remifentanil; Urolithiasis

Human volunteer studies demonstrate ketamine-reversible opioid-induced hyperalgesia, consistent with reports of increased postoperative pain and analgesic consumption. However, recent clinical trials showed controversial results after intraoperative administration of high-dose remifentanil.. To investigate in lower abdominal surgery patients whether postoperative pain intensity and analgesic consumption are increased following intraoperative high-dose vs. low-dose remifentanil, and whether this could be prevented by preoperative administration of the NMDA antagonist amantadine.. Randomised, placebo-controlled, clinical study.. University hospital.. Sixty patients scheduled for elective major lower abdominal surgery.. Patients were randomly assigned to one of three anaesthetic regimens. First, in the group 'low-dose remifentanil and preoperative isotonic saline' (n=15), a remifentanil infusion was maintained at a rate of 0.1 μg kg min throughout anaesthesia, and the end-tidal concentration of sevoflurane started at 0.5 minimum alveolar concentration (MAC) and was increased by 0.2% increments according to clinical demand. Preoperatively, 500 ml NaCl 0.9% were infused as study solution. Second, in the group 'high-dose remifentanil and preoperative saline' (n=17), the end-tidal concentration of sevoflurane was maintained at 0.5 MAC throughout anaesthesia. A remifentanil infusion was started at a rate of 0.2 μg kg min and subsequently increased by 0.05 μg kg min increments to clinical demand. Preoperatively, these patients also received a solution of 500 ml NaCl 0.9% as study solution. Third, the group 'high-dose remifentanil and preoperative amantadine' (n=16) received the same anaesthetic protocol as the second group, but the preoperative study solution was substituted by amantadine (200 mg/500 ml).. Pain intensity measured by the numerical rating scale and cumulative morphine consumption.. The remifentanil dose in both high-dose groups was significantly higher compared with the low-dose remifentanil group (0.20±0.04 and 0.23±0.02 vs. 0.08±0.04 μg kg min; P<0.001). Pain intensity gradually increased up to 45 min postoperatively in all groups, and then decreased again towards low levels in parallel with a linear increase in morphine consumption. Postoperative pain intensity and morphine consumption did not significantly differ between groups. Moreover, preoperative amantadine revealed no additional benefit.. We were not able to demonstrate any influence on routine clinical outcome parameters of pain after high-dose remifentanil. Although not without limitations, these findings are in line with other clinical trials that could not detect an opioid-induced impact on postoperative pain parameters, which might be less sensitive to detect opioid-induced hyperalgesia compared with quantitative sensory testing.. DRKS00004626.

Topics: Abdomen; Aged; Amantadine; Analgesics, Non-Narcotic; Analgesics, Opioid; Double-Blind Method; Female; Humans; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Remifentanil

Pain in the throat after extubation is one of the most common complaints after maxillofacial operations under general anaesthesia. We have evaluated the amount of pain after extubation when we controlled the pressure in the endotracheal cuff during operation by analysing the records of 43 patients who had maxillofacial operations under general anaesthesia. In the study group (n=20) the cuff pressure of the endotracheal tube was adjusted using a pressure gauge at the beginning of intubation and every hour during operation. In the control group (n=23), an experienced anaesthetist adjusted the pressure only at the beginning of the operation by palpating the pilot balloon. Throat pain was evaluated 1, 6, and 24h postoperatively on a visual analogue scale (VAS), and the pain scores in the control and study groups postoperatively was 5.3 (1.1) compared with 3.9 (1.5) (p=0.002); 4.5 (1.3) compared with 3.1 (1.5) (p=0.002); and 1.9 (1.1) compared with 1.6 (1.2) (p=0.4), respectively. The differences between the two groups at 1h and 6h postoperatively were significant, but that at 24h was not. Control of the cuff pressure of the endotracheal tube with a gauge at the beginning of the operation, and adjustment of the pressure during operation, can reduce postoperative complications such as throat pain.

Topics: Adult; Airway Extubation; Anesthesia, General; Anesthetics, Intravenous; Double-Blind Method; Equipment Design; Female; Follow-Up Studies; Humans; Intubation, Intratracheal; Male; Operative Time; Orthognathic Surgical Procedures; Pain Measurement; Pain, Postoperative; Pharyngeal Diseases; Piperidines; Pressure; Propofol; Prospective Studies; Remifentanil; Visual Analog Scale

The purpose of this study was to compare the analgesic effects of remifentanil with fentanyl following pediatric cardiac surgery. Fifty patients were included in the study and were randomized into two groups. Patients in group R were given remifentanil (50 μg/ml) at an infusion rate of 0.07 μg/kg/min and with bolus doses of 0.25 μg/kg with a 5-min lockout time; group F patients received fentanyl (50 μg/ml) at an infusion rate of 0.1 μg/kg/min and with bolus doses of 1 μg/kg with a 5-min lockout time. Pain was assessed using the Face, Legs, Activity, Cry, Consolability scale (FLACC scale), and sedation was assessed using the Ramsay sedation score. The number of boluses and demands, time to extubation, and side effects were analyzed. The FLACC scale, Ramsay sedation score, and mean extubation times were similar in the two groups. The total number of boluses and demands were significantly greater for group R than for group F. Itching as a side-effect was more severe in group F (p < .05). NCA remifentanil and fentanyl offer similarly effective pain control after pediatric cardiac surgery, but remifentanil has fewer side effects than fentanyl, indicating the suitability of remifentanil for use in NCA systems.

Topics: Analgesics, Opioid; Cardiac Surgical Procedures; Child, Preschool; Fentanyl; Humans; Infant; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

Scoliosis repair is a major orthopaedic surgery associated with severe post-operative pain. Ketamine and magnesium have an established efficacy as morphine-sparing agents. Our purpose was to evaluate the morphine-sparing effect of both magnesium and ketamine given simultaneously compared with ketamine alone during scoliosis surgery.. Fifty patients scheduled for posterior instrumentation were randomised in a prospective double-blind study. The Gr (K + Mg) received, after induction, an intravenous (IV) bolus of ketamine 0.2 mg/kg and magnesium 50 mg/kg, followed by continuous infusion of ketamine (0.15 mg/kg/h) and magnesium (8 mg/kg/h) until extubation. The Gr (K) received the same dose of ketamine associated with bolus and continuous infusion of normal saline. All patients received multimodal analgesia associated with IV morphine administered via patient-controlled analgesia pump. Morphine consumption, visual analogue scale (VAS) pain scores and occurrence of side effects were followed until 48 h post-operatively. Sleep quality and patient satisfaction were also followed. P < 0.05 was considered statistically significant.. The average cumulative morphine consumption was significantly lower in the Gr (K + Mg) compared with the Gr (K) at post-operative hours 4, 8, 12, 18, 30, 36 and 48. The relative difference in the post-operative morphine consumption was 29.5%: Gr (K + Mg) 51.53 mg vs. Gr (K) 73.16 mg. VAS scores were not statistically different between the two groups. However, qualities of sleep and satisfaction scores on the first night were significantly better in the Gr (K + Mg) (P = 0.027 and P = 0.016, respectively).. Ketamine and magnesium association reduces the post-operative morphine consumption after scoliosis surgery. It seems to provide a better sleep quality and improves patient satisfaction.

Topics: Adolescent; Analgesia, Patient-Controlled; Analgesics; Child; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Hyperalgesia; Infusions, Intravenous; Internal Fixators; Intraoperative Complications; Ketamine; Magnesium Sulfate; Male; Morphine; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Prosthesis Implantation; Remifentanil; Scoliosis; Sleep; Spinal Fusion

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.. 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.. 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).. 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.. 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.

Topics: Adolescent; Adult; Analgesics, Opioid; Dose-Response Relationship, Drug; Double-Blind Method; Female; Follow-Up Studies; Humans; Intraoperative Care; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Complications; Prognosis; Prospective Studies; Remifentanil; Thyroid Diseases; Thyroidectomy; Young Adult

Remote ischemic preconditioning (RIPC) may confer the protection in critical organs. The authors hypothesized that limb RIPC would reduce lung injury in patients undergoing pulmonary resection.. In a randomized, prospective, parallel, controlled trial, 216 patients undergoing elective thoracic pulmonary resection under one-lung ventilation with propofol-remifentanil anesthesia were randomized 1:1 to receive either limb RIPC or conventional lung resection (control). Three cycles of 5-min ischemia/5-min reperfusion induced by a blood pressure cuff served as RIPC stimulus. The primary outcome was PaO2/FIO2. Secondary outcomes included other pulmonary variables, the incidence of in-hospital complications, markers of oxidative stress, and inflammatory response.. Limb RIPC significantly increased PaO2/FIO2 compared with control at 30 and 60 min after one-lung ventilation, 30 min after re-expansion, and 6 h after operation (238 ± 52 vs. 192 ± 67, P = 0.03; 223 ± 66 vs. 184 ± 64, P = 0.01; 385 ± 61 vs. 320 ± 79, P = 0.003; 388 ± 52 vs. 317 ± 46, P = 0.001, respectively). In comparison with control, it also significantly reduced serum levels of interleukin-6 and tumor necrosis factor-α at 6, 12, 24, and 48 h after operation and malondialdehyde levels at 60 min after one-lung ventilation and 30 min after re-expansion (all P < 0.01). The incidence of acute lung injury and the length of postoperative hospital stay were markedly reduced by limb RIPC compared with control (all P < 0.05).. Limb RIPC attenuates acute lung injury via improving intraoperative pulmonary oxygenation in patients without severe pulmonary disease after lung resection under propofol-remifentanil anesthesia.

Topics: Acute Lung Injury; Aged; Analysis of Variance; Anesthesia, Intravenous; Anesthetics, Intravenous; Carcinoma, Non-Small-Cell Lung; Cytokines; Female; Humans; Inflammation; Ischemic Preconditioning; Lung; Lung Neoplasms; Male; Malondialdehyde; Middle Aged; Oxidative Stress; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Respiratory Function Tests; Sample Size; Treatment Outcome

Remifentanil is a powerful analgesic with fast onset and ultra-short duration of action. Its context-sensitive half-time is consistently short even after a prolonged infusion. Remifentanil is effective for providing better postoperative analgesia, but this method is not generally accepted in Japan. The present study was conducted to document efficacy and safety of low-dose remifentanil infusion in postoperative patients.. Forty patients undergoing abdominal surgery were studied prospectively. They were randomly assigned to either remifentanil (0.02 microg x kg(-1) x min(-1)) or placebo group. Postoperatively all patients received continuous epidural anesthesia with lidocaine and IV patient-controlled analgesia with fentanyl. Flurbiprofen was administered only when no pain relief was achieved. Visual analogue scale (VAS), requirement of fentanyl and flurbiprofen, and the incidence of remifentanil-related adverse effects (respiratory depression, nausea, vomiting, pruritus) were examined at 3 hourly intervals for 12 hours.. There are no statistical differences between two groups in pain scores. No adverse events including respiratory depression occurred throughout the study in both groups.. Remifentanil infusion at 0.02 microg x kg(-1) x min(-1) can safely be used without any serious adverse events, while it may not be enough for postoperative analgesia. The best dosage of this drug for postoperative analgesia remains to be elucidated.

Topics: Abdomen; Adult; Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, General; Double-Blind Method; Female; Fentanyl; Humans; Infusions, Intravenous; Lidocaine; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Care; Remifentanil; Surgical Procedures, Operative; Young Adult

We had for aim to compare the effects of intra-operative opioid analgesia according to the drug kinetics.. We conducted a prospective, controlled, randomized, double-blinded trial including 60 patients scheduled for ambulatory multiple third molar avulsion. The general anesthesia, performed with propofol and analgesia was a target-controlled infusion of either remifentanil or sufentanil. The anesthesia was set to reach an optimal bispectral index and adjusted to a clinical target throughout the procedure. The main endpoints were: postoperative request for morphine and other opioids; postoperative pain; postoperative adverse effects of opioids.. In the post-operative care unit (French acronym PACU), patients who received remifentanil were extubated earlier (17 vs. 26 min.), but had more pain and required twice more morphine for analgesia (6 vs. 3 mg), than those who had received sufentanil. However, the need for post-surgery oral opioid intake was greater in the sufentanil group, so the overall postoperative opioid consumption and patient satisfaction were identical in both groups. The time spent in the PACU was also identical for both groups.. Using an ultra-short kinetic opioid such as remifentanil does not seem useful, since the shorter delay before extubation is compensated by a greater need for morphine in the PACU.

Topics: Administration, Intravenous; Adolescent; Adult; Analgesia; Analgesics, Opioid; Anesthesia, General; Female; Humans; Male; Molar, Third; Outpatients; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil; Tooth Avulsion; Young Adult

adequate pain control after cardiac surgery is mandatory to reduce its remarkable morbidity. In this study, we aimed to compare the efficacy of patient-controlled analgesia with remifentanil or sufentanil for pain management after coronary artery bypass grafting.. 249 patients who underwent coronary artery bypass were randomly assigned to receive patient-controlled analgesia with remifentanil or sufentanil during the first 24 h postoperatively. Pain intensity during patient-controlled analgesia was assessed using 4 different pain rating scales.. patients given remifentanil had lower Visual Analog Scale scores at 24 h compared to those given sufentanil (p = 0.002). The Numeric Rating Scale at 24 h was also significantly lower in patients using remifentanil (p = 0.004). The Faces Pain Scale scores at 4, 18, and 24 h were significantly lower in patients using remifentanil compared to those using sufentanil (p = 0.045, 0.036, and 0.011, respectively). No significant differences between groups were seen in the pain intensity assessed by the Behavior Rating Scale at any time point during the first 24 h postoperatively.. our study showed that both remifentanil and sufentanil patient-controlled analgesia can provide acceptable analgesia after coronary artery bypass. The difference between their efficacies was inconspicuous until 24 h postoperatively. Remifentanil seems to result in better pain relief at 24 h postoperatively.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Coronary Artery Bypass; Female; Humans; Iran; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil; Time Factors; Treatment Outcome

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.

Topics: Adult; Anesthetics, Intravenous; Double-Blind Method; Female; Gynecologic Surgical Procedures; Hemodynamics; Humans; Laparoscopy; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil

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.. 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.. 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.. 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.

Topics: Aged; Analgesia, Patient-Controlled; Anesthetics, Combined; Anesthetics, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Antiemetics; Cough; Female; Humans; Hysterectomy; Laparoscopy; Methyl Ethers; Middle Aged; Narcotics; Ovariectomy; Oxycodone; Pain Management; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Remifentanil; Salpingectomy; Sevoflurane; Single-Blind Method

Acute pain is common during the endotracheal extubation period, and is related to complications and adverse outcomes. Patients with delayed extubation after craniotomy are vulnerable to pain and complications of extubation. However, pain control during extubation is still inadequate. Remifentanil, a new opioid with rapid onset and short duration of action, provides adequate analgesia during procedures with minimal effect of respiratory depression.. The study is a prospective, randomised, double-blinded, controlled parallel-group design. Patients with delayed extubation after intracranial surgery are screened daily. Adult patients ready for extubation are enrolled and assigned randomly to one of the two treatment study groups, labelled as the 'Remi group' or 'Saline group'. Patients in the Remi group receive an intravenous bolus dose of remifentanil 0.5 μg/kg over 60 s followed by a continuous infusion 0.05 μg/kg/min for 20 min. Patients in the Saline group receive an intravenous infusion of 0.9% sodium chloride at a volume and rate equal to that of remifentanil. Pain intensity is measured by the visual analogue scale (VAS) pain score. Adverse events during drug infusion are documented and reported. Patients will be followed up until hospital discharge, death or 60 days after the trial intervention on a first come, first served basis. Details of the incidence of reintubation and reoperation within 72 h after extubation, length of stay in the intensive care unit and hospital and mortality are collected. The primary end point is the incidence of severe pain (defined as a VAS pain score more than 5 cm) during the periextubation period (defined as the period of time from immediately before extubation to 20 min after extubation).. The study was approved by the Institutional Review Board (IRB) of the Beijing Tiantan Hospital, Capital Medical University. The study findings will be disseminated through peer-reviewed publications and conference presentations.. ClinicalTrials (NCT): ChiCTR-PRC-13003879.

Topics: Adolescent; Adult; Aged; Airway Extubation; Analgesia; Analgesics, Opioid; Craniotomy; Double-Blind Method; Humans; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Statistics as Topic; Young Adult

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

Emergence delirium (ED) refers to a variety of behavioral disturbances commonly seen in children following emergence from anesthesia. Vapor-based anesthesia with sevoflurane, the most common pediatric anesthetic technique, is associated with the highest incidence of ED. Propofol has been shown to reduce ED, but these studies have been methodologically limited.. To conduct a randomized-controlled trial comparing the incidence of ED in children following sevoflurane (SEVO) anesthesia and propofol-remifentanil total intravenous anesthesia (TIVA).. One hundred and twelve children, ASA I-II, aged ≥ 2 and ≤ 6 years, undergoing strabismus repair, were assigned to receive TIVA (intravenous induction and maintenance of anesthesia with propofol and remifentanil) or SEVO (inhalational induction and maintenance of anesthesia with sevoflurane). Parent-child induction behavior was scored using the Perioperative Adult Child Behavior Interaction Scale (PACBIS). Postoperatively, ED was assessed by a masked investigator using the Pediatric Anesthesia Emergence Delirium (PAED) Scale and pain using the Face, Legs, Activity, Cry, Consolability (FLACC) Scale every 5 min.. Data are reported for 94 subjects. Incidence of ED was higher with SEVO (38.3% vs 14.9%, P = 0.018). There was no difference in the median PACBIS score. A higher FLACC score was seen with SEVO (median 3 vs 1, P = 0.033). Subjects experiencing ED had higher FLACC scores vs those unaffected by ED (median 7 vs 1, P < 0.0001).. There was a lower incidence of ED after TIVA. Both intravenous and inhalational inductions were similarly well-tolerated. The use of TIVA was associated with reduced postoperative pain as measured using FLACC scores.

Topics: Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Behavior; Child, Preschool; Delirium; Female; Humans; Interpersonal Relations; Intraoperative Care; Male; Methyl Ethers; Nurses; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Recovery Room; Remifentanil; Sevoflurane; Treatment Outcome

The aim of this study was to compare fentanyl-based versus remifentanil-based anesthesia with regards to the intraoperative hemodynamic stress response and recovery profiles in patients undergoing Le Fort I osteotomy. Seventeen patients were randomly divided into two groups: patients in the F-group received 2 μg/kg fentanyl intravenously followed by an infusion of 0.03-0.06 μg/kg/min, while patients in the R-group received a 0.5 μg/kg bolus of remifentanil followed by an infusion of 0.0625-0.250 μg/kg/min. Mean arterial pressure and heart rate were recorded at the following points: before anesthetic induction, at endotracheal intubation, 5 min after intubation, at incision, just before the osteotomy, during the osteotomy, during the maxillary fracturing, at suturing, at extubation, 5 min after extubation, and then 15 and 30 min postoperatively. Heart rate and mean arterial pressure were significantly lower in the R-group in comparison to the F-group from t1 to t9 (P<0.05). All measured recovery times were significantly shorter in the R-group (P<0.05). The incidence of postoperative side effects was comparable between groups. Remifentanil-based anesthesia is an appropriate alternative to fentanyl during Le Fort I orthognathic surgery; it promotes hemodynamic stability, blunts the stress response to noxious stimuli, and provides a better recovery profile.

Topics: Adolescent; Adult; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Antihypertensive Agents; Arterial Pressure; Blood Loss, Surgical; Female; Fentanyl; Follow-Up Studies; Heart Rate; Humans; Intubation, Intratracheal; Labetalol; Male; Maxilla; Methyl Ethers; Monitoring, Intraoperative; Orthognathic Surgical Procedures; Osteotomy, Le Fort; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Sevoflurane; Single-Blind Method; Wound Closure Techniques; Young Adult

To explore the effect of dexmedetomidine in acute postoperative pain and remifentanil-induced hyperalgesia.. From January 2011 to June 2012, 120 patients scheduled for elective abdominal surgery under general anesthesia were included in this study. All patients received intravenous remifentanil infusion during operation, and dexmedetomidine was given after anesthesia induction. The postoperative mechanical pain threshold, pain visual analog scale (VAS) score, morphine consumption, and score of sedation (Ramsay) was recorded.. Relatively large-dose intraoperative remifentanil resulted in lower mechanical pain threshold and higher dose of postoperative morphine consumption. Dexmedetomidine reduced postoperative morphine consumption significantly, and increased Ramsay scores, but had no effect on mechanical hyperalgesia.. Dexmedetomidine can alleviate the acute postoperative pain effectively, but the effect is not dependent on inhibiting remifentanil-induced hyperalgesia.

Topics: Adult; Aged; Dexmedetomidine; Female; Humans; Hyperalgesia; Male; Middle Aged; Pain Threshold; Pain, Postoperative; Piperidines; Remifentanil

Different anesthetic techniques have been used for fast tracking in cardiac anesthesia. Remifentanil, with its unique pharmacokinetic profile, could be an ideal drug for fast tracking. Possible limitations of remifentanil are rapid onset of postoperative pain after discontinuation of the drug infusion, which may increase the risk of an ischemic event. We conducted this randomized study to compare the efficacy of remifentanil versus low doses of fentanyl in fast-track cardiac anesthesia. It has been hypothesized that remifentanil would provide a safe anesthesia with no impact on myocardial function and with positive effects on extubation time and mobilization.. We compared the postoperative course of patients, the remifentanil group (RG) and the low-dose fentanyl group (LDFG), in whom remifentanil and low-dose fentanyl, respectively, were used for fast-track cardiac anesthesia. The study was designed as a prospective randomized study. The primary outcomes were changes in the cardiac index and creatine kinase MB fraction (CKMB), extubation times, mobilization times, and lengths of stay in the intensive care unit (ICU) and the hospital. Frequency of myocardial infarction (MI), reoperations due to excessive bleeding, renal impairment, and cerebral complications were registered as well.. Seventy-one patients were enrolled in the study, and 7 were excluded due to difficult airway, bleeding, and technical difficulties. The RG comprised 33 patients and the LDFG comprised of 31 patients. There were no differences between the groups in terms of age, Euroscore, types of surgery, extracorporeal circulation, and aortic cross-clamp time. We did not find significant difference in cardiac index, CKMB, extubation times, mobilization times, length of stay in the ICU and in the hospital between the groups. Postoperative complications such as MI, rates of reoperations, renal and cerebral complications and incidence of atrial fibrillation did not show any significant differences.. Remifentanil fast-track anesthesia for cardiac patients has no negative impact on myocardial function. Both remifentanil and low-dose fentanyl are equally effective and safe for fast-track cardiac anesthesia. The study did not highlight any statistical superiority of remifentanil anesthesia over low-dose fentanyl anesthesia.

Topics: Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Cardiac Surgical Procedures; Denmark; Dose-Response Relationship, Drug; Female; Fentanyl; Hospital Mortality; Humans; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Operative Time; Pain, Postoperative; Piperidines; Prevalence; Remifentanil; Risk Factors; Survival; Treatment Outcome

To investigate whether a continuous infusion of low-dose esmolol results in an opioid-sparing effect during surgery.. Randomized, double-blinded, placebo-controlled clinical comparison study.. Operating room of a university hospital.. 56 ASA physical status 1 and 2 patients, aged 20 to 60 years, undergoing laparoscopic gynecologic surgery of less than two hours' duration.. The esmolol group (n = 28) received a 0.5 mg/kg loading dose of esmolol followed by an infusion of esmolol 30 μg/kg/min; the saline group (n = 28) received equivalent volumes of normal saline.. The effect-site concentration of remifentanil (ng/mL) to maintain adequate anesthetic depth before infusion of the study drug (before-concentration) was measured. During infusion of study drug, the effect-site concentration of remifentanil was adjusted every 5 minutes to maintain systolic blood pressure within 15% of baseline and a Bispectral Index value between 50-60. The average of these adjusted concentrations (after-concentration) was measured and compared to the before-concentration. The quality of postoperative recovery was assessed.. In the esmolol group, the after-concentration of remifentanil was decreased by 33.3% compared with the before-concentration. The total dose of remifentanil infused was also lower in the esmolol group (0.09 ± 0.1 vs 0.14 ± 0.03 μg/kg/min; P = 0.031). The esmolol group had lower scores on a pain numerical rating scale and required less fentanyl in the Postanesthesia Care Unit.. Intraoperative esmolol infusion decreases both the requirement for remifentanil and postoperative administration of rescue analgesics.

Topics: Adrenergic beta-1 Receptor Antagonists; Adult; Analgesics, Opioid; Anesthetics, Intravenous; Double-Blind Method; Drug Administration Schedule; Female; Gynecologic Surgical Procedures; Humans; Infusions, Intravenous; Laparoscopy; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Care; Propanolamines; Remifentanil; Young Adult

Clinical and pre-clinical data agree that opioids disrupt sleep architecture. Recently, remifentanil has been suggested to cause possible long-term disturbances of sleep quality. This randomized controlled clinical trial was designed to substantiate or refute a possible long-term effect of remifentanil on the quality of sleep.. One hundred patients undergoing elective surgery were randomized to receive either fentanyl or remifentanil-based anaesthesia. Before operation (T0) and 3 (T3) and 6 (T6) months after operation, the quality of sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI).. Overall, the quality of sleep for patients in the remifentanil or fentanyl group was not significantly different at any time point. Patients in the fentanyl group screened as good sleepers before operation showed no differences across time course of the study in PSQI scores. In contrast, good sleepers in the remifentanil group had significantly impaired sleep quality for at least 3 months after operation. Patients who were before operation screened as poor sleepers showed no significant changes in PSQI scores at T3 and T6 in both groups.. The intraoperative use of remifentanil in a general patient population does not significantly alter the quality of sleep in the postoperative period. However, it may result in a significant reduction in the quality of sleep in patients before operation considered good sleepers. These changes were not observed in the group of patients receiving fentanyl. The relevance of these findings in terms of patient recovery and quality-of-life warrants further investigation. Trial Registration. ACTRN12610000362099.

Topics: Acetaminophen; Adolescent; Adult; Analgesics, Non-Narcotic; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Entropy; Female; Follow-Up Studies; Humans; Male; Middle Aged; Orthopedic Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil; Sample Size; Serotonin 5-HT3 Receptor Antagonists; Sleep; Young Adult

Obesity is a multisystem disorder, particularly involving the respiratory and cardiovascular systems; therefore, a multidisciplinary approach is required. In spite of widespread performance of weight reduction (bariatric) surgeries, information regarding the anesthetic care of morbidly obese patients is scarce. The aim of this study was to compare the impact of fentanyl and remifentanil on the time of recovery, breathing parameters, and postoperative pain in morbidly obese patients undergoing laparoscopic adjustable gastric banding operations.. In this prospective randomized study, 66 morbidly obese patients (BMI>35 kg/m(2)), aged between 24 and 70 years, scheduled for a laparoscopic adjustable gastric banding operation were divided into 2 groups based on the opioid used for anesthesia: group 1 whose who received remifentanil; and group 2, fentanyl). The following parameters were recorded: peripheral blood oxygenation (SpO2) while breathing room air at baseline and 5 minutes after preoxygenation (100%); end-tidal carbon dioxide pressure at designated time points during the procedure; time to extubation; SpO2 in the postanesthesia care unit; and pain intensity (using the visual analogue scale); and the presence of nausea and vomiting.. The time to extubation was shorter in the remifentanil group, but there was no significant difference in the time to discharge from the postanesthesia care unit. The recovery of respiratory parameters to the baseline values was better and faster in the remifentanil group. The intensity of postoperative pain was similar in both groups (VAS, <3) CONCLUSIONS: Remifentanil showed good analgesic properties during laparoscopic gastric banding surgery. Postanesthesia recovery and return of respiratory parameters to the baseline values was faster when remifentanil was used. Postoperative pain and the rate of opioid-induced side effects after analgesia with remifentanil were similar as after anesthesia with a longer acting opioid, fentanyl. Despite the problem widely discussed in literature about remifentanil-induced hyperalgesia, no cases of analgesic overconsumption were registered in our study.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Intravenous; Clinical Protocols; Female; Fentanyl; Gastroplasty; Humans; Hyperalgesia; Laparoscopy; Male; Middle Aged; Obesity, Morbid; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Respiration; Young Adult

There is some evidence that propofol may reduce post-operative pain. However, the results on the analgesic effects of propofol are inconsistent. Thus, we hypothesized that propofol reduces acute pain if confounding factors like opioids are avoided.. In this prospective, randomized, subject- and assessor-blind, parallel-group, head-to-head comparative study, 90 American Society of Anesthesiologists I or II females underwent elective laparoscopies were randomized to receive either propofol-based (PR), or sevoflurane-based (SR), or sevoflurane-propofol-based anesthesia (SPR). Pain score at rest assessed by a numerical rating scale at 0.5 h after surgery was the primary outcome. The secondary outcomes included pain score at 1 and 24 h post-operatively, duration of post-anesthesia care units stay (PACU), incidence of post-operative nausea and vomiting, incidence of shivering, and post-operative quality of recovery score (QoR-40) within the first 24 h post-operatively.. No patients received rescue analgesia. The pain score at 0.5 h post-operatively was less in group PR when compared with group SR (0.7 ± 1.4 vs. 2.1 ± 1.8; P = 0.010) or group SPR (0.7 ± 1.4 vs. 2.1 ± 2.2; P = 0.008). Group PR was also associated with shorter PACU stay than group SR (21.8 ± 5.7 vs. 26.2 ± 6.9; P = 0.050) or group SPR (21.8 ± 5.7 vs. 27.8 ± 8.9; P = 0.005). Intraoperative bispectral index values, hemodynamic values and post-operative QoR-40 scores did not differ among the three groups.. Propofol anesthesia was associated with significantly less pain at 0.5 and 1 h after surgery in patients undergoing gynecological laparoscopies with planned opioid-free post-operative analgesia.

Topics: Adult; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Double-Blind Method; Female; Gynecologic Surgical Procedures; Humans; Infertility, Female; Laparoscopy; Methyl Ethers; Monitoring, Intraoperative; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Sample Size; Sevoflurane; Treatment Outcome; Young Adult

This study evaluated the effect of limiting maximal infusion-pump flow rate on suppression of remifentanil-induced cough during target-controlled infusion. Two hundred and ten patients were randomly assigned to receive remifentanil at an effect-site concentration of 4.0 ng.ml(-1) with maximal flow rate limited to 100 (group R(100)), 200 (group R(200)), or 1200 ml.h(-1) (group R(1200)). The number of episodes of cough were recorded and graded as mild (1-2), moderate (3-4), or severe (5 or more). The incidence of cough was 2.9% in group R(100), 5.7% in group R(200) and 25.7% in group R(1200). Patients in group R(100) and R(200) had a significantly lower incidence of cough than those in group R(1200) (p < 0.05). Zero, two and five patients coughed a moderate amount in groups R(100), R(200) and group R(1200), respectively (p < 0.05). Limiting maximal infusion rate during remifentanil TCI suppressed remifentanil-induced cough.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Antitussive Agents; Cough; Drug Delivery Systems; Female; Humans; Infusion Pumps; Infusions, Intravenous; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Young Adult

Thoracotomy is one of the most painful surgical incisions. Little is known, however, about the effect of type of anaesthesia on chronic post-thoracotomy pain syndrome (CPTS). We therefore compared the incidence of CPTS after total intravenous anaesthesia (TIVA) and inhalation anaesthesia.. Patients (n = 366) were prospectively randomized into two groups: Group I (n = 173) received TIVA (propofol + remifentanil) and Group II (n = 170) received inhalation anaesthesia with sevoflurane. We assessed acute pain on postoperative days 1, 3 and 5, and the prevalence of CPTS at 3 and 6 months using a numerical rating scale (NRS).. The prevalence of CPTS was significantly lower in patients receiving TIVA than in those receiving inhalation anaesthesia at 3 months (38.2% versus 56.5%, P = 0.001) and at 6 months (33.5% versus 50.6%, P = 0.002), respectively. Moreover, allodynia-like pain was significantly less common in the TIVA group at 3 (P = 0.021) and 6 months (P = 0.032). NRS score of acute pain, however, did not differ significantly between the two groups.. TIVA with propofol and remifentanil may reduce the incidence of CPTS at 3 and 6 months.

Topics: Acute Pain; Adolescent; Adult; Aged; Analgesics; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Chronic Disease; Drug Administration Schedule; Esophageal Neoplasms; Female; Humans; Lung Neoplasms; Male; Methyl Ethers; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Sevoflurane; Thoracotomy; Young Adult

Remifentanil is known to cause bradycardia and hypotension, as well as the decreases of cardiac output (CO). We hypothesized that hemodynamic suppression by remifentanil would affect the onset time of rocuronium. This study investigated whether the onset of rocuronium was influenced by the drug-administration sequence during induction of anesthesia with target-controlled infusion of propofol and remifentanil.. Healthy adult patients (n = 126) undergoing elective surgery under general anesthesia were randomized into two groups according to drug-administration sequence. In Remi-Pro-Rocu group (n = 62), remifentanil was infused first, followed by propofol. Then, rocuronium was administered lastly. In Pro-Rocu-Remi group (n = 64), propofol, rocuronium, and remifentanil were given in that order. As a primary outcome, the onset time of rocuronium was measured. Mean arterial pressure (MAP), heart rate (HR), CO, and stroke volume were recorded before anesthesia (T1), at injection of rocuronium (T2), immediately before and after intubation (T3 and T4).. In Remi-Pro-Roc group, the onset of rocuronium was delayed significantly compared with Pro-Rocu-Remi group [median (interquartile range); 130 (105-150) vs. 90 (71-100) s, P < 0.001]. At the time of rocuronium injection (T2), MAP, HR, and CO were significantly lower in Remi-Pro-Rocu group than Pro-Rocu-Remi group (P < 0.001).. The onset time of rocuronium is prolonged significantly by early administration of remifentanil during target-controlled infusion of propofol and remifentanil, and it may be due to the decreased CO caused by remifentanil.

Topics: Adult; Androstanols; Anesthetics, Intravenous; Blood Pressure; Cardiac Output; Double-Blind Method; Drug Interactions; Female; Hemodynamics; Humans; Male; Middle Aged; Neuromuscular Junction; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Rocuronium; Sample Size; Stroke Volume; Time Factors; Treatment Outcome

Controversy surrounds the optimal technique to moderate pain after laparoscopic cholecystectomy (LC). Opioid analgesics, sympatholytic drugs, and adjuvants, such as ketamine, have all been used. We compared esmolol with a combination of remifentanil plus ketamine in patients undergoing LC to determine the impact of these drugs on morphine requirements and pain control.. Sixty American Society of Anesthesiologists physical status I-II patients undergoing LC and anesthetized with sevoflurane were randomized to one of two groups. Group E patients received a bolus of esmolol 0.5 mg·kg(-1) iv at induction followed by an infusion of 5-15 μg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5 mg·kg(-1) iv and remifentanil 0.5 μg·kg(-1) iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5 μg·kg(-1)·min(-1). All patients received paracetamol, dexketoprofen, and levobupivacaine via infiltration of laparoscopic port sites. After surgery, a predetermined bolus of morphine was administered according to a verbal numerical rating scale (VNRS) for pain intensity. The primary outcome of interest was postoperative morphine requirement.. Median consumption of morphine was higher in Group R-K than in Group E (5 mg [4-6] vs 0 mg [0-2], respectively; P < 0.001). In the postanesthesia care unit, patients in Group R-K had higher pain scores than patients in Group E (difference in maximum VNRS, -11; 95% confidence interval (CI), -19 to -3). The concentration of sevoflurane to maintain a bispectral index~40 was higher in Group E than in Group R-K (between-group difference 0.3%; 95% CI, 0.15 to 0.40). The incidence of postoperative nausea and vomiting was similar between the two groups.. Intraoperative esmolol infusion reduces morphine requirements and provides more effective analgesia compared with a combination of remifentanil-ketamine given by infusion in patients undergoing LC.

Topics: Adrenergic beta-1 Receptor Antagonists; Adult; Aged; Analgesics; Analgesics, Opioid; Cholecystectomy, Laparoscopic; Double-Blind Method; Drug Therapy, Combination; Female; Humans; Infusions, Intravenous; Ketamine; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Propanolamines; Remifentanil

Intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain, opioid requirement and specifically periincisional hyperalgesia. The aim of this study was to investigate the effect of magnesium in preventing remifentanil-induced hyperalgesia.. This study was performed on 60 (ASA I-II) patients planned for abdominal hysterectomy. Sixty patients were randomized into two equal groups. Before anesthesia, saline solution was given to the patients in group I (control group), 50 mg/kg i.v. Magnesium in group II (magnesium group). Anesthesia was induced with 1 µg/kg remifentanil combined with 4-5 mg/kg thiopental and 0.5 mg/kg atracurium, maintained with 0.5 MAC sevoflurane and 0.4 µg/kg/min remifentanil in both groups. Sevoflurane concentration was titrated according to autonomic responses. Thirty minutes before the anticipated end of surgery, a 0.15 mg/kg bolus dose of morphine was intravenously. At the end of surgery, patients received tramadol i.v via a PCA device. Pain score, tramadol demand and delivery were assessed at 2, 4, 6, 12, 24 h after surgery. Total tramadol consumption were recorded for 24-48 h after surgery. Periincisional hyperalgesia was assessed by measuring pain threshold to pressure by using an algometer and electronic von Frey filaments before operation and at 28-48 h postoperatively.. The pain scores and cumulative tramadol consumption were significantly lower in the magnesium group compared with the control group (p<0.05). Pressure and mechanical pain threshold were significantly less at 24-48 h postoperatively in control group than magnesium group.. Magnesium administered preemptively reduced remifentanil-induced hyperalgesia.

Topics: Administration, Intravenous; Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Female; Humans; Hyperalgesia; Hysterectomy; Intraoperative Period; Magnesium; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Tramadol

A clear preference for intravenous or inhalational anaesthesia has not been established for craniotomy in patients without signs of cerebral hypertension.. The NeuroMorfeo trial was designed to test equivalence of inhalational and intravenous anaesthesia maintenance techniques in the postoperative recovery of patients undergoing elective supratentorial surgery.. This trial is a multicentre, randomised, open-label, equivalence design. A balanced stratified randomisation scheme was maintained using a centralised randomisation service. Equivalence was tested using the two one-sided tests procedure.. Fourteen Italian neuroanaesthesia centres participated in the study from December 2007 to March 2009.. Adults, 18 to 75 years old, scheduled for elective supratentorial intracranial surgery under general anaesthesia were eligible for enrolment if they had a normal preoperative level of consciousness and no clinical signs of intracranial hypertension.. Patients were randomised to one of three anaesthesia maintenance protocols to determine if sevoflurane-remifentanil or sevoflurane-fentanyl were equivalent to propofol-remifentanil.. The primary outcome was the time to achieve an Aldrete postanaesthesia score of at least 9 after tracheal extubation. Secondary endpoints included haemodynamic parameters, quality of the surgical field, perioperative neuroendocrine stress responses and routine postoperative assessments.. Four hundred and eleven patients [51% men, mean age 54.8 (SD 13.3) years] were enrolled. Primary outcome data were available for 380. Median (interquartiles) times to reach an Aldrete score of at least 9 were 3.48 (2.02 to 7.56), 3.25 (1.21 to 6.45) and 3.32  min (1.40 to 8.33) for sevoflurane-fentanyl, sevoflurane-remifentanil and propofol-remifentanil anaesthesia respectively, which confirmed equivalence using the two one-sided tests approach. Between-treatment differences in haemodynamic variables were small and not clinically relevant. Urinary catecholamine and cortisol responses had significantly lower activation with propofol-remifentanil. Postoperative pain and analgesic requirements were significantly higher in the remifentanil groups.. Equivalence was shown for inhalational and intravenous maintenance anaesthesia in times to reach an Aldrete score of at least 9 after tracheal extubation. Haemodynamic variables, the quality of surgical field and postoperative assessments were also similar. Perioperative endocrine stress responses were significantly blunted with propofol-remifentanil and higher analgesic requirements were recorded in the remifentanil groups.. Eudract 2007-005279-32.

Topics: Adult; Aged; Airway Extubation; Analgesics, Opioid; Analysis of Variance; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Biomarkers; Chi-Square Distribution; Craniotomy; Elective Surgical Procedures; Female; Fentanyl; Hemodynamics; Humans; Italy; Linear Models; Male; Methyl Ethers; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Recovery of Function; Remifentanil; Sevoflurane; Shivering; Time Factors; Treatment Outcome

A randomized, placebo-controlled, double-blind study to evaluate the effect of intravenously (IV) administered acetaminophen on postoperative pain in children and adolescents undergoing surgery for idiopathic scoliosis or spondylolisthesis.. To evaluate effectiveness of IV-administered acetaminophen on postoperative analgesia, opioid consumption, and acetaminophen concentrations after major spine surgery in adolescents.. Scoliosis surgery is associated with severe postoperative pain, most commonly treated with IV-administered opioids. Nonsteroidal anti-inflammatory drugs (NSAIDs), as adjuvant to opioids, improve analgesia and reduce the need for opioids. However, by inhibiting cyclo-oxygenase enzymes peripherally, NSAIDs may inhibit bone healing. Acetaminophen, a centrally acting analgesic, does not have the adverse effects of NSAIDs and has improved analgesia in children after another orthopedic surgery.. In an institutional review board approved study, 36 American Society of Anesthesiology patient classification I to III patients of 10 to 18 years of age were analyzed. Acetaminophen 30 mg/kg, administered IV or 0.9% NaCl was administered at the end of scoliosis or spondylolisthesis surgery, and thereafter twice at 8-hour intervals. Timed blood samples for acetaminophen determination were taken between 0.25 and 20 hours after the first dose. All patients received standard propofol-remifentanil anesthesia. Pain scores (visual analogue scale [VAS], 0-10), opioid consumption, and adverse effects were recorded.. In the surgical ward, 7 (39%) patients in the acetaminophen and 13 (72%) in the placebo group had a VAS pain score 6 or more (P < 0.05). There were fewer hours with VAS score 6 or more in the acetaminophen group compared with the placebo group (8.7% vs. 17.8% of the hours, P < 0.05). There was no difference in oxycodone consumption during the 24-hour follow-up between the 2 groups.. IV-administered acetaminophen 90 mg/kg/day, adjuvant to oxycodone, did improve analgesia, but did not diminish oxycodone consumption during 24 hours after major spine surgery in children and adolescents. All acetaminophen concentrations were in nontoxic levels.

Topics: Acetaminophen; Administration, Intravenous; Adolescent; Analgesics, Non-Narcotic; Analgesics, Opioid; Child; Dose-Response Relationship, Drug; Double-Blind Method; Drug Administration Schedule; Drug Therapy, Combination; Female; Humans; Male; Nausea; Oxycodone; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Scoliosis; Spinal Diseases; Spondylolisthesis; Treatment Outcome; Vomiting

Chronic thoracic pain after cardiac surgery is a serious condition affecting many patients. The aim of this study was to identify predictors for chronic thoracic pain after sternotomy in cardiac surgery patients by analysing patient and perioperative characteristics.. A follow-up study was performed in 120 patients who participated in a clinical trial on pain levels in the early postoperative period after cardiac surgery. The presence of chronic thoracic pain was evaluated by a questionnaire 1 yr after surgery. Patients with and without chronic thoracic pain were compared. Associations were studied using multivariable logistic regression analysis.. Questionnaires of 90 patients were analysed. Chronic thoracic pain was reported by 18 patients (20%). In the multivariable regression model, remifentanil during cardiac surgery, age below 69 yr, and a body mass index above 28 kg m(-2) were independent predictors for chronic thoracic pain {odds ratios 8.9 [95% confidence interval (CI) 1.6-49.0], 7.0 (95% CI 1.6-31.7), 9.1 (95% CI 2.1-39.1), respectively}. No differences were observed in patient and perioperative characteristics between patients receiving remifentanil (58%, n=52) compared with patients not receiving remifentanil (42%, n=38). The association between remifentanil and chronic thoracic pain appeared dose-dependent, both for total dose and for dose corrected for kilogram lean body mass and duration of surgery (P-value for trend: <0.01 and <0.005, respectively).. In this follow-up study in cardiac surgery patients, intraoperative remifentanil was predictive for chronic thoracic pain in a dose-dependent manner. Randomized studies designed to evaluate the influence of intraoperative remifentanil on chronic thoracic pain are needed to confirm these results.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, Intravenous; Anesthesiology; Anesthetics, Intravenous; Cardiac Surgical Procedures; Chronic Pain; Critical Care; Dose-Response Relationship, Drug; Double-Blind Method; Female; Follow-Up Studies; Humans; Intraoperative Period; Male; Middle Aged; Multivariate Analysis; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Risk Factors; ROC Curve; Sternotomy; Surveys and Questionnaires

A synergy between ketamine and methadone (ME) to produce antinociception has been demonstrated in experimental neuropathy. We wanted to compare post-operative opioid requirements in patients undergoing multilevel lumbar arthrodesis after the administration combined ME-ketamine (MK) or ME alone.. This was a randomised double-blind study. During sevoflurane-remifentanil anaesthesia, 11 patients in each group received the following: ketamine bolus (0.5 mg/kg) after tracheal intubation, followed by an infusion of 2.5 μg/kg/min in the MK or saline bolus plus infusion in the ME group. Post-operative analgesia - during 48 h - was provided by patient-controlled analgesia (PCA), delivering bolus containing the following: ME 0.25 mg plus ketamine 0.5 mg in the MK group or ME 0.5 mg in the ME group. Lockout was 10 min, maximum of 3 boluses/h in both groups. Before closing the wound, all the patients received intravenous (i.v.) ME 0.1 mg/kg, dexketoprophen and paracetamol. Pain intensity was evaluated by a numerical rating scale (NRS), on arrival at recovery room (RR) and 24 and 48 h after surgery. In the RR, i.v. ME was administered until NRS was 3 when PCA was started. Dexketoprophen and paracetamol were administered 48 h.. Remifentanil requirements were higher in the MK group (P = 0.004). Patients in the MK group received 70% less ME by PCA at 24 h (MK vs. ME group, median and interquartile range) - 3.43 mg (1.9-6.5) vs. 15 mg (9.65-17.38) (P < 0.001) - and at 48 h - 2 mg (0.5-3.63) vs. 9.5 mg (3.5-13.75) (P = 0.001). Patients in the MK group also attempted less doses, at 24 h: 19.5 (12.75-79.5) vs. 98 (41.5-137) (P = 0.043). Both groups had similar NRS values and comparable side effects.. Perioperative ketamine-ME combination significantly decreased opioid consumption by PCA.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Anesthetics, Dissociative; Double-Blind Method; Female; Follow-Up Studies; Humans; Infusions, Intravenous; Ketamine; Male; Methadone; Middle Aged; Pain, Postoperative; Perioperative Care; Piperidines; Remifentanil; Spinal Fusion; Spine

This prospective, randomised double-blind study compared the effects of target control infusion (TCI) of sufentanil and remifentanil on the quality of recovery and post-operative pain control in morbidly obese patients undergoing laparoscopic gastroplasty.. Following institutional Ethics Committee approval and written informed consent, 100 morbidly obese patients were randomised to receive either TCI sufentanil (0.3 ng ml⁻¹; S-group; N = 50) or TCI remifentanil (3 ng ml⁻¹; R-group; N = 50) in combination with desflurane (O₂/air mixture: FiO₂, 50%). Quality of recovery was estimated by means of the modified Aldrete score and by the ability to perform psychomotor tests with the same competence post-operatively as pre-operatively. Post-operative pain was evaluated by the quantity of piritramide needed to achieve a visual analogue scale (VAS) less than 3. Statistical analysis was performed using an unpaired Student's t-test, Mann-Whitney U-test and χ² test, as appropriate.. Patient and surgical characteristics were similar among groups. In the R-group, time to extubation was significantly shorter, but VAS significantly higher than that in the S-group (P < 0.01). Quality of recovery and duration of post-anaesthesia care unit stay were comparable between groups (S-group: 119 ± 27 min and R-group: 119 ± 35 min). Piritramide consumption during the first 4 post-operative hours was higher in the R-group than in the S-group [S-group (median, range): 11.5 mg, 5.5-16.0; R-group: 18.0 mg, 14-22, P < 0.01], but not later on.. In the conditions of the present study, although TCI sufentanil resulted in slower awakening than TCI remifentanil, it was associated with a better quality of recovery.

Topics: Adult; Analgesics, Opioid; Anesthesia Recovery Period; Female; Gastroplasty; Humans; Laparoscopy; Male; Middle Aged; Obesity, Morbid; Pain Measurement; Pain, Postoperative; Piperidines; Pirinitramide; Psychomotor Performance; Remifentanil; Sufentanil; Time Factors

Sevoflurane is widely used for paediatric anaesthesia. However, many cases of emergence agitation after sevoflurane anaesthesia have been reported and pain was suggested as a major contributing factor. The purpose of this study was to evaluate the effect of sub-Tenon lidocaine injection on emergence agitation in children receiving sevoflurane or propofol-remifentanil anaesthesia.. We enrolled 260 children, aged 4-10 years, who were scheduled for strabismus surgery, and randomized them to one of four groups: group SS, SL, BS, and BL. Anaesthesia was maintained with sevoflurane (SS, SL) or propofol-remifentanil infusion (BS, BL). At the end of surgery, the surgeon injected into the sub-Tenon space 1 ml of isotonic saline (SS, BS) or 2% lidocaine (SL, BL). Emergence behaviour was assessed in the post-anaesthesia care unit using a 5-point scoring scale (score 1, asleep; 2, awake and calm; 3, irritable or consolable crying; 4, inconsolable crying; and 5, severe restlessness). We defined a score of 4 or 5 as emergence agitation. The incidence of emergence agitation was analysed using χ² and Fisher's exact test.. The incidence of emergence agitation in group SL and BL was significantly lower compared to group SS and BS, respectively (P = 0.011, 0.019). The lidocaine-injected group showed significantly lower occurrence of emergence agitation (10.4%) than isotonic saline-injected group (27.2%; P = 0.001). Emergence agitation was significantly higher following sevoflurane (25.0%) than balanced anaesthesia (13.1%; P = 0.023).. The frequency of emergence agitation is significantly reduced by sub-Tenon lidocaine injection regardless of the modality of anaesthesia used.

Topics: Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Child; Child, Preschool; Female; Follow-Up Studies; Humans; Incidence; Lidocaine; Male; Methyl Ethers; Ophthalmologic Surgical Procedures; Pain, Postoperative; Piperidines; Propofol; Psychomotor Agitation; Remifentanil; Sevoflurane; Strabismus

Various research programmes have shown that intraoperative infusion of remifentanil has been associated with postoperative hyperalgesia. Previous studies have demonstrated that low-dose ketamine can inhibit central sensitisation and prevent opioid-induced hyperalgesia (OIH). However, the optimal ketamine dose to prevent OIH has not been determined. In the present study we aimed to determine the ED50 and ED95 of ketamine for prevention of postoperative hyperalgesia after remifentanil-based anaesthesia in patients undergoing laparoscopic cholecystectomy.. Fifty-four patients undergoing laparoscopic cholecystectomy were randomised into two groups: group C and group K. Group K was given ketamine before skin incision. An equal volume of normal saline was given to the patients in group C. Pain was assessed using visual analog scale (VAS) at 10 min after tracheal extubation. The ED50 and ED95 were determined by modified up-and-down method and the incidences of adverse effects were recorded.. The incidences of adverse effects were similar in the two groups and the VAS score was significantly lower in group K than in group C. The ED50 and ED95 of ketamine for prevention of postoperative hyperalgesia were 0.24 mg/kg (95%CI, 0.20~0.30 mg/kg) and 0.33 mg/kg (95%CI, 0.28~0.62 mg/kg) respectively.. The ED50 and ED95 of ketamine for prevention of postoperative hyperalgesia after remifentanil-based anaesthesia in patients undergoing laparoscopic cholecystectomy were 0.24 mg/kg and 0.33 mg/kg respectively.

Topics: Analgesics; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Dose-Response Relationship, Drug; Female; Humans; Hyperalgesia; Ketamine; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

In the postoperative period, α2-adrenergic agonists have an opioid sparing effect. In a previous, experimental study, it was also shown that clonidine attenuates remifentanil-induced hyperalgesia. In this study, we examined under clinical conditions whether early administration of a single dose of clonidine can inhibit remifentanil-induced hyperalgesia in patients undergoing elective surgery of the shoulder and with continuous intraoperative use of remifentanil.. In this study 40 patients received double-blind and randomized either 150 µg clonidine or placebo intravenously before skin incision. Anaesthesia was maintained with propofol and remifentanil (0.23 ± 0.09 µg/kg body weight/min) and morphine (0.1 mg/kg body weight) was administered 20 min before incision closure. Postoperatively, the patients were given a patient-controlled analgesia pump (PCA) with morphine.. Overall morphine consumption as well as overall assessment of pain with the visual analogue scale in the first 24 h postoperatively did not differ significantly between the groups. Isolated pain scores at 12 h and 24 h were significantly enhanced in the clonidine group (p<0.05).. An early single dose of 150 µg of clonidine did not reduce the postoperative morphine consumption and pain scores in patients undergoing elective surgery of the shoulder with remifentanil/propofol-based anaesthesia. After the effect of clonidine has presumably subsided the pain can even increase, therefore further studies with repetitive doses of clonidine should be carried out.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics; Analgesics, Opioid; Anesthetics, Intravenous; Arthroscopy; Austria; Clonidine; Dose-Response Relationship, Drug; Double-Blind Method; Female; Humans; Hyperalgesia; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Shoulder; Shoulder Injuries; Shoulder Pain

In a randomized, double-blind, prospective study, we investigated whether an intraoperative high versus low dose of remifentanil increased postoperative hyperalgesia and whether magnesium can prevent remifentanil-induced hyperalgesia.. Ninety patients undergoing thyroidectomy were randomly assigned to 1 of 3 groups. Remifentanil was intraoperatively infused at 0.05 μg/kg/min (group LO) or 0.2 μg/kg/min (groups HI and HM). Patients in group HM received MgSO(4) 30 mg/kg at induction followed by an intraoperative infusion of 10 mg/kg/h. Mechanical pain thresholds on the forearm and periincisional area were assessed by von Frey filament the evening before surgery and postoperatively at 24 and 48 hours. Pain measured on a verbal numerical rating scale (VNRS) (0-10) and additional analgesics were recorded in the postanesthesia care unit postoperatively at 6, 24, and 48 hours.. There was a significantly greater decrease in pain threshold on the periincisional area at 24 and 48 hours postoperatively in group HI, as compared with the other 2 groups. The 95% confidence intervals for the mean difference in pain thresholds on the periincisional area at 24 and 48 hours postoperatively were 0.31 to 1.11 and 0.36 to 1.14 for group HI versus group LO, 0.45 to 1.26 and 0.54 to 1.32 for group HI versus group HM (values are log(10) of force in milligrams). The change in pain threshold on the forearm was similar among the groups. Group HI had significantly higher VNRS scores (median [interquartile range], 3 [2-4]) than group LO (2 [1-3] and group HM (2 [1-3]) at 48 hours postoperatively. The 95% confidence intervals for median difference in VNRS score at 48 hours postoperatively were 1 to 2 for group HI versus group LO and 0 to 2 for group HI versus group HM. There were no significant differences in the number of patients who requested rescue analgesics in the postoperative anesthesia care unit and general ward during 48 hours postoperatively among the 3 groups.. A relatively high dose of intraoperative remifentanil enhances periincisional hyperalgesia. Intraoperative MgSO(4) prevents remifentanil-induced hyperalgesia. However, hyperalgesia did not reach clinical relevance in terms of postoperative pain or analgesic consumption in patients undergoing thyroidectomy.

Topics: Adult; Aged; Analgesics; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Intravenous; Blood Pressure; Double-Blind Method; Female; Heart Rate; Humans; Hyperalgesia; Magnesium Sulfate; Male; Middle Aged; Pain Measurement; Pain Threshold; Pain, Postoperative; Physical Stimulation; Piperidines; Recovery Room; Remifentanil; Thyroidectomy; Young Adult

One of the strategies to attenuate opioid-induced hyperalgesia (OIH) may be to decrease intraoperative doses of opioids by using target-controlled infusion (TCI).. Double-blind and randomized study.. A single university hospital.. Forty American Society of Anesthesiologists II to III patients scheduled for elective cardiac surgery.. patients were randomized to 1 of the 2 groups: 1 group received an infusion of intraoperative remifentanil using TCI (target: 7 ng/mL), and the 2nd one was given an intraoperative continuous infusion (CI) (0.3 μg/kg/min). The anesthestic protocol and postoperative pain management were the same in both groups. The extent of mechanical dynamic hyperalgesia on the middle line perpendicular to the wound was considered the primary endpoint. The secondary endpoints were other results of dynamic and punctuate hyperalgesia until postoperative day 7, visual analog scale (VAS) and verbal rating scale (VRS) scores, and total morphine consumption until postoperative day 2.. Morphometric and demographic characteristics and duration of surgery were comparable in both groups. Intraoperative remifentanil consumption was greater in CI than in TCI group (5,329 [1,833] v 3,662 [1,160] μg, p = 0.003). During the first 44 hours, there were no differences in morphine consumption, VAS, and VRS. The extent of hyperalgesia was significantly lower on postoperative days 1, 2, and 4 in the TCI group than in the CI group on the 3 evaluated lines (p < 0.05). Punctuate hyperalgesia evaluating 3 different points was lower in the TCI than in the CI group from postoperative day 1 until postoperative day 7 (p < 0.05).. The intraoperative decrease of opioid consumption when comparing the CI versus TCI mode of administration of remifentanil led to less OIH after cardiac surgery.

Topics: Acetaminophen; Aged; Analgesics, Opioid; Anesthesia, General; Anesthesia, Intravenous; Blood Pressure; Cardiac Surgical Procedures; Double-Blind Method; Drug Delivery Systems; Electroencephalography; Female; Heart Rate; Humans; Hyperalgesia; Male; Middle Aged; Morphine; Pain Measurement; Pain Threshold; Pain, Postoperative; Physical Stimulation; Piperidines; Postoperative Nausea and Vomiting; Preanesthetic Medication; Remifentanil; Sternotomy

To evaluate the effects of three different target-controlled remifentanil infusion rates during target-controlled propofol infusion on hemodynamic parameters, pain, sedation, and recovery score during oocyte retrieval.. Sixty-nine women were scheduled for oocyte retrieval. Target-controlled propofol infusion at an effect-site concentration of 1.5 μg/mL was instituted. The patients were randomly allocated to receive remifentanil at an effect-site concentration of either 1.5 (group I, n = 23), 2 (group II, n = 23) or 2.5 ng/mL (group III, n = 23). Hemodynamic variables, sedation, pain, the Aldrete recovery score, and side effects were recorded.. Hemodynamic variables, sedation and pain scores and the number of patients with the maximum Aldrete recovery score 10 min after the procedure were comparable among the groups. The number of patients in group III with the maximum Aldrete recovery score 5 min after the procedure was significantly lower than that in groups I and II. One patient in group II and one patient in group III suffered from nausea.. Similar pain-free conscious sedation conditions without significant changes in hemodynamic parameters were provided by all three protocols. However, target controlled infusion of remifentanil at 1.5 or 2 ng/mL proved superior at providing early recovery compared to 2.5 ng/mL.

Topics: Adult; Anesthesia Recovery Period; Anesthetics, Intravenous; Blood Pressure; Female; Heart Rate; Humans; Infusions, Intravenous; Middle Aged; Oocyte Retrieval; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil

Patients undergoing gynecological laparotomy were randomized to receive either 0.5 mg/kg ketamine at induction of anesthesia followed by an infusion of 0.3 mg/kg/h until the end of surgery (ketamine group, n = 32), or an equivalent volume of normal saline (control group, n = 32). Anesthesia was maintained with IV propofol, a fixed infusion rate of remifentanil (0.25 μg/kg/min), and epidural ropivacaine. Postanesthetic shivering (PAS) was evaluated for 30 minutes after emergence. Intraoperative temperatures were similar between the 2 groups. The incidence of PAS was less frequent in the ketamine group (n = 2, 6%) compared with the control group (n = 12, 38%, P = 0.005). We conclude that, during the early recovery phase, intraoperative ketamine reduces remifentanil-induced PAS.

Topics: Adult; Analgesics, Opioid; Anesthesia Recovery Period; Chi-Square Distribution; Drug Administration Schedule; Excitatory Amino Acid Antagonists; Female; Humans; Hysterectomy; Intraoperative Care; Japan; Ketamine; Laparoscopy; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Shivering; Time Factors; Treatment Outcome

Postoperative pain can delay functional recovery after outpatient surgery. Multimodal analgesia can improve pain and possibly improve quality of recovery. In this study, we evaluated the dose-dependent effects of a preoperative transversus abdominis plane (TAP) block on patient recovery using the Quality of Recovery 40 (QoR-40) questionnaire after ambulatory gynecological laparoscopic surgery. Global QoR-40 scores range from 40 to 200, representing very poor to outstanding quality of recovery, respectively.. Healthy women undergoing outpatient gynecological laparoscopy were randomly allocated to receive a preoperative TAP block using saline, ropivacaine 0.25%, or ropivacaine 0.5%. Needle placement for the TAP blocks was performed using ultrasound guidance and 15 mL of the study solution was injected bilaterally by a blinded investigator. QoR-40 score and analgesic use were assessed 24 hours postoperatively. The primary outcome was global QoR-40 score at 24 hours after surgery. Data were analyzed using the Kruskal-Wallis test. Post hoc pairwise comparisons were made using the Dunn test with P values and 95% confidence intervals Bonferroni corrected for 6 comparisons.. Seventy-five subjects were enrolled and 70 subjects completed the study. The median (range) for the QoR-40 score after the TAP block was 157 (127-193), 173 (133-195), and 172 (130-196) for the saline group and 0.25% and 0.5% ropivacaine groups, respectively. The median difference (99.2% confidence interval) in QoR-40 score for 0.5% bupivacaine (16 [1-30], P=0.03) and 0.25% bupivacaine (17 [2-31], P=0.01) was more than saline but not significantly different between ropivacaine groups (-1 [-16 to 12], P=1.0). Increased global QoR-40 scores correlated with decreased area under the pain score time curve during postanesthesia recovery room stay (ρ=-0.56, 99.2% upper confidence limit [UCL]=-0.28), 24-hour opioid consumption (ρ=-0.61, 99.2% UCL=-0.34), pain score (0-10 scale) at 24 hours (ρ=-0.53, 99.2% UCL=-0.25), and time to discharge readiness (ρ=-0.65, 99.2% UCL=-0.42). The aforementioned variables were lower in the TAP block groups receiving ropivacaine compared with saline.. The TAP block is an effective adjunct in a multimodal analgesic strategy for ambulatory laparoscopic procedures. TAP blocks with ropivacaine 0.25% and 0.5% reduced pain, decreased opioid consumption, and provided earlier discharge readiness that was associated with better quality of recovery.

Topics: Abdomen; Adult; Ambulatory Surgical Procedures; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Local; Double-Blind Method; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Morphine; Nerve Block; Pain Measurement; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Treatment Outcome; Ultrasonography

A prospective, randomized, open study. The regional technique used was not blinded.. A university teaching hospital.. Forty-eight patients undergoing video-assisted thoracoscopic surgery (VATS) for tumor resection.. Patients received either continuous extrapleural block or continuous epidural block using ropivacaine for a period of 60 hours after surgery.. To evaluate postoperative pain control, the primary and secondary endpoints were the visual analog scale (VAS) on movement and the amount of rescue analgesia, respectively. There were no significant differences between the extrapleural and epidural block groups with regard to VAS at rest and during movement assessed at 4, 12, 24, 36, and 48 hours after surgery, dosage of intravenous morphine (extrapleural: 12.9 ± 11.3, epidural: 10.2 ± 6.9 mg), supplemental nonsteroidal anti-inflammatory drugs, incidence of postoperative nausea and vomiting (extrapleural: 12/20, epidural: 11/20), postoperative ambulation (extrapleural: 18 at postoperative day [POD] 1 and 20 at POD 2, epidural: 19 at POD 1 and 20 at POD 2) and hospital stay after surgery (extrapleural: 12.7 ± 6.3, epidural: 12.6 ± 4.7 days).. Although this study did not show the superiority of continuous extrapleural block relative to continuous epidural in VATS patients, the results suggest that both methods provided effective analgesia with a relatively small dose of rescue morphine. Although the analgesic effects of these techniques were comparable, extrapleural block has the advantage of safety and precise placement of the catheter and can be considered an alternative to epidural block in VATS patients.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, Epidural; Early Ambulation; Female; Humans; Length of Stay; Lung; Male; Middle Aged; Morphine; Nerve Block; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Thoracic Surgery, Video-Assisted

This prospective, randomized, double-blind study compared the effects of dexmedetomidine and remifentanil on haemodynamic stability, sedation and postoperative pain control in the postanaesthetic care unit (PACU). Fifty consecutive patients scheduled for total laparoscopic hysterectomy were randomly assigned to receive infusions of either dexmedetomidine (1 μg/kg) i.v. over 10 min followed by 0.2 - 0.7 μg/kg per h continuous i.v. infusion or remifentanil (0.8 - 1.2 μg/kg) i.v. over 1 min followed by 0.05 - 0.1 μg/kg i.v. per min, starting at the end of surgery to the time in the PACU. Modified observer's assessment of alertness scores were significantly lower in the dexmedetomidine group than in the remifentanil group at 0, 5 and 10 min after arrival in the PACU. Blood pressure and heart rate in the dexmedetomidine group were significantly lower than that recorded in the remifentanil group in the PACU. Dexmedetomidine, at the doses used in this study, had a significant advantage over remifentanil in terms of postoperative haemodynamic stability.

Topics: Adult; Blood Pressure; Dexmedetomidine; Double-Blind Method; Female; Heart Rate; Hemodynamics; Humans; Hypnotics and Sedatives; Hysterectomy; Intraoperative Period; Laparoscopy; Middle Aged; Pain, Postoperative; Perioperative Period; Pilot Projects; Piperidines; Remifentanil

Remifentanil is being increasingly used as an analgesic in fast-track surgery, but severe postoperative pain may happen occasionally. In this study, we evaluated the effects of systemic administration of lidocaine on postoperative pain and morphine requirements after propofol-remifentanil-based anaesthesia.. Forty patients undergoing thoracic surgery were randomly assigned to lidocaine (33.0 microg kg(-1) min(-1)) and physiological saline control groups in propofol-remifentanil-based anaesthesia. The setting of the plasma concentration (C(p)) of the target-controlled infusion of propofol was adjusted according to the bispectral index of the electroencephalogram and blood pressure. The C(p) and effect-site concentration (C(e)) of propofol were calculated by target-controlled infusion pump during the intraoperative period. Pain scoring includes a four-point verbal rating scale, Riker's sedation-agitation scale and a visual analogue scale; the morphine requirement in the postanaesthesia care unit and the morphine consumption via a patient-controlled analgesia device on the ward were recorded during the postoperative period.. Morphine requirements within 30, 30-60 and 0-120 min in the postanaesthesia care unit of the lidocaine group decreased significantly (P < 0.05, n = 20 per group) compared with that of the control group. The four-point verbal rating scale at 30 min in the postanaesthesia care unit, visual analogue scale at 6 h on coughing and patient-controlled analgesia morphine consumption during 2-6 h postoperative time were also significantly (P < 0.05, n = 20 per group) reduced in the lidocaine group. In addition, the intraoperative propofol C(e) in the lidocaine group during the periods of intubation, organ resection, closing of chest cavity and extubation was significantly lower (P < 0.05, n = 20 per group) than that in the control group under the same hypnotic depth.. Systemic administration of lidocaine could reduce morphine requirements, postoperative pain and intraoperative propofol C(e) of patients undergoing thoracic surgery after propofol-remifentanil-based anaesthesia.

Topics: Adult; Anesthetics, Intravenous; Double-Blind Method; Female; Humans; Lidocaine; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Thoracic Surgery; Time Factors; Treatment Outcome

To investigate the relationships between 2 anesthetic techniques, or the extent of allodynia around the surgical wound, and the occurrence of chronic post-thoracotomy pain.. Prospective, randomized study.. A single-institution, university hospital.. Thirty-eight patients who underwent elective thoracotomy under general anesthesia.. High-dose remifentanil (average effect-site concentration 5.61 +/- 0.84 ng/mL) with epidural analgesia started and at the end of surgery or low-dose remifentanil (average effect site concentration 1.99 +/- 0.02 ng/mL) with epidural analgesia with 0.5% ropivacaine started at the beginning of anesthesia.. Pain intensity and the extent of allodynia around the wound were measured during the hospital stay. The presence and intensity of residual pain were assessed 1, 3, and 6 months after surgery and at the end of the study (6-13 months, average 9 months). A DN4 neuropathic pain diagnostic questionnaire was conducted at the same times. In the high-dose group, the area with allodynia was three times larger than the area in the low-dose group. The increased allodynia was associated with a higher incidence of chronic pain (RR: 2.7-4.2) 3 and 6 months after surgery and at the end of the study (median follow-up: 9.5 months).. High-dose remifentanil (0.14-0.26 microg/kg/min) without epidural analgesia during surgery is associated with a large area of allodynia around the wound. These patients develop a much higher incidence of chronic pain than those receiving low-dose remifentanil with epidural analgesia during surgery.

Topics: Aged; Analgesia, Epidural; Anesthetics; Chronic Disease; Dose-Response Relationship, Drug; Drug Therapy, Combination; Female; Follow-Up Studies; Humans; Incidence; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Preoperative Care; Prospective Studies; Remifentanil; Thoracotomy

The aim of this study was to examine to what extent the use of electroencephalography (EEG) monitoring leads to an adaptation of the target-controlled infusion (TCI) concentration of propofol during propofol anaesthesia with different doses of remifentanil.. With ethics committee approval 60 patients (27-69 years old) with American Society of Anesthesiologists classification (ASA) I-III received anaesthestics with propofol (TCI, Diprifusor, AstraZeneca, Wedel, Deutschland) and 0.2, 0.4, or 0.6 microg/kg body weight remifentanil, respectively (groups 1-3). Anaesthesia was maintained at a level of deep hypnosis (EEG stages D(2)/E(0), EEG monitor: Narcotrend, version 2.0/5.0, manufacturer: MT MonitorTechnik, Bad Bramstedt, Germany).. During the steady state the propofol concentration in groups 1-3 was 3.02+/-0.86, 1.93+/-0.53 and 1.60+/-0.55 microg/ml, respectively (p<0.001). Women had a higher propofol consumption than men (p<0.05). Dreams during anaesthesia were more often reported by women than by men (p<0.05). The need for postoperative analgesia decreased with an increasing intraoperative remifentanil dose (p<0.05).. The study demonstrates that remifentanil has both analgetic and hypnotic effects. With increasing remifentanil dose the propofol requirement decreased and in this context EEG monitoring is useful to adapt the target concentrations of propofol to the patients' age and gender.

Topics: Adult; Aged; Aging; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Dose-Response Relationship, Drug; Double-Blind Method; Dreams; Electroencephalography; Female; Heart Rate; Humans; Infusions, Intravenous; Male; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Sex Characteristics

Nearly every anesthetic agent has been used for craniotomy, yet the choice between intravenous or volatile agents has been considered an area of significant debate in neuroanesthesia. We designed a Randomized Clinical Trial to test the hypothesis that inhalation anesthesia (sevoflurane/remifentanil--group S) reduces emergence time by 5 minutes compared with intravenous anesthesia (propofol/remifentanil--group P) in patients undergoing neurosurgery for supratentorial neoplasms.. Adult ASA I-III elective patients were randomly assigned to group S or P. The primary outcome was time to reach an Aldrete test score (AS) of more than equal to 9; secondary outcomes were times to eyes opening (TEO) and extubation (ET), adverse events, intraoperative hemodynamics, brain relaxation score (BRS), opioid consumption, and diuresis.. No significant differences were found between S (n=149) and P (n=153) treatments in primary outcomes: median time to reach AS=9 was 5 minutes (25th to 75th percentile 5 to 10 minutes in both groups, P > or = 0.05); and 15 minutes to reach AS=10 (P group 95% CI=10.3-19.7 min; S group 95% CI=11.4-18.5 min, P > or = 0.05) in both groups. TEO and ET expressed as median values (95% CI) were, respectively: 8 (6.8 to 9.2) minutes in group P versus 6 (4.6 to 7.4) in group S, P < 0.05; 10 (9.6 to 10.4) minutes in group P versus 8 (7 to 9) in group S, P < 0.05. Shivering, postoperative nausea and vomiting, pain, and seizure during the first 3 postoperative hours were not significantly different between the 2 groups, nor was BRS. Hypotension was more frequent in group S. Intraoperative diuresis and opioid consumption were greater in group P.. Sevoflurane/remifentanil neuroanesthesia is not superior to propofol/remifentanil in time to reach an AS > or = 9.

Topics: Aged; Anesthesia Recovery Period; Anesthesia, Inhalation; Anesthetics, Inhalation; Anesthetics, Intravenous; Craniotomy; Female; Hemodynamics; Humans; Kaplan-Meier Estimate; Male; Methyl Ethers; Middle Aged; Monitoring, Physiologic; Pain, Postoperative; Piperidines; Propofol; Regression Analysis; Remifentanil; Sevoflurane; Supratentorial Neoplasms; Treatment Outcome

This study is aimed at conducting a program for two different anesthetic methods used during a spinal fusion surgery to ensure better intra-operative hemodynamic stability and post-operative pain control.. A prospective, randomized, double blind study in patients scheduled for spinal fusion surgery, who were randomly allocated to two groups, G1 and G2, (n = 15 per group), class I-II ASA, was carried out. Both groups received pre-operatively midazolam, followed intra-operatively by propofol, sevoflurane, atracurium, and either remifentanil infusion 0.2 microg/kg/min (G1), or the same dose of remifentanil infusion and low doses of ketamine infusion 1 microg/kg/min (G2) anesthetics, antidote medication and post-operative morphine doses. HR, MAP, vital signs, surgical bleeding, urine output, duration of surgery and duration of anesthesia were recorded. In a 24-h recovery period in a post-anesthesia care unit (PACU) the recovery time, the first pain score and analgesic requirements were measured.. Intra-operative HR and arterial BP were significantly less (p < 0.05) in G1 as compared to G2. In the PACU the first pain scores were significantly less (p < 0.05) in G2 than in G1. The time for the first patient analgesia demand dose was greater in G2, as also morphine consumption which was greater in G1 than G2 (p < 0.05). Other results were the same. None of the patients had any adverse drug reaction.. Adding low doses of ketamine hydrochloride could be a routine therapy to improve the hemodynamic stability and reduce the post-operative morphine consumption during spinal fusion surgery.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Dissociative; Anesthetics, Intravenous; Blood Pressure; Double-Blind Method; Female; Heart Rate; Humans; Ketamine; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Spinal Fusion

Although remifentanil provides profound analgesia during operation, postoperative occurrence of hyperalgesia and tolerance after remifentanil administration could be a challenge to the postoperative pain control. In this investigation, we sought to determine the effect of maintenance with propofol or sevoflurane on postoperative analgesia after remifentanil-based anaesthesia.. Two hundred and fourteen women undergoing breast cancer surgery under remifentanil-based general anaesthesia were randomly included in this prospective and double-blind trial. The patients were anaesthetized with sevoflurane (S) or propofol (P) under high (H) or low (L) effect-site concentration (Ce) of remifentanil-based anaesthesia using a target-controlled infusion system; the patients were allocated into the SH, SL, PH, and PL groups. Pain intensity (visual analogue score, VAS) and cumulative morphine requirements were recorded 30 min, 1, 6, 12, and 24 h after operation.. The patient characteristics were similar. Cumulative morphine consumption at 24 h after surgery was higher in the SH group [38.6 (sd 14.9)] compared with the SL [31.5 (3.7)], PH [31.7 (8.3)], and PL groups [30.1 (6.1)] (P<0.001). The VAS scores during 24 h after surgery were also higher in the SH group than the SL, PH, and PL groups (P<0.001).. Remifentanil hyperalgesia was induced by high dose of remifentanil-based anaesthesia during sevoflurane anaesthesia, whereas that was not apparent during propofol anaesthesia. Also, remifentanil hyperalgesia did not occur during low dose of remifentanil-based anaesthesia. Maintenance of propofol during high-dose remifentanil-based anaesthesia provided better postoperative analgesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Inhalation; Anesthetics, Intravenous; Breast Neoplasms; Double-Blind Method; Drug Administration Schedule; Drug Interactions; Female; Humans; Hyperalgesia; Methyl Ethers; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Sevoflurane

In this study, we compared the quality of transitional analgesia provided by bilateral superficial cervical plexus block (SCPB) or morphine following a remifentanil-based anesthesia for infratentorial or occipital craniotomy.. In this randomized controlled and double-blind study, 30 patients scheduled for infratentorial or occipital craniotomy were divided randomly into two groups: group morphine (morphine 0.1 mg·kg⁻¹ iv after dural closure and a SCPB performed with 20 mL of 0.9% saline at the end of the surgery) or group block (10 mL of 0.9% saline iv instead of morphine after dural closure and a SCPB performed with 20 mL of a 1:1 mixture of 0.5% bupivacaine and 2% lidocaine at the end of the surgery). Postoperative pain was assessed at one, two, four, eight, 12, 16, and 24 hr using an 11-point (0-10) numerical rating scale (NRS). Analgesia was provided with subcutaneous codeine.. Average NRS scores were similar between the two groups at each time interval over the study period. The average scores (with 95% confidence interval) were 3.9 (3.4-4.4) and 4.3 (3.8-4.9) for the block and morphine groups, respectively (P = 0.25). The delay before administration of the first dose of codeine was not statistically different between the two groups: 25 min (5-2,880) vs 21.5 min (5-90), median and range for the block and morphine groups, respectively. The incidence of nausea and vomiting was similar between the two groups.. Bilateral superficial cervical plexus block provides transitional analgesia that is clinically equivalent to morphine following remifentanil-based anesthesia in patients undergoing occipital or infratentorial craniotomies.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Intravenous; Anesthetics, Local; Bupivacaine; Cervical Plexus; Codeine; Craniotomy; Double-Blind Method; Female; Humans; Lidocaine; Male; Middle Aged; Morphine; Nerve Block; Pain, Postoperative; Piperidines; Remifentanil; Time Factors

The study was conducted to determine whether bolus administrations of remifentanil-propofol could provide adequate analgesia and similar patient comfort with a faster recovery profile compared with bolus administrations of fentanyl-propofol during dilatation and sharp curettage.. The patients were randomized to a remifentanil group (n=36) or fentanyl group (n=36). The remifentanil group received an IV bolus dose of 1 pg kg(-1) remifentanil. The fentanyl group received an IV bolus dose of fentanyl 0.5 microg kg(-1). The Verbal Pain Scale (VPS), modified Aldrete scores, blood pressure, heart rate, peripheric oxygen saturation, recovery time from anesthesia and adverse events during or after surgery were evaluated.. The groups were found to be similar in duration of the surgical procedure, anesthesia time and hemodynamic variables and VPS scores. Patients in the remifentanil group recovered from anesthesia earlier. Modified Aldrete scores were higher in the remifentanil group at 5 and 10 min postoperatively. The frequency of perioperative adverse events did not differ significantly between the groups.. Bolus injections of remifentanil appear to be a safe and effective alternative to fentanyl, producing faster recovery in providing analgesia during dilatation and sharp curettage procedures.

Topics: Adult; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Dilatation and Curettage; Female; Fentanyl; Humans; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

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

The aim was to investigate the effect of magnesium sulfate on postoperative pain and analgesic consumption after remifentanil-based anesthesia.. Forty women 18 to 65 years old were enrolled in this prospective, randomized, double-blinded clinical study. The study solutions were randomly preoperatively prepared for groups M (magnesium) and R (normal saline). A bolus of 0.2 ml/kg of study solution (30 mg/kg magnesium or saline) was given before induction of anesthesia and infusion was started at a rate of 3.3 ml/h (500 mg/h magnesium or saline). A 1 microg/kg loading dose of remifentanil following infusion was started at a rate of 0.25 micro g/kg/min, subsequently increasing stepwise by 0.05 micro g/kg/min increments if insufficient anesthesia was suspected. All postoperative outcome data were collected by an anesthesiologist who was blinded to the anesthetic regimen. Pain intensity using a visual analogue scale (VAS) was recorded for 24 hours postoperatively.. Hemodynamic and respiratory variables such as diastolic and systolic blood pressure, heart rate, and oxygen saturation were similar in both groups. The mean intraoperative remifentanil consumption in groups M and R was similar. The VAS score was significantly lower in the magnesium group at 15 and 30 minutes postoperatively. Total morphine consumption was significantly lower in the magnesium group than in the remifentanil-alone group.. It was concluded that magnesium sulfate decreased the postoperative morphine requirement when remifentanil was used for intraoperative analgesia.

Topics: Adolescent; Adult; Aged; Anesthesia; Atropine; Blood Pressure; Diastole; Double-Blind Method; Ephedrine; Female; Humans; Magnesium Sulfate; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Systole

Ketamine 0.15-1 mg kg(-1) decreases postoperative morphine consumption, but 0.5 mg kg(-1) is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents. The purpose of our investigation was to study the effect of ketamine 0.2 mg kg(-1) administered over a 5 min period on the BIS during stable target-controlled infusion (TCI) propofol-remifentanil general anaesthesia.. Thirty ASA I or II patients undergoing abdominal laparoscopic surgery were included in this double-blind, randomized study. Anaesthesia was induced and maintained with a TCI of propofol and remifentanil. After 5 min of steady-state anaesthesia (BIS at 40) without surgical stimulation, patients received either an infusion of ketamine 0.2 mg kg(-1) or normal saline. The test drug was infused over 5 min. Standard parameters and BIS values were recorded every minute until 15 min post-infusion.. The baseline mean (sd) value for the BIS was 37 (6.5) for the ketamine group and 39 (8.2) for the placebo group. The highest mean BIS value during the recording period was 41.5 (8.7) for the ketamine group and 40.1 (8.9) for the placebo group. BIS values were not statistically different between the groups (P=0.62); there was no significant change over time (P=0.65) with no group-time interaction (P=0.55).. Under stable propofol and remifentanil TCI anaesthesia, a slow bolus infusion of ketamine 0.2 mg kg(-1) administered over a 5 min period did not increase the BIS value over the next 15 min.

Topics: Adult; Aged; Analgesics; Anesthetics, Combined; Anesthetics, Dissociative; Anesthetics, Intravenous; Double-Blind Method; Drug Interactions; Electroencephalography; Female; Humans; Ketamine; Laparoscopy; Male; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Young Adult

To evaluate the applicability, effectiveness, immediate postoperative complaints and requirements for a postanaesthesia care unit stay after elective abdominal hysterectomy under a well defined, multimodal anaesthetic regime.. Observational study of 145 consecutive patients scheduled for the procedure at a major university hospital in Denmark. Perioperative treatments and postoperative complaints were recorded continuously until discharge from the postanaesthesia care unit. Main outcome measures were treatment regimen adherence, pain, nausea and vomiting, respiratory insufficiency and time of discharge readiness.. The structured regime consisting of total intravenous anaesthesia (propofol-remifentanil), well defined fluid administration, prophylactic antiemetics (dexamethasone, ondansetron, droperidol), weak analgesics (celecoxib, paracetamol) and intraoperative epidural analgesia (bupivacaine, morphine) was feasible in more than 90% of all patients. In the postanaesthesia care unit, 64% did not require opioids, but 25% experienced severe pain. Mean length of stay was 2 h with a mean discharge readiness of 80 min. Half the patients required supplemental oxygen for 1 h or more to sustain an SpO2 greater than 92%, and 8% experienced nausea or vomiting. A complicated recovery, defined as the presence of severe complaints (pain, nausea or vomiting), with more than five treatment interventions in the postanaesthesia care unit, or a length of stay more than 2 h, was seen in 52%.. We conclude that a structured multimodal anaesthetic regime is feasible in daily clinical practice and advantageous, and that postoperative pain and oxygen requirements (to sustain an SpO2 >92%) are the major determinants for length of stay in the postanaesthesia care unit. Further research should focus on nonopioid analgesic systemic adjuvants to improve early recovery and reduce stay in the postanaesthesia care unit.

Topics: Adult; Aged; Aged, 80 and over; Analgesics; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Intravenous; Antiemetics; Cohort Studies; Denmark; Elective Surgical Procedures; Female; Hospitals, University; Humans; Hysterectomy; Length of Stay; Middle Aged; Oxygen; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Remifentanil

To evaluate the analgesic efficacy of bilateral superficial cervical plexus block and combined superficial and deep cervical plexus block for incision pain, headache and posterior neck pain after thyroidectomy.. Ninety patients were divided into a control group (group C, n = 30), a bilateral superficial cervical plexus group (group S, n = 30) and a bilateral combined superficial and deep cervical plexus block group (group CO, n = 30). Before general anaesthesia, we performed bilateral superficial cervical plexus block (18 ml) and combined superficial (14 ml) and deep (4 ml) cervical plexus block with 0.25% bupivacaine. Anaesthesia was maintained with propofol-remifentanil-N2O-O2.. The average concentration of remifentanil was significantly reduced in group S compared with group C and group CO (1.1 +/- 0.3, 1.8 +/- 0.4, 1.8 +/- 0.7 ng ml, respectively; P < 0.05). The incision pain at rest and on swallowing were significantly reduced at 0, 2 and 4 h in group S compared with group C (P < 0.05). Headache showed a tendency to be reduced in group S and group CO, but the posterior neck pain was not different among the three groups. After surgery, the opioid and nonopioid requirement was significantly reduced in group S (P < 0.05). There were fewer side effects and greater patients' satisfaction in group S.. Superficial cervical plexus block is a more effective technique than combined superficial and deep cervical plexus block to reduce the pain during and immediately after thyroidectomy.

Topics: Amides; Anesthesia, General; Anesthetics, Local; Cervical Plexus; Combined Modality Therapy; Female; Humans; Hypnotics and Sedatives; Male; Middle Aged; Nerve Block; Pain, Postoperative; Piperidines; Preoperative Care; Propofol; Remifentanil; Ropivacaine; Thyroidectomy; Treatment Outcome

To investigate the adjuvant effect of intraoperative and postoperative low-dose ketamine administration to remifentanil consumption in patient-controlled analgesia (PCA) for lower limb fracture.. A total of 200 patients with lower limb fracture receiving the surgery were randomly divided into 4 groups. In Groups A, B and C, patients received 0.5 mg/kg ketamine infusion under general anesthesia, and ketamine in a dose of 0.1 mg/ kg, 0.05 mg/kg, 0.01 mg/kg per hour continuously for 24 hours after surgery, respectively. The control group (Group D) received an equivalent volume of normal saline only. With 20 microgram/ml remifentanil in normal saline, postoperative PCA was administered with a background infusion at 2 ml/h following 2 ml as a loading dose and 1ml demand dose with a 3-minute lockout period. Remifentanil consumption, 11-point visual analog scale (VAS) scores, global satisfaction score (GSS), and side effects were also recorded by the acute pain service.. Cumulative PCA remifentanil consumption in Groups A and B were (1378+/-77) microgram and (1531+/-402) microgram, significantly lower than (1807+/-510) microgram and (1838+/-523) microgram in Groups C and D (P<0.01). VAS scores in Groups A and B were significantly lower than those in Groups C and D (P<0.01). In the first 12 hours after operation, GSS was improved (P<0.01). No respiratory depression was observed. No significant difference in side effects was observed among groups.. Low-dose ketamine can relieve postoperative pain and moderately decrease remifentanil consumption for PCA, with no obvious side effects of ketamine.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Double-Blind Method; Female; Fractures, Bone; Humans; Ketamine; Lower Extremity; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

This prospective, randomized study was designed to compare remifentanil and magnesium sulphate during middle ear surgery in terms of postoperative pain and other complications.. Eighty patients undergoing middle ear surgery were enrolled in the study. Patients were randomized into two groups of 40 to receive remifentanil (Group R) or magnesium sulphate (Group M) infusion. Propofol 2 mg kg(-1) was administered to induce anaesthesia, which was maintained using sevoflurane. Group R received a continuous infusion of remifentanil titrated between 3 and 4 ng ml(-1) using target-controlled infusion, whereas Group M received an i.v. magnesium sulphate bolus of 50 mg kg(-1) followed by a 15 mg kg(-1) h(-1) continuous infusion to maintain a mean arterial pressure (MAP) between 60 and 70 mm Hg. Haemodynamic variables, surgical conditions, postoperative pain, and adverse effects, such as postoperative nausea and vomiting (PONV) and shivering, were recorded.. Controlled hypotension was well maintained in both groups. MAP and heart rate were higher in Group R than in Group M after operation. Surgical conditions were not different between the two groups. Postoperative pain scores were significantly lower in Group M than in Group R (P<0.05). Seventeen patients in Group R (43%) and seven patients in Group M (18%) developed PONV (P=0.01).. Both magnesium sulphate and remifentanil when combined with sevoflurane provided adequate controlled hypotension and proper surgical conditions for middle ear surgery. However, patients administered magnesium sulphate had a more favourable postoperative course with better analgesia and less shivering and PONV.

Topics: Adult; Analgesics; Analgesics, Opioid; Anesthesia, General; Antihypertensive Agents; Blood Pressure; Ear, Middle; Female; Heart Rate; Humans; Hypotension, Controlled; Magnesium Sulfate; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil

Gabapentin is an anticonvulsant drug that has analgesic properties for acute postoperative pain. However, the analgesic effect of gabapentin as an antiepileptic prophylactic drug on patients undergoing craniotomy is unclear. In this study, we evaluated the postoperative effectiveness of gabapentin on acute postoperative pain when it is used for antiepileptic prophylaxis in patients undergoing craniotomy for supratentorial tumor resection.. Eighty patients undergoing craniotomy for supratentorial tumor resection were randomly assigned into two groups. Patients in Group G (n = 40) received oral gabapentin (3 x 400 mg), and patients in Group P (n = 40) received oral phenytoin (3 x 100 mg) for 7 days before the operation and postoperatively. An identical anesthesia protocol was performed for both the groups. Anesthesia was maintained with propofol and remifentanil infusion. Patient-controlled analgesia with morphine was used, and pain levels were measured. The antiepileptic-related side effects, anesthetic consumption, duration of anesthesia and surgery, tracheal extubation time, postoperative pain scores, morphine consumption, and sedation scores were recorded.. Thirty-seven patients in Group G and 38 patients in Group P completed the study. During the preoperative period in Group G, one patient had severe fatigue, one had severe dizziness, and one patient's surgical procedure was changed. The median plasma levels of gabapentin were 34 micromol/mL (range, 23-51 micromol/mL) in 34 patients. In Group P, one patient withdrew from the study preoperatively and one developed transient neurological symptoms postoperatively. The demographic data and mean duration of anesthesia and surgery were similar in both the groups. The total propofol and remifentanil consumption in Group G (1847 +/- 548 mg/3034 +/- 1334 microg) was significantly less than that of Group P (2293 +/- 580 mg/4287 +/- 1282 microg) (P = 0.01). However, tracheal extubation could be done earlier in Group P (4.5 +/- 2 min) than in Group G (16.6 +/- 22 min) (P < 0.001). Pain scores were significantly higher in Group P at 15 min, 30 min, and 1 h (P < 0.001). The total morphine consumption was also significantly higher in Group P (33 +/- 17 mg vs 24 +/- 19 mg) (P = 0.01). The postoperative sedation scores were significantly higher in Group G at 15 min, 30 min, 1 h, and 2 h (P < 0.001).. The administration of gabapentin to patients undergoing craniotomy for supratentorial tumor resection was effective for acute postoperative pain. It also decreased analgesic consumption after surgery. However, it may lead to side effects such as delayed tracheal extubation and increased sedation postoperatively.

Topics: Administration, Oral; Adult; Amines; Analgesia, Patient-Controlled; Analgesics; Analgesics, Opioid; Anesthetics, Intravenous; Anticonvulsants; Craniotomy; Cyclohexanecarboxylic Acids; Dizziness; Drug Administration Schedule; Fatigue; Female; Gabapentin; gamma-Aminobutyric Acid; Humans; Intubation, Intratracheal; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Phenytoin; Piperidines; Preanesthetic Medication; Propofol; Prospective Studies; Remifentanil; Sleep; Supratentorial Neoplasms; Time Factors; Treatment Outcome

Intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain, opioid requirement and specifically peri-incisional hyperalgesia. The aim of this study was to investigate the effect of lornoxicam in preventing remifentanil-induced hyperalgesia.. Patients were randomly divided into two groups. Fifteen minutes before surgery, saline solution was given to the patients in group I and 16 mg i.v. Lornoxicam in group II. Anesthesia was induced with 1 microg/kg remifentanil combined with 1.5-2 mg/kg propofol and maintained with 0.5 MAC desflurane and 0.4 microg/kg/dk remifentanil in both groups. Desflurane concentration was titrated according to autonomic responses. All patients were given i.v. 0.15 mg/kg morphine 30 min before the end of surgery. At the end of surgery, patients received morphine i.v. Via a PCA (Patient Controlled Analgesia) device. Pain score, morphine demand and delivery were assessed at 2, 4, 6, 12 and 24 h after surgery. Total morphine consumption was recorded for 24-48 h. Peri-incisional hyperalgesia was assessed by measuring pain threshold to pressure using an algometer before operation and at 24-48 h postoperatively.. The pain scores and cumulative morphine consumption were significantly lower in the lornoxicam group when compared with the control group (p<0.05). Pain thresholds were significantly less at 24-48 h postoperatively in the control group than in the lornoxicam group. No significant difference was observed in side effects (p>0.05).. Lornoxicam administered preemptively prevented remifentanil-induced hyperalgesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Female; Humans; Hyperalgesia; Hysterectomy; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Preoperative Care; Propofol; Remifentanil; Sensory Thresholds

We have investigated whether, after major abdominal surgery, the addition of remifentanil to tramadol for intravenous patient-controlled analgesia improved analgesia and lowered pain scores, compared to a patient-controlled analgesia containing only tramadol.. Sixty-two patients were allocated randomly to receive an intravenous patient-controlled analgesia with tramadol alone (T), or tramadol plus remifentanil (TR), in a double-blind randomized study. Whenever patients complained of pain, they were allowed to use bolus doses of tramadol (0.2 mg kg-1) or tramadol (0.2 mg kg-1) plus remifentanil (0.2 microg kg-1) mixture every 10 min without a time limit and background infusion. Discomfort, sedation, pain scores, total and bolus patient-controlled analgesia tramadol consumption, and side-effects were recorded for up to 24 h after the start of patient-controlled analgesia.. Pain scores at rest were statistically significantly lower in the TR group at 6, 12 and 24 h than in T group (P < 0.05). Pain scores at movement and patient comfort scores were also found to be significantly lower in the TR group at 2, 6, 12 and 24 h than in the T group (P < 0.05). Although the TR group consumed less tramadol, there were no statistically significant differences in the cumulative tramadol consumptions between the groups at any time. However, the number of patients requiring rescue analgesia and average supplementary doses used was significantly higher in the T group than in the TR group (P < 0.05).. After major abdominal surgery, adding remifentanil (0.2 microg kg(-1)) to tramadol (0.2 mg kg(-1)), with 10-min lockout times, for patient-controlled analgesia offered better postoperative pain relief and patient comfort, without causing any sedation or respiratory depression.

Topics: Abdomen; Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Double-Blind Method; Female; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Tramadol; Treatment Outcome

The aim of this study was to investigate the effect of bispectral index (BIS) monitoring on hemodynamic parameters, drug consumption and awareness during total intravenous anesthesia (TIVA) with remifentanil and propofol in lumbar discectomies. After institutional ethical committee approval, ASAI-II 56 patients were divided as control and BIS groups. Anesthesia was induced by bolus remifentanil 1 mug/kg in both groups; propofol 2 mg/kg in was used in the control group while propofol was titrated to BIS 45- 65 values in the BIS group. Anesthesia was maintained by remifentanil and propofol infusions. Drug consumption, time to extubation and awareness were recorded. Demographic parameters were similar between the groups. Consumption of propofol was lower, and time to extubation was shorter in the BIS group; there was no difference between awareness among groups. BIS monitoring was helpful for propofol titration and decreased propofol consumption, but not enough to prevent reaction to noxious stimuli. Standard anesthesia titration considering hemodynamic parameters was enough for most ASA I-II patients for lumbar discectomies. BIS might be more helpful for patients who cannot show hemodynamic responses to noxious stimuli. More studies are needed to investigate the correlation between positioning and awareness using BIS monitoring.

Topics: Adult; Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Awareness; Blood Pressure; Diskectomy; Female; Heart Rate; Humans; Lumbar Vertebrae; Male; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Propofol; Remifentanil

To assess pain intensity and quality of postoperative recovery in patients given fast-track anesthesia and spinal analgesia versus patients treated with standard anesthesia.. A prospective, randomized, controlled study.. A private institution.. Eighty-three patients who underwent cardiac surgery with cardiopulmonary bypass were analyzed.. General anesthesia consisted of remifentanil and spinal analgesia (low-dose morphine and clonidine) for the fast-track group (FTG) and sufentanil without spinal analgesia for the control group (CG). During the postoperative period, paracetamol and patient-controlled intravenous analgesia (PCA) with morphine were given.. Postoperative pain intensity was evaluated during 48 hours with visual analog scale scores and intravenous morphine consumption. Pain impact on quality of life was assessed with the brief pain inventory (BPI) score (days 1-8), and recovery was evaluated with the quality of recovery score (QoR-40, day 4). Compared with the CG, FTG pain intensity was significantly lower 0 to 4 (p < 0.01) and 6 to 12 hours (p < 0.05) after surgery, as was their cumulative intravenous PCA morphine consumption (p = 0.01). BPI scores supported that FTG patients had significantly (p < 0.01) less "pain at its worst" on days 1 and 2, their BPI-assessed pain interfered significantly less with daily life on day 1 (p < 0.001), and their global QoR-40 score (day 4) was significantly higher (p < 0.05).. Fast-track anesthesia combined with morphine-clonidine spinal analgesia controlled postoperative pain better and obtained a better QoR than conventional analgesia.

Topics: Aged; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthesia, Spinal; Cardiovascular Surgical Procedures; Female; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Single-Blind Method; Time Factors

To compare the efficacy of remifentanil-propofol with that of fentanyl-propofol for monitored anesthesia care during hysteroscopy.. Prospective, randomized study.. Operating room and postanesthesia care unit of a university hospital.. 30 ASA physical status I and II adult patients undergoing hysteroscopic procedures.. After propofol infusion, patients received a bolus of remifentanil (group R, 0.5 microg/kg) or fentanyl (group F, 1 microg/kg) 4 minutes before starting the procedure and then received a continuous infusion of remifentanil (group R, 0.05 microg/kg per min) or bolus doses of fentanyl (group F, 0.5 microg/kg).. Patients in group R had lower pain scores than patients in group F (0-0 vs 0-7, P < 0.05) and more stable blood pressures (74 +/- 15 vs 85 +/- 9 mmHg, P < 0.05) one minute after the start of the procedure. However, no differences were observed in other variables (recovery profiles and satisfaction scores).. Remifentanil seems to be a safe and effective analgesic adjunct for monitored anesthesia care of hysteroscopic surgery.

Topics: Adolescent; Adult; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Intravenous; Blood Pressure; Female; Fentanyl; Humans; Hysteroscopy; Infusions, Intravenous; Injections, Intravenous; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Patient Satisfaction; Piperidines; Propofol; Prospective Studies; Remifentanil; Young Adult

Remifentanil-based anesthesia is commonly used to facilitate neurophysiologic monitoring during pediatric scoliosis surgery. Acute opioid tolerance and/or hyperalgesia resulting from remifentanil-based anesthesia may involve activation of N-methyl-D-aspartate systems. We hypothesized that low-dose intraoperative infusion of the N-methyl-d-aspartate antagonist ketamine would suppress the development of tolerance and thereby decrease postoperative morphine consumption in children receiving remifentanil-based anesthesia for scoliosis surgery.. Thirty-four adolescents aged 12-18 yr scheduled for scoliosis surgery were randomly assigned to receive intraoperative low-dose ketamine (bolus dose of 0.5 mg/kg followed by continuous infusion of 4 microg.kg(-1).min(-1)) or an equal volume of saline during propofol/remifentanil anesthesia. Cumulative morphine consumption was assessed using a patient-controlled analgesia device for 72 h after surgery. Postoperative morphine consumption, pain scores at rest and during cough, and sedation scores were recorded by a blinded investigator every hour for the first 4 h, every 4 hours for 20 h, and then every 12 hours for 72 h.. Cumulative morphine consumption at 24, 48, and 72 h after surgery did not differ significantly between groups (ketamine group: 1.57+/-0.56, 3.05+/-1.14, and 4.46+/-1.53 mg/kg; saline group: 1.60+/-0.53, 2.87+/-1.05, and 4.11+/-1.71 mg/kg, respectively). No differences in pain or sedation scores were found. The duration of anesthesia was similar in the two groups.. These data do not support the use of intraoperative low-dose ketamine to prevent the development of remifentanil-induced acute opioid tolerance and/or hyperalgesia during pediatric scoliosis surgery.

Topics: Adolescent; Analgesia, Patient-Controlled; Analgesics; Analgesics, Opioid; Anesthetics, Intravenous; Child; Double-Blind Method; Drug Tolerance; Female; Humans; Intraoperative Care; Ketamine; Male; Morphine; Pain, Postoperative; Piperidines; Remifentanil; Scoliosis

We evaluated the use of continuous infusion of ketamine to reduce intraoperative remifentanil side effects, such as bradycardia and hypotension, and to improve postoperative analgesia from balanced anesthesia with remifentanil.. Forty patients undergoing spine surgery under remifentanil-based anesthesia were randomly assigned to intraoperative ketamine group and saline (control) group. Balanced anesthesia was maintained with infusion of propofol (2-4 mg x kg(-1) x hr(-1)), remifentanil (6-8 microg x kg(-1) hr(-1)) and vecuronium (60-80 microg x kg(-1) x hr(-1)) with nitrous oxide (60%) and with or without ketamine (300-400 microg x kg(-1) x hr(-)). All patients were given scheduled NSAIDs by their own doctor at the end of surgery. Intraoperative bradycardia (HR <50) and hypotension (SBP <80), and postoperative additional NSAIDs request were recorded.. Adverse events, such as bradycardia and hypotension, were less frequent in the ketamine group (P < 0.05). Less additional NSAIDs was required in the ketamine than in the control group (P < 0.05). Emergence time from anesthesia was within 5 min in both groups.. Remifentanil-based anesthesia with continuous ketamine decreases intraoperative side effects and postoperative NSAIDs request. Thus, intraoperative continuous ketamine may be a useful adjuvant to remifentanil.

Topics: Adjuvants, Anesthesia; Adult; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Bradycardia; Humans; Hypotension; Infusions, Intravenous; Intraoperative Complications; Ketamine; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Spine

Remifentanil, an ultra short-acting opioid commonly used to supplement general anesthesia, is associated with the development of hyperalgesia that manifests clinically as an increase in postoperative analgesic requirement. This study involving adolescents undergoing scoliosis surgery evaluated whether pre-treatment with morphine prior to commencing remifentanil infusion would decrease the initial 24-hr morphine consumption and pain scores.. Forty ASA I-II pediatric patients undergoing surgical correction of idiopathic scoliosis were recruited in a prospective, randomized, double-blind fashion to receive 150 microg x kg(-1) morphine or an equal volume saline prior to commencing remifentanil by infusion. The primary outcome was the initial 24-hr postoperative morphine consumption. Numeric rating scale (NRS) pain scores at rest and on coughing were recorded, as were scores for nausea, vomiting, and sedation and incidences of pruritus.. The groups were demographically similar. No differences were observed between groups vis-à-vis the initial 24-hr morphine consumption, NRS pain scores, sedation, nausea, or vomiting.. Pre-treatment with 150 microg x kg(-1) morphine did not decrease the initial 24-hr morphine consumption in adolescents who received remifentanil by infusion for surgical correction of idiopathic scoliosis.

Topics: Adolescent; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Double-Blind Method; Drug Administration Schedule; Female; Humans; Hyperalgesia; Intraoperative Care; Male; Morphine; Orthopedic Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Premedication; Prospective Studies; Remifentanil; Scoliosis

To assess the value of compound anesthesia of transcutaneous electrical point stimulation and Remifentanil and the efficacy of this method on postoperative acute pain.. Sixty cases with vertebral lamina internal fixation decompression operation were selected and randomly divided into 2 groups, an observation group and a control group, 30 cases in each group. The patients in the observation group received compound anesthesia of transcutaneous electrical point stimulation at Hegu (LI 4), Laogong (PC 8), Neiguan (PC 6) and Waiguan (TE 5) 30 min before anesthesia induction with HANS stimulator and then Remifentanil anesthesia. During the operation, the stimulation was lasted for 30 min and ceased for 30 min until the end of operation. The patients in the control group received simple Remifentanil anesthesia. The dosage of the narcotic, changes of both blood pressure and heart rate during operation, before and after extubation and the pain degree, etc. were investigated in the two groups.. (1) The dosage of Isoflurane, (0.52 +/- 0.33)vol%, in the observation group was significantly lower than (1.12 +/- 0.18) vol% in the control group (P < 0.01). (2) Both blood pressure and heart rate during operation, before and after extubation in the observation group were lower than those before operation (P < 0.01), and both the blood pressure and heart rate during operation in the control group were lower than those before operation (P < 0.01). The blood pressure after extubation in the observation group was significantly lower than that of the control group (P < 0.01), and the heart rate before and after extubation in the observation group was significantly lower than that of the control group (P < 0.01). (3) The time of extubation and palinesthesia in the observation group were significantly shorter than those in the control group (P < 0.01). (4) In the observation group, the VAS scores after palinesthesia in 26 cases were < 4, and in 4 cases were > or = 5, while in the control group, the scores in 4 cases were < 4 and in 20 cases > or = 5, with a significant difference between the two groups (P < 0.01).. Compound anesthesia of transcutaneous electrical point stimulation and Remifentanil can reduce the dosage of narcotics, shorten the time of palinesthesia and effectively prevent and treat acute pain after Remifentanil anesthesia.

Topics: Acupuncture Analgesia; Adult; Anesthesia Recovery Period; Anesthetics, Intravenous; Electroacupuncture; Female; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Spine

Remifentanil's short-acting analgesic effect and the potential of producing hyperalgesia is a challenge to post-operative pain control. This study investigated whether pre-treating the patients with fentanyl before remifentanil-based anaesthesia could reduce post-operative pain or analgesic consumption.. One-hundred patients admitted for anterior cruciate ligament repair were included in a double-blind study. Propofol and remifentanil were used for general anaesthesia. Group Pre received fentanyl 1.5 microg/kg intravenously (IV) and Group Post placebo before the remifentanil infusion. At the end of surgery, Group Pre received 1.5 microg/kg and Group Post received 3.0 microg/kg. Patient-controlled analgesia with fentanyl was used as analgesic rescue medication during the first 4 h post-operatively. Oxycodone 5 mg orally was taken as needed during the subsequent 4-24-h period.. A mean dose of remifentanil 0.43 microg/kg/min was used for 90 min during surgery in both groups. There were no differences in the verbal rate scale (VRS) score or need of rescue analgesic medication between the groups during the first 4 h. Group Post had significantly less pain in the 4-24-h period after surgery, with a median VRS score of 'slight pain' vs. 'moderate pain' in Group Pre (P<0.05). The oxycodone consumption was similar in both groups.. Pre-treatment with fentanyl 1.5 microg/kg IV yielded no reduction in post-operative pain or analgesic consumption after 90 min of remifentanil-based anaesthesia with 0.43 microg/kg/min of remifentanil.

Topics: Acetaminophen; Adolescent; Adult; Aged; Analgesia, Patient-Controlled; Analgesics; Anesthesia, Intravenous; Anesthetics, Intravenous; Anterior Cruciate Ligament; Anterior Cruciate Ligament Injuries; Double-Blind Method; Female; Fentanyl; Humans; Hyperalgesia; Male; Middle Aged; Oxycodone; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Reoperation; Treatment Failure

The administration of nitrous oxide (N2O) may be associated with side effects and toxicities. Remifentanil shares characteristics with N2O, including MAC-reducing and antinociceptive effects and a rapid decrease in clinical effect when discontinued. We compared the outcome after ambulatory orthopedic surgery with desflurane and fentanyl supplemented with clinically equivalent doses of either N2O or remifentanil.. Seventy patients undergoing ambulatory orthopedic surgery were studied. Thirty-five received 66% N2O and 35 received remifentanil 0.085 microg x kg(-1) x min(-1) in addition to desflurane, titrated to a bispectral index (BIS) value of 50, and a fentanyl infusion. The principle outcome measure was time to awakening to verbal stimulation. Secondary outcome measures included neuropsychological testing, time to orientation, hemodynamic values, pain and nausea visual analog scores, discharge times, and satisfaction scores. The average end-tidal desflurane concentration and fentanyl effect-site concentration were determined.. The median time (interquartile range) to awakening to verbal stimulation, 3.0 min (3.0-5.0 min) in the remifentanil group and 4.6 min (3.0-8.1 min) in the N2O group was not significantly different. Median time to orientation was significantly faster in the remifentanil group: 6.0 min (5.0-8.5 min) compared with 8.0 min (5.0-12.8 min) for the N2O group. There was no difference between groups in desflurane or fentanyl administration, neuropsychological testing, or any other outcome measure.. This study demonstrates that a remifentanil infusion of 0.085 microg x kg(-1) x min(-1) may be substituted for 66% N2O during desflurane/fentanyl anesthesia without any clinically significant change in outcome.

Topics: Adult; Ambulatory Surgical Procedures; Analgesics; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Female; Fentanyl; Hemodynamics; Humans; Isoflurane; Length of Stay; Male; Motor Skills; Nitrous Oxide; Orientation; Orthopedic Procedures; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Nausea and Vomiting; Remifentanil; Time Factors; Treatment Outcome; Wakefulness

This randomized, double-blind, prospective study was undertaken to evaluate the effects of magnesium sulphate on anaesthetic requirements and postoperative analgesia in patients undergoing total i.v. anaesthesia (TIVA).. Fifty patients who underwent gynaecological surgery were randomly divided into two groups. Before induction of anaesthesia, the magnesium group (Group M) received magnesium sulphate 50 mg kg(-1) i.v. as a bolus and then 15 mg kg(-1) h(-1) i.v. by continuous infusion. The control group (Group S) received the same amount of isotonic saline. TIVA (propofol+remifentanil) was administered under bispectral index monitoring during anaesthesia induction and maintenance. Rocuronium was administered before orotracheal intubation and during surgery when the train-of-four count was 2 or more. After operation, patient-controlled analgesia with a solution of ketorolac and morphine was used and the consumption of this solution was recorded. Pain scores at rest and upon movement were evaluated 30 min, 4, 24, and 48 h after surgery.. Patients in Group M required less rocuronium than those in Group S [mean (SD) 0.44 (0.09) vs 0.35 (0.07) microg kg(-1) min(-1), P<0.05]. The total amounts of propofol and remifentanil administered were similar in the two groups. Postoperative pain scores, cumulative analgesic consumption, and shivering incidents were significantly lower in Group M (P<0.05). Mean arterial pressure just after intubation and during the immediate postoperative period was also significantly lower in Group M (P<0.05).. I.v. magnesium sulphate during TIVA reduced rocuronium requirement and improved the quality of postoperative analgesia.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Drug Administration Schedule; Female; Gynecologic Surgical Procedures; Humans; Magnesium Sulfate; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil

Postoperative shivering and pain are frequent problems in patients recovering from anaesthesia with particularly high incidences being observed after remifentanil-isoflurane-based general anaesthesia. The opioid tramadol is generally effective in preventing shivering and treating pain, but its effects are not characterized after remifentanil-based general anaesthesia. This randomized, placebo-controlled, double-blind study evaluated the effects of intraoperative intravenous tramadol on postoperative shivering and pain after remifentanil-based general anaesthesia.. After Ethics Committee approval, 60 patients scheduled for lumbar disc surgery were included. Surgery was performed under general anaesthesia (remifentanil, isoflurane). Patients were randomly assigned to receive 2 mg kg(-1) tramadol in 30 mL 0.9% saline infused intravenously (n = 30) or 30 mL saline (n = 30) 45-30 min before skin closure. The following parameters were assessed every 10 min for 2 h: shivering, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation. The primary outcome variable was the incidence of shivering during the first 2 postoperative hours. Secondary variables were: shivering intensity, pain, postoperative nausea and vomiting, sedation, heart rate, non-invasive blood pressure and peripheral oxygen saturation.. Shivering was less frequent in patients treated with tramadol (20% vs. 70%, P = 0.0009) and was of lower intensity (severe shivering: 10% vs. 46.7%, P = 0.003). Pain scores were similar between the groups and all other secondary outcome variables failed to reveal significant differences.. Compared with placebo, intraoperative intravenous administration of 2 mg kg(-1) tramadol reduces the incidence and extent of postoperative shivering without alterations in pain perception after lumbar disc surgery under remifentanil-isoflurane-based general anaesthesia.

Topics: Analgesics, Opioid; Anesthesia, General; Anesthetics, Inhalation; Double-Blind Method; Female; Humans; Intervertebral Disc; Intraoperative Care; Isoflurane; Lumbar Vertebrae; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil; Shivering; Tramadol; Treatment Outcome

Remifentanil is being used increasingly during fast-track cardiac surgery. Postoperative hyperalgesia and opioid tolerance have been reported in volunteer studies and in patients after major abdominal surgery with remifentanil infusion. In the present study, the authors evaluated whether high-dose remifentanil infusion induces opioid tolerance in 90 patients undergoing coronary artery bypass surgery with sternotomy.. Prospective, randomized, and double-blind study.. Single-institution, tertiary level, university hospital.. Ninety patients undergoing coronary artery bypass surgery.. Patients were randomized to receive a 3-hour infusion of remifentanil (0.3 microg/kg/min, n = 45) or placebo (n = 45) intraoperatively as adjunct to a standardized sufentanil/propofol-based general anesthesia.. Opioid consumption, pain, and sedation scores, as well as adverse events and patients' satisfaction with pain therapy, were recorded for 48 postoperative hours. There were no differences in postoperative opioid consumption between the groups (median oxycodone consumption in the remifentanil group, 98 mg [range, 29-166] and in the placebo group, 99 mg [42-219]). Pain scores were comparable at rest, but during a deep breath pain scores were lower in the remifentanil group (p = 0.020). Sedation scores, satisfaction with analgesia, and adverse events were similar between the 2 groups. The most common adverse event was nausea, with a 33% incidence in the placebo and 40% incidence in the remifentanil group.. Three-hour remifentanil infusion did not increase postoperative pain or opioid consumption in cardiac surgery patients. The present results suggest that high-dose remifentanil does not elicit opioid tolerance when given during cardiac surgery.

Topics: Analgesics, Opioid; Coronary Artery Bypass; Double-Blind Method; Drug Tolerance; Female; Humans; Infusions, Intravenous; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

In this randomized, double-blind study, we investigated the analgesic efficacy and side effects of continuous constant-dose infusions of remifentanil after total abdominal hysterectomy and compared it to fentanyl.. Fifty-six adult female patients scheduled for elective total abdominal hysterectomy were enrolled in this study. Patients were randomly assigned to two groups according to fentanyl (group F, n=28) or remifentanil (group R, n=28) for postoperative analgesia. Patients in group F were given fentanyl intravenously with an infusion rate of fentanyl 0.5 microg/kg/hr; group R was given remifentanil with an infusion rate of remifentanil 0.05 microg/kg/min for 2 days. Pain intensity at rest, occurrence of postoperative nausea and vomiting (PONV), dizziness, pruritus, and respiratory depression were assessed 1 hr after arrival at the post-anesthesia care unit, at 6; 12; 24; and 48 hr post-operation and 6 hr post-infusion of the study drug. Pain was evaluated by using visual analogue scale (VAS; 0-10). The time that patients first requested analgesics was recorded as well as additional analgesics and antiemetics.. There were no significant differences in VAS, time to first postoperative analgesics, and additional analgesics between the 2 groups. The incidences and severities of PONV and opioid related side effects were not different between the groups; however, there were 3 episodes (10.7%) of serious respiratory depression in group R.. Continuous infusion technique of remifentanil did not reveal any benefits compared to fentanyl. Furthermore, it is not safe for postoperative analgesia in the general ward.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Drug Administration Schedule; Female; Fentanyl; Humans; Hysterectomy; Infusions, Intravenous; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Treatment Outcome

The purpose of this study was to compare the safety and efficacy of fast-track cardiac anesthesia with remifentanil (group R) versus sufentanil (group S).. Prospective, single-blinded, randomized study.. University hospital.. One hundred twenty patients undergoing coronary artery bypass graft surgery and/or cardiac valve surgery.. After routine standardized anesthesia induction, anesthesia was maintained with isoflurane (0.4-0.8 vol%) together with either remifentanil (group R) (1 microg/kg/min) or sufentanil (group S) (1 microg/kg for induction, 0.5 microg/kg for skin incision, and then 0.02 microg/kg/min). After surgery, which included cardiopulmonary bypass in all cases, postoperative sedation was achieved in both groups with propofol until the patient was deemed ready for extubation. Additionally, patients in group R received remifentanil, 0.25 microg/kg/min.. Recovery profile in group R patients was faster (p < 0.05), with a median time interval between end of surgery and eligibility for extubation of 295 minutes versus 375 minutes. Time from end of surgery to being eligible for discharge from intensive care unit was similar in both groups, with 22.9 hours in group R versus 26.3 hour in group S. Remifentanil provided a better protection against intraoperative stimuli at skin incision and maximal sternal spread (p < 0.05). The incidence of adverse events was comparable in both groups. Postoperative pain scores during the first hour of weaning were higher in group R (p < 0.05).. Remifentanil for fast-track cardiac anesthesia provided safe and stable operating conditions and facilitated earlier tracheal extubation. However, postoperative pain management should be planned carefully.

Topics: Anesthesia; Anesthetics, Intravenous; Cardiac Surgical Procedures; Female; Humans; Intraoperative Complications; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Prospective Studies; Remifentanil; Single-Blind Method; Sufentanil; Surveys and Questionnaires; Time Factors; Treatment Outcome

To compare hemodynamics, recovery profiles, postoperative side effects and costs of desflurane-remifentanil and propofol-remifentanil anesthesia for septorhinoplasty operations.. A prospective and randomized study was carried out at the Gazi University Hospital, Ankara, Turkey from April to September 2003. Forty patients undergoing septorhinoplasty operations were randomly allocated to receive desflurane-remifentanil (Group DES-REM) or total intravenous anesthesia (TIVA) (Group TIVA). Anesthesia was induced in both groups with remifentanil 1 microg x ml (-1), propofol 2-2.5 mg.kg-1 and pancuronium 0.1 mg.kg-1. Maintenance was achieved with O2 50% in air at 4 L.min-1 and infusion of remifentanil 0.1 microg x ml (-1).min-1 in both groups. Group DES-REM received desflurane at 1 minimum alveolar concentration and Group TIVA received 10-4 mg.kg-1.hour-1 of propofol. Propofol infusion and desflurane were discontinued with the last surgical stitches, but remifentanil infusion continued in both groups until the nose was covered with plaster. Hemodynamic variables were recorded during the operation and one hour postoperatively in 5 min intervals. We recorded time of extubation, spontaneous eye opening and response to verbal commands times, visual analog scale pain scores, postoperative nausea and vomiting and Aldrete Recovery Score. Drug dosages and costs of each technique were determined.. There were no statistically significant differences between the groups with respect to hemodynamic parameters, recovery profile, adverse effects, Aldrete Recovery Score and cost analysis. Visual analog scale at 5 min postoperatively was higher in group desflurane-remifentanil compared to group propofol-remifentanil (p<0.05).. Both desflurane-remifentanil and TIVA provide perioperative hemodynamic stability, early and easy recovery with similar cost profiles for septorhinoplasty operations.

Topics: Adolescent; Adult; Anesthesia Recovery Period; Anesthetics, Intravenous; Blood Pressure; Chi-Square Distribution; Cost-Benefit Analysis; Elective Surgical Procedures; Female; Follow-Up Studies; Heart Rate; Humans; Male; Middle Aged; Nasal Septum; Pain Measurement; Pain, Postoperative; Piperidines; Probability; Propofol; Prospective Studies; Remifentanil; Rhinoplasty; Statistics, Nonparametric; Treatment Outcome

Surgery and anesthetic method have immunomodulating effects on hemodynamic response and stress. We compared the effects of 2 intraoperative analgesic regimens on patients undergoing abdominal hysterectomy.. We conducted a randomized double-blind trial in ASA 1 and 2 patients undergoing abdominal hysterectomy under balanced anesthesia. Twenty-nine patients were randomized to 2 groups. One group received analgesia by infusion of remifentanil plus morphine and nonsteroidal anti-inflammatory drugs as rescue medications; the other received conventional analgesia with bolus doses of fentanyl according to changes in hemodynamic variables. We measured levels of proinflammatory (interleukin [IL]-6) and antiinflammatory (IL-10) cytokines, cortisol, and C-reactive protein preoperatively, at incision, and at 1, 4 and 24 hours after surgery.. There were no significant differences between the 2 groups in terms of the markers studied at baseline. In each group, however, there were significant changes from baseline at the various points in time. IL-6 and IL-10 levels were significantly elevated (P < .05) at 4 hours. The changes in cortisol levels were significantly different at 1 and 4 hours. Finally, there were significant increases in C-reactive protein at 24 hours.. Unlike other clinical trials, our study detected no differences between the 2 techniques in response to surgical stress evaluated by analyzing concentrations of pro- and anti-inflammatory cytokines, cortisol, and C-reactive protein.

Topics: Aged; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Biomarkers; C-Reactive Protein; Dipyrone; Double-Blind Method; Drug Administration Schedule; Female; Fentanyl; Humans; Hydrocortisone; Hysterectomy; Inflammation; Infusions, Intravenous; Injections, Intravenous; Interleukin-10; Interleukin-6; Intraoperative Complications; Kinetics; Middle Aged; Morphine; Narcotics; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil; Stress, Physiological

Choice of opioid may influence postoperative pain, recovery, and respiratory homeostasis in morbid obesity. The aim of this study was to compare the effects of target-controlled infusions (TCIs) of remifentanil or sufentanil on postoperative analgesia, recovery, and pulmonary function after laparoscopic gastric banding.. Forty morbidly obese patients undergoing laparoscopic gastric banding received BIS-guided desflurane anaesthesia combined with remifentanil TCI (Group R) or sufentanil TCI (Group S). Intraoperative haemodynamic stability, BIS controllability, and immediate recovery in the operating room were measured. Pulmonary function, modified Aldrete score, modified Observers Assessment of Alertness and Sedation score, blood gas analysis, and visual analogue score for pain and postoperative nausea and vomiting were measured on admission to the post-anaesthesia care unit and 30, 60, 120 min afterwards. After operation, patients received patient-controlled analgesia with morphine.. During the first two postoperative hours, cumulative morphine consumption was higher in the remifentanil group compared with the sufentanil group, but was equal values after that time. Recovery profiles and spirometry showed no significant differences. During maintenance, remifentanil gave a better haemodynamic stability.. As few differences occurred in the postoperative period, the theoretical advantage of remifentanil over the longer acting sufentanil can be questioned when using TCI technology.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Blood Pressure; Drug Administration Schedule; Female; Forced Expiratory Volume; Gastroplasty; Heart Rate; Humans; Male; Middle Aged; Morphine; Obesity, Morbid; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Single-Blind Method; Sufentanil; Vital Capacity

This clinical study tested the hypothesis whether intraoperative high versus low dose of intravenous remifentanil resulted in postoperatively increased pain sensitivity to painful cold or pressure stimulation in eye surgery patients without significant postoperative pain.. Forty-two minor eye surgery patients were randomized to receive intraoperative high (0.4 microg/kg/min) or low (0.1 microg/kg/min) dose of intravenous remifentanil plus isoflurane over an average period of 70 minutes. Pain assessment at the surgical site, postoperative versus preoperative baseline measurements by the cold as well as the pressor test, sedation score, and withdrawal signs were evaluated 30 and 90 minutes after stop of remifentanil infusion. Patients with pain at the surgical site were excluded.. Pressure pain tolerance thresholds at the palmar carpus of the right hand were significantly decreased in these patients after cessation of intraoperative high but not low dose of IV remifentanil. However, withdrawal latencies to cold stimulation were not significantly altered. Isoflurane concentrations were slightly higher in patients receiving the low dose of remifentanil, however, there were no significant differences in length of anesthesia and postoperative sedation. Signs of withdrawal were not observed.. After high dose intravenous remifentanil our results show signs of a reduced tolerance to painful pressure but not cold stimuli distant to the surgical field. Although clinically relevant surgical pain was not reported in these patients, the demonstrated induction of hyperalgesia to painful pressure stimuli suggests a general effect in the central nervous system.

Topics: Analgesics, Opioid; Dose-Response Relationship, Drug; Female; Humans; Intraoperative Care; Male; Middle Aged; Pain Measurement; Pain Threshold; Pain, Postoperative; Physical Stimulation; Piperidines; Premedication; Remifentanil; Sensitivity and Specificity; Treatment Outcome

We investigated the effects of gabapentin and dexamethasone given together or separately 1 h before the start of surgery on laryngoscopy, tracheal intubation, intraoperative hemodynamics, opioid consumption, and postoperative pain in patients undergoing varicocele operations.. Patients were randomly divided into four double-blind groups: group C (control, n = 20) received placebo, group G (gabapentin, n = 20) received 800 mg gabapentin, group D (dexamethasone, n = 20) received 8 mg dexamethasone, group GD (gabapentin plus dexamethasone) received both 800 mg gabapentin and 8 mg dexamethasone IV 1 h before the start of surgery. Standard induction and maintenance of anesthesia were accomplished and continued by propofol and remifentanil infusion. Heart rate and arterial blood pressure were recorded before induction and after intubation. Intraoperative total remifentanil consumption was recorded. Hemodynamic variables and visual analog scale were recorded for 24 h. Side effects were noted.. Hemodynamics at 1, 3, 5, and 10 min after tracheal intubation, total remifentanil consumption during surgery, postoperative visual analog scale scores at 30 min, 1, 2, 4, 6, and 12 h, and postoperative nausea and vomiting were found to be significantly lower in group GD than in group G and group D (P < 0.05 for both), and substantially lower when compared with group C (P < 0.001). All values in group C were also higher than in groups G and D (P < 0.05).. Gabapentin and dexamethasone administered together an hour before varicocele surgery results in less laryngeal and tracheal intubation response, improves postoperative analgesia, and prevents postoperative nausea and vomiting better than individual administration of each drug.

Topics: Adult; Amines; Analgesics; Analgesics, Opioid; Blood Pressure; Cyclohexanecarboxylic Acids; Dexamethasone; Double-Blind Method; Drug Therapy, Combination; Gabapentin; gamma-Aminobutyric Acid; Glucocorticoids; Heart Rate; Humans; Intubation, Intratracheal; Male; Oxygen; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Preoperative Care; Remifentanil; Varicocele

Our aim was to investigate the effects of patient-controlled sedo/analgesia with fentanyl or remifentanil during cataract surgery with phacoemulsification method under topical anaesthesia. The ethical committee has approved the prospective, randomized, double-blind study. ASA I-III, 120 patients underwent cataract surgery were randomly allocated to 3 groups. Fentanyl was administered in 0.7 microg/kg loading, 10 microg bolus dose with 5 minutes lockout time, remifentanil was administered 0.3 microg/kg loading, 20 microg bolus dose with 3 minutes lockout time by patient controlled analgesia (PCA) equipment. In the control group, saline solution was given without any analgesic drug. Cardiorespiratory system findings, verbal pain scale and sedation scores were recorded preoperatively and intraoperatively at the 5th, 10th, 15th, 20th and 30th minutes. Discomfort during surgery, pressing the PCA button, and complications were recorded. The verbal pain scale scores was significantly lower in the drug groups than the those in control group at the 15th minute. The sedation scores was significantly higher in the remifentanil group at the 5th minute (p=0.019) and in the fentanyl group at the 10th minute (p=0.007) than those in the control group. The number of patients pressing the PCA button was much higher in the control group than the drug groups (p<0.05). Patient comfort and surgeon satisfaction were higher in the drug groups (p<0.05). Intravenous-PCA sedo/analgesia addition to topical anaesthesia provides an advantage in sedo/analgesia, patient comfort, and surgeon satisfaction. PCA is a convenient and safe method, especially at the beginning of the operation when anxiety is intense, and during healon/lens implantation.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Cataract Extraction; Double-Blind Method; Female; Fentanyl; Humans; Infusions, Intravenous; Male; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Treatment Outcome

Alvimopan is a peripherally acting mu-opioid receptor (PAM-OR) antagonist for accelerating gastrointestinal recovery after surgery.. Patients undergoing open laparotomy (bowel resection, n = 418; hysterectomy, n = 197) were randomized to receive alvimopan 6 or 12 mg or placebo orally > or = 2 h before surgery and then b.i.d. until hospital discharge (up to 7 days). The primary efficacy endpoint was time to gastrointestinal (GI) recovery (measured by toleration of solid food and passage of flatus/stool; GI-3). Secondary endpoints included time to GI-2 recovery (toleration of solid food and passage of stool) and hospital discharge order written (DCO).. Alvimopan did not significantly accelerate GI-3 compared with placebo [6 mg: hazard ratio (HR) = 1.20, p = 0.080; 12 mg: HR = 1.24, p = 0.038). However, after adjustment for significant covariates (sex/surgical duration), benefits were significant for both doses (6 mg: HR = 1.24, p = 0.037; 12 mg: HR = 1.26, p = 0.028). Alvimopan also significantly accelerated time to GI-2 (6 mg: HR = 1.37, p = 0.008; 12 mg: HR = 1.33, p = 0.018) and DCO (6 mg: HR = 1.31, p = 0.008; 12 mg: HR = 1.28, p = 0.015). Adverse events were similar between groups.. Alvimopan (6 or 12 mg) accelerates GI recovery and is well tolerated in patients undergoing open laparotomy.

Topics: Abdomen; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Double-Blind Method; Female; Gastrointestinal Tract; Humans; Hysterectomy; Ileus; Laparotomy; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Pelvis; Piperidines; Proportional Hazards Models; Receptors, Opioid, mu; Recovery of Function; Survival Analysis; Treatment Outcome

Opioids may activate pain facilitatory systems opposing analgesia. We investigated whether large-dose remifentanil given during IV anesthesia caused postoperative morphine overconsumption and whether nefopam (a centrally acting analgesic) could reduce this. Sixty patients scheduled for abdominal surgery were included in this prospective, randomized study. The first 30 patients received either small-dose (Group S: 3 ng/mL) or large-dose (Group L: 8 ng/mL) remifentanil administrated by a target-controlled infusion during propofol anesthesia. Before skin closure, patients received morphine 0.15 mg/kg. Another 30 patients also received nefopam 20 mg intraoperatively. Postoperative pain was controlled by titration of morphine, followed by patient-controlled morphine analgesia (PCA). Morphine was requested earlier in Group L than in Group S (10 [1-63] min versus 37 [5-90] min, median [range]; P < 0.002). The dose of morphine by titration was larger in Group L than in Group S (0.28 [0.04-0.38] mg/kg versus 0.16 [0.03-0.41] mg/kg; P < 0.05). PCA morphine consumption and pain scores were similar. There were no differences between the nefopam groups in the time to first morphine request or in the dose of morphine by titration. Postoperative morphine overconsumption occurred after large-dose remifentanil and propofol anesthesia during the early postoperative period. Pretreatment with nefopam could be useful to prevent pain sensitization induced by opioids.

Topics: Adult; Aged; Digestive System Surgical Procedures; Double-Blind Method; Drug Tolerance; Female; Humans; Male; Middle Aged; Morphine; Nefopam; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

The purpose of the study was to compare time of recovery, return of cognitive function, post-anaesthetic care unit (PACU) stay and costs of a propofol/remifentanil (TIVA) with a desflurane/fentanyl-based anaesthesia (desflurane group) in surgical procedures lasting more than 150 min.. Forty-nine patients undergoing elective abdominal prostatectomy were allocated randomly to receive bispectal index (BIS)-controlled desflurane/fentanyl (n=24) or propofol/remifentanil (n=25). Awakening, clinical recovery, direct drug acquisition and post-operative pain treatment were documented. Cognitive skills were tested using the Mini-Mental Status (MMST) test.. Extubation was significantly faster with desflurane (6.9+/-3.5 min) than with TIVA (11.2+/-4.0 min) as well as times for stating name and date of birth (desflurane: 6.1+/-3.9 and 6.6+/-4.0 min; TIVA: 12.4+/-11.5 min and 13.4+/-11.3 min). There were no significant differences in PACU discharge times or MMS scores between the groups. Significantly more patients suffered post-operative nausea and vomiting (PONV) in the desflurane (33% vs. 0%) than the TIVA group. Overall costs were significantly higher in the TIVA (58.8+/-11.6 euro) than in the desflurane group (35.0+/-5.7 euro).. Patients undergoing prolonged surgical procedures showed a faster early recovery after desflurane/fentanyl than using TIVA, whereas stay in the PACU and recovery of cognitive function were similar in both groups. Costs of a TIVA regimen were significantly higher than using a desflurane-based anaesthesia technique.

Topics: Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Cognition; Desflurane; Drug Costs; Fentanyl; Hospital Units; Humans; Isoflurane; Length of Stay; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Prostatectomy; Remifentanil

Magnesium is a calcium and an NMDA-receptor antagonist and can modify important mechanisms of nociception. We evaluated the co-analgesic effect of magnesium in the postoperative setting after on-pump cardiac surgery.. Forty patients randomly received either magnesium gluconate as an i.v. bolus of 0.21 mmol kg(-1) (86.5 mg kg(-1)) followed by a continuous infusion of 0.03 mmol(-1) kg(-1) h(-1) (13.8 mg kg(-1) h(-1)) or placebo for 12 h after tracheal extubation. After surgery, remifentanil was decreased to 0.05 microg kg(-1) min(-1) and titrated according to a pain intensity score (PIS, range 1-6) in the intubated, awake patient and a VAS scale (range 1-100) after extubation. If PIS was > or =3 or VAS > or =30, the infusion was increased by 0.01 microg kg(-1) min(-1); if ventilatory frequency was < or =10 min(-1) it was decreased by the same magnitude.. Magnesium lowered the cumulative remifentanil requirement after surgery (P<0.05). PIS > or =3 was more frequent in the placebo group (P<0.05). Despite increased remifentanil demand, VAS scores were also higher in the placebo group at 8 (2 vs 8) and 9 h after extubation (2 vs 7) (P<0.05). Dose reductions attributable to a ventilatory frequency < or =10 min(-1) occurred more often in the magnesium group (17 vs 6; P<0.05). However, time to tracheal extubation was not prolonged.. Magnesium gluconate moderately reduced the remifentanil consumption without serious side-effects. The opioid-sparing effect of magnesium may be greater at higher pain intensities and with increased dosages.

Topics: Adult; Aged; Analgesics, Opioid; Cardiac Surgical Procedures; Double-Blind Method; Drug Administration Schedule; Drug Synergism; Drug Therapy, Combination; Female; Gluconates; Humans; Magnesium; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

To evaluate the preemptive effects of diclofenac sodium, in combination with remifentanil and ketamine.. A prospective, randomized, double blind, placebo-controlled trial was carried out at the Hacettepe University Hospital, Ankara, Turkey from September to December 2004. Forty-three, American Society of Anesthesiology physical status group I-II women, aged >18 years, who would undergo both diagnostic and operative laparoscopic surgery were randomly assigned into 2 groups. All patients received intraoperative 0.1 microg x kg(-1)min(-1) remifentanil infusion. Diclofenac (1 mg x kg(-1) intramuscular) was administered, 20 minutes before the operation. Ketamine (0.8 mg x kg(-)1 intravenously) was administered 5 minutes before the skin incision and at completion of skin closure. We divided the patients into 2 groups; Group I (diclofenac + remifentanil + ketamine), Group II (remifentanil + ketamine). Pain was evaluated postoperatively using the visual analogue scale (VAS) while global satisfaction by verbal rating scale (VRS).. All 43 female patients have a mean +/- SD age of 32.3 +/- 6.5 years, height of 163 +/- 5.3 cm, and weight of 62.9 +/- 9.5 kg. The VAS and VRS scores and also time to first analgesic request were not different between the groups. In all groups, >98% of the patients were satisfied or very satisfied.. We have not found any preemptive or additive effect of diclofenac sodium with the concomitant use of ketamine.

Topics: Adult; Analgesics, Opioid; Anesthetics, Dissociative; Anti-Inflammatory Agents, Non-Steroidal; Diclofenac; Double-Blind Method; Female; Genitalia, Female; Humans; Ketamine; Laparoscopes; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Turkey

We tested the hypothesis that continuous intraoperative infusion of remifentanil is associated with the development of clinically relevant acute opioid tolerance in adolescents undergoing scoliosis surgery. Thirty adolescents were randomly assigned to receive an intraoperative analgesic regimen consisting of continuous remifentanil infusion or intermittent morphine alone. Postoperative analgesic consumption was assessed with a patient-controlled analgesia device that was used to self-administer morphine. Cumulative postoperative morphine consumption, pain scores, and sedation scores were recorded by a blinded investigator every hour for the first 4 h postoperatively and then every 4 h for a total of 24 h. Cumulative morphine consumption in the remifentanil group was significantly more than that in the morphine group at each time point in the initial 24 h after surgery (P < 0.0001). At 24 h after surgery, cumulative morphine consumption was 30% greater in the remifentanil group (1.65 +/- 0.41 mg/kg) than in the morphine group (1.27 +/- 0.32 mg/kg) (95% confidence interval for the difference, 0.11 to 0.65 mg/kg). Differences in pain and sedation scores were not statistically significant. These data suggest that intraoperative infusion of remifentanil is associated with the development of clinically relevant acute opioid tolerance in adolescents undergoing scoliosis surgery.

Topics: Adolescent; Analgesia, Patient-Controlled; Analgesics, Opioid; Child; Double-Blind Method; Drug Tolerance; Female; Humans; Infusions, Intravenous; Intraoperative Period; Male; Morphine; Pain, Postoperative; Piperidines; Remifentanil; Scoliosis

This study was designed to quantify the additional postoperative analgesic efficacy of a single dose of ketoprofen in patients undergoing thyroid surgery using two different intraoperative analgesic regimens.. One hundred and twenty patients were randomly assigned to one of four groups: intraoperative fentanyl or remifentanil with or without ketoprofen (n = 30 for each group). Intravenous ketoprofen (1.5 mg kg-1) or saline was administered 45 min before the end of surgery. Pain scores, opioid demand and length of stay in the postanaesthesia care unit were assessed in a blinded manner.. Patients receiving intraoperative fentanyl with saline had significantly lower visual analogue scale pain scores in the postanaesthesia care unit compared with those receiving intraoperative remifentanil with saline (55 +/- 10 mm vs. 80 +/- 18 mm, P < 0.05) and they stayed shorter in the postanaesthesia care unit (86 +/- 24 min vs. 126 +/- 37 min). In conjunction with intraoperative fentanyl, ketoprofen significantly decreased postoperative pain scores (40 +/- 10 mm, P < 0.05 compared with fentanyl alone) and opioid demand (4 of 30 patients vs. 14 of 30 patients compared with fentanyl alone, P < 0.05). Patients receiving intraoperative remifentanil had no additional analgesic benefit with ketoprofen.. After thyroid surgery, patients receiving intraoperative fentanyl had lower pain scores and needed less rescue analgesia compared with patients receiving intraoperative remifentanil. The adjunction of ketoprofen further improved analgesia in patients who received intraoperative fentanyl only.

Topics: Adult; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Drug Therapy, Combination; Female; Fentanyl; Humans; Injections, Intravenous; Intraoperative Period; Ketoprofen; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Thyroid Gland; Treatment Outcome

Critical care nurses and physicians are familiar with the principles of patient controlled analgesia and the opioid analgesics' regimens and observations necessary for pain control in the postoperative cardiac surgical patients. The objective of the study was to compare the effects of morphine, fentanyl, meperidine, remifentanil and tramadol which were administered by patient controlled analgesia and continuous intravenous infusion combination on the various parameters. This study was designed as prospective randomised trial. Fifty patients undergone open heart surgery with sternotomy were entered equally into five randomized groups. Visual analog scale was used by researcher nurse to assess the patient' pain status. Respiratory rate, heart rate and blood gases (pO2, pCO2, SaO2), radial arterial blood pressures were measured in the first 24 hrs postoperatively. Bolus requirements were determined by physicians and side effects of the analgesics were documented. Fentanyl group showed statistically higher levels of mean pO2 (p=0.002). Meperidine had the lowest number of bolus doses (p=0.001). There were no significant differences between the groups for pain management except higher visual analog scales on tramadol. Headache, stomach-ache and, palpitations were observed in our patients. Remifentanil, meperidine, fentanyl and morphine showed similar effect with each other for pain relief except tramadol.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Cardiac Surgical Procedures; Female; Fentanyl; Humans; Infusions, Intravenous; Male; Meperidine; Middle Aged; Morphine; Pain, Postoperative; Patient Education as Topic; Piperidines; Prospective Studies; Remifentanil; Sternum; Tramadol

We compared the haemodynamics, emergence and recovery characteristics of total intravenous anaesthesia using propofol/remifentanil with sevoflurane/remifentanil anaesthesia, under bispectral index guidance, in 103 patients undergoing surgical procedures lasting > 3.5 h. Time to tracheal extubation was significantly shorter in the propofol group than in the sevoflurane group (mean (SD) 8.3 (3.5) min vs 10.8 (4.6) min, respectively; p = 0.0024), but further recovery was comparable in both groups. There were no significant differences in haemodynamic parameters, intensity of pain or postoperative nausea and vomiting. During and after anaesthesia of comparable depth for long lasting surgical procedures, both propofol/remifentanil and sevoflurane/remifentanil enable haemodynamic stability and fast emergence. The shorter time to extubation in the propofol group does not offer a relevant clinical advantage.

Topics: Abdomen; Adolescent; Adult; Aged; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Cognition; Electroencephalography; Female; Hemodynamics; Humans; Intraoperative Period; Male; Methyl Ethers; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Sevoflurane; Urologic Surgical Procedures

We compared transitional analgesia provided by scalp nerve block (SNB) or morphine after remifentanil-based anesthesia in neurosurgery. Fifty craniotomy patients were randomly divided into two groups: morphine (morphine 0.1 mg x kg(-1) IV after dural closure and an SNB performed with 20 mL of 0.9% saline at the end of surgery) and block (10 mL of 0.9% saline instead of morphine after dural closure and an SNB performed with a 1:1 mixture of bupivacaine 0.5% and lidocaine 2% at the end of surgery). Postoperative pain was assessed at 1, 2, 4, 8, 12, 16, and 24 h using a 10-point numerical rating scale. Analgesia consisted of subcutaneous codeine. Average numerical rating scale scores were similar between the two groups at each time interval. Total codeine dosage was also similar, except at 4 h postoperatively when it was higher in the block group. The delay before administration of the first dose of codeine was not statistically different between groups: 45 min (20-2880) vs 30 min (10-2880), median and range for the block and morphine group, respectively. Postoperative hemodynamics were similar for both groups. The incidence of nausea and vomiting was slightly more frequent in the morphine group, but the occurrence of confusion did not differ between groups. In conclusion, SNB provides a quality of transitional analgesia that is similar to that of morphine with the same postoperative hemodynamic profile.

Topics: Adult; Aged; Analgesia; Double-Blind Method; Female; Humans; Male; Middle Aged; Morphine; Nerve Block; Neurosurgical Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Scalp

To compare three anesthetic strategies with respect to the time of extubation after coronary artery bypass graft (CABG) surgery and to assess patient satisfaction with the procedure.. Prospective, randomized, clinical study.. Tertiary-care referral center.. 180 cardiac surgical patients undergoing primary CABG from January through June 2004.. After induction of general anesthesia, patients were allocated to one of three groups. All three groups received a continuous infusion of intravenous (IV) propofol perioperatively and postoperatively. Group 1 (fentanyl infusion group, n = 60) received continuous IV fentanyl infusion perioperatively and postoperatively for analgesia. Group 2 (diclofenac group, n = 60) received fentanyl bolus doses intraoperatively and diclofenac suppository postoperatively. Group 3 (remifentanil group, n = 60) received continuous infusion of IV remifentanil perioperatively and IV fentanyl as an immediate postoperative bolus followed by continuous fentanyl infusion. Duration of postoperative ventilation up to the time of extubation, inotrope requirement, time at which analgesic infusion was discontinued, postextubation arterial blood gas analysis, pain evaluation via visual analog scale, need for rescue analgesia, awareness during surgery, and length of postcardiac surgical unit stay, were evaluated in each patient.. The diclofenac group exhibited the shortest time to extubation, the least inotrope use, and the fewest rescue doses of analgesic than did patients of the other two groups.. Intravenous propofol with bolus doses of IV fentanyl intraoperatively in combination with postoperative nonsteroidal antiinflammatory drugs had the best recovery profile in patients undergoing primary CABG than did the other two regimens studied.

Topics: Anesthesia, General; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Blood Gas Analysis; Coronary Artery Bypass; Diclofenac; Drug Therapy, Combination; Female; Fentanyl; Humans; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Perioperative Care; Pilot Projects; Piperidines; Postoperative Care; Propofol; Prospective Studies; Remifentanil; Respiration, Artificial; Time Factors

Effective postoperative analgesia is a critical part of fast-track cardiac surgery. This study compared the postoperative analgesic effect of fast-track anesthesia with remifentanil and spinal morphine and clonidine with that of sufentanil anesthesia followed by patient-controlled administration of intravenous morphine.. Prospective, blinded, randomized study.. Single private institution.. Forty patients selected for coronary artery bypass graft surgery allocated randomly into 2 groups.. General anesthesia was performed with etomidate, isoflurane, cisatracurium, and either remifentanil (0.10-0.25 microg/kg/min) or sufentanil (up to 3.5 microg/kg). In the remifentanil group, patients received spinal morphine (4 microg/kg) and clonidine (1 microg/kg) before induction. Postoperatively, patients in both groups were connected to an intravenous patient-controlled analgesia (PCA) morphine pump that delivered a 1-g bolus with a 7-minute lockout interval.. Patients were evaluated for pain on a visual analog scale (VAS), at rest and on deep breathing, and for intravenous PCA morphine consumption during 24 hours. The intravenous PCA morphine 24-hour cumulative dose was lower in the fast-track than in the control group (15.8+/-12.6 v 32.7+/-22.3 mg, p<0.05). Before extubation, VAS scores were higher in the fast-track group, but after they were lower both at rest and during deep breathing. Extubation delay was shorter in the fast-track group (156.5+/-46.1 v 272+/-116.4 minutes, p<0.05).. The combination of anesthesia with remifentanil and spinal analgesia with morphine and clonidine produces effective analgesia after coronary artery surgery and a rapid extubation time.

Topics: Aged; Anesthesia, General; Anesthesia, Spinal; Clonidine; Coronary Artery Bypass; Drug Therapy, Combination; Female; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil

Studies on monitoring the depth of anaesthesia have shown that with the use of these monitors the peroperative consumption of anaesthetics can be reduced. Studies have also indicated that the peroperative depth of anaesthesia may affect the postoperative course. The purpose of this study was to evaluate a possible relation between the depths of anaesthesia and the postoperative pain score and consumption of morphine.. We used middle latency auditory evoked potentials (MLAEPs) for monitoring the depth of anaesthesia. The study was prospective, observer blinded and included 50 women scheduled for elective abdominal hysterectomy. Anaesthesia was induced using propofol and remifentanil. Before leaving the recovery room the patients were provided with a programmed patient-controlled pump (PCA), which was only activated on demand. Auditory evoked potentials were registered from just before induction of anaesthesia and during the whole procedure, but the anaesthetist did not have access to the monitor.. Fifty patients were included and seven were excluded. The remaining 43 patients were divided into two groups: Group High (n=12) with an AAI>28 for >5% of the registration time and Group Low (n=31) with an AAI>28 for <5% of the registration time. Group High had significantly higher morphine requirements in the recovery and activated the PCA-pump more frequently during the first 24 postoperative hours.. The results indicate that the peroperative depth of anaesthesia may have effects on the postoperative analgesic requirements.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Evoked Potentials, Auditory; Female; Humans; Hysterectomy; Middle Aged; Monitoring, Intraoperative; Morphine; Pain Measurement; Pain, Postoperative; Perioperative Care; Pilot Projects; Piperidines; Postoperative Care; Propofol; Prospective Studies; Remifentanil; Single-Blind Method

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5-2.0 mg/kg) and morphine (7 mug/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 mug/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO(2), lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.

Topics: Anesthesia, Spinal; Cardiac Surgical Procedures; Child, Preschool; Female; Fentanyl; Humans; Infant; Infant, Newborn; Male; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Tetracaine

The combination of non-opioid analgesic drugs, though widely used, has been rarely evaluated. The aim of this study was to compare the efficacy of propacetamol and the non-steroidal analgesic drug ketoprofen, alone or in combination, on pain relief after thyroid surgery performed using remifentanil.. Ninety-seven patients were randomly allocated to one of the three groups: propacetamol 2 g (32), ketoprofen 100 mg (33) and propacetamol 2 g + ketoprofen 100 mg (32). Each regimen was administered intravenously (i.v.) 30 min before the end of surgery and then every 6 h. If pain was not relieved, patients received an i.v. bolus of tramadol 100 mg. Tramadol consumption and pain intensity using a visual analogue scale was recorded at 1, 2, 8 and 14 h after the end of surgery.. Pain scores were significantly higher with propacetamol compared with ketoprofen 2 h after surgery (35 +/- 3.7, 21 +/- 2.6, respectively; P < 0.01). The number of patients receiving tramadol was higher with propacetamol alone compared with the two other groups, 1 h (14/32, 4/33, 2/32, respectively; P > 0.01) and 2 h (24/32, 6/33, 8/32, respectively; P < 0.01) after surgery. There was no difference between ketoprofen alone and ketoprofen plus propacetamol, and there was no difference between the three groups from the 8th hour onward.. In the immediate postoperative period after thyroid surgery performed using remifentanil, the concomitant use of propacetamol and ketoprofen does not improve analgesia compared with ketoprofen alone.

Topics: Acetaminophen; Analgesics, Opioid; Analysis of Variance; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Female; Humans; Ketoprofen; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Remifentanil; Thyroidectomy; Time Factors; Tramadol; Treatment Outcome

This randomized, double-blinded clinical study was designed to compare the efficacy and safety of remifentanil and morphine administered using intravenous (i.v.) patient-controlled analgesia (PCA) for postoperative analgesia after major abdominal surgery during the first 24 postoperative hours.. Sixty-nine patients were randomly allocated into two groups, each receiving remifentanil or morphine. The first group received i.v. remifentanil PCA with a loading dose of 45 microg, a maintenance dose of 1 microg min(-1), a bolus dose of 15 microg and a lockout interval of 10 min during the first 24 postoperative hours. The second group received i.v. morphine PCA with a loading dose of 5 mg, a maintenance dose of 0.3 mg h(-1), a bolus dose of 1 mg and a lockout interval of 15 min. Age, weight, sex, history of general anaesthesia, duration of surgery and time spent in the post-anaesthesia care unit were recorded. Preoperative pulse rate, systolic and diastolic blood pressures (BP), respiration rate and arterial blood gases were collected. Pulmonary function was tested before induction of anaesthesia, as well as at 4 and 26 h after operation. Pulse rate, systolic and diastolic BP, respiration rate, arterial blood gases, sedation and visual analogue scores, and presence of side-effects in the recovery room and on the ward for 24 h were recorded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation. Total drug use, number of boluses delivered, number of boluses demanded and delivery/demand ratio were collected.. Sixty patients were evaluated. The groups did not differ in age, weight, sex, history of general anaesthesia, duration of surgery or time spent in the recovery unit. There were also no clinically relevant differences between the groups with regard to haemodynamic and respiratory parameters as well as sedation and visual analogue scores (P > 0.05). More bolus doses were demanded and delivered and the delivery/demand ratio was significantly higher in the remifentanil group (P < 0.05). There was no finding suggesting acute opioid tolerance during remifentanil or morphine PCA.. The i.v. remifentanil PCA with the chosen dosage regimen after abdominal surgery produces postoperative analgesia and has cardiovascular side-effects similar to those achieved with i.v. morphine. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.

Topics: Abdomen; Analgesia, Patient-Controlled; Analgesics, Opioid; Blood Gas Analysis; Blood Pressure; Double-Blind Method; Female; Heart Rate; Humans; Infusions, Intravenous; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Respiration; Respiratory Function Tests; Time Factors; Treatment Outcome

The aim of this study was to investigate the effects of tramadol administered with ketorolac on the Bispectral Index (BIS) during anaesthesia with sevoflurane and remifentanil.. Forty-six adult patients, ASA I-III, scheduled for elective minor surgical procedures were studied. Patients were premedicated with remifentanil infusion 0.4 microg kg(-1) min(-1) and anaesthesia was induced 4-5 min later with propofol 1.5 mg kg(-1) and maintained with air-oxygen (FI(O(2)) 0.4), remifentanil 0.1-0.15 microg kg(-1) min(-1) and sevoflurane, adjusted to keep the BIS between 40 and 50. After 20 min of stable anaesthesia, the subjects were allocated randomly to receive i.v. tramadol 1.5 mg kg(-1) and i.v. ketorolac 0.3 mg kg(-1) (tramadol group) or saline (control group). BIS values, mean arterial pressure, heart rate and end-tidal carbon dioxide were recorded every 5 min for 20 min.. Mean BIS values after tramadol administration were not significantly different from those recorded in patients receiving saline throughout the period of observation. There were no patients who presented explicit recall of events under anaesthesia. No significant changes in mean arterial pressure, heart rate and end-tidal carbon dioxide were noted after tramadol injection.. Tramadol, given with ketorolac to prevent postoperative pain, during anaesthesia maintained with sevoflurane and remifentanil at BIS between 40 and 50, does not modify the BIS value.

Topics: Adult; Aged; Analgesics; Analysis of Variance; Anesthesia, General; Anesthetics, Combined; Blood Pressure; Carbon Dioxide; Chi-Square Distribution; Electroencephalography; Female; Heart Rate; Humans; Ketorolac; Male; Methyl Ethers; Middle Aged; Minor Surgical Procedures; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Sevoflurane; Signal Processing, Computer-Assisted; Tramadol

Remifentanil is increasingly used as a component of cardiac anaesthesia. Following cardiac surgery remifentanil is often substituted for alternative opioids on the intensive care unit. We were interested to evaluate postoperative continuation of remifentanil in the form of remifentanil patient control analgesia (RPCA) for those patients who received intraoperative remifentanil. The objectives of this study were to assess the safety, efficacy and feasibility of the RPCA.. Ten patients who received an intravenous infusion of remifentanil perioperatively for coronary artery bypass graft surgery (CABG) had their remifentanil infusion converted to RPCA following extubation on the intensive care unit. Remifentanil patient control analgesia delivered an initial background infusion consistent with the infusion rate at extubation and with a bolus facility of 50 microg administered over 5 min followed by a 5-min lockout. Data collection included sedation and pain scores, respiratory rate, arterial blood gases, number of successful/unsuccessful attempts and the background infusion rate for each subject over a period of 12 h following extubation.. The data from nine male and one female patient were analyzed by using SPSS11 for Windows. During the study period the patients achieved adequate pain control and made more RPCA attempts at lower background infusion rates. No episodes of apnoea, SpO(2) less than 95% or a rise in PaCO(2) greater than 6.5 kPa were observed.. Remifentanil patient control analgesia with a background infusion was effective and safe for postoperative pain relief in this group of spontaneously breathing ICU patients following cardiac surgery.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Blood Gas Analysis; Cardiac Surgical Procedures; Coronary Artery Bypass; Female; Hemodynamics; Humans; Infusions, Intravenous; Male; Middle Aged; Oxygen; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Respiratory Function Tests

Remifentanil-induced secondary hyperalgesia has been documented experimentally in both animals and healthy human volunteers, but never clinically. This study tested the hypotheses that increased pain sensitivity assessed by periincisional allodynia and hyperalgesia can occur after relatively large-dose intraoperative remifentanil and that small-dose ketamine prevents this hyperalgesia.. Seventy-five patients undergoing major abdominal surgery were randomly assigned to receive (1) intraoperative remifentanil at 0.05 microg x kg(-1) x min(-1) (small-dose remifentanil); (2) intraoperative remifentanil at 0.40 microg x kg(-1) x min(-1) (large-dose remifentanil); or (3) intraoperative remifentanil at 0.40 microg x kg(-1) x min(-1) and 0.5 mg/kg ketamine just after the induction, followed by an intraoperative infusion of 5 microg x kg(-1) x min(-1) until skin closure and then 2 microg x kg(-1) x min(-1) for 48 h (large-dose remifentanil-ketamine). Pain scores and morphine consumption were recorded for 48 postoperative hours. Quantitative sensory tests, peak expiratory flow measures, and cognitive tests were performed at 24 and 48 h.. Hyperalgesia to von Frey hair stimulation adjacent to the surgical wound and morphine requirements were larger (P < 0.05) and allodynia to von Frey hair stimulation was greater (P < 0.01) in the large-dose remifentanil group compared with the other two groups, which were comparable. There were no significant differences in pain, pressure pain detection threshold with an algometer, peak flow, cognitive tests, or side effects.. A relatively large dose of intraoperative remifentanil triggers postoperative secondary hyperalgesia. Remifentanil-induced hyperalgesia was prevented by small-dose ketamine, implicating an N-methyl-d-aspartate pain-facilitator process.

Topics: Adult; Aged; Female; Humans; Hyperalgesia; Ketamine; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

Ketamine has been claimed to prevent acute opioid tolerance and hyperalgesia following acute exposure to opioids and its use has been proposed to decrease postoperative morphine consumption.. We conducted a randomized, double-blind, controlled study to evaluate the effect of intravenous (i.v.) ketamine on postoperative pain for 48 h after major ear, nose and throat (ENT) surgery. Thirty-one patients received i.v. ketamine 0.15 mg kg(-1) before induction and 2 microg kg(-1) min(-1) during anaesthesia, and 31 patients were administered placebo in a similar manner. Anaesthesia was standardized with remifentanil and propofol, but without nitrous oxide. Standardized postoperative analgesia included paracetamol, methylprednisolone and morphine administered via a patient controlled analgesia (PCA) device.. Intra-operative remifentanil consumption was not different between the ketamine group (0.25 +/- 0.07 microg kg(-1) min(-1)) and the control group (0.22 +/- 0.07 microg kg(-1) min(-1)). In the postoperative period, both groups experienced an identical pain course evolution. Cumulative morphine consumption was not significantly different between groups: at 24 h it was 33.3 +/- 14.9 with ketamine and 31.9 +/- 15.3 mg in controls, at 48h it was 40.4 +/- 20.6 mg with ketamine and 42.5 +/- 25.9 mg in controls.. Low-dose ketamine added to a remifentanil-based propofol anaesthesia did not reduce morphine consumption after major ENT surgery.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Dissociative; Anesthetics, Intravenous; Double-Blind Method; Female; Humans; Ketamine; Male; Middle Aged; Morphine; Otorhinolaryngologic Surgical Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

The use of remifentanil requires other analgesics for postoperative pain relief compared to fentanyl in patients undergoing craniotomy. This could possibly reduce the postoperative advantages of this short-acting opioid.. We compared remifentanil and fentanyl-based anaesthesia in a randomized observer and patient blinded trial on patients, undergoing an elective craniotomy. Twenty patients received anaesthesia using remifentanil with a small dose of piritramide (0.1 mg kg(-1)) after closure of the dura mater. Twenty patients underwent a fentanyl-based protocol. In both groups, anaesthesia was induced with thiopental and rocuronium, and maintained with 0.6-1 minimum alveolar concentration (MAC) isoflurane in a nitrous oxide/oxygen mixture 2:1 and rocuronium. Patients received 1 g of paracetamol rectally postoperatively. A visual analogue scale (VAS) for pain, the Glasgow Coma Score, a modified Aldrete Score, arterial carbon dioxide tension (PaCO2) and piritramide consumption were evaluated every half an hour postoperatively.. No significant differences were found for pain, Aldrete or Glasgow Coma scores or for PaCO2 between the groups when controlled for age, although the pain and Glasgow Coma Scores were consistently higher and PaCO2 lower in the remifentanil group. Furthermore, 11 out of 20 patients in the remifentanil group requested extra piritramide as opposed to 7 out of 20 in the fentanyl group (P = 0.11).. Despite the intraoperative use of piritramide in the remifentanil group, patients experienced more pain postoperatively. A significant influence of age on pain intensity was found. The use of remifentanil with a small dose of piritramide of 0.1 mg kg(-1) has no evident advantage over the use of fentanyl considering the postoperative conditions after craniotomy.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Carbon Dioxide; Craniotomy; Double-Blind Method; Female; Fentanyl; Glasgow Coma Scale; Humans; Male; Middle Aged; Neurosurgical Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Pirinitramide; Prospective Studies; Remifentanil

We have prospectively assessed the effects of remifentanil on morphine requirement in the first hour after emerging from general anaesthesia after elective coronary artery bypass surgery and in the first 12 h postoperatively, and pain and agitation scores in the first hour after emerging from general anaesthesia.. Twenty patients undergoing off-pump coronary artery bypass surgery, receiving standardized propofol-fentanyl-based anaesthesia, randomly received infusions of either remifentanil 0.1 microg kg(-1) min(-1) (Group R, n=10) or saline (Group S, n=10), each infused at 0.12 ml kg(-1) h(-1). Propofol and trial drug infusion were continued into the postoperative period until the patients were ready to be woken up. Postoperative analgesia was provided with morphine infusion commenced immediately after operation, and was additionally nurse controlled on the basis of a visual analogue scale (VAS) score (0-10). Agitation score was recorded using a VAS of 0-3.. In the first hour after discontinuing propofol and trial infusion, morphine requirements were significantly higher in the remifentanil group (8.15 (sd 3.59) mg) compared with the saline group (3.29 (2.36) mg) (P<0.01). There was no difference in the total morphine given during the period after stopping propofol or in the total requirement in the first 12 h postoperatively. There was no significant difference in either pain scores or agitation scores between the two groups.. Use of remifentanil is associated with increased opioid requirement in the first hour after it has been discontinued.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Combined; Coronary Artery Bypass, Off-Pump; Double-Blind Method; Drug Administration Schedule; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Care; Propofol; Prospective Studies; Remifentanil

Analgesia-based sedation techniques are becoming more established in the intensive care unit (ICU) setting. The aim of this study was to compare remifentanil and fentanyl infusions for postoperative analgesia in pediatric ICU patients.. After receiving ethical committee approval, a prospective randomized, double-blind study was performed. Twenty-two postoperative orthopedic surgery patients received either remifentanil 0.1 microg.kg(-1).min(-1) or fentanyl 0.025 microg.kg(-1).min(-1) infusions diluted to the same volume. Analgesic infusion was titrated to predefined levels of analgesia [behavioral pain scale (BPS) score of 3]. Propofol was added if sedation was unsatisfactory after BPS score 3 had been achieved.. There were no differences in groups regarding demographics, tracheal extubation times, and pain scores of the patients. After cessation of the opioid infusion, the sedation scores and the heart rates were always higher in the remifentanil group compared with the fentanyl group. The incidences of nausea, vomiting, apnea, desaturation, reintubation within 24 h and constipation were also similar between the two groups.. We conclude that a remifentanil infusion provides clinically comparable analgesia with a fentanyl infusion in mechanically ventilated postoperative pediatric patients. These two drugs are suitable for short-term analgesia-based sedation in pediatric postoperative ICU patients.

Topics: Adolescent; Analgesics, Opioid; Child; Child, Preschool; Conscious Sedation; Double-Blind Method; Female; Fentanyl; Humans; Intensive Care Units, Pediatric; Male; Pain, Postoperative; Piperidines; Remifentanil; Respiration, Artificial

Remifentanil, a widely used analgesic agent in anaesthesia, has a rapid onset and short duration of action. In clinical settings, this requires an appropriate pain strategy to prevent unacceptable pain in the post-operative period. The aim of this study was to investigate whether remifentanil had any impact on post-operative pain and opioid consumption after major abdominal surgery.. Fifty patients undergoing major abdominal surgery were randomized to receive either remifentanil 0.4 microg/kg/min or placebo intra-operatively, in addition to basic combined general and epidural anaesthesia, in this double-blind study. Patients received patient-controlled analgesia with morphine for 24 h post-operatively. Morphine consumption, assessment of pain at rest and during coughing, side-effects and levels of sensory block were recorded during the first 24 h post-operatively.. Twenty-one patients receiving remifentanil and 18 patients receiving placebo completed the study. The median visual analogue scale (VAS) score at rest from 0 to 2 h was significantly increased in the remifentanil group [40 mm (27-61 mm)] vs. placebo [13 mm (3-35 mm)] (P < 0.05). No significant differences in morphine consumption, VAS score during coughing or adverse effects were observed between the groups.. The results are weak and difficult to interpret. They could indicate that a high dose of remifentanil added to otherwise sufficient combined general and epidural anaesthesia may induce opioid-induced hyperalgesia and/or clinically acute opioid tolerance after major abdominal surgery; however, as no significant differences could be observed between the groups after 2 h post-operatively, the clinical relevance of these observations is questionable.

Topics: Abdomen; Aged; Analgesics, Opioid; Anesthesia, Intravenous; Double-Blind Method; Female; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Population Density; Remifentanil

Although the synergistic interaction between hypnotics and opioids for total i.v. anaesthesia has been repeatedly demonstrated, questions about different dose combinations of hypnotics and opioids remain. The optimal combination would be based on maximal synergy, using the lowest dose of both drugs and having the lowest incidence of side-effects.. The major goal of this prospective randomized study was to compare two different dose combinations of propofol and remifentanil (both administered by target controlled infusion (TCI)) in respect of haemodynamics during surgery and recovery, and the need for cardiovascular treatment in the recovery room. A secondary goal was to compare pain scores (VAS) and morphine consumption in the recovery room. Anaesthesia was induced in both groups using TCI propofol, adjusted to obtain a bispectral index score (BIS) value between 40 and 60. TCI for remifentanil commenced at an initial effect-site concentration of 0.5 ng ml(-1), and was adjusted according to haemodynamics. Patients were divided into one of two groups during anaesthesia: (i). Group H, hypnotic anaesthesia (n=23), propofol effect-site concentration maintained at 2.4 microg x ml(-1); and (ii). Group O, opioid anaesthesia (n=23), propofol effect-site concentration maintained at 1.2 microg x ml(-1). In both groups, remifentanil effect-site concentration was adjusted according to haemodynamics and changes in BIS value.. In Group O, more episodes of intraoperative hypotension (P<0.02) and hypertension (P<0.01), and fewer episodes of tachycardia were observed. More patients in Group O required nicardipine administration for postoperative hypertension (8 patients in Group H vs 15 patients in Group O, P<0.04). During recovery, morphine titration was necessary in approximately 50% of patients. No significant difference between groups was observed concerning pain scores or requirement for morphine titration.. Maintenance of anaesthesia predominantly with propofol and a low dose of remifentanil, both administered using TCI, is associated with greater stability in perioperative haemodynamics than anaesthesia predominantly with remifentanil alone. Postoperative pain was identical in both groups of patients who underwent relatively short duration, and relatively painless surgery.

Topics: Aged; Aged, 80 and over; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Combined; Anesthetics, Intravenous; Carotid Stenosis; Endarterectomy, Carotid; Female; Hemodynamics; Humans; Infusions, Intravenous; Intraoperative Complications; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Postoperative Care; Propofol; Prospective Studies; Remifentanil

To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA).. One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets.. Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05).. Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.

Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Epidural; Anesthetics, Local; Bupivacaine; Coronary Artery Bypass; Feasibility Studies; Female; Fentanyl; Humans; Intubation, Intratracheal; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Time Factors

There are anecdotal reports of dysphoria occurring in patients on the first day after anaesthesia with remifentanil. This study was performed to investigate this allegation and to find a possible relationship to postoperative shivering or to nausea and vomiting.. Patients undergoing otorhinolaryngeal surgery took part in a prospective, randomized, double-blind study comparing total intravenous anaesthesia with propofol (2 mg kg(-1) bolus injection then 100 microg kg(-1) min(-1)) and remifentanil (1 microg kg(-1) bolus then 0.1-0.5 microg kg(-1) min-1) or alfentanil (30 microg kg(-1) bolus then 0.16-0.83 microg kg((-1) min(-1)). The patients were carefully insulated and actively warmed by convective heating and rectal temperature was monitored continuously. Postoperative shivering was graded on a three-point scale, and the cumulative incidence of nausea and vomiting were registered at 24 h after surgery. Pre- and postoperative mood was measured with the von Zerssen mood scale (Befindlichkeits-Skala) and changes tested for significance. High scores reflect discontent and dysphoria.. The data of 98 patients (49 in each group, ASA I-II, age 42 +/- 13 yr, anaesthesia time 141 +/- 60 min; mean +/- SD; intergroup P values > 0.1) were evaluated. Core temperature did not change perioperatively (before 36.6 +/- 0.2 degrees C; after 36.8 +/- 0.3 degrees C, inter- and intragroup P > 0.1). The incidence of nausea was the same in each group; vomiting occurred with equal frequency (6/49 vs. 7/49). Shivering was significantly more frequent after remifentanil (41% vs. 10%, P < 0.001). The patients' mood remained stable after remifentanil but worsened after alfentanil (von Zerssen score from 9.3 +/- 2.5 to 13.9 +/- 3.6; mean +/- 95% confidence intervals; P < 0.01).. Postoperative shivering was more frequent after remifentanil but was unrelated to intraoperative heat loss. Contrary to preliminary informal observations, there was no evidence that remifentanil caused postanaesthetic dysphoria on the day one after surgery.

Topics: Adult; Affect; Alfentanil; Anesthesia, Intravenous; Anesthetics, Intravenous; Body Temperature; Body Temperature Regulation; Double-Blind Method; Female; Humans; Male; Middle Aged; Otorhinolaryngologic Surgical Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Shivering

To investigate if early extubation, 2 hours after surgery, would result in more postoperative pain or in an increased use of opioid analgesics compared with late extubation, 6 hours after surgery.. Prospective, randomized study.. Intensive care unit, university hospital.. Sixty patients undergoing cardiac surgery with cardiopulmonary bypass.. Patients were randomized into 2 groups: extubation at about 2 (early) or 6 (late) hours. Anesthesia was based on propofol and remifentanil. There was no epidural analgesia and no local anesthesia in the wound. A bolus of the opioid ketobemidone was administered toward the end of surgery followed by a continuous infusion.. Pain, provoked during deep breathing or coughing, evaluated with a visual analog scale (VAS) going from 0 to 10, was measured after extubation, and at 8 and 16 hours after surgery. Unprovoked pain was measured hourly. If VAS was greater than 3, the infusion rate was increased and a bolus of ketobemidone was given. Three patients in the late group were excluded because of incomplete data. Pain did not differ between the early and late groups at any time. In all patients, 21 never scored >3, 11 scored >3 once, and 25 scored >3 more than once. Nine patients had 1 score >5. The amount of ketobemidone was similar in both groups.. Early extubation had no negative effect on the quality of postoperative pain control and was not followed by an increased use of analgesics.

Topics: Analgesics, Opioid; Analysis of Variance; Anesthetics, Intravenous; Blood Gas Analysis; Blood Pressure; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Dose-Response Relationship, Drug; Female; Humans; Intubation, Intratracheal; Length of Stay; Male; Meperidine; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Care; Propofol; Prospective Studies; Remifentanil; Time Factors

To compare the efficacy and safety of remifentanil with fentanyl used for intraoperative anesthesia.. Fifty-four patients undergoing modified radical mastectomy or total hysterectomy were randomly assigned to remifentanil group or fentanyl group with 27 cases in each group. Anesthesia was induced with propofol (2 mg/kg) and either remifentanil (2 micrograms/kg) or fentanyl (2.5 micrograms/kg), and was maintained with inhalation of nitrous oxide in oxygen (2:1) and a continuous infusion of either remifentanil (0.2 microgram.kg-1.min-1) or fentanyl (0.03 microgram.kg-1.min-1). Depth of anesthesia, hemodynamic changes, recovery profile of anesthesia, postoperative analgesia and adverse reactions were observed.. The number of patients exhibited light depth of anesthesia during tracheal intubation and maintenance in the remifentanil group was significantly fewer than that in the fentanyl group (P < 0.05). Hemodynamic changes during intubation, skin incision, maintenance of anesthesia and extubation in the remifentanil group were significantly smaller than those in the fentanyl group (P < 0.05, P < 0.01). The time to opening eyes on command and the time for extubation after surgery were comparable between the two groups. More patients in the remifentanil group required bolus injection of morphine for postoperative pain relief than those in the fentanyl group (P < 0.05). There was no significant difference between the two groups in the aspect of adverse reactions.. The anesthetic and analgesic effects of remifentanil are more potent than those of fentanyl. Remifentanil can offer superior intraoperative hemodynamic stability compared with fentanyl without compromising recovery from anesthesia.

Topics: Adolescent; Adult; Anesthetics, Intravenous; Breast Neoplasms; Female; Fentanyl; Hemodynamics; Humans; Hysterectomy; Mastectomy, Modified Radical; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

In a prospective randomized double-blind study, the analgesic effect produced by sub-Tenon infiltration was compared with classic analgesic drugs in patients scheduled for posterior segment surgery under general anaesthesia.. One hundred patients were randomized into two groups of 50. One group received sub-Tenon infiltration (group 1) with 3 mL of bupivacaine 0.50% by the surgeon before the end of the surgery and the other (group 2) received only classical analgesic drugs postoperatively. A visual analogue scale (VAS) (graded from 1 to 10) was used to assess pain. For both groups, when VAS was between 1 and 3 paracetamol (3 g/24 h) associated with ketoprofen (200 mg/24 h) was given; between 3 and 6 nalbuphine (0.2 mg/kg slowly intravenously repeated every 4 h if necessary) was given; and over 6 morphine was given. Morphine 1 mg was injected every 2 min until VAS below 3 was obtained.. All patients in group 2 (control) experienced pain in the recovery room period; however, no patient in group 1 required analgesic drugs in the first 6 h after the sub-Tenon infiltration. In the recovery room period, the VAS pain score in patients who received sub-Tenon infiltration (group 1) was 0.6 +/- 1.3 (mean +/- SD) compared to 3.4 +/- 2.2 in group 2. The difference was statistically significant (P = 0.000001). All patients in group 2 asked for analgesic drugs in the recovery room, some of whom required morphine. Despite the administration of drugs the pain score was statistically higher in group 2. Between the end of the recovery room period and the 6th hour, the VAS pain score in group 1 was statistically lower. From the 6th until the 24th hour, the pain score was not statistically significantly different between the groups. Regarding consumption of analgesic drugs from the recovery room until the 24th hour, the consumption of level 1 analgesic drugs (paracetamol, ketoprofen) and level 3 (morphine) was statistically lower in group 1 (P = 0.0009). The difference was not significant for level 2, probably because the number of patients was not sufficient.. Sub-Tenon infiltration with 3 mL of bupivacaine 0.50% offers excellent postoperative analgesia for about 6 h and is an excellent alternative to classical drugs. Furthermore, it is highly reliable and safe.

Topics: Adult; Analgesia; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Connective Tissue; Double-Blind Method; Fascia; Female; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Retinal Diseases; Time Factors; Vitrectomy

Duration of hospitalization after laparoscopic cholecystectomy (LC) is mainly determined by temporary side effects such as pain, nausea, and vomiting. In this study we compared remifentanil, a short acting opioid, and sufentanil, a longer acting opioid, on their ability to reduce these postoperative effects and facilitate LC in day case surgery.. Seventy patients scheduled for elective LC were randomized in two groups. Remifentanil was used in group 1 as part of the anesthetic protocol, sufentanil was used in group 2. After surgery, patients were asked to evaluate pain and nausea on a verbal rate scale (VRS). Frequency of vomiting and analgesic medication consumption was registered. Time between surgery and to the start of micturition, drinking, mobilization, dressing, and discharge was recorded. Patients registered their satisfaction on a VRS. Details of any other adverse events throughout the study were recorded.. Twenty-two patients (63%) of group 1 were treated as day cases vs. 27 (77%) in group 2 (P = NS). All patients who were not discharged as day cases left the hospital one day postoperatively. Immediately after surgery, patients in group 2 reported significantly less pain. There were no other significant differences between groups.. The majority of patients scheduled for LC can be safely discharged on the day of surgery. Reported satisfaction one week postoperatively was high for all patients. We found no major relevant differences between the two anesthetic protocols.

Topics: Adult; Analgesics, Opioid; Chi-Square Distribution; Cholecystectomy, Laparoscopic; Female; Humans; Length of Stay; Male; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil; Treatment Outcome

The type of opioid used during general anesthesia in the morbidly obese influences recovery and the postoperative period. In a randomized clinical trial, the postoperative recovery profile and early period after general anesthesia with remifentanil, fentanyl and alfentanil were compared in morbidly obese patients.. 60 morbidly obese patients with BMI >35 kg/m(2) (mean 43.31) undergoing open Roux-en-y gastric bypass were randomly divided into 3 groups: remifentanil (R), fentanyl (F), and alfentanil (A). Dosage of opioids was based on ideal body weight (IBW): fentanyl 5 mcg/kg for intubation followed by infusion of 0.025-0.05 mcg/kg/min; alfentanil 15 mcg/kg initially, then 1.0-1.5 mcg kg/min; and remifentanil 1 mcg/kg followed by infusion of 0.25-1.5 mcg/kg/min. Anesthesia was induced with infusion of propofol and oxygen with N(2)O (1:1). After anesthesia, the duration to response to verbal command, spontaneous respiration, adequate respiration, and safe extubation were recorded. The incidence of postoperative nausea and vomiting were recorded. Using verbal scale for evaluation of postoperative pain, the early postoperative analgesia requirements were assessed.. Demographic profiles and duration of procedure did not differ between groups. A total dose of propofol was significantly lower in Group R compared with Groups A and F (P <0.05). Duration to spontaneous respiration, adequate respiration and safe extubation were significantly shorter in Group R compared with Group F (P <0.05). Shortly after anesthesia, significantly more patients in Group R required additional dose of analgesic than in Group F (P <0.05). Postoperative nausea and vomiting (PONV) occurred significantly more often in Group R compared with Group F (P <0.05). Recovery profile of Group A was more similar to Group R, and postoperative pain and PONV evaluation more similar to Group F.. In morbidly obese individuals, alfentanil or fentanyl and remifentanil can be safely used, but there is a higher rate of PONV and postoperative pain in the remifentanil group.

Topics: Adult; Alfentanil; Analgesics, Opioid; Anesthesia, General; Anesthetics, Intravenous; Fentanyl; Gastric Bypass; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Postoperative Period; Propofol; Remifentanil

We compared the effect of S(+)-ketamine to remifentanil, both in combination with propofol, on the neurocognitive outcome after open-heart surgery in 106 patients. A battery of neurocognitive tests was administered before surgery and 1 and 10 wk after surgery. Fourteen patients (25%) in the control group and 10 patients (20%) in the S(+)-ketamine group had 2 or more tests with a cognitive deficit (decline by at least one preoperative SD of that test in all patients) 10 wk after surgery (P = 0.54). Z-scores were calculated for all tests. No significantly better performance could be detected in the S(+)-ketamine group, except for the Trailmaking B test 10 wk after surgery. We conclude that S(+)-ketamine offers no greater neuroprotection compared with remifentanil during open-heart surgery.. N-methyl-D-aspartic acid receptors play an important role during ischemic brain injury. We could not demonstrate that S(+)-ketamine resulted in greater neuroprotective effects compared with remifentanil during cardiopulmonary bypass procedures when both were combined with propofol.

Topics: Aged; Cardiopulmonary Bypass; Chi-Square Distribution; Cognition Disorders; Female; Humans; Ketamine; Male; Middle Aged; Neuroprotective Agents; Neuropsychological Tests; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

Remifentanil is a short acting, potent synthetic opioid that does not accumulate after infusion or repeated bolus doses. It may be rapidly titrated to the requirements of individual patients. Titrated infusion of remifentanil may be able to provide potent analgesia required for pediatric cardiac surgery and obtund the stress response in theater whilst not having the persistent respiratory depression and sedation seen with longer acting opioids.. Twenty patients were randomized to receive a titrated infusion of remifentanil (0-1 microg x kg(-1) x min(-1)) or a standard dose of fentanyl (30 microg x kg(-1)) prebypass plus morphine (1 mg x kg(-1)) on rewarming. Blood samples for glucose and cortisol were taken at regular intervals from induction through bypass and into the first 24 h of postoperative intensive care. In addition to biochemical indicators of the stress response we recorded baseline hemodynamic parameters and any acute physiological events.. Ten patients received morphine, seven received remifentanil. There were no statistically significant differences between the two treatment groups in cortisol measurements, mean arterial pressure or heart rate recordings. In the last time period the remifentanil group had a larger rise in blood glucose concentration (baseline 3.9, rise 3 mmol x l(-1)) than the fentanyl/morphine group (baseline 4.2 rise 1.9 mmol x l(-1)), CI -4.3 to -0.2.. The only significant difference was in glucose in the postbypass time periods. Although statistically significant, this difference is insufficient evidence of increased stress in the remifentanil group. The results show that in the patients studied there was no clinically important difference between the two techniques.

Topics: Analgesics, Opioid; Blood Glucose; Blood Pressure; Cardiac Surgical Procedures; Child; Child, Preschool; Drug Combinations; Female; Fentanyl; Heart Rate; Humans; Infant; Male; Morphine; Pain; Pain, Postoperative; Piperidines; Remifentanil; Stress, Physiological

The transition from intraoperative analgesia to postoperative analgesia must be planned carefully after remifentanil-based anesthesia, due to the short duration of action of remifentanil. The aim of this study is to compare the efficacy and safety of 2 transition strategies using sufentanil or tramadol for early postoperative pain relief in patients who had major abdominal surgery under general anesthesia with remifentanil/sevoflurane.. Sixty patients participated in this double-blind, prospective study and were randomly assigned to either sufentanil (S) group or tramadol (T) group. Twenty minutes before the end of surgery the patients received either a bolus of 0.15 microg kg(-1) sufentanil (group S) or tramadol 100 mg (group T). Mean arterial pressure (MAP), heart rate (HR) and rate pressure product (RPP=systolic arterial pressure (SAP)xHR), analgesia by a verbal rating score (VRS) and sedation by a sedation score (SS) were evaluated at emergence from anesthesia.. A statistically significant difference in HR between the 2 groups was recorded at extubation (78+/-13 in group S vs 86+/-24 in group T). A significant decrease of RPP values at extubation and 5 minutes later were found in group S in comparison with group T. VRS values were significantly lower in sufentanil group at 5 and 10 minutes after awakening.. Sufentanil provided more effective transition analgesia in comparison with tramadol. The effects of remifentanil dissipated rapidly and analgesia with major opioids was required. A bolus dose of sufentanil 0.15 microg kg(-1) was efficacious in controlling the hemodynamic parameters at awakening from anesthesia. The lower HR values and, consequently the lower RPP values are of utmost importance especially in the aged cardiovascular risk patient.

Topics: Abdomen; Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Female; Hemodynamics; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Sufentanil; Tramadol

We hypothesized that remifentanil-propofol cardiac anaesthesia, plus administration of pirinitramide (piritramide) upon cessation of the remifentanil infusion, would be associated with a shorter time to tracheal extubation than alfentanil-propofol anaesthesia, without the occurrence of major haemodynamic instability.. Haemodynamic stability and recovery characteristics of two remifentanil infusion regimens (0.5 microg kg(-1)min(-1); 0.25 microg kg(-1)min(-1)) were therefore compared with an alfentanil infusion regimen (1 microg kg(-1)min(-1)), in combination with target-controlled infusion of propofol, in a randomized blinded trial in 75 coronary artery surgery patients.. Pirinitramide provided good postoperative analgesia without prolonging extubation times: median extubation time in minutes after stopping the opioid-sedative drugs was 300 in the higher-dose remifentanil group and 270 in the lower-dose remifentanil group and alfentanil group (P = 0.606). Significant time-by-treatment interactions were seen for systolic arterial pressure (P = 0.015), mean arterial pressure (P = 0.009) and diastolic arterial pressure (P = 0.006). No significant interaction (P = 0.489) and no constant treatment effect were seen for heart rate (P = 0.288). Time effects were highly significant (P < 0.0001) for all haemodynamic variables. Heart rate remained stable in all groups. In the higher-dose remifentanil group, blood pressure was significantly different and lower during surgery and in this group less bolus doses of the opioid-sedative drugs (P = 0.015) had to be given.. The higher-dose remifentanil infusion provided superior suppression of haemodynamic responses to noxious stimuli with better haemodynamic stability.

Topics: Aged; Alfentanil; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Cardiac Surgical Procedures; Female; Hemodynamics; Humans; Intubation, Intratracheal; Male; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Physical Stimulation; Piperidines; Pirinitramide; Postoperative Care; Propofol; Remifentanil

Surgical procedures on the vertebral column may result in spinal cord damage, leading to neurological deficits that demand immediate therapeutical intervention. We designed this study to determine which anesthetic regimen allows a rapid wake-up test during and after surgery to detect neurological deficits. Fifty-four patients were randomly allocated to the following groups: group PR (propofol/remifentanil): target-controlled infusion with propofol (plasma concentration, 2-4 microg/mL) and remifentanil 0.2-0.5 microg . kg(-1) . min(-1); group PS (propofol/sufentanil): propofol (2-4 microg/mL) and repetitive boluses of 0.1-0.2 microg/kg of sufentanil adjusted to patients requirements; and group DR (desflurane/remifentanil): desflurane/air 3.0-4.0 vol% combined with remifentanil 0.2-0.5 microg . kg(-1) . min(-1). Group PS required significantly longer times for the onset of breathing (8.9 +/- 1.6 min), elevation of the head (17.0 +/- 3.8 min), and motion of the feet (17.0 +/- 7.4 min) than group PR (6.9 +/- 2.6 min, 9.3 +/- 2.2 min, and 9.4 +/- 2.4 min, respectively) or group DR (5.4 +/- 0.8 min, 6.1 +/- 1.0 min, and 6.2 +/- 1.0 min, respectively). The anesthetic regimen with desflurane and remifentanil allowed faster awakening during and after surgery that permitted immediate neurological examination after spinal surgery compared with propofol/remifentanil.

Topics: Aged; Analgesia, Patient-Controlled; Anesthesia Recovery Period; Anesthesia, General; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Intravenous; Arousal; Cognition; Desflurane; Double-Blind Method; Female; Humans; Intraoperative Period; Isoflurane; Male; Middle Aged; Monitoring, Intraoperative; Neurologic Examination; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Period; Propofol; Psychomotor Performance; Remifentanil; Spine; Sufentanil

[corrected] To study the analgesia, hemodynamic stability and inflammatory response in patients undergoing carotid endarterectomy under different types of general anesthesia.. A comparison of 80 patients randomized to 4 groups: group 1, maintenance with sevoflurane at a minimum alveolar concentration (MAC) of 1; group 2, sevoflurane at MAC 1.5; group 3, remifentanil; group 4, propofol. Variables studied were hemodynamic alterations during and after surgery, level of postoperative analgesia, differential white cell counts, levels of interleukin-6 (IL-6), and clinical signs and symptoms of systemic inflammatory response syndrome in the first 24 hours after surgery.. The incidences of episodes of intraoperative hypertension were 60% in group 1, 65% in group 2, 50% in group 3, and 60% in group 4. The incidences of episodes of intraoperative hypotension were 85% in group 1, 80% in group 2, 80% in group 3, and 75% in group 4. Patients in groups 3 and 4 had higher incidences of systemic inflammatory response syndrome (p<0.05) in the first 24 hours after surgery and higher levels of IL-6 (p<0.05). Postoperative analgesia was similar in all 4 groups.. Increased levels of IL-6 in peripheral blood and of systemic inflammatory response syndrome were found in the early postoperative period in groups that did not receive halogenated gases. Hemodynamic stability and analgesia were similar in all groups, however.

Topics: Aged; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Cardiovascular Diseases; Endarterectomy, Carotid; Hemodynamics; Humans; Incidence; Inflammation; Interleukin-6; Intraoperative Complications; Male; Methyl Ethers; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Sevoflurane

Remifentanil has a short duration of action and constant elimination, which allow administration of high doses, without prolonging recovery. Remifentanil has been compared to alfentanil, as part of a total intravenous anaesthetic technique, where remifentanil provided better anaesthetic conditions than alfentanil, without adverse effect on recovery. However, these results were obtained during anaesthesia involving neuromuscular blockade, which may mask both signs of insufficient anaesthesia and side-effects such as muscle rigidity. The aim of this study was to compare remifentanil with alfentanil for anaesthesia without neuromuscular blockade.. We performed a prospective, randomized, double-blind, four-centre study to compare remifentanil infusion 15 microg kg(-1) h(-1) and alfentanil infusion 60 microg kg(-1) h(-1), using a total intravenous technique for non-paralysed patients, and the laryngeal mask airway for airway management. We enrolled 192 patients, 18-65 yr of age with ASA I-II, undergoing minor surgery. The primary endpoint was the number of patients having pre-defined responses to surgical stimulation. A number of secondary criteria was evaluated to assess undesirable properties of the procedures.. In the alfentanil group, 85% of patients responded to surgical stimulation, vs. 35% in the remifentanil group (P < 0.0001). No difference was found in recovery data, or in any other parameter than those related to insufficient anaesthesia.. The remifentanil-based technique provided significantly better anaesthetic conditions than the alfentanil-based technique in the setting of this study, without causing any significant adverse effects.

Topics: Adolescent; Adult; Aged; Alfentanil; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Humans; Laryngeal Masks; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil

Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 micro g. kg(-1) x min(-1)) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 micro g x kg(-1) x min(-1) after intubation, then adapted by step of 0.05 micro g x kg(-1) x min(-1) according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N(2)O/O(2). Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of beta-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 +/- 290 versus 1390 +/- 555 micro g, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller beta-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remif. Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.

Topics: Adrenergic beta-Antagonists; Aged; Analgesics, Opioid; Anesthesia, General; Endarterectomy, Carotid; Endpoint Determination; Female; Hemodynamics; Humans; Hypotension; Infusions, Intravenous; Male; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Vascular Surgical Procedures

Perioperative pain is still a major problem, and new pharmacological means should be explored to mitigate such pain. Adenosine is an ubiquitous endogenous substance; when exogenously administered, it provides a number of salutary effects including neuromodulation, antinociception, and cytoprotective actions. The aim of this study was to characterize the perioperative antinociceptive-analgesic effects of intraoperative adenosine infusion and determine the duration of actions in the postoperative period, and compare them to those of remifentanil in patients undergoing major surgical procedures in a double-blind study.Sixty-two patients were randomly assigned to one of the two treatments. After standard induction of anesthesia, the lungs were mechanically ventilated. Anesthesia was maintained with a constant alveolar concentration of inhaled anesthetics (3% desflurane and 65% nitrous oxide in oxygen). A variable-rate of intravenous infusion of adenosine (50-500 microg kg(-1) x min(-1)) or remifentanil (0.05-0.5 microg kg(-1) x min(-1)) was initiated 5 min before the skin incision and was titrated to maintain systolic blood pressure and heart rate within 20% of baseline values during surgery. Postoperative evaluations included the level of sedation, degree of pain severity, opioid analgesic (fentanyl, morphine) consumption, and cardiorespiratory variables for 48 h. Intraoperative inhibition of the cardiovascular responses to surgical stimulation could be equally achieved by adenosine or remifentanil, and both could maintain excellent hemodynamic stability. Postoperatively, however, there were striking differences: (1). initial pain score was reduced by 60% (P<0.001) in the adenosine group compared to the remifentanil group and it remained lower throughout the 48 h recovery period; (2). postoperative morphine requirements during the first 0.25, 2 and 48 h were consistently lower in the adenosine group as compared to the remifentanil group (78, 71 and 42%, P<0.001, respectively); (3). adenosine patients remained significantly less sedated at all evaluations; (4) the end-tidal and arterial carbon dioxide values in the remifentanil group were significantly higher when patients were admitted to the postanesthesia care unit. No adverse effect of adenosine was observed at any time. Intraoperative adenosine infusion provided a salutary recovery from anesthesia associated with a pronounced and sustained postoperative pain relief. Compared to remifentanil, adenosine si

Topics: Adenosine; Adult; Analgesics; Analgesics, Opioid; Anesthesia, Inhalation; Double-Blind Method; Female; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Treatment Outcome

BACKGROUND AND STUDY GOALS: Strabismus surgery in children is frequently associated with a very high incidence of postoperative nausea and vomiting (PONV). In this study we investigated, whether TIVA is superior to inhalation anaesthesia concerning PONV when a prophylaxis using dimenhydrinate (diphenhydramine chlorotheophyllate) is administered in both groups.. 110 patients (3-10 years) were prospectively and randomly allocated to one of the following groups: Group TD (TIVA/dimenhydrinate; n= 55): anaesthesia was induced and maintained using remifentanil and propofol in common clinical dosages. Patients were ventilated with 30% O(2) in air. Group VD (Volatile/ dimenhydrinate; n= 55): anaesthesia was induced and maintained with sevoflurane in common clinical concentrations together with N(2)O in 30% O(2). All patients received dimenhydrinate 1 mg.kg(-1) i.v. after induction. PONV was recorded within the first 24 h postoperatively. The chi-square test and a multivariate analysis were used for statistical analysis.. 52 patients of group TD and 54 of group VD were analysed. There was a trend in the incidence of postoperative nausea (PN): group TD 17%, 95% CI: 8-30%) compared to group VD 31%, 95% CI: 20-46%), p = 0.09. No difference was seen for PV and PONV: 21% (95% CI: 11-35%) in group TD vs. 35% (95% CI: 23-49%) in group VD, p = 0.109. These non-significant results can be easily attributed to the lack of power about 30%) of this study. According to the results of the multivariate analysis volatile anaesthesia was identified as an independent risk factor for PONV (OR: 2.92, 95% CI: 1.02-8.36). Other variables that were found to be an independent risk factor included history of PONV (OR: 8.19, 95% CI: 1.84-36.43), surgery lasting longer than 30 min (OR: 5.89, 95% CI: 1.82-19.82) and "Faden-operations" (retroequatorial myopexy) (OR: 5.48, 95% CI: 1.74-17.21).. TD only showed a trend to lower PN incidences and no differences as for PV and PONV incidences, most likely due to a lack of power of this study. However, according to the results of the multivariate analysis, inhalation anaesthesia was shown to be an independent risk factor for PONV, as were history of PONV, surgery >30 min and "Faden-operations".

Topics: Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Antiemetics; Child; Child, Preschool; Dimenhydrinate; Female; Humans; Male; Methyl Ethers; Nitrous Oxide; Ophthalmologic Surgical Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil; Risk Factors; Sevoflurane; Strabismus

No standardized instrument exists for the systematic analysis of emergence behaviour in children after anaesthesia. Our purpose was to evaluate children's behaviour prior to anaesthetic induction and immediately upon emergence to develop an assessment tool using psychiatric terminology and techniques.. This prospective study evaluated 25 children from 2 to 9 years of age for preanaesthetic psychosocial factors that might affect behaviour. Children's behaviour was observed from admission to the surgical unit through the induction of anaesthesia. All children received a standardized premedication and induction of anaesthesia. The maintenance anaesthetic was randomized to intravenous remifentanil or inhaled isoflurane. All children underwent repair of strabismus. We assessed the behaviour of children for 30 min upon emergence from anaesthesia for symptoms of pain, distress and delirium using an assessment tool we developed guided by the principles of psychiatry as described in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).. Using our assessment tool, 44% of children demonstrated altered behaviour on emergence; 20% demonstrated complex symptoms with characteristics of delirium. Children anaesthetized with isoflurane had significantly higher postanaesthesia behaviour assessment scores than those anaesthetized with remifentanil (P = 0.04). Age was a significant variable; children <62 months were more prone to altered behaviour than those >62 months (P = 0.02). Scores did not correlate with preanaesthetic risk factors including preexisting psychological or social variables or observed preanaesthetic distress. There was no delay in hospital discharge in children assessed as having altered behaviour.. This exploratory study suggests that postanaesthetic behaviour abnormalities with characteristics of distress or delirium can be categorized using known DSM-IV terminology; in our cohort this behaviour was dependent on age and anaesthetic technique.

Topics: Age Factors; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child Behavior; Child, Preschool; Delirium; Female; Humans; Isoflurane; Pain, Postoperative; Piperidines; Prospective Studies; Psychiatric Status Rating Scales; Psychomotor Agitation; Random Allocation; Remifentanil

To compare the efficacy and safety of remifentanil and fentanyl in patients undergoing a modified radical mastectomy or total hysterectomy.. Fifty-four patients were evenly randomised into remifentanil group and fentanyl group. Anesthesia was induced by propofol (1 - 2 mg/kg) and either remifentanil (2 microg/kg) or fentanyl (2.5 microg/kg), and was maintained with inhalation of nitrous oxide in oxygen (2:1) and continuous infusion of either remifentanil (0.2 microg.kg(-1).min(-1)) or fentanyl (0.03 microg.kg(-1).min(-1)).. The number of patients exhibiting light anesthesia responses in the remifentanil group during intubation and the maintenance of anesthesia was significantly less than that in the fentanyl group. Both systolic and diastolic blood pressures in the fentanyl group were significantly higher than those in the remifentanil group during intubation, skin incision, maintenance of anesthesia and extubation. The time to opening eyes on command and the time for extubation after surgery was comparable between the two groups. More patients in the remifentanil group (25 patients) required bolus injection of morphine for postoperative pain relief than those in the fentanyl group (5 patients, P < 0.05). There was no significant difference between the two groups in terms of side effects.. Under the condition of this study protocol, the anesthetic and analgesic effects of remifentanil are more potent than those of fentanyl. Remifentanil can offer superior intraoperative hemodynamic stability in comparison with fentanyl, and has no compromising recovery from anesthesia.

Topics: Adolescent; Adult; Anesthetics, Intravenous; Blood Pressure; Female; Fentanyl; Humans; Mastectomy, Modified Radical; Pain, Postoperative; Piperidines; Remifentanil

The residual depressant effect of opioid is a major concern in infants scheduled for cleft palate repair. Remifentanil is associated with a fast and predictable recovery, independent of age.. About 40 infants in the 2-12 month age range were prospectively enrolled in this open study, to receive either remifentanil (infusion starting at 0.25 microg x kg(-1) x min(-1)) or sufentanil as part of a balanced anaesthesia regimen. Isoflurane was maintained at an endtidal concentration of 1.2% in oxygen and nitrous oxide and the opioid dosing was titrated to autonomic responses. Postoperative pain relief was provided by morphine infusion. Morphine administration started intraoperatively in the remifentanil group.. Consistent haemodynamic stability was achieved throughout surgery in both groups. Infants of the remifentanil group required, on average, lower concentrations of isoflurane than children of the sufentanil group (1.2 +/- 0.2% vs 1.7 +/- 0.3%, P < 0.001). The median time from last suture to tracheal extubation was 12.5 min (5-25 min) in the remifentanil group and 15.0 min (10-30 min) in the sufentanil group. There was no evidence of hyperalgesia or enhanced morphine consumption in the remifentanil group compared with the sufentanil group. Postoperative pain scores were even lower in the remifentanil group, compared with the sufentanil group, soon after arrival in the postanaesthesia care unit.. Remifentanil-based anaesthesia appeared well suited for primary cleft palate repair in young infants.

Topics: Analgesics, Opioid; Anesthetics, Inhalation; Blood Pressure; Cleft Palate; Female; Heart Rate; Humans; Infant; Isoflurane; Male; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Sufentanil; Time Factors; Treatment Outcome

We wanted to compare totally intravenous anaesthesia with propofol and remifentanil to mixed anaesthesia with isoflurane and fentanyl in terms of postoperative pain, nausea, length of stay and costs.. We present a prospective, non-randomised, anaesthetist-based double-blind study with a cost-utility analysis on consecutive patients undergoing laparoscopic gynaecologic day-care surgery. Premedication consisted of paracetamol and diclofenac. The mixed anaesthesia group received propofol, isoflurane, fentanyl, vecuronium, N2O and O2,the total intravenous group propofol, remifentanil, vecuronium, N2O and O2. Paracetamol and ketobemidon, metoklopramid and ondansetron were given to relieve pain and nausea, respectively. Patients were asked to report pain and nausea on a visual analogue scale after 4 and 24 hours.. 26 mixed and 27 totally intravenous patients were comparable by age, body mass index and ASA (American Society of Anesthesiologists) scores. There was a protocol violation, as fewer totally intravenous patients received pre-medication (16/26 vs. 8/27 p < 0.001). Totally intravenous patients had significantly higher consumption of ketobemidon (mean 2.35 vs. 5.43 mg/24 h p < 0.004). Within the totally intravenous group, scores for pain at 24 hours were significantly higher as compared with 4-hour scores (p = 0.012). At 24 hours, scores for nausea were significantly higher for the totally intravenous group (1.87 vs. 3.21 p = 0.014). Length of stay did not differ significantly (mean 649 vs. 729 min p > 0.2). Costs of medication were significantly higher for the totally intravenous group (mean 211 vs 285 NOK p <0.001).. The use of totally intravenous anaesthesia led to more nausea and more expenses than mixed anaesthesia in laparoscopic gynaecologic day-care surgery. No recommendations for either method can be made because of the non-randomized design.

Topics: Anesthetics, Intravenous; Cost-Benefit Analysis; Double-Blind Method; Drug Costs; Female; Fentanyl; Genital Diseases, Female; Humans; Isoflurane; Laparoscopy; Length of Stay; Nitrous Oxide; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Preanesthetic Medication; Propofol; Prospective Studies; Remifentanil; Vecuronium Bromide

The aim of this study was to assess postoperative analgesia after preincisional and postincisional administration of remifentanil.. Randomized trial, 24 hours.. University hospital, hospitalized care.. 48 adult patients scheduled for lumbar vertebral surgery.. in group R5, patients received an infusion of 0.2 microg kg(-1) min(-1) remifentanil over 5 minutes, followed by a break of 15 minutes before anesthesia was started. Anesthesia was induced by infusion of 0.25 microg kg(-1) min(-1) remifentanil and a bolus of 1.5 microg kg(-1) propofol, followed by a continuous infusion of 2 to 3 microg kg(-1) h-1 propofol and 0.25 microg kg(-1) min(-1) remifentanil until end of anesthesia. In group R20, patients received 0.05 microg kg(-1) min(-1) remifentanil over 20 minutes before the induction of anesthesia. In group RL, anesthesia was induced and maintained with propofol. After surgery began, a remifentanil infusion of 0.5 microg kg(-1) min(-1) was given for 50 minutes, then reduced to 0.25 microg kg(-1) min(-1). The total remifentanil doses were similar in the 3 groups.. patients used patient-controlled analgesia (piritramide) for postoperative pain management. They recorded pain on a numeric rating scale every half hour.. Kruskal-Wallis test, pairwise Mann-Withney U-test, orthogonal polynomials (pain scores).. PATIENTS given postincisional remifentanil (RL) had the slowest decrease in postoperative pain scores (p<0.01) and the highest cumulative piritramide consumption (p<0.08).. The preincisional administration of remifentanil followed by a continuous infusion of 0.25 microg kg(-1) min(-1) appears to reduce pain scores and piritramid consumption when compared with a postincisional regimen.

Topics: Adult; Aged; Analgesics, Opioid; Drug Administration Schedule; Female; Humans; Lumbar Vertebrae; Male; Middle Aged; Pain, Postoperative; Piperidines; Pirinitramide; Preanesthetic Medication; Prospective Studies; Remifentanil

Few studies exist of using remifentanil and intravenous ketamine for anaesthetic induction in paediatric day case anaesthesia. Therefore, we studied 75 unpremedicated ASA I-II children (age 1-7 years) who were randomly assigned in a double-blind fashion to receive either remifentanil (1 microgram/kg), ketamine (0.7 mg/kg) or placebo before the anaesthetic induction. Anaesthesia was induced with propofol and maintained with O2-N2O-sevoflurane. Induction characteristics, recovery times and the need for postoperative analgesia were evaluated. The required induction dose of propofol was lower in the groups receiving remifentanil and ketamine compared with the group receiving placebo. After tracheal intubation heart rate and blood pressure were better attenuated with remifentanil than with ketamine or placebo. In the recovery room children in the placebo group required more doses of oxycodone than the other two groups but this did not reach statistical significance. There were no differences between the groups in achieving predetermined recovery end-points, attaining full points on the Steward score or in the well being at home. In conclusion, remifentanil provides haemodynamically more stable induction of anaesthesia compared with ketamine or placebo. Ketamine with its' longer duration of action does not prolong recovery but does not have a clear opioid-sparing effect either in the immediate postoperative period.

Topics: Adenoidectomy; Ambulatory Surgical Procedures; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Dissociative; Anesthetics, Intravenous; Blood Pressure; Child; Child, Preschool; Double-Blind Method; Female; Heart Rate; Humans; Infant; Ketamine; Male; Oxycodone; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Surveys and Questionnaires

To test whether prophylactic neural blockade of noziceptive afferents or antiemetics diminutes postoperative nausea and vomiting (PONV) we studied in a randomised, prospective, and ouble-blind fashion 102 patients receiving implantation of an episcleral radioactive applicator for treatment of ocular malignant melanoma during remifentanil-propofol-anaesthesia.. 15 minutes prior to induction Dolasetron 12.5 mg (n = 18) or 50 mg (n = 20), Ondansetron 8 mg (n = 18), Droperidol 20 microg/kg (n = 23) or NaCl 0.9 % (n = 22) were randomly injected i.v. Furthermore, 4-8 ml Mepivacain 2 %/Bupivacain 0.5 % (n = 52) or saline (n = 50) were injected into the retrobulbar space after anaesthetic induction. Piritramid (0.1 mg/kg) was given for postoperative analgesia 30 minutes before end of surgery. Metamizol (1 g i.v.) and Dolasetron (12.5 mg i.v.) were provided on request as "rescue" medications. Variables were assessed by standardised questioning (NRS; yes/no) before and 1, 6, and 24 hours after surgery.. Chi(2)-, Mann-Whitney-U-, Kruskal-Wallis-test and logistic regression analysis, p < 0.05.. Although retrobulbar anaesthesia decreased ocular pain (p = 0.013) and total postoperative complaints (p = 0.017) the incidence of PONV was not diminished. Droperidol was the only antiemetic to decrease PONV significantly (p = 0.001).. Although prophylactic blockade of nozizeptive afferents by retrobulbar anesthesia decreased ocular pain and postoperative complaints, it failed to decrease the incidence of PONV. Thus, PONV after ocular surgery under propofol-remifentanil anaesthesia is not attenuated by preoperative blockade of noziceptive afferents. In patients undergoing total intravenous anaesthesia with propofol-remifentanil, droperidol prevented PONV more effectively than the used serotonin receptor antagonists.

Topics: Aged; Anesthesia, Intravenous; Anesthetics, Intravenous; Anesthetics, Local; Bupivacaine; Double-Blind Method; Eye Neoplasms; Female; Humans; Injections, Spinal; Male; Melanoma; Middle Aged; Neurons, Afferent; Nociceptors; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Prospective Studies; Remifentanil

Sufentanil and remifentanil are characterized by two different pharmacokinetic profiles. The aim of this study was to compare the effects of sufentanil and remifentanil administered using target-controlled infusion (TCI) on recovery and postoperative analgesia after major abdominal surgery.. Thirty adult patients scheduled for open colorectal surgery were included in a prospective, randomized study. Sufentanil TCI (sufentanil group) or remifentanil TCI (remifentanil group) was administered during surgery. In the remifentanil group, 30 min before the anticipated end of surgery, morphine 0.15 mg x kg(-1) was administered i.v. In the sufentanil group, an effect-site concentration of 0.25 ng x ml(-1) was targeted at extubation. In both groups, postoperative pain was controlled by titration of i.v. morphine and then patient-controlled analgesia with morphine.. The extubation time was similar in the two groups (mean (SD) 13 (6) and 14 (6) min in the sufentanil and remifentanil groups respectively). Visual analogue scale scores were significantly greater during the first 2 h after tracheal extubation in the remifentanil group than in the sufentanil group. The time to first analgesic request in the postanaesthesia care unit was significantly longer in the sufentanil group than in the remifentanil group (55 (64) (range 2-240) vs 11 (7) (1-29) min; P<0.001). The cumulative morphine dose for titration was significantly greater in the remifentanil group (P<0.01). The cumulative morphine dose used during titration and patient-controlled analgesia was significantly greater in the remifentanil group 4, 12 and 24 h after extubation (P<0.05).. TCI sufentanil (0.25 ng ml(-1) effect-site concentration at extubation) is more effective than the intraoperative combination of remifentanil TCI infusion with morphine bolus (0.15 mg x kg(-1)) for postoperative pain relief after major abdominal surgery and does not compromise extubation and recovery.

Topics: Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Colon; Drug Administration Schedule; Drug Therapy, Combination; Female; Humans; Infusions, Intravenous; Intraoperative Care; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Sufentanil

The most frequently used drugs for premedication are benzodiazepines and alpha (2)-adrenoceptor agonists. In this study we examined midazolam and clonidine for premedication in combination with target controlled infusion anaesthesia (TCI) in patients undergoing orthopaedic shoulder surgery and analysed the effects on the peri- and postoperative course.. Forty-five Patients (ASA I-III) were included in this prospective randomized, double blind study. Sixty minutes prior to anaesthetic induction the patients received clonidine in a dosage of 2 microg x kg(-1) (group ND) or 5 microg x kg(-1) (group HD) or 0.1 mg x kg(-1) midazolam (group midazolam) per orally. Anaesthesia was performed as TCI with propofol (plasma concentration 2.0-4.0 microg x ml(-1)) und remifentanil (plasma concentration 0.2-0.4 microg x ml(-1) x min(-1)). 15 minutes before the operation was finished, all patients received a bolus dose of 0.1 mg x kg(-1) piritramid i.v., followed by administration of piritramid via a PCA pump (patient controlled analgesia) for a duration of 24 hours. During the time of the operation the influence of premedication on the anaesthetic course was determined by vital parameters and ranking scales. For statistic evaluation we used the Kruskal-Wallis test, ANOVA with Tukey as post hoc test and the test named after Fisher (p < 0.05).. The effects of premedication on haemodynamic parameters and ranking scales for sedation as well as anaesthetic requirements were comparable in all three groups. In the postoperative period the incidence of postoperative nausea and vomiting (PONV) (ND: n = 8, HD: n = 2, midazolam: n = 6) and the use of pritramid were lower in the clonidine HD group (HD: 38.7 +/- 30.7 mg, ND: 51.7 +/- 25.1 mg, midazolam: 45.1 +/- 30.4 mg) than in the other groups.. Premedication with the alpha(2)-adrenoceptor agonist clonidine is as good as with benzodiazepines in combination with TCI. Because of the lower incidence of PONV and the need of piritramid in the postoperative period patients premedicated with 5 microg x kg(-1) clonidine may benefit from this premedication.

Topics: Adolescent; Adrenergic alpha-2 Receptor Agonists; Adrenergic alpha-Agonists; Adult; Aged; Analgesia, Patient-Controlled; Anesthesia, Conduction; Anesthetics, Intravenous; Clonidine; Double-Blind Method; Female; Hemodynamics; Humans; Male; Midazolam; Middle Aged; Narcotics; Orthopedic Procedures; Pain, Postoperative; Piperidines; Pirinitramide; Postoperative Nausea and Vomiting; Premedication; Propofol; Prospective Studies; Remifentanil; Shoulder

Since the time to peak analgesic effect of intravenous morphine can be longer than 40-60 min in volunteers, the goal of this study was to evaluate the effect of the timing of intraoperative morphine administration on early postoperative pain.. A total of 120 adult patients undergoing laparoscopic cholecystectomy were studied. Anaesthesia was induced with remifentanil and etomidate and maintained with remifentanil and sevoflurane/nitrous oxide. Morphine 150 micrograms kg-1 was given randomly at three different times during surgery, and a fourth group received placebo. Times to eyes opening and extubation were measured, and pain was evaluated in the post-anaesthesia care unit (PACU) using a visual analogue scale (VAS). Morphine 2-3 mg was given when the VAS score was > or = 50 mm. The four groups were, according to the time elapsed from morphine administration to the end of surgery, group 1 (n = 30): placebo; group 2 (n = 33): < 20 min; group 3 (n = 30): 20-40 min; group 4 (n = 27): > 40 min.. Recovery from anaesthesia and pain scores were similar in all groups. However, mean (SD) morphine consumption was 5.7 (4.7) mg in group 1, 4.4 (4.2) mg in group 2, 4.7 (4.7) mg in group 3, and 2.2 (4.0) mg in group 4 (P < 0.05, group 1 vs 4). Morphine was required in only 38% of patients in group 4 compared with 83%, 67% and 69% in groups 1, 2, and 3, respectively (P < 0.01, group 1 vs 4).. The timing of intraoperative morphine administration did not affect the early recovery from anaesthesia. However, the reduction in the number of patients requiring morphine in the PACU when morphine had been given more than 40 min before the end of surgery supports this practice, rather than administration closer to the end of surgery.

Topics: Adult; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Cholecystectomy, Laparoscopic; Drug Administration Schedule; Female; Humans; Intraoperative Period; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

In this prospective, randomized study we compared bispectral index (BIS), hemodynamics, time to extubation, and the costs of target-controlled infusion (TCI) and manually-controlled infusion (MCI) of propofol. Forty patients undergoing first-time implantation of a cardioverter-defibrillator were included. Anesthesia was performed with remifentanil (0.2-0.3 micro g. kg(-1). min(-1)) and propofol. Propofol was used as TCI (plasma target concentration, 2.5-3.5 micro g/mL; n = 20) or MCI (3.0-4.0 mg. kg(-1). h(-1); n = 20). BIS, heart rate, and arterial blood pressure were measured at six data points: T1, before anesthesia; T2, after intubation; T3, after skin incision; T4, after first defibrillation; T5, after third defibrillation; and T6, after extubation. There were no significant hemodynamic differences between the two groups. BIS was significantly lower at T3 and T4 in the TCI group than in the MCI group. The mean dose of propofol was larger in TCI patients (5.8 +/- 1.4 mg. kg(-1). h(-1)) than in the MCI patients (3.7 +/- 0.6 mg. kg(-1). h(-1)) (P < 0.05), whereas doses of remifentanil did not differ. Time to extubation did not differ between the two groups (TCI, 13.7 +/- 5.3 min; MCI, 12.3 +/- 3.5 min). One patient in the MCI group had signs of intraoperative awareness without explicit memory after first defibrillation (BIS before shock, 49; after shock, 83). Costs were significantly less in the MCI group (34.83 US dollars) than in the TCI group (39.73 US dollars). BIS failed to predict the adequacy of anesthesia for the next painful stimulus.. In this prospective, randomized study, bispectral index (BIS), hemodynamics, time to extubation, and costs of target-controlled infusion (TCI) and manually-controlled infusion of propofol were compared. TCI increased the amount of propofol used. BIS failed to predict the adequacy of anesthesia for the next painful stimulus.

Topics: Aged; Anesthetics, Intravenous; Defibrillators, Implantable; Drug Costs; Electroencephalography; Female; Hemodynamics; Humans; Infusions, Intravenous; Male; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Remifentanil

A short hospital stay is nowadays desirable and affordable for a wide range of surgical pathology, respecting safety of care and home discharge. In the present study, the Authors investigated the use of TIVA with propofol/remifentanil during microsurgical vertebral disc resection to maintain a controlled vascular hypotension for bloodless surgical field aiming to reduce the operating time and consequently recovery room length of stay and morbility related to anaesthesia.. The study took place in a 300 bed Orthopaedics hospital over a period of 3 months and 50 ASA I-II patients were enrolled in this trial; further data are presented for comparison of 50 ASA I-II patients homogeneous for age and sex to the studied population, operated under a standard TIVA with propofol and boluses of fentanyl. Duration of anaesthesia and surgery, time for awakening after cessation of TIVA, incidence of postoperative nausea and vomiting (PONV), amount and quality of postoperative analgesia, length of stay in the recovery room are reported in statistical presentation.. Time of surgery and anaesthesia were reduced in the remifentanil group compared with the fentanyl group, thanks to an easily reachable and durable state of controlled hypotension in the first group without the use of any other drug. The recovery profile was shorter in the remifentanil group the drug being rapidly metabolised by plasma cholinesterase.. No difference occurred between the two groups regarding quality and amount of postoperative analgesia, while PONV presented more in the fentanyl group and shivering more in the remifentanil group.

Topics: Adult; Ambulatory Surgical Procedures; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Loss, Surgical; Female; Fentanyl; Hemodynamics; Humans; Intervertebral Disc; Length of Stay; Male; Middle Aged; Neurosurgical Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil

The relative importance of different nociceptive mechanisms for the intensity, duration, and character of postoperative pain is not well established. It has been suggested that sensitization of dorsal horn neurones may contribute to pain in the postoperative period. We hypothesized that wound hyperalgesia in postoperative patients and experimentally heat-induced secondary hyperalgesia share a common mechanism, sensitization of central neurones, and consequently, that the short-acting opioid remifentanil would have comparable effects on hyperalgesia in both conditions.. In a randomized, controlled, double-blind trial, we assessed mechanical hyperalgesia in skin bordering the surgical wound, and an area of experimentally heat-induced secondary hyperalgesia on the thigh, in 12 patients who underwent abdominal hysterectomy within 5 days prior to the investigation. Observations were made before and during a drug challenge with remifentanil, which has been demonstrated to reduce the area of heat-induced secondary hyperalgesia in volunteers.. The area of skin with surgically-induced mechanical hyperalgesia, the area of heat-induced secondary hyperalgesia, and pain during cough, were significantly reduced during remifentanil infusion compared with placebo (P = 0.008, P = 0.006, and P = 0.002, respectively). The relative reduction (% of baseline) of the area of skin with surgically-induced hyperalgesia and heat-induced secondary hyperalgesia during infusion of remifentanil was significantly associated (R2 = 0.72, P = 0.001).. Although remifentanil is not a highly targeted "antihyperalgesic," these results support the hypothesis that both wound hyperalgesia in postoperative patients and experimentally heat-induced secondary hyperalgesia may share common mechanisms, and that central neuronal sensitization may contribute to some aspects of postoperative pain. Antihyperalgesic drugs should be further developed and evaluated in clinical trials of postoperative pain.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia, General; Double-Blind Method; Female; Hot Temperature; Humans; Hyperalgesia; Hysterectomy; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

We investigated the effect of preincisional rectal diclofenac on pain scores and postoperative morphine requirements of children undergoing tonsillectomy after remifentanil-propofol anaesthesia in a randomized clinical trial.. Induction and maintenance of anaesthesia were with remifentanil and propofol. Forty children were randomly assigned into two groups before incision. The diclofenac group (n=20) received diclofenac suppositories (approximately 1 mg x kg(-1)) and the control group (n=20) received no treatment. Following discontinuation of remifentanil, patient-controlled analgesia (PCA) with morphine (a loading dose 50 micro g x kg(-1), a background infusion 4 micro g x kg(-1) x h(-1) and a demand dose 20 micro g x kg(-1) with 5-min intervals) was started. We assessed pain score [verbal analogue scales (VAS), 0-10] and sedation level at 5-min intervals and recorded the total morphine consumption of the first hour in the PACU. Patients were discharged to the ward with a new PCA morphine programme (a demand dose 20 micro g.kg-1 with a lockout time of 30 min, for 4 h), and total morphine consumption was recorded.. The mean VAS score of the diclofenac group was significantly lower than the control group on arrival in the PACU (2.85 +/- 0.77, 7.60 +/- 0.83, respectively, P < 0.01) and it remained significantly lower in the PACU stay of the children. The mean total morphine consumption of the diclofenac group was less than the control group in the PACU (130.33 +/- 11.26 and 169.92 +/- 9.22, respectively, P=0.012) and the ward (50.80 +/- 11.38 and 87.77 +/- 10.55, respectively, P=0.021).. Preemptive diclofenac given rectally reduced pain intensity and morphine requirements of children anaesthetized with remifentanil for tonsillectomy.

Topics: Adolescent; Analgesics, Opioid; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Child; Child, Preschool; Diclofenac; Double-Blind Method; Female; Humans; Male; Morphine; Pain, Postoperative; Piperidines; Remifentanil; Tonsillectomy

To determine if the combined remifentanil and intrathecal morphine (RITM) anesthetic technique facilitates early extubation in patients undergoing coronary artery bypass graft (CABG) surgery.. Prospective, randomized, controlled clinical trial.. Referral center for cardiothoracic surgery at a university hospital.. Patients (n = 24) undergoing first-time elective CABG surgery.. Two groups represented RITM (n = 12) and fentanyl-based (controls, n = 12) anesthesia. Premedication was standardized to temazepam, 0.4 mg/kg, and anesthesia was induced with etomidate, 0.3 mg/kg, in both groups. The RITM group received remifentanil, 1 microg/kg bolus followed by 0.25 to 1 microg/kg/min infusion, and intrathecal morphine, 2 mg. The control group received fentanyl, 12 microg/kg in 3 divided doses. Anesthesia was maintained with isoflurane and pancuronium in both groups. After completion of surgery, the remifentanil infusion was stopped. Complete reversal of muscle relaxation was ensured with a nerve stimulator, and a propofol infusion, 0.5 to 3 mg/kg/h, was started in both groups. All patients were transferred to the intensive care unit (ICU) to receive standardized postoperative care. Intensivists and ICU nurses were blinded to the group assignment. Propofol infusion was stopped, and the tracheal extubation was accomplished when extubation criteria were fulfilled.. Both groups were similar with respect to demographic data and surgical characteristics. Extubation times were 156 +/- 82 minutes and 258 +/- 91 minutes in the RITM and control groups (p = 0.012). Patients in the RITM group exhibited lower visual analog scale pain scores during the first 2 hours after extubation (p < 0.04). Morphine requirements during the 24 hours after extubation were 2.5 +/- 3 mg in the RITM group and 16 +/- 11 mg in the control group (p = 0.0018). Sedation scores were lower in the RITM group during the first 3 hours after extubation (p < 0.03). Pulmonary function tests as assessed by spirometry were better in the RITM group at 6 and 12 hours after extubation (p < 0.04). There were no significant differences in PaO(2) and PaCO(2) after extubation between the 2 groups. None of the patients had episodes of apnea during the immediate 24-hour postextubation period. Two patients from the RITM group required reintubation on the second and sixth postoperative days. There were no differences in ICU and hospital length of stay between the 2 groups.. Implementation of the RITM technique provided earlier tracheal extubation, decreased level of sedation, excellent analgesia, and improved spirometry in the early postoperative period. The impact of RITM on ICU and hospital length of stay and potential cost benefits require further evaluation.

Topics: Analgesics, Opioid; Anesthesia; Anesthetics, Combined; Anesthetics, Intravenous; Coronary Artery Bypass; Device Removal; Female; Fentanyl; Humans; Injections, Spinal; Intubation, Intratracheal; Length of Stay; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil

The aim of this study was to compare the analgesic efficacy of three different postoperative treatments after supratentorial craniotomy. Sixty-four patients were allocated prospectively and randomly into three groups: paracetamol (the P group, n = 8), paracetamol and tramadol (the PT group, n = 29), and paracetamol and nalbuphine (the PN group, n = 27). General anesthesia was standardized with propofol and remifentanil using atracurium as the muscle relaxant. One hour before the end of surgery, all patients received 30 mg/kg propacetamol intravenously then 30 mg/kg every 6 hours. Patients in the PT group received 1.5 mg/kg tramadol 1 hour before the end of surgery. For patients in the PN group, 0.15 mg/kg nalbuphine was injected after discontinuation of remifentanil, because of its mu-antagonist effect. Postoperative pain was assessed in the fully awake patient after extubation (hour 0) and at 1, 2, 4, 8, and 24 hours using a visual analog scale (VAS). Additional tramadol (1.5 mg/kg) or 0.15 mg/kg nalbuphine was administered when the VAS score was > or = 30 mm. Analgesia was compared using the Mantha and Kaplan-Meier methods. Adverse effects of the drugs were also measured. The three groups were similar with respect to the total dose of remifentanil received (0.27 +/- 0.1 mircog/kg/min). In all patients, extubation was obtained within 6 +/- 3 minutes after remifentanil administration. Postoperative analgesia was ineffective in the P group; therefore, inclusions in this group were stopped after the eighth patient. Postoperative analgesia was effective in the two remaining groups because VAS scores were similar, except at hour 1, when nalbuphine was more effective (P = .001). Nevertheless, acquiring such a result demanded significantly more tramadol than nalbuphine (P < .05). More cases of nausea and vomiting were observed in the PT group but the difference was not significant (P < .06). In conclusion, pain after supratentorial neurosurgery must be taken into account, and paracetamol alone is insufficient in bringing relief to the patient. Addition of either tramadol or nalbuphine to paracetamol seems necessary to achieve adequate analgesia, with, nevertheless, a larger dose of tramadol to fulfill this objective.

Topics: Acetaminophen; Adult; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Craniotomy; Double-Blind Method; Drug Therapy, Combination; Female; Glasgow Coma Scale; Humans; Male; Middle Aged; Nalbuphine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Supratentorial Neoplasms; Tramadol

Postoperative vomiting (POV) after strabismus surgery in children results in discomfort and prolonged hospital stays. Opioids increase the incidence of POV. Remifentanil has a context-sensitive half-life of 3 to 4 min, and how this short half-life influences POV in those patients is unknown. We conducted a prospective, double-blinded study in 81 ASA status I or II children from 2 to 12 yr of age undergoing elective strabismus surgery under general anesthesia. Patients were randomized to receive either remifentanil (bolus 1 microg/kg; infusion 0.1-0.2 microg x kg(-1) x min(-1)) or fentanyl (2 microg/kg, and 1 microg/kg every 45 min). POV episodes were recorded for 25 h. Pain scores were obtained by using an objective pain scale for 60 min during recovery. The number of patients who experienced POV did not differ significantly between groups (49% vs 48%). However, in the Remifentanil group, POV episodes were significantly less frequent (0.95 vs 2.2 episodes). In contrast, fentanyl was associated with lower pain scores during the first 30 min of recovery. We conclude that children undergoing strabismus surgery under balanced anesthesia with remifentanil, compared with fentanyl, showed less frequent POV. However, early postoperative analgesia was better with fentanyl.. Opioids increase the incidence of postoperative vomiting (POV). Remifentanil is characterized by the shortest half-life of all opioids used in anesthetic practice. Therefore, we studied the effect of remifentanil on POV compared with the longer-acting opioid fentanyl in children undergoing strabismus surgery.

Topics: Analgesics, Opioid; Child; Child, Preschool; Double-Blind Method; Female; Fentanyl; Humans; Incidence; Male; Pain, Postoperative; Piperidines; Postoperative Complications; Prospective Studies; Remifentanil; Strabismus; Vomiting

To compare hemodynamics, recovery profiles, early postoperative pain control and costs of total intravenous anesthesia (TIVA) with propofol and remifentanil and propofol and alfentanil.. Randomized, double-blind study.. University hospital.. 40 ASA physical status I and II adult patients scheduled for lumbar discectomy.. Patients were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 1 microg kg(-1) or alfentanil 20 microg kg(-1) with propofol 2 mg kg(-1), and maintained with infusions of propofol 150 to 100 microg kg(-1)min(-1) and either remifentanil 0.1 microg kg(-1) min(-1) or alfentanil 0.5 microg kg(-1) min(-1).. Hemodynamic parameters (heart rate and mean arterial pressure), times to awakening, and tracheal extubation were recorded. In the postanesthesia care unit, pain level, frequency of analgesic demand, frequency of postoperative nausea and vomiting (PONV), partial oxygen saturation (SpO2), and respiratory rates were noted. Drug dosages and costs of each technique were determined.. The mean arterial pressure significantly decreased compared to baseline values 1 minute after induction (p < 0.05) in both groups, and it significantly decreased at 5, 15, and 30 minutes perioperatively in the remifentanil group compared to the alfentanil group (p < 0.05). Time of extubation, spontaneous eye opening, and response to verbal command were similar in both groups. Visual analog scale pain scores at 30 minutes and 60 minutes were significantly lower in the alfentanil group than remifentanil group (p < 0.05). At 15, 30, and 60 minutes after terminating the operation oxygen saturation and respiratory rate were significantly higher (p < 0.05) and analgesics were required sooner in the remifentanil group than the alfentanil group (p < 0.05). The frequency of PONV was similar in both groups. The remifentanil-propofol anesthesia was found to be slightly more expensive as compared to the alfentanil based TIVA (33.41 +/- 4.53 vs. 29.97 +/- 4.1 USD) (p < 0.05).. Both remifentanil and alfentanil provided a reasonably rapid and reliable recovery. The remifentanil-based TIVA was associated with high intraoperative cost and early postoperative pain, but it allowed a more rapid respiratory recovery.

Topics: Adult; Aged; Alfentanil; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Double-Blind Method; Female; Heart Rate; Hemodynamics; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Male; Middle Aged; Oximetry; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Respiratory Function Tests; Time Factors

Relative large-dose intraoperative remifentanil could lead to the need for more postoperative analgesics. Intraoperative N-methyl-D-aspartate receptor antagonists, such as ketamine, decrease postoperative opioid use. We therefore tested the hypothesis that intraoperative small-dose ketamine improves postoperative analgesia after major abdominal surgery with remifentanil-based anesthesia. Fifty patients undergoing abdominal surgery under remifentanil-based anesthesia were randomly assigned to intraoperative ketamine or saline (control) supplementation. The initial ketamine dose of 0.15 mg/kg was followed by 2 microg. kg(-1). min(-1). In both groups, desflurane was kept constant at 0.5 minimum alveolar anesthetic concentration without N(2)O, and a remifentanil infusion was titrated to autonomic responses. All patients were given 0.15 mg/kg of morphine 30 min before the end of surgery. Pain scores and morphine consumption were recorded for 24 postoperative h. Less of the remifentanil was required in the Ketamine than in the Control group (P < 0.01). Pain scores were significantly larger in the Control group during the first 15 postoperative min but were subsequently similar in the two groups. The Ketamine patients required postoperative morphine later (P < 0.01) and received less morphine during the first 24 postoperative h: 46 mg (interquartile range, 34-58 mg) versus 69 mg (interquartile range, 41-87 mg, P < 0.01). No psychotomimetic symptoms were noted in either group. In conclusion, supplementing remifentanil-based anesthesia with small-dose ketamine decreases intraoperative remifentanil use and postoperative morphine consumption without increasing the incidence of side effects. Thus, intraoperative small-dose ketamine may be a useful adjuvant to intraoperative remifentanil.. Supplementing remifentanil-based anesthesia with small-dose ketamine decreased intraoperative remifentanil use and postoperative morphine consumption. These data demonstrate that N-methyl-D-aspartate antagonists, such as ketamine, can be a useful adjuvant to intraoperative remifentanil.

Topics: Adjuvants, Anesthesia; Aged; Analgesics, Opioid; Anesthetics, Dissociative; Anesthetics, Inhalation; Desflurane; Female; Hemodynamics; Humans; Isoflurane; Ketamine; Male; Middle Aged; Monitoring, Intraoperative; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Remifentanil

ADL-8-2698 is a novel peripherally restricted opioid antagonist that may selectively prevent opioid-induced gastrointestinal effects without reversing analgesia. Gastrointestinal transit time (lactulose hydrogen breath test) was measured in 14 volunteers with oral and intravenous placebo, oral placebo and intravenous morphine (0.05 mg x kg(-1)), and oral ADL 8-2698 (4 mg) and intravenous morphine (0.05 mg x kg(-1)) in a double blind, cross-over study. Morphine prolonged gastrointestinal transit time from 69 to 103 minutes (P = .005); this was prevented by ADL 8-2698 (P = .004). Postoperatively, 45 patients were randomly assigned in a double-blind fashion to receive ADL 8-2698 (4 mg) or placebo and intravenous morphine (0.15 mg/kg) or to receive oral and intravenous placebo. Analgesia and pupil constriction were measured. Morphine analgesia and pupil constriction were unaffected by ADL 8-2698 and differed from placebo (P < .002). We conclude that ADL 8-2698 prevents morphine-induced increases in gastrointestinal transit time by means of selective peripheral opioid anitagonism without affecting central opioid analgesia.

Topics: Adult; Analgesics, Opioid; Double-Blind Method; Drug Interactions; Female; Gastrointestinal Diseases; Gastrointestinal Transit; Humans; Male; Molar, Third; Morphine; Narcotic Antagonists; Pain Measurement; Pain, Postoperative; Piperidines; Tooth Extraction; Tooth, Impacted

Nitrous oxide (N2O) has been suggested to contribute to bowel distension, resulting in worsened operating conditions for laparoscopic surgery, and to increase incidence of postoperative nausea and vomiting. Therefore, our objective was to assess the feasibility of two remifentanil-based anaesthetic regimens free from N2O with special regard to recovery profile, postoperative analgesic demand and side effects in patients undergoing laparoscopic cholecystectomy.. Fifty patients (ASA I-II, 23-65 yr) were randomly assigned to receive remifentanil-based anaesthesia in conjunction with propofol (group R/P) or desflurane (group R/D). After standardised induction of anaesthesia, analgesia was continued with remifentanil in all patients. For maintenance of hypnosis, propofol or desflurane were used in concentrations to ensure loss of consciousness, lack of awareness, and maintenance of heart rate and blood pressure within +/- 25% of initial values. At the end of surgery all anaesthetics were discontinued without tapering and early emergence and recovery were recorded. Pain scores were assessed by using a visual analogue scale. Patient-controlled analgesia with i.v. piritramide was used for treatment of postoperative pain and recorded for 90 min in the postanaesthesia care unit (PACU). In addition, side effects were noted.. Early emergence from anaesthesia did not differ between the groups. In group R/P, time to eye opening, spontaneous respiration and extubation was 4.4 +/- 2.9 min, 5.2 +/- 3.4 min and 5.5 +/- 3.3 min respectively, compared with 4.7 +/- 2.7 min, 5.3 +/- 2.4 min and 5.7 +/- 2.5 min in group R/D. While pain scores did not differ between both groups on admission to the PACU, patients receiving desflurane required more i.v. piritramide as compared to those receiving propofol, 22.0 +/- 6.5 mg and 17.9 +/- 7.0 mg, respectively (P<0.05). Nausea was less frequent after propofol (16% vs. 48%, P<0.05).. In patients undergoing laparoscopic cholecystectomy, remifentanil-based anaesthetic regimens in conjunction with propofol or desflurane are suitable and allow for rapid recovery from anaesthesia. However, the use of propofol results in less postoperative analgesic consumption and nausea as compared to desflurane.

Topics: Adult; Aged; Anesthesia; Cholecystectomy, Laparoscopic; Desflurane; Female; Hemodynamics; Humans; Isoflurane; Male; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Remifentanil

We evaluated the analgesic efficacy and safety of two continuous constant-dose infusions of IV remifentanil, without infusion rate increments or the addition of boluses, in patients with severe postoperative pain during the first 4 h after general anesthesia with IV propofol-remifentanil. Thirty patients were randomly assigned to two groups of 15 subjects each according to the remifentanil dose administered: 0.1 microg. kg(-1). min(-1) IV (Group A) or 0.05 microg. kg(-1). min(-1) IV (Group B). Rescue analgesia was provided with meperidine (0.5 mg/kg IV) when pain intensity on the simple verbal scale (SVS) > or =2. The criteria for adequate analgesia (SVS 0-1, respiratory frequency >8/min. and SpO(2) >90%) after 4 h were met by 78% and 75% of the patients in Groups A and B, respectively (P = ns). "Meperidine rescue" analgesia was significantly more in Group B (26%) than in Group A (6%) (P < 0.05). There were no cases of respiratory depression, and nausea and emesis occurred in one patient in each group (6.5%). We conclude that IV remifentanil is an effective and safe opioid for the treatment of postoperative pain at a constant dose of 0.1 microg. kg(-1). min(-1) with a need for rescue analgesia 4 times less than a constant dose of 0.05 microg. kg(-1). min(-1).. Our study suggests that the use of a constant continuous infusion of remifentanil 0.1 microg.kg(-1).min(-1)IV is an effective alternative in the treatment of severe postoperative pain.

Topics: Adult; Aged; Analgesics, Opioid; Female; Hemodynamics; Humans; Infusions, Intravenous; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

We investigated the haemodynamic stability and emergence characteristics of isoflurane/nitrous oxide anaesthesia supplemented with remifentanil or fentanyl in patients undergoing carotid endarterectomy.. Anaesthesia was induced with propofol (1-2 mg kg-1) and either remifentanil (0.5 microgram kg-1) or fentanyl (1 microgram kg-1), followed by an infusion of remifentanil (0.2 microgram kg-1 min-1) or fentanyl (2 micrograms kg-1 h-1).. There were no significant differences between the groups in haemodynamic variables, postoperative pain, nausea or vomiting. After induction there was a significant decrease in mean arterial pressure for both groups (P < 0.001) and a decrease in heart rate (P = 0.001) in the remifentanil group. In both groups these haemodynamic changes continued during maintenance of anaesthesia (P < 0.05). The time to eye opening after surgery was significantly shorter with remifentanil compared with fentanyl (6.62 +/- 3.89 vs. 18.0 +/- 15.18 min, P = 0.015).. Remifentanil appears to be a comparable opioid to fentanyl when supplementing isoflurane/nitrous oxide anaesthesia for carotid endarterectomy.

Topics: Adjuvants, Anesthesia; Adult; Aged; Aged, 80 and over; Anesthesia, General; Anesthetics, Intravenous; Constriction; Double-Blind Method; Endarterectomy, Carotid; Female; Fentanyl; Hemodynamics; Humans; Intraoperative Period; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

To assess the efficacy and safety of remifentanil for analgesia and sedation during subarachnoidea anesthesia, and to compare remifentanil with propofol.. Ninety ASA I-III patients undergoing orthopedic or traumatologic surgery under subarachnoid anesthesia were enrolled for prospective study and randomly assigned to two treatment groups. The propofol group (n = 45) received a single dose of 0.5 mg/kg followed by infusion at 3 mg/kg/h. The remifentanil group (n = 45) received a single dose of 0.5 microgram/kg followed by infusion at 0.1 microgram/kg/min. We evaluated quality of sedation, pain intensity during nerve blockade, hemodynamic and respiratory parameters and time until recovery.. The remifentanil group experienced less moderate-to-intense pain (13%) than did the propofol group (63%) (p < 0.01). Sedation was adequate in both groups and was easy to control by adjusting the rate of infusion. Times until recovery of consciousness and respiratory frequency after withdrawal of infusion until recovery of baseline levels were 7.87 +/- 3.54 min and 5.22 +/- 2.49 min, respectively, in the remifentanil group and 8.72 +/- 4.59 min and 5.36 +/- 2.49 min, respectively, in the propofol group, respectively. Patients in the remifentanil group experienced a significantly greater decrease in SpO2 than did those in the propofol group (20% and 4%, respectively; p < 0.05). Mean blood pressure was higher for patients treated with remifentanil. The incidence of vomiting was also higher in the remifentanil group than in the propofol group (9% vs 0%).. Remifentanil is more effective in reducing pain related to nerve blockade and level of sedation is lower; however remifentanil is associated with a higher incidence of respiratory depression and vomiting.

Topics: Adolescent; Adult; Aged; Anesthesia, Spinal; Anesthetics, General; Female; Humans; Hypnotics and Sedatives; Hypoxia; Male; Middle Aged; Orthopedic Procedures; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Respiration Disorders; Safety; Vomiting

We evaluated the use of remifentanil administered as a component of an inhalation or of a Target Controlled Infusion (TCI) anesthetic technique during outpatient oral surgery. Sixty-three unpremedicated patients undergoing removal of four impacted third molars participated to this prospective, randomized study. Anesthesia was induced with Propofol and Rocuronium. Remifentanil 1 microgram.kg-1 i.v. was given over 30 s followed by a continuous infusion reduced from 25% each time a tooth was removed (0.25-->0.0625 microgram.kg-1 min-1). Anesthesia was maintained with Desflurane (group D, n = 31) (end-tidal concentration 4-6%) or Propofol (group P, n = 32) (initial infusion TCI 8 micrograms.ml-1 reduced to 2-3 micrograms.ml-1 after intubation). Corticosteroids, a non-steroidal anti-inflammatory drug (NSAID) (Diclofenac) and a partial mu agonist drug (Tramadol) were administered i.v. during the procedure to prevent early postoperative pain. Recovery time, postoperative pain, recovery of cognition and nausea or vomiting were also evaluated during the first six postoperative hours. Overall mean systolic blood pressures and heart rate were similar in the two groups during surgery. Mean times to extubation and to recall of birth-date and room number were also similar. The quality of awakening was good in the two groups. Most patients complained of moderate pain or had no pain during the first six postoperative hours. The incidence of nausea and vomiting was similar in both groups. No other side effect was observed. These data suggest that the association of Remifentanil, Methylprednisolone, Diclofenac and Tramadol is an useful technique in ambulatory oral surgery in two comparable anesthetic regimens.

Topics: Adolescent; Ambulatory Surgical Procedures; Anesthesia Recovery Period; Anesthesia, Dental; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Female; Humans; Isoflurane; Male; Methylprednisolone; Molar, Third; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Tooth Extraction; Tooth, Impacted

and objective This open, multicentre study compared the efficacy and safety of remifentanil with fentanyl during balanced anaesthesia with 0.8% isoflurane (end-tidal concentration) for major abdominal and gynaecological surgery, and the efficacy and safety of remifentanil for pain management in the immediate postoperative period.. Two-hundred and eighty-six patients were randomized to receive remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min-1 (n=98), remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) (n=91) or fentanyl 3 microg kg(-1) (n=97) at induction. Thereafter, the study opioids and isoflurane were titrated to effect during the operation.. Compared with fentanyl, remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) reduced the incidence of response to tracheal intubation (30% vs. 13%, P < 0.01), skin incision (33% vs. 4%, P < 0.001) and skin closure (11% vs. 3%, P < 0.05), respectively. Patients receiving remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min(-1) had fewer responses to skin incision than the fentanyl group (12% vs. 33%, P < 0.001), but the incidences of response to tracheal intubation and skin closure were similar. Significantly fewer patients in both remifentanil groups had > or = 1 responses to surgical stress intraoperatively compared with fentanyl (68% and 48% vs. 87%, P < 0.003). The mean isoflurane concentrations required were less in both remifentanil groups compared with the fentanyl group (0.1%, P=0.05). In remifentanil-treated patients, continuation of the infusion at 0.1 microg kg(-1) min(-1) with titration increments of +/- 0.025 microg kg(-1) min(-1) was effective for the management of immediate postoperative pain prior to transfer to morphine analgesia. However, a high proportion of patients experienced at least moderate pain whilst the titration took place.. Anaesthesia combining isoflurane with a continuous infusion of remifentanil was significantly more effective than fentanyl at blunting responses to surgical stimuli. Significantly fewer patients responded to tracheal intubation with remifentanil at 0.4 microg kg(-1) min(-1), supporting the use of a higher initial infusion rate before intubation. Both remifentanil and fentanyl were well-tolerated, with reported adverse events typical of mu-opioid agonists.

Topics: Abdomen; Adult; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Female; Fentanyl; Gynecologic Surgical Procedures; Humans; Isoflurane; Male; Oxygen; Pain, Postoperative; Piperidines; Remifentanil; Respiratory Mechanics

We investigated the analgesic effect and the neurological recovery time after administration of remifentanil in mechanically ventilated patients in an intensive care unit. Twenty patients, after trauma or major surgery with no intracranial pathology, were randomized to receive either remifentanil/propofol (n=10) or sufentanil/propofol (n=10). A sedation score and a simplified pain score were used to assess adequate sedation and analgesia. Medication was temporarily stopped after 24 h. Immediately before and 10 and 30 min after, the degree of sedation and pain score were evaluated. Adequate analgesia and sedation was achieved with remifentanil 10.6 microg kg(-1) h(-1) and propofol 2.1 mg kg(-1) h(-1), or sufentanil 0.5 microg kg(-1) h(-1) and propofol 1.3 mg kg(-1) h(-1). The difference in propofol dose between groups was significant. Ten minutes after terminating the medication, the degree of sedation decreased significantly after remifentanil and all patients could follow simple commands. During the following 20 min, all patients with remifentanil emerged from sedation and complained of considerable pain. By contrast, in the sufentanil group, only six (7) responded to commands after 10 (30) min and their pain score remained essentially unchanged during the 30-min observation period. We conclude that, in contrast to sufentanil, remifentanil facilitates rapid emergence from analgesia and sedation, allowing a clinical neurological examination within 10-30 min in mechanically ventilated patients with no intracranial pathology.

Topics: Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Combined; Female; Heart Rate; Humans; Male; Middle Aged; Mouth Neoplasms; Multiple Trauma; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Respiration, Artificial; Sufentanil; Wounds and Injuries

Postoperative recovery of gastrointestinal function and resumption of oral intake are critical determinants of the length of hospital stay. Although opioids are effective treatments for postoperative pain, they contribute to the delayed recovery of gastrointestinal function.. We studied the effects of ADL 8-2698, an investigational opioid antagonist with limited oral absorption that does not readily cross the blood-brain barrier, on postoperative gastrointestinal function and the length of hospitalization. We randomly assigned 79 patients--including 1 whose surgery was canceled--to receive one capsule containing 1 mg or 6 mg of ADL 8-2698 or an identical-appearing placebo capsule two hours before major abdominal surgery and then twice daily until the first bowel movement or until discharge from the hospital. Data were analyzed for 26 patients in each of the three groups; all received opioids for postoperative pain relief. Observers who were unaware of the group assignments evaluated the outcomes.. Fifteen patients underwent partial colectomy and 63 underwent total abdominal hysterectomy. Patients given 6 mg of ADL 8-2698 had significantly faster recovery of gastrointestinal function than those given placebo. The median time to the first passage of flatus decreased from 70 to 49 hours (P=0.03), the median time to the first bowel movement decreased from 111 to 70 hours (P=0.01), and the median time until patients were ready for discharge decreased from 91 to 68 hours (P=0.03). Effects in the group that received 1 mg of ADL 8-2698 were less pronounced.. Selective inhibition of gastrointestinal opioid receptors by an antagonist with limited oral absorption that does not readily cross the blood-brain barrier speeds recovery of bowel function and shortens the duration of hospitalization.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Colectomy; Defecation; Digestive System; Female; Flatulence; Humans; Hysterectomy; Intestinal Obstruction; Length of Stay; Male; Meperidine; Middle Aged; Morphine; Narcotic Antagonists; Pain, Postoperative; Piperidines; Postoperative Complications; Receptors, Opioid; Time Factors

To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists' satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population.. Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol.. Multicenter study including 156 hospitals and ambulatory surgery facilities.. 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness > or =30 minutes.. Patients were randomized to receive either intravenous (IV) remifentanil (0.5 microg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 microg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists' discretion, in the fentanyl patients.. Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists' satisfaction with the anesthetic regimen was assessed at the end of surgery.. Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10-15 mmHg) and lower heart rates (by 10-15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients.. This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Remifentanil; Single-Blind Method; Time Factors

The aim of this study was to compare total intravenous anaesthesia (TIVA) using propofol and remifentanil (P/R-group) and balanced anaesthesia (BA) using sevoflurane and remifentanil (S/R-group) for paediatric surgery.. A total of 120 patients aged 6 months to 16 years scheduled for elective minor lower abdominal surgery were randomly assigned to receive either propofol (5-10 mg/kg/h) and remifentanil (0.125-1.0 microgram/kg/min) or sevoflurane (1.0-1.5 MAC) and remifentanil (0.125-1.0 microgram/kg/min). Perioperative haemodynamics as well as recovery and discharge times, PONV and side-effects were studied. The patients vigilance, comfort and pain intensity were assessed postoperatively using the objective pain discomfort scale, the Steward post-anaesthetic recovery score and a visual analogue scale.. Postoperative recovery (9.0 vs 11.6 min) and extubation times (11.8 vs. 15.0 min) as well as the time taken until a Steward post-anaesthetic recovery score > 3/4 (15.2 vs. 21.4 min) was reached were significantly shorter in the P/R-group. However, the length of time until discharge to the ward, postoperative comfort, pain intensity and analgesic requirements as well as PONV were comparable in both groups.. With regards to the investigated parameters, TIVA with propofol and remifentanil is equally effective as BA with sevoflurane and remifentanil in paediatric patients. However, considering the selected dosing regimen, recovery times were significantly shorter for children after TIVA.

Topics: Abdomen; Adjuvants, Anesthesia; Adolescent; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child, Preschool; Female; Hemodynamics; Humans; Infant; Intraoperative Period; Male; Methyl Ethers; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil; Sevoflurane

Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after.. The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Halothane; Hemodynamics; Humans; Infant; Infant, Newborn; Nitrous Oxide; Pain, Postoperative; Piperidines; Postoperative Complications; Pyloric Stenosis; Pylorus; Remifentanil

We have prospectively assessed whether remifentanil-based anaesthesia is associated with clinically relevant acute opioid tolerance, expressed as greater postoperative pain scores or morphine consumption. Sixty patients undergoing elective gynaecological, non-laparoscopic, surgery were randomly assigned to receive remifentanil (group R, n=30) or sevoflurane (group S, n=30) based anaesthesia. Postoperative analgesia was provided with morphine through a patient-controlled infusion device. Mean (SD) remifentanil infusion rate in group R was 0.23 (0.10) microg kg(-1) min(-1) and mean inspired fraction of sevoflurane in group S was 1.75 (0.70)%. Mean (SD) cumulative morphine consumption during the first 24 postoperative hours was similar between groups: 28.0 (14.2) mg (group R) vs 28.6 (12.4) mg (group S). Pain scores, were also similar between groups during this period. These data do not support the development of acute opioid tolerance after remifentanil-based anaesthesia in this type of surgery.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Inhalation; Anesthetics, Intravenous; Drug Administration Schedule; Drug Interactions; Drug Tolerance; Female; Gynecologic Surgical Procedures; Humans; Methyl Ethers; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Prospective Studies; Remifentanil; Sevoflurane

Otologic procedures require a still surgical field and are associated with a 50% incidence of emetic symptoms. Propofol reduces nausea and vomiting but not intraoperative movement. This study compares a remifentanil/propofol anesthetic to a propofol/fentanyl combination to determine which provides the best perioperative conditions for otologic microsurgery. Eighty healthy patients were randomly assigned to receive one of the anesthetic combinations. Demographic data, hemodynamic variables, movement, and bispectral index monitoring values in addition to anesthetic emergence, nausea, vomiting, pain, and other recovery variables were compared between groups with appropriate statistical methods. Both groups were similar. Times to eye opening (7.7 +/- 0.7 vs 12.4 +/- 1.2 minutes) and extubation (9.8 +/- 0.9 vs 12.4 +/- 1.0 minutes) were shorter with remifentanil. This group also had lower hemodynamic variables and movement (23% vs 65%) under anesthesia. Postoperative pain was mild in both groups, but remifentanil patients had more than the propofol group. All other postoperative parameters were similar. Remifentanil-based anesthesia produces better hemodynamic stability, less movement, and faster emergence after otologic surgery, with propofol's antiemetic effect, for the same cost.

Topics: Adolescent; Adult; Aged; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Intravenous; Female; Fentanyl; Hemodynamics; Humans; Male; Middle Aged; Otologic Surgical Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil

We evaluated the effect of perioperative administration of two doses of morphine for postoperative analgesia after remifentanil-based anesthesia. The prospective, randomized study included 245 patients from 33 centers. All patients were scheduled for abdominal or urological surgery lasting more than 1 h. General anesthesia used remifentanil as the perioperative opioid (1 microg/kg as a bolus then, 0.5 microg/kg as a continuous infusion). A morphine bolus of 0. 15 mg/kg (0.15-mg group) or 0.25 mg/kg (0.25-mg group) was administered 30 min before the end of surgery. In the postanesthesia care unit, pain scores for patients were evaluated by using behavioral pain scores of 1-3, verbal pain scores of 0-3, and visual analog scale scores of 0-10). Postoperative analgesia was obtained by a morphine titration (3 mg every 5 min). Demographic and surgery characteristics were similar in both groups. The delay for first demand of morphine was similar in the 0.15-mg and the 0.25-mg groups (26 [9-60] and 30 [10-60] min, respectively). The frequency of morphine titration was similar in both groups (75% and 66%, respectively). The amount of morphine used in the postanesthesia care unit was smaller in the 0.25-mg group (0.16 [0.0-1.25] vs 0.10 [0.0-0.56] mg/kg; P = 0.008). In the 0.25-mg group, the behavioral pain score was lower at 15 min, the verbal pain score was lower at 60 min (P < 0.001), and similar at 30 min. The visual analog scale pain score at 30 min and 60 min was similar in both groups. The incidence of minor side effects was similar in both groups. However, three cases of postoperative respiratory depression occurred in the 0.25-mg group compared with no cases in the 0.15-mg group. In conclusion, perioperative administration of morphine alone does not provide entirely adequate immediate postoperative pain control after remifentanil-based anesthesia in major surgery.. The administration of 0.15 or 0.25 mg/kg perioperative morphine during remifentanil-based anesthesia for major surgery does not preclude additional morphine administration in the postanesthesia care unit. The larger dose of 0.25 mg/kg slightly improves postoperative analgesia; however, it may be responsible for postoperative respiratory depression.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, General; Female; Humans; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Respiration

We compared, in a double-blinded manner, the anesthetic maintenance and recovery properties of remifentanil with a clinically comparable fentanyl-based anesthetic technique in pediatric ambulatory surgical patients. Anesthesia was induced with either halothane or sevoflurane and nitrous oxide and oxygen. Patients were randomized (computer generated) to receive either remifentanil or fentanyl in a blinded syringe with nitrous oxide and oxygen in one of four possibilities: halothane/remifentanil, halothane/fentanyl, sevoflurane/remifentanil or sevoflurane/fentanyl. In patients receiving remifentanil, a placebo bolus was administered, and a continuous infusion (0.25 microg. kg(-1). min(-1)) was begun. In patients receiving fentanyl, a bolus (2 microg/kg) was administered followed by a placebo continuous infusion. The time from discontinuation of the anesthetic to extubation, discharge from the postanesthesia care unit (PACU), and discharge to home, as well as pain scores, were assessed by a blinded nurse observer. Systolic blood pressure and heart rate were noted at selected times, and adverse events were recorded. Remifentanil provided faster extubation times and higher pain-discomfort scores. PACU and hospital discharge times were similar. There were no statistical differences among the groups for adverse events. There were statistically, but not clinically, significant differences in hemodynamic variables. We noted that continuous infusions of remifentanil were intraoperatively as effective as bolus fentanyl. Although patients could be tracheally extubated earlier with remifentanil, this did not translate to earlier PACU or hospital discharge times. In addition, remifentanil was associated with higher postoperative pain scores. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children.. This is a study designed to examine the efficacy and safety of a short-acting opioid, remifentanil, when used in pediatric patients. The frequent incidence of postoperative pain observed in the postoperative recovery room suggests that better intraoperative prophylactic analgesic regimens for postoperative pain control are necessary to optimize remifentanil's use as an anesthetic for children.

Topics: Adenoidectomy; Ambulatory Surgical Procedures; Anesthetics, Intravenous; Blood Pressure; Child; Child, Preschool; Double-Blind Method; Fentanyl; Heart Rate; Humans; Infant; Pain, Postoperative; Piperidines; Remifentanil; Tonsillectomy

We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.

Topics: Abdomen; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Double-Blind Method; Female; Fentanyl; Humans; Isoflurane; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Propofol; Remifentanil

Eighty patients undergoing major abdominal surgery using remifentanil-based anaesthesia were randomly allocated in a double-blind manner to receive an intravenous bolus of fentanyl, buprenorphine, morphine or piritramide 20 min before the end of surgery. A reduced dose was administered postoperatively when patients reported moderate pain. Subsequent analgesia was provided by patient-controlled analgesia (PCA). The mean time from the end of anaesthesia to spontaneous respiration was 9 +/- 5 min. At first pain assessment, 63% of patients reported no or mild pain; 80% of patients required the second opioid bolus, those receiving piritramide needed the bolus significantly later than patients receiving buprenorphine or fentanyl. First PCA requirement also occurred significantly later in the piritramide group. This technique provided effective postoperative pain relief and transition to routine PCA and did not compromise recovery.

Topics: Abdomen; Adult; Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia Recovery Period; Buprenorphine; Double-Blind Method; Female; Fentanyl; Humans; Intraoperative Care; Male; Middle Aged; Morphine; Pain, Postoperative; Pilot Projects; Piperidines; Pirinitramide; Remifentanil

Most patients undergoing minimally invasive direct coronary artery bypass surgery can be awakened and tracheally extubated in the operating room. We have compared two techniques of total IV anesthesia in this patient population: 30 patients (aged 44 to 74 yr; 24 male) premedicated with temazepam were randomly assigned to receive either remifentanil-propofol or alfentanil-propofol. Anesthesia was induced with remifentanil 2 microg/kg or with alfentanil 40 microg/kg, with propofol, and maintained with remifentanil at 0.25 or 0.5 microg x kg(-1) x min(-1) or alfentanil at 0.5 or 1 microg x kg(-1) x min(-1). The stable maintenance infusion rate of propofol was adjusted for age. Times to awakening and tracheal extubation were recorded. Postoperatively, IV morphine provided by patient-controlled analgesia was used for 48 h. Times to awakening and tracheal extubation (mean +/- SD) were shorter (P < 0. 01) in patients receiving remifentanil, and interpatient variations in times to awakening and tracheal extubation smaller (awakening 25 +/- 7 vs 74 +/- 32 min, and extubation 27 +/- 7 vs 77 +/- 32 min). Analysis of variance revealed that postoperative consumption of morphine was dependent on both the intraoperative opioid and the time elapsed after surgery (P < 0.05): patient-controlled analgesia morphine use during the first 3 h after awakening was more in patients receiving remifentanil (P < 0.01).. Recovery of patients undergoing Minimally Invasive Direct Coronary Artery Bypass Surgery is significantly shorter and more predictable after total IV anesthesia with remifentanil-propofol than with alfentanil-propofol, which may be important if the goal is that patients will be awakened and tracheally extubated in the operating room.

Topics: Aged; Alfentanil; Analgesia, Patient-Controlled; Anesthesia, Intravenous; Anesthetics, Intravenous; Blood Pressure; Consciousness; Coronary Artery Bypass; Creatine Kinase; Double-Blind Method; Female; Humans; Intubation, Intratracheal; Isoenzymes; Male; Middle Aged; Minimally Invasive Surgical Procedures; Pain, Postoperative; Piperidines; Propofol; Remifentanil

To determine if morphine sulphate was an effective transition analgesic in patients receiving a remifentanil-based anesthetic regimen.. Open-label remifentanil or fentanyl was administered to 210 randomized patients undergoing inpatient surgery. Isoflurane and nitrous oxide was administered to all patients. Thirty minutes before the end of surgery, patients receiving remifentanil were randomized to receive morphine 0.15 mg x kg(-1) (R/M15 group) or 0.20 mg x kg(-1) (R/M20 group). Following extubation and prior to patient-controlled analgesia (PCA) initiation, 2 mg boluses of morphine were administered for moderate/severe pain. Efficacy endpoints were total morphine used in the post anesthesia care unit (PACU) and 24 and 48 hr postoperatively; postoperative pain; time to first morphine bolus; time to first PCA administration; and time to recovery endpoints.. Mean total morphine used in PACU was not different among groups (15.5 mg, 16.5 mg and 13.3 mg in R/M 15, R/M20 and F groups, respectively). Mean total 24 hr morphine use (58.1 mg, 56.93 mg and 53.6 mg in R/M15, R/M20 and F groups) and mean total morphine used at 48 hr were not different (69.8 mg, 64.7 mg and 62.1 mg in R/M15, R/M20 and F/I groups). Groups were similar with respect to pain severity ratings at all postoperative times. Patients in the fentanyl arm experienced faster times to some recovery endpoints than patients receiving either remifentanil regimen.. Morphine sulphate regimens of 0.15 or 0.20 mg x kg(-1) administered 30 min before the end of surgery are equally effective transition regimens for inpatient procedures.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Double-Blind Method; Female; Fentanyl; Humans; Male; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Remifentanil

Rapid development of acute opioid tolerance is well established in animals and is more likely to occur with large doses of short-acting drugs. The authors therefore tested the hypothesis that intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain and opioid requirement.. Fifty adult patients undergoing major abdominal surgery were randomly assigned to two anesthetic regimens: (1) desflurane was kept constant at 0.5 minimum alveolar concentrations and a remifentanil infusion was titrated to autonomic responses (remifentanil group); or (2) remifentanil at 0.1 microg. kg-1. min-1 and desflurane titrated to autonomic responses (desflurane group). All patients were given a bolus of 0.15 mg/kg morphine 40 min before the end of surgery. Morphine was initially titrated to need by postanesthesia care nurses blinded to group assignment. Subsequently, patients-who were also blinded to group assignment-controlled their own morphine administration. Pain scores and morphine consumption were recorded for 24 postoperative h.. The mean remifentanil infusion rate was 0.3 +/- 0.2 microg. kg-1. min-1 in the remifentanil group, which was significantly greater than in the desflurane group. Intraoperative hemodynamic responses were similar in each group. Postoperative pain scores were significantly greater in the remifentanil group. These patients required morphine significantly earlier than those in the desflurane group and needed nearly twice as much morphine in the first 24 postoperative h: 59 mg (25-75% interquartile range, 43-71) versus 32 mg (25-75% interquartile range, 19-59; P < 0.01).. Relatively large-dose intraoperative remifentanil increased postoperative pain and morphine consumption. These data suggest that remifentanil causes acute opioid tolerance and hyperalgesia.

Topics: Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthetics, Inhalation; Colectomy; Desflurane; Drug Tolerance; Female; Hemodynamics; Humans; Intraoperative Period; Isoflurane; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil

The purpose of this cardiac fast-track study was to evaluate the use of remifentanil (R) combined with intrathecal (IT) morphine as an alternative to sufentanil (S) during desflurane anesthesia with respect to postoperative pain control. Prior to entering the operating room, patients in the R group (n = 20) received morphine, 8 microg/kg IT. Anesthesia was induced using a standardized anesthetic technique in all patients. In the R group, anesthesia was maintained with R, 0.1 microg. kg(-1). min(-1) in combination with desflurane 3-10%. In the S group (n = 20), patients received S 0.3 microg. kg(-1). h(-1) and desflurane 3-10%. There were no differences between the two groups with respect to time from arrival in the intensive care unit to tracheal extubation (5.1 +/- 4.3 h vs 5.8 +/- 6.7 h for R and S groups, respectively). After extubation, patients in the R group had significantly lower visual analog pain scores, reduced patient-controlled analgesic requirements, and greater satisfaction with their perioperative pain management, compared with patients in the S group. We conclude that R combined with IT morphine provided superior pain control after cardiac surgery compared with a S-based general anesthetic technique.. As part of a cardiac fast-tracking program involving desflurane anesthesia, the use of intrathecal morphine in combination with a remifentanil infusion provided improved postoperative pain control, compared with IV sufentanil alone.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Combined; Anesthetics, Inhalation; Anesthetics, Intravenous; Cardiac Surgical Procedures; Desflurane; Female; Humans; Injections, Spinal; Isoflurane; Male; Middle Aged; Morphine; Pain, Postoperative; Patient Satisfaction; Piperidines; Remifentanil; Sufentanil

We compared the recovery profile and postoperative SpO(2) after the administration of general anesthesia with either sevoflurane-remifentanil or sevoflurane-sufentanil in 30 healthy patients undergoing upper abdominal surgery. They were randomly allocated to receive general anesthesia with sevoflurane and small doses of either remifentanil (n = 15) or sufentanil (n = 15), followed by postoperative epidural analgesia. The median sevoflurane minimum alveolar anesthetic concentration-hour was 2.3 (1.2-6.3) in group Remifentanil and 2.6 (1.4-5.2) in group Sufentanil (P: = 0.39), while the median consumption of remifentanil was 1.3 mg (0.7-3.4 mg) and sufentanil 0.09 mg (0.05-0.6 mg). Tracheal extubation required 10 min (6-18 min) with remifentanil and 14 min (8-24 min) with sufentanil (P: = 0.05); however, no differences in time to discharge from the recovery area were reported (24 min [12-75 min] with remifentanil and 30 min [12-135 min] with sufentanil; P: = 0. 35). From the first to seventh hour after surgery, SpO(2) was decreased more in the sufentanil than in the remifentanil group (P: = 0.001), and seven patients in the sufentanil group showed at least one episode with SpO(2) < or = 90% for more than 1 min (P: = 0.006) (median: 1 episode; range: 0-17 episodes; P: = 0.003). When added to sevoflurane, remifentanil is as effective as sufentanil during the intraoperative period, but provides shorter time to tracheal extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.. In this double-blinded study, we evaluated the effects of adding small infusions of either remifentanil or sufentanil to sevoflurane in combination with postoperative epidural analgesia for upper abdominal surgery. We demonstrated that remifentanil is as effective as sufentanil during the intraoperative period, but that it provides shorter time to extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.

Topics: Abdomen; Adjuvants, Anesthesia; Adult; Aged; Analgesia, Epidural; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Anesthetics, Inhalation; Double-Blind Method; Female; Humans; Male; Methyl Ethers; Middle Aged; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Respiration; Sevoflurane; Sufentanil

Studies in animals and volunteers have suggested the development of acute tolerance to opioid analgesics. In this article, we present data from patients who regulated their own target-controlled infusions of alfentanil and remifentanil to provide analgesia in the immediate postoperative period. Fifty-one patients received alfentanil for 24 h after cardiac surgery, and 30 patients received remifentanil for 6 h after orthopedic surgery. Satisfactory analgesia, defined as a rating of < or =3 on an 11-point visual analog scale, was obtained by patients after each type of surgery. The target concentrations of the opioids required to produce postoperative analgesia and the cumulative opioid doses administered over the course of the clinical observation suggest there was no tolerance to the analgesic effects of the opioids. The requirements for both analgesic drugs in individual patients had a large variation (>200%). We conclude that our results may indicate an absence of tolerance to opioids in postoperative analgesia. Nonetheless, our data show that the postoperative requirement for these rapidly acting drugs is qualitatively similar to that for other opioids in that dosage escalation does not occur.. The development of acute tolerance to opioid analgesics has been suggested based on experimental studies in animals and volunteers. Our report from patients who self-controlled their analgesic requirements by using target-controlled infusions of alfentanil and remifentanil for postoperative analgesia provides no evidence of tolerance to opioids.

Topics: Aged; Alfentanil; Analgesics, Opioid; Coronary Artery Bypass; Drug Tolerance; Humans; Infusions, Intravenous; Male; Orthopedic Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Self Administration

There are few data in the literature that describe the use of remifentanil when administered as a component of an inhalation or total i.v. anaesthetic (TIVA) technique. We studied 251 male and female patients, aged 18-75 years, ASA I-II, undergoing inguinal hernia repair, arthroscopic knee surgery or varicose vein surgery of at least 30 min duration without premedication. Patients were randomized to receive a remifentanil loading dose of 1.0 microgram kg-1 followed by a continuous infusion of 0.5 microgram kg-1 min-1 in combination with isoflurane (end-tidal concentration 0.6%), (Group I, n = 115) or propofol (initial infusion rate 9 mg kg-1 h-1 reduced to 6 mg kg-1 h-1 after 10 min), (Group P, n = 118). The remifentanil infusion rate was reduced by 50%, 5 min after tracheal intubation. Intraoperative stresses were treated with a remifentanil bolus (1 microgram kg-1) followed by an increase in the remifentanil infusion rate. At the insertion of the last suture, the remifentanil infusion and concomitant anaesthetic were switched off simultaneously. Times to spontaneous respiration, adequate respiration and tracheal extubation were significantly shorter in group I compared with group P (6.4 min vs 7.6 min, P < 0.01; 7.6 min vs 9.3, P < 0.003; 7.8 min vs 9.5 min, P < 0.015). Overall mean systolic blood pressures during surgery were greater in group P compared with group I (P < 0.05) but the absolute differences were clinically insignificant (4-5 mm Hg).

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Anesthetics, Inhalation; Anesthetics, Intravenous; Female; Humans; Isoflurane; Length of Stay; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Propofol; Prospective Studies; Remifentanil

Animal studies suggest that substance P, a peptide that preferentially activates the neurokinin-1 (NK1) receptor, is involved in pain transmission, with particular importance in pain after inflammation.. The analgesic efficacy of CP-99,994, a NK1 receptor antagonist, was compared with ibuprofen and placebo in 78 subjects undergoing third molar extraction. The initial 60 subjects randomly received 1 of 3 possible treatments in a double-blind fashion before oral surgery: 750 microg/kg CP-99,994 infused intravenously over 5 hours on a tapering regimen starting 2 hours before surgery, 600 mg oral ibuprofen 30 minutes before surgery, or placebo. In a second study, 18 subjects were randomized to the same regimens starting 30 minutes before surgery to maximize the amount of CP-99,994 circulating during pain onset.. In the first study, ibuprofen significantly reduced pain, as measured by visual analog scale, from 90 to 240 minutes postoperatively compared with placebo. CP-99,994 produced analgesia that was significant at 90 minutes (P < 0.01 compared with placebo), but not at subsequent time points. In the second study, ibuprofen and, to a lesser extent, CP-99,994 significantly suppressed pain in comparison to placebo at 60, 90, and 120 minutes (P < 0.05). The incidence of side effects was similar across groups.. This replicate demonstration that a NK1 receptor blocker relieves clinical pain supports the hypothesis that substance P contributes to the generation of pain in humans. The reduction in postoperative pain at doses not producing side effects suggests that NK1 antagonists may be clinically useful.

Topics: Acute Disease; Analgesics; Double-Blind Method; Humans; Neurokinin-1 Receptor Antagonists; Pain Measurement; Pain, Postoperative; Piperidines; Time Factors; Tooth Extraction; Treatment Outcome

We studied 30 male patients in the early postoperative period to assess the efficacy, safety and feasibility of a patient-demand, target-controlled infusion (TCI) of remifentanil. All patients received the same TCI-based propofol-remifentanil anaesthetic for elective orthopaedic surgery. At the end of surgery, infusion of remifentanil was reduced progressively until patients were breathing spontaneously. After extubation and transfer to the post-anaesthesia care unit, patients were given control of a hand-set and were able to increase the target remifentanil blood concentration by increments of 0.2 ng ml-1. If there were no demands, the TCI controller automatically reduced the target concentration. Pain scores, sedation level, ventilatory frequency, oxygen saturation and nausea were assessed. Mean time to onset of satisfactory analgesia (VAS < or = 3, out of 10) was 18.9 (95% confidence interval (Cl) 15.8-21.9) min at a mean target remifentanil concentration of 2.02 (Cl 1.87-2.16) ng ml-1. There were no episodes of hypoxaemia and the lowest ventilatory frequency was 9 bpm. Nausea occurred in 26.6% of patients and 10% vomited. The majority of patients were only slightly sedated. These results imply an effective tool without respiratory side effects in the early postoperative period after anaesthesia using remifentanil as the analgesic component.

Topics: Adult; Aged; Analgesia, Patient-Controlled; Analgesics, Opioid; Child; Feasibility Studies; Humans; Male; Middle Aged; Orthopedic Procedures; Oxygen; Pain, Postoperative; Piperidines; Postoperative Care; Remifentanil; Respiration

To compare remifentanil, an esterase-metabolized opioid, to a standard propofol-based sedation technique for monitored anesthesia care (MAC).. Non-randomized, open label.. University hospital.. 44 healthy female outpatients undergoing breast biopsy procedures under local anesthesia.. All patients received intravenous (IV) midazolam 2 mg, followed by a continuous infusion of either propofol 75 micrograms/kg/min, or remifentanil 0.1 microgram/kg/min, which was subsequently titrated to maintain optimal patient comfort without respiratory depression. Surgical-related pain was treated by injecting additional local anesthetic solution and "rescue" boluses of fentanyl 25 micrograms IV.. Sedation, pain, and discomfort were monitored using standardized rating scales at 1 to 5 minute intervals. Recovery times were measured from the end of the study drug infusions. Propofol resulted in significantly higher median sedation scores compared with remifentanil, with 73% of patients requiring a decrease in the propofol infusion rate because of "excessive" sedation. Local anesthetic requirements, pain, and discomfort scores during surgery were similar in both groups. Remifentanil resulted in greater respiratory depression compared with propofol, with decreases in the remifentanil infusion rate required by 41% of patients because of a slow respiratory rate (< 8 bpm) and/or oxygen desaturation measured by pulse oximetry (SpO2 < 90%). Median times to ambulation and to being judged "fit for discharge" were significantly shorter following propofol (40 and 47 minutes, respectively) compared with remifentanil (52 and 58 minutes, respectively).. Remifentanil provided comparable intraoperative conditions and patient comfort at a lower sedation level compared with propofol. However, remifentanil was associated with greater respiratory depression and a longer time to home readiness.

Topics: Adolescent; Adult; Aged; Anesthesia, Local; Anesthetics, Intravenous; Anesthetics, Local; Female; Hemodynamics; Humans; Lidocaine; Middle Aged; Monitoring, Intraoperative; Oxygen; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil

The efficacy and safety of remifentanil and alfentanil for patients undergoing major abdominal surgery were compared. Premedicated patients received a loading dose of remifentanil (1.0 microgram.kg-1; n = 116) and a continuous infusion of 0.5 microgram.kg-1.min-1, or a loading dose of alfentanil (25 micrograms.kg-1; n = 118) and a continuous infusion of 1.0 microgram.kg-1.min-1. Propofol was administered (10 mg every 10 s) until loss of consciousness. Patients' lungs were ventilated with 66% nitrous oxide and 0.5% (end-tidal) isoflurane in oxygen. The study drug infusion rate was reduced by 50% 5 min after intubation. Alfentanil was discontinued 15 min before the end of surgery, whereas remifentanil was continued in the immediate postoperative period at a reduced dose. Responses to intubation (28%) and skin incision (17%) occurred approximately twice as often in the alfentanil group (15% and 8%; p = 0.014 and p = 0.037, respectively). More patients receiving alfentanil had one or more responses to surgery (72% vs. 57%; p = 0.016). The time to spontaneous respiration, adequate respiration, response to verbal command and time to recovery room discharge were similar. However, owing to decreased variability, the time to extubation was shorter with remifentanil than with alfentanil (p = 0.048). There was a similar overall incidence of adverse events in both groups, 82% and 75% of patients, respectively. Adverse events associated with remifentanil were rapidly controlled by dose reductions. The incidence of intra-operative hypotension and bradycardia was higher in the remifentanil group (p < or = 0.033). An initial remifentanil infusion rate of 0.1 microgram.kg-1.min-1 titrated to individual need provided postoperative pain relief in the presence of adequate respiration in 71% of patients. When using remifentanil in the immediate postoperative setting, rapid administration of bolus doses and infusion rate increases resulted in a relatively high incidence of muscle rigidity, respiratory depression and apnoea. Changing the postoperative regimen to avoid rapid changes in remifentanil blood concentration resulted in more effective analgesia and dramatically reduced the incidence of adverse events during this period. In patients undergoing major abdominal surgery, remifentanil appears to offer superior intra-operative haemodynamic stability during stressful surgical events compared with alfentanil without compromising recovery from anaesthesia. Remifentanil can be a

Topics: Abdomen; Adolescent; Adult; Aged; Aged, 80 and over; Alfentanil; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Dermatologic Surgical Procedures; Double-Blind Method; Female; Hemodynamics; Humans; Intubation, Intratracheal; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil

Remifentanil hydrochloride is a new, ultrashort-acting opioid metabolized by nonspecific plasma and tissue esterases. We conducted this multicenter study to examine the hemodynamic response and recovery profile of premedicated children undergoing strabismus repair who were randomly assigned to receive one of four treatment drugs (remifentanil, alfentanil, isoflurane, or propofol) along with nitrous oxide and oxygen for maintenance of anesthesia. Induction of anesthesia was by nitrous oxide, oxygen, and halothane or nitrous oxide, oxygen, and propofol. Anesthesia was then maintained with remifentanil 1.0 microgram/kg over 30-60 s, followed by a constant infusion of 1.0 microgram.kg-1.min-1, alfentanil 100 micrograms/kg bolus followed by a constant infusion of 2.5 micrograms.kg-1.min-1, propofol 2.5 mg/kg bolus followed by a constant infusion of 200 micrograms.kg-1.min-1, or isoflurane 1.0 minimum alveolar anesthetic concentration. The infusions of the anesthetics and the administration of the inhaled gases were adjusted clinically by predetermined protocols. Elapsed time intervals from the end of surgery to the time the patients were tracheally extubated and displayed purposeful movement, as well as the time the patients met the postanesthesia care unit (PACU) and hospital discharge times, were recorded. Heart rate and systolic and diastolic blood pressure were measured at fixed intervals. In addition, cardiovascular side effects (bradycardia, hypotension, and hypertension) as well as vomiting, pruritus, agitation, and postoperative hypoxemia were also noted. There were no significant differences in patient demographics among the treatment groups. There was no difference in the early recovery variables (times to extubation and purposeful movement) or the times to PACU and hospital discharge among groups. There were significant differences in side effects among the groups. Patients who received remifentanil had higher PACU objective pain-discomfort scores than those who received alfentanil and propofol. Patients anesthetized with alfentanil had a greater incidence in the use of naloxone and a greater incidence of postoperative hypoxemia compared with those anesthetized with remifentanil. The incidence of postoperative hypoxemia was the same for remifentanil, propofol, and isoflurane groups. There were no significant differences in the incidence of emesis among the four groups, and all four groups had similar hemodynamic profiles. We conclude that remifentan

Topics: Alfentanil; Ambulatory Surgical Procedures; Analgesics, Opioid; Anesthesia; Anesthesia Recovery Period; Anesthetics, Inhalation; Anesthetics, Intravenous; Child; Child, Preschool; Elective Surgical Procedures; Female; Hemodynamics; Humans; Isoflurane; Male; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Strabismus

Remifentanil is an ultrashort acting mu opioid, well suited to total intravenous (i.v.) anaesthesia. Pain immediately following emergence from anaesthesia is a potential problem because of the rapid offset. This study investigated the transition from remifentanil/propofol total intravenous anaesthesia to post-operative analgesia with epidural or patient controlled analgesia morphine in 22 patients undergoing major abdominal surgery. A remifentanil post-operative infusion initiated during emergence was titrated in the recovery room for 30 min, at which time 14% of patients had a pain score of 2 and 86% had pain scores of 0 or 1 (0 = no pain; 1 = mild pain; 2 = moderate pain; 3 = severe pain), at a mean infusion rate of 0.086 microgram kg-1 min-1. A smooth transition was then made to either epidural analgesia or patient controlled analgesia with morphine; pain scores were not significantly changed during the transition. Nausea occurred in 16 of the 22 patients, but only following administration of morphine. Epidural analgesia produced significantly lower pain scores on the surgical ward compared with patient controlled analgesia.

Topics: Abdomen; Adult; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Double-Blind Method; Female; Humans; Injections, Intravenous; Male; Morphine; Pain, Postoperative; Piperidines; Propofol; Remifentanil

The transition from remifentanil intraoperative anesthesia to postoperative analgesia must be planned carefully due to the short duration of action (3-10 min) of remifentanil hydrochloride, a potent, esterase-metabolized mu-opioid agonist. This study compared the efficacy and safety of transition regimens using remifentanil or morphine sulfate for immediate postoperative pain relief in patients who had surgery under general anesthesia with remifentanil/propofol.. One hundred fifty patients who had received open-label remifentanil and propofol for intraoperative anesthesia participated in this multicenter, double-blind, double-dummy study and were randomly assigned to either the remifentanil (R) group or the morphine sulfate (M) group. Twenty minutes before the anticipated end of surgery, the propofol infusion was decreased by 50%, and patients received either a placebo bolus (R group) or a bolus of 0.15 mg/kg morphine (M group). At the end of surgery, the propofol and remifentanil maintenance infusions were discontinued and the analgesic infusion was started: either 0.1 microg x kg(-1) x min(-1) remifentanil (R group) or placebo analgesic infusion (M group). During the 25 min after tracheal extubation, remifentanil titrations in increments of 0.025 microg x kg(-1) x min(-1) and placebo boluses (R group), or 2 mg intravenous morphine boluses and placebo rate increases (M group) were administered as necessary at 5-min intervals to control pain. Patients received the 0.075 mg/kg intravenous morphine bolus (R group) or placebo (M group) at 25 and 30 min after extubation, and the analgesic infusion was discontinued at 35 min. From 35 to 65 minutes after extubation, both groups received 2-6 mg open-label morphine analgesia every 5 min as needed.. Successful analgesia, defined as no or mild pain with adequate respiration (respiratory rate [RR] > or =8 breaths/min and pulse oximetry > or = 90%), was achieved in more patients in the R group than in the M group (58% vs. 33%, respectively) at 25 min after extubation (P < 0.05). The median remifentanil rate for successful analgesia was 0.125 microg x kg(-1) x min(-1) (range, 0.05-0.23 microg x kg(-1) x min(-1)), and the median number of 2-mg morphine boluses used was 2 (range, 0-5 boluses). At 35 min after extubation, > or = 74% of patients in both groups experienced moderate to severe pain. Median recovery times from the end of surgery were similar between groups. Transient respiratory depression, apnea, or both were the most frequent adverse events (14% for the R group vs. 6% for the M group; P > 0.05).. Remifentanil provided safe and effective postoperative analgesia when administered at a final rate of 0.05-0.23 microg x kg(-1) x min(-1) in the immediate postextubation period. Remifentanil provided more effective postoperative analgesia than did intraoperative treatment with morphine (0.15 mg/kg) followed by morphine boluses (< or = five 2-mg boluses). The effects of remifentanil dissipated rapidly after ending the infusion, and alternate analgesia was required. Further studies are underway to define transition regimens that will improve postoperative analgesia in patients receiving anesthesia with remifentanil.

Topics: Adult; Analgesia; Anesthesia, Intravenous; Elective Surgical Procedures; Hemodynamics; Humans; Morphine; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Respiration

We evaluated the use of an infusion of remifentanil to provide postoperative analgesia during recovery from total intravenous anesthesia (TIVA) with remifentanil and propofol. One hundred fifty-seven patients from seven medical centers underwent abdominal, spine, joint replacement, or thoracic surgery. Remifentanil was titrated in an effort to limit pain to 0 or 1 on a 0-3 scale. At the end of the 30-min titration period, 78% of infusion rates were in the range of 0.05 to < or = 0.15 microgram.kg-1.min-1, 5% were < 0.05 microgram.kg-1.min-1, and 17% were > 0.15 microgram.kg-1.min-1. Pain scores were 0 or 1 in 64% of patients. Nausea occurred in 35% and emesis in 8% of patients; the peak incidence of nausea followed discontinuation of the remifentanil infusion at the time of administering morphine. Respiratory adverse events (oxygen saturation by pulse oximetry [Spo2] < 90% or respiratory rate < 12) affected 29% of patients. Apnea occurred in 11 patients (7.0%). There was a large variation in the incidence of respiratory depression between the centers, ranging from 0 to 75%. The explanation for the large variability in respiratory outcome was not evident.

Topics: Abdomen; Adult; Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Apnea; Female; Humans; Incidence; Infusions, Intravenous; Joint Prosthesis; Male; Middle Aged; Morphine; Nausea; Oxygen; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Respiration; Spine; Thoracic Surgery; Vomiting

1. The analgesic efficacy and safety of a single 50 mg intramuscular dose of rac-picenadol, a centrally acting agonist-antagonist opioid analgesic, were compared with pethidine (meperidine) 100 mg and placebo in 60 patients with moderate to severe postoperative pain using hourly pain intensity and relief measurements for up to 6 h following injection of the study medications. 2. Both picenadol and pethidine were statistically significantly (P < 0.05) more effective than placebo in reducing pain intensity and in increasing total relief. Patients receiving picenadol and pethidine had higher frequency of somnolence than patients receiving placebo. In addition, patients receiving picenadol 50 mg experienced a higher incidence of confusion (30%), speech disorders (30%), and tremors (25%) than the patients receiving either pethidine or placebo. 3. These results were compared with those of a similar study which investigated the effects of a 25 mg intramuscular dose of picenadol vs pethidine and placebo. This comparison suggests that 25 mg of picenadol is a more acceptable dosage since both 25 and 50 mg were effective dosages.

Topics: Adult; Analgesics; Female; Humans; Injections, Intramuscular; Male; Pain Measurement; Pain, Postoperative; Piperidines

The study evaluates the effect of 20 mg cisapride twice daily on symptoms and biliary drainage in patients with the postcholecystectomy syndrome. Nineteen patients, all female, went through a randomized, double-blind, placebo-controlled, crossover trial with two 4-week treatment periods separated by a 2-week washout period. Symptoms were registered on diary cards. Biliary drainage was studied with dynamic cholescintigraphy. The down slope of the time-activity curve (T1/2 and elimination index) was used as a measure of the biliary drainage. More symptoms were registered during cisapride therapy than with placebo. This unfavourable effect of cisapride was statistically significant in a subgroup of patients with postcholecystectomy complaints identical to the biliary pain they experienced during injection of contrast at the endoscopic retrograde cholangiopancreatographic examination. Cisapride statistically significantly hastened biliary drainage. The median T1/2 values were 24 and 28 min after cisapride and placebo, respectively (p less than 0.01). In conclusion, cisapride promoted biliary drainage in patients with the postcholecystectomy syndrome but had an unfavourable symptomatic effect in those with bile duct-triggered postcholecystectomy complaints.

Topics: Adult; Aged; Cholangiopancreatography, Endoscopic Retrograde; Cholecystectomy; Cholestasis; Cisapride; Female; Humans; Imino Acids; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Complications; Radionuclide Imaging; Serotonin Antagonists

A double-blind, parallel study was conducted to evaluate the analgesic effect and safety of a single 25 mg oral dose of picenadol, a centrally acting analgesic, and to compare it with a 60 mg dose of codeine and a placebo in patients with postoperative pain. Two sites using similar protocols enrolled a total of 178 inpatients with postoperative pain. Pain intensity, relief, and adverse experiences were then measured for up to 6 hours after administration of the test medications. Both picenadol and codeine were significantly more effective than placebo in reducing pain intensity (mean sum of pain intensity difference scores: picenadol 5.21, codeine 5.19, and placebo 2.82) and increasing total relief (mean total pain relief: picenadol 10.21, codeine 11.07, and placebo 6.96). Adverse experience profiles were similar among the three treatment groups.

Topics: Adult; Analgesics; Clinical Trials as Topic; Codeine; Female; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines

A two-phase, double-blind study was performed to assess the efficacy of various drugs in the relief of postoperative pain. Oral analgesia with two compounds (paracetamol 320 mg, caffeine 32 mg, codeine phosphate 8 mg and meprobamate 150 mg (Stopayne; Rio Ethicals) and dipyrone 500 mg, pitofenone hydrochloride 5 mg and fenpiverinium bromide 0,1 mg (Baralgan HS; Albert)) was found to produce satisfactory pain relief, and it is suggested that these oral compounds may be used from 12 hours postoperatively in uncomplicated cases. Parenteral administration of either pethidine 100 mg or dipyrone 2500 mg was found to be an ineffective form of pain relief, and it is suggested that the use of these drugs should be reviewed. In both phases of the study side-effects were infrequent and mild, and smoking did not have an influence on the results.

Topics: Acetaminophen; Administration, Oral; Adult; Analgesics; Benzophenones; Caffeine; Clinical Trials as Topic; Codeine; Dipyrone; Double-Blind Method; Drug Combinations; Female; Humans; Hysterectomy; Injections, Intramuscular; Meperidine; Meprobamate; Pain, Postoperative; Piperidines; Random Allocation; Smoking; Time Factors

Picenadol (LY 150720) is a racemic mixture of an N-methyl-4-phenylpiperidine derivative, with agonist-antagonist opiate properties. Preclinical animal pharmacology and toxicology studies demonstrated analgesic activity and a low order of toxicity. Clinical pharmacology studies have demonstrated its safety in man. Hospitalized post-cesarean section patients with postoperative pain were blindly given an intramuscular dose of picenadol, 25 mg, meperidine, 100 mg, or placebo. Analgesia and side effects of picenadol and meperidine were similar.

Topics: Adolescent; Adult; Analgesics; Cesarean Section; Double-Blind Method; Drug Evaluation; Female; Humans; Meperidine; Pain, Postoperative; Piperidines; Placebos; Pregnancy; Random Allocation

Topics: Adolescent; Adult; Aged; Ambulatory Care; Anti-Inflammatory Agents, Non-Steroidal; Clinical Trials as Topic; Epirizole; Female; Humans; Isoxazoles; Male; Middle Aged; Minor Surgical Procedures; Mouth; Oxazoles; Pain, Postoperative; Periodontal Cyst; Piperidines; Placebos; Tooth Extraction

Topics: Anesthesia, General; Female; Humans; Hypotension; Isonipecotic Acids; Meperidine; Nitriles; Pain, Postoperative; Perphenazine; Piperidines; Postoperative Complications; Sleep; Sterilization, Tubal

Topics: Adult; Analgesics; Blood Pressure; Clinical Trials as Topic; Female; Humans; Isonipecotic Acids; Levorphanol; Male; Meperidine; Middle Aged; Nitriles; Opium; Pain, Postoperative; Pentazocine; Phenoperidine; Piperidines; Positive-Pressure Respiration; Sleep

Topics: Acetophenones; Adolescent; Adult; Aged; Analgesics; Arteries; Blood Pressure; Carbon Dioxide; Chemical Phenomena; Chemistry; Clinical Trials as Topic; Female; Humans; Male; Meperidine; Middle Aged; Oxygen; Pain, Postoperative; Phenols; Piperidines; Pulse; Respiration

Topics: Analgesics; Analysis of Variance; Clinical Trials as Topic; Humans; Injections, Intramuscular; Isonipecotic Acids; Morphine; Movement; Nausea; Nitriles; Pain, Postoperative; Piperidines; Respiration; Time Factors; Vomiting

Opioids are metabolised by enzymes the activities of which vary with the circadian rhythm. We examined whether opioid infusions administered at different times of the day produce varying degrees of opioid-induced hyperalgesia (OIH) in animal experiments and clinical studies.. Male Sprague-Dawley rats received remifentanil infusions (1 μg kg. Sprague-Dawley rats that received remifentanil infusion exhibited a robust rhythmic paw withdrawal threshold (JTK_CYCLE: P=0.001, Q=0.001, Phase=26). Wistar rats infused with remifentanil or sufentanil at ZT8 exhibited greater OIH (P<0.001) than those infused at ZT0, with higher blood concentrations (P<0.001) and lower metabolic enzyme activities (P=0.026 and P=0.028, respectively). Patients in the afternoon group exhibited higher pressure pain sensitivity at forearm (P=0.002), higher NRS (P<0.05), higher drug concentrations (sufentanil: P=0.037, remifentanil: P=0.005), and lower nonspecific esterase activity (P=0.024) than the morning group.. Opioid infusions administered at different times of day produced varying degrees of OIH, possibly related to circadian rhythms of metabolic enzyme activities.. NCT05234697.

Topics: Analgesics, Opioid; Animals; Carboxylesterase; Humans; Hyperalgesia; Male; Pain, Postoperative; Piperidines; Rats; Rats, Sprague-Dawley; Rats, Wistar; Remifentanil; Sufentanil

This study aimed to investigate the differential effects of remifentanil and sufentanil anesthesia on post-operative pain and recovery of cognitive functions following surgical resection of human colon cancer orthotopically transplanted in rats. Human colon cancer cells HT-29 were used to establish a rat model of orthotopically transplanted colon cancer on to the cecal wall of rats. The transplanted tumors were then surgically removed after 5 weeks, using different doses of remifentanil and sufentanil anesthesia. At 24 h after the surgery, von Frey test, hot plate test and voluntary wheel running test were used to evaluated post-operative pain in the rats. Morris water maze test and fear conditioning test were employed to assess cognitive functions. Serum and colon tissues of the rats were also subjected to ELISA to measure levels of stress response factors, while colon tissues were analyzed by RT-PCR and Western blot to measure expression of inflammation response factors and NF-κB pathway-related factors. Sufentanil showed better effect in reducing post-operative pain, while remifentanil showed better recovery of cognitive functions after surgery. In addition, remifentanil resulted in less stress and inflammation response, caused milder activation of NF-κB pathway-related factors after surgery. Remifentanil and sufentanil exhibited differential effects on post-operative pain and recovery of cognitive function. Specifically, remifentanil caused lower stress and inflammation response, associated with dampened activation of the NF-κB pathway. Our results could provide theoretical basis for adopting appropriate analgesic strategy and agents according to the characteristics of individual patients.

Topics: Analgesics, Opioid; Anesthesia; Animals; Cognition; Colonic Neoplasms; Humans; Inflammation; Motor Activity; NF-kappa B; Pain, Postoperative; Piperidines; Rats; Remifentanil; Sufentanil

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

Topics: Analgesics, Opioid; Humans; Infusions, Intravenous; Pain, Postoperative; Piperidines; Remifentanil; Retrospective Studies

Remifentanil-induced postoperative hyperalgesia is an intractable side effect of the clinical use of remifentanil, the mechanism of which remains obscure, especially in the peripheral nervous system. N-methyl-D-aspartate receptor (NMDAR) phosphorylation in dorsal root ganglion (DRG) plays a pronociceptive role in neuropathic pain. The contribution of the P2Y1 purinergic receptor (P2Y1R) in DRG to pain hypersensitivity derived from various origins and P2Y1R upregulation-induced NMDAR activation in neurons have also been uncovered. This study aimed to investigate whether P2Y1R participates in nociceptive processing in the DRG and spinal cord in remifentanil-induced postoperative hyperalgesia.. Rats with remifentanil-induced postoperative hyperalgesia were intrathecally injected with NMDAR antagonist MK801 or P2Y1R antagonist MRS2179 at 10 min prior to remifentanil infusion. Mechanical allodynia, heat hyperalgesia, and cold hyperalgesia were measured at -24 h, 2 h, 6 h, 24 h, and 48 h following remifentanil infusion. The P2Y1R expression and NMDAR expression and phosphorylation in DRG ipsilateral to the incision were detected by Western blot and immunofluorescence.. Incision and remifentanil induced mechanical allodynia, heat hyperalgesia, and cold hyperalgesia accompanied by upregulated P2Y1R expression, increased NMDAR subunit NR1 expression and phosphorylation at Ser896, and NR2B expression and phosphorylation at Tyr1472 in DRG. Inhibition of NMDAR phosphorylation by MK801 effectively attenuated remifentanil-induced postoperative hyperalgesia. Furthermore, P2Y1R blockade by MRS2179 not only lessened remifentanil-evoked postoperative hypersensitivity to mechanical, heat, and cold stimuli, but also suppressed the increases in NR1 and NR2B expression and phosphorylation in DRG induced by incision and remifentanil.. The process by which P2Y1R mediates NMDAR expression and phosphorylation represents a mechanism of remifentanil-induced postoperative hyperalgesia in the DRG and/or spinal cord.

Topics: Animals; Ganglia, Spinal; Hyperalgesia; Pain, Postoperative; Phosphorylation; Piperidines; Rats; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Receptors, Purinergic P2Y1; Remifentanil; Spinal Cord

Pain is considered as being one cause of post-operative emergence agitation (EA) from sevoflurane anaesthesia. The purpose of this study was to investigate the pure effect of post-operative pain on EA after sevoflurane anaesthesia in preschool children undergoing excision of scalp nevi.. Forty-four children, 1-7 years old, undergoing scalp nevus excision were enrolled. Patients were randomly assigned to two groups: the remifentanil group received single intravenous injection of short-acting synthetic opioid, remifentanil 1 μg/kg just before the scalp incision, and the block group received scalp nerve block with 0.25% ropivacaine after intubation. The end-tidal sevoflurane concentration was maintained around 1.5 vol% unless the mean arterial pressure is out of ±20% range of preoperative values during surgery in both groups. Watcha behaviour scale for EA and face, legs, activity, cry, consolability (FLACC) scale scores for pain were recorded post-operatively.. There was no difference in end-tidal sevoflurane concentration between the two groups during surgery and the emergence period. Agitation incidence and scores were not different between the two groups during the recovery period. FLACC scale was significantly lower in the block group than in the remifentanil group at post-anaesthesia care unit (PACU) arrival, at 10 and 20 min after PACU arrival, respectively.. The scalp nerve block decreased the early post-operative pain after paediatric nevus excision, but it did not decrease the incidence of EA with sevoflurane anaesthesia.

Topics: Amides; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Child; Child Behavior; Child, Preschool; Emergence Delirium; Female; Humans; Infant; Male; Methyl Ethers; Nerve Block; Nevus; Pain, Postoperative; Piperidines; Prospective Studies; Psychomotor Agitation; Remifentanil; Ropivacaine; Scalp; Sevoflurane; Single-Blind Method

Glutamate signaling in the central nervous system is known to play a key role in pain regulation. AMPAkines can enhance glutamate signaling through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors. previous studies have shown that AMPAkines are effective analgesic agents, and their site of action is likely in the brain. It is not known, however, if AMPAkines can provide complementary analgesia in combination with opioids, the most commonly used analgesics. Here, we show that the co-administration of an AMPAkine with morphine can provide additional analgesia, both in naïve rats and in rats that experience postoperative pain. Furthermore, we show that this AMPAkine can be administered directly into the prefrontal cortex to provide analgesia, and that prefrontal AMPAkine infusion, similar to systemic administration, can provide added pain relief to complement morphine analgesia.

Topics: Analgesia; Analgesics, Non-Narcotic; Analgesics, Opioid; Animals; Dioxoles; Disease Models, Animal; Dose-Response Relationship, Drug; Drug Synergism; Excitatory Amino Acid Agents; Glutamic Acid; Hot Temperature; Male; Morphine; Pain Threshold; Pain, Postoperative; Piperidines; Prefrontal Cortex; Rats, Sprague-Dawley; Receptors, AMPA

We present the case of an 8‑year-old female child with suspected peroxisomal disorder requiring general anesthesia for adenotomy, paracentesis and brainstem-evoked response audiometry. Peroxisomes are small intracellular organelles that catalyse key metabolic reactions. Peroxisomal disorders are a heterogeneous group of rare genetic diseases. Anesthesia can be challenging as adrenal insufficiency, mental retardation, muscle weakness, risk of pulmonary aspiration, airway complications, seizure disorders and altered pharmacokinetics and pharmacodynamics can occur in these patients but guidelines for anesthesia do not exist due to the heterogeneity and rarity of these diseases and case reports are rare. Anesthesia was induced by sevoflurane via a face mask, followed by remifentanil and rocuronium for oral intubation after intravenous access was obtained. Anesthesia was maintained with sevoflurane and remifentanil. Dexamethasone was given for prophylaxis of postoperative nausea and vomiting as well as perioperative adrenal crises. Piritramide was given for postoperative analgesia. With this approach anesthesia was uneventful. The trachea was extubated with the patient awake and she was taken to the recovery room in a stable condition. The classification and breadth of clinical manifestations of peroxisomal disorders is complex and briefly summarized. Anesthesiologists should consider characteristics of their particular patient's form of peroxisomal disorder, as this may greatly influence procedural planning.

Topics: Airway Extubation; Analgesics, Opioid; Androstanols; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Antiemetics; Child; Dexamethasone; Female; Humans; Methyl Ethers; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Peroxisomal Disorders; Piperidines; Pirinitramide; Postoperative Nausea and Vomiting; Remifentanil; Rocuronium; Sevoflurane

Recent animal studies demonstrated immunosuppressive effects of opioid withdrawal resulting in a higher risk of infection. The aim of this study was to determine the impact of remifentanil discontinuation on Post-Anesthesia Care Unit (PACU)-acquired infection after a schedule of sedoanalgesia of at least 6 days.. All patients over 18 years of age with a unit admission of more than 4 days were consecutively selected. The study population was the one affected by surgical pathology of any origin where sedation was based on any hypnotic and the opioid remifentanil was used as analgesic for at least 96 hours in continuous perfusion. Patients who died during admission to the unit and those with combined analgesia (peripheral or neuroaxial blocks) were excluded. Bivariate analysis was performed to determine risk factors for infection acquired in the unit. A comparative study between periods of 6 days before and after the cessation of remifentanil was performed. Paired samples test and McNemar test was used for quantitative and categorical variables, respectively.. There were 1,789 patients admitted to the PACU during the study and the population eligible was constituted for 102 patients. The incidence rate of PACU-acquired infection was 38 per 1,000 PACU days. Ventilator-associated pneumonia was the most frequently diagnosed PACU-acquired infection. Pseudomona aeruginosa was the most frequently isolated microorganism. Hospital mortality was 36.27%. No statistically significant differences were seen in the incidence of HAI in cancer patients in relation to discontinuation of remifentanil (p=0.068).. The baseline state of immunosuppression of cancer patients does not imply a higher incidence of HAI in relation to the interruption of remifentanil. It would be of interest to carry out a multicenter PACU study that included immunological patterns.

Topics: Aged; Analgesics, Opioid; Cross Infection; Female; Humans; Immunosuppressive Agents; Male; Midazolam; Middle Aged; Neoplasms; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Withholding Treatment

The intraoperative modulation of opioids continues to be based on clinical signs. This may result in adverse events such as sympathetic reactivity or opioid-induced hyperalgesia. Recently, the Analgesia/Nociception Index (ANI), a non-invasive 0-100 index derived from heart rate variability analysis, has been proposed for nociception assessment. However, the ability of the ANI to adequately guide intraoperative opioid administration has never been demonstrated. We designed a prospective study to evaluate the ability of the ANI to guide remifentanil administration in vascular surgery.. One hundred and eighty adults presenting for elective surgery were included. All received total intravenous anaesthesia with propofol adjusted to entropy and remifentanil adjusted to the ANI. The primary endpoint was the number of patients without any episode of reactivity defined as a 20% increase in heart rate or arterial pressure or the occurrence of movement. Secondary endpoints included opioid use and maximal pain rate in the first postoperative day.. Anaesthesia was achieved without any episode of reactivity in 160 (89%) patients. Twenty-five episodes of reactivity occurred in 20 (11%) patients. The median remifentanil dose was 0.042 [0.040-0.044]μg.kg. This prospective study demonstrated that the ANI can be used to adequately guide intraoperative remifentanil administration during vascular surgery. Such guidance resulted in low remifentanil consumption, low postoperative pain rates and low opioid rescue analgesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Arterial Pressure; Elective Surgical Procedures; Endpoint Determination; Entropy; Female; Heart Rate; Humans; Intraoperative Care; Male; Middle Aged; Nociception; Oxycodone; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Vascular Surgical Procedures; Young Adult

Myasthenia gravis (MG) is an autoimmune disease characterized by the production of antibodies against the acetylcholine receptor, muscle-specific kinase (MuSK), or other proteins at the neuromuscular junction. MG with antibodies against MuSK (MuSK-MG) has been described recently. Here, we report the first case of anesthetic management of a patient with MuSK-MG undergoing an open cholecystectomy. In our case, propofol and remifentanil-based anesthesia were used for successful management without using muscle relaxants. Patients with MuSK-MG have predominantly ocular, bulbar, and respiratory symptoms that may increase the risk of aspiration. Anesthesiologists need to pay attention to perioperative respiratory failure and respiratory crisis.

Topics: Analgesia, Epidural; Anesthesia, General; Anesthetics, Intravenous; Autoantibodies; Cholecystectomy; Cholecystitis; Female; Humans; Middle Aged; Myasthenia Gravis; Pain, Postoperative; Piperidines; Propofol; Receptor Protein-Tyrosine Kinases; Receptors, Cholinergic; Remifentanil

Remifentanil-induced secondary hyperalgesia has been demonstrated in both animal experiments and clinical trials. Enhancement of N-methyl-D-aspartate (NMDA) receptor trafficking as well as protein kinase C (PKC) and calmodulin-dependent protein kinase II (CaMKII) have been reported to be involved in the induction and maintenance of central sensitization. In the current study, it was demonstrated that dexmedetomidine could prevent remifentanil-induced hyperalgesia (RIH) via regulating spinal NMDAR-PKC-Ca2+/ CaMKII pathway in vivo and in vitro. We firstly investigated the effect of dexmedetomidine, a highly selective α2-adrenergic receptor agonist, on mechanical and thermal hyperalgesia using a rat model of RIH. NMDA receptor subunits (NR1, NR2A and NR2B) expression and membrane trafficking as well as PKC and CaMKII expression in spinal cord L4-L5 segments were measured by Western blot analysis. The expression of NMDA receptor subunits (NR1, NR2A and NR2B) were also detected by immunohistochemistry. Further more, the effect of dexmedetomidine on NMDA receptor current amplitude and frequency in spinal cord slices were investigated by whole-cell patch-clamp recording. We found that remifentail infusion at 1.2 μg.kg-1.min-1 for 90 min caused mechanical and thermal hyperalgesia, up-regulated NMDA receptor subunits NR1 and NR2B expression in both membrane fraction and total lysate as well as increased PKC and CaMKII expression in spinal cord dorsal horn. Subcutaneously injection of dexmedetomidine at the dose of 50 μg/kg at 30 min before plantar incision significantly attenuated remifentanil-induced mechanical and thermal hyperalgesia from 2 h to 48 h after infusion, and this was associated with reversal of up-regulated NR1 and NR2B subunits in both membrane fraction and total lysate as well as increased PKC and CaMKII expression in spinal cord dorsal horn. Furthermore, remifentanil incubation increased amplitude and frequency of NMDA receptor-induced current in dorsal horn neurons, which was dose-dependently attenuated by dexmedetomidine. These results suggest that dexmedetomidine can significantly ameliorate RIH via modulating the expression, membrane trafficking and function of NMDA receptors as well as PKC and CaMKII level in spinal dorsal horn, which present useful insights into the mechanistic action of dexmedetomidine as a potential anti-hyperalgesic agents for treating RIH.

Topics: Animals; Calcium-Calmodulin-Dependent Protein Kinase Type 2; Cells, Cultured; Chemoprevention; Dexmedetomidine; Hyperalgesia; Male; Pain Management; Pain, Postoperative; Phosphorylation; Piperidines; Postoperative Period; Protein Kinase C; Protein Transport; Rats; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Remifentanil; Signal Transduction; Spinal Cord

Objective To evaluate the effects of an ultrasound-guided transverse abdominis plane (US-TAP) block used for postoperative pain relief by comparing the efficacy of two different volumes/concentrations of the local anaesthetic bupivacaine in patients undergoing laparoscopic cholecystectomies. Methods This randomized study enrolled patients undergoing laparoscopic cholecystectomies. They were randomized to two groups: group A received a 20 ml US-TAP block (50 mg bupivacaine +10 ml saline solution) and group B received a 30 ml US-TAP block (50 mg bupivacaine + 20 ml saline solution). The intraoperative consumption of remifentanil, the requirement for postoperative rescue analgesics, patient satisfaction scores, postoperative complications, and postoperative pain as measured by a visual analogue scale at 20 min, 12 h, and 24 h were recorded. Results A total of 60 patients enrolled in the study. There were no differences between the two groups with respect to demographic characteristics, duration of anaesthesia and patient satisfaction scores. The intraoperative consumption of remifentanil, postoperative VAS scores (20 min, 12 h and 24 h) and the requirement for postoperative analgesics were all significantly lower in group B who received a larger volume but a lower concentration of local anaesthetic solution compared with group A. Conclusion A US-TAP block can form part of a balanced postoperative analgesic regimen following laparoscopic cholecystectomy.

Topics: Abdominal Muscles; Adolescent; Adult; Aged; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Cholecystectomy, Laparoscopic; Female; Humans; Male; Middle Aged; Nerve Block; Pain Measurement; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Ultrasonography

Although remifentanil is used widely by many clinicians during general anesthesia, there are recent evidences of opioid-induced hyperalgesia as an adverse effect. This study aimed to determine if intraoperative remifentanil infusion caused increased pain during the postoperative period in patients who underwent a thyroidectomy. A total of 7511 patients aged ≥ 20 years, who underwent thyroidectomy between January 2009 and December 2013 at the Asan Medical Center were retrospectively analyzed. Enrolled patients were divided into 2 groups: group N (no intraoperative remifentanil and only volatile maintenance anesthesia) and group R (intraoperative remifentanil infusion including total intravenous anesthesia and balanced anesthesia). Following propensity score matching analysis, 2582 patients were included in each group. Pain scores based on numeric rating scales (NRS) were compared between the 2 groups at the postoperative anesthetic care unit and at the ward until 3 days postoperation. Incidences of postoperative complications, such as nausea, itching, and shivering were also compared. The estimated NRS pain score on the day of surgery was 5.08 (95% confidence interval [CI] 4.97-5.19) in group N patients and 6.73 (95% CI 6.65-6.80) in group R patients (P < 0.001). There were no statistically significant differences in NRS scores on postoperative days 1, 2, and 3 between the 2 groups. Postoperative nausea was less frequent in group R (31.4%) than in group N (53.5%) (P < 0.001). However, the incidence of itching was higher in group R (4.3%) than in group N (0.7%) (P < 0.001). Continuous infusion of remifentanil during general anesthesia can cause higher intensity of postoperative pain and more frequent itching than general anesthesia without remifentanil infusion immediately after thyroidectomy. Considering the advantages and disadvantages of continuous remifentanil infusion, volatile anesthesia without opioid may be a good choice for minor surgeries, such as thyroidectomy.

Topics: Adult; Anesthesia, Inhalation; Anesthetics, Intravenous; Female; Humans; Hyperalgesia; Male; Middle Aged; Pain, Postoperative; Piperidines; Propensity Score; Remifentanil; Retrospective Studies; Thyroidectomy

Intraoperative remifentanil has been associated with postoperative hyperalgesia, higher visual analogic pain scores, and increased postoperative morphine consumption. However, this has not been investigated from patient's perspective by using a patient-reported outcomes (PROs) approach with a validated questionnaire.. We joined the largest prospective observational study on postoperative pain, PAIN OUT Project (NCT02083835), and collected data for 2 years. We studied the effects of remifentanil (R+) vs nonremifentanil (R-) anesthesia on PROs regarding their pain management after elective thyroidectomy. We selected 5 primary PROs (worst pain experienced, time spent in severe pain, relief received by treatment, satisfaction about pain management, wish for more pain treatment) and five secondary PROs (drowsiness, itching, nausea, dizziness, waking up due to pain) from the validated International Pain Outcomes questionnaire.. The analysis included 317 patients, 208 in the R+ group (65.6%) and 109 in the R- group (34.4%), the latter receiving fentanyl as intraoperative opioid. Although the R+ group received more frequently intraoperative nonopioids (202/208, 97.1% vs 86/109, 78.9%; P < .0001) and opioids (184/208, 88.5% vs 38/109, 34.9%; P < .001), it reported higher worst pain (5.1±2.1 vs 4.3±2.1, P < .005), lower satisfaction (7.4±2.0 vs 8.1±2.1, P < .001), and worse results in 4 secondary PROs. A sensitivity analysis performed matching 67 couples of patients yielded similar results in primary PROs.. Our study suggests that remifentanil-based anesthesia is associated with worse pain-related PROs in patients undergoing thyroidectomy despite more frequent intraoperative analgesic administration. This study adds further evidence to the growing literature about opioid- and remifentanil-induced hyperalgesia.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia, Intravenous; Anesthetics, Intravenous; Drug Administration Schedule; Female; Humans; Hyperalgesia; Male; Middle Aged; Pain Management; Pain, Postoperative; Patient Reported Outcome Measures; Piperidines; Remifentanil; Thyroidectomy

Diabetic foot ulcer is the most common cause of diabetes-associated nontraumatic lower extremity amputation. Most patients who undergo lower extremity amputation for a diabetic foot have had diabetes for a long time and suffer from multiorgan disorder; thus, it can be a challenge to ensure sufficient anesthetic and analgesic effects while maintaining stable hemodynamics. Recently, peripheral nerve block has gained popularity owing to its attenuating effects of systemic concerns. This retrospective observational study aimed to compare the effects of remifentanil-based general anesthesia (GEA) and popliteal nerve block (PNB) on postoperative pain and hemodynamic stability in diabetic patients undergoing distal foot amputation.A total of 59 consecutive patients with a diabetic foot who underwent distal foot amputation between January 2012 and May 2014 were retrospectively reviewed. Patients received remifentanil-based GEA (GEA group, n = 32) or PNB (PNB group, n = 27). The primary outcomes were to evaluate postoperative analgesic effects and perioperative hemodynamics. Also, postoperative pulmonary complications and 6-month mortality were assessed as secondary outcomes.Significant differences in pain scores using numeric rating scale were observed between the groups in a linear mixed model analysis (PGroup×Time = 0.044). Even after post hoc analysis with the Bonferroni correction, the numeric rating scale scores were significantly lower in the PNB group. Furthermore, patients in the PNB group required less pethidine during the first 6 hours after surgery (27 ± 28 vs 9 ± 18 mg; P = 0.013). The GEA group had a lower mean blood pressure (Bonferroni-corrected P < 0.01), despite receiving more ephedrine (P < 0.001). Significantly more patients in the GEA group suffered from postoperative pneumonia and required the management in intensive care unit (P = 0.030 and 0.038, respectively). However, the groups did not differ in terms of 6-month mortality.This study demonstrated that compared with remifentanil-based GEA, PNB might be a favorable option for diabetic patients undergoing distal foot amputation, despite the lack of significant mortality benefits, as PNB was associated with improved postoperative analgesia, hemodynamic stability, and a low incidence of pulmonary complications during the immediate postoperative period, especially in high-risk patients.

Topics: Aged; Amputation, Surgical; Anesthesia, General; Diabetic Foot; Female; Hemodynamics; Humans; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Peripheral Nerves; Piperidines; Remifentanil; Retrospective Studies

People with special needs undergoing dental surgery frequently require general anesthesia. We investigated the effect of remifentanil vs fentanyl on stress response and postoperative pain in people with special needs undergoing day-case dental surgery.. Forty-six adult patients with cognitive impairment undergoing day-case dental surgery under general anesthesia were allocated to receive intraoperatively either fentanyl 50 μg iv bolus (group F, n = 23) or continuous infusion of remifentanil 0.5-1 μg/kg/min (group R, n = 23). Iintraoperative hemodynamic parameters were recorded and serum inflammatory mediators [tumor necrosis factor-α, substance-P], stress hormons (melatonin, cortisol) and β-endorphin were measured. Postoperative pain was assessed during the first postoperative 12 hours with the Wong-Baker faces pain-rating scale.. Demographics were similar in two groups. The two groups did not differ regarding their effects on inflammatory mediators, stress hormons and postoperative pain scores. However, the use of remifentanil prevented intraoperative increases of arterial blood pressure and heart rate.. Remifentanil and fentanyl did not affect differently stress and inflammatory hormones during day-case dental surgery, although remifentanil may render intraoperative management of hemodynamic responses easier. Both opioids are equally efficient for postoperative pain management following dental surgery in people with special needs.

Topics: Adult; Ambulatory Surgical Procedures; Analgesics, Opioid; Cognition Disorders; Female; Fentanyl; Hemodynamics; Humans; Male; Pain, Postoperative; Pilot Projects; Piperidines; Remifentanil; Stress, Psychological

Activation of NMDA receptors play an important role in the development of remifentanil-induced hyperalgesia. We hypothesized that in addition to ketamine, intrathecal MgSO4 could also relieve thermal and mechanical hyperalgesia in rats.. Initially, 24 Sprague-Dawley rats were divided into control group, remifentanil group, surgical incision group and remifentanil combined with surgical incision group to create an experimental model. Subsequently, 40 rats were divided into control group, model group, model group plus 100 μg MgSO4, 300 μg MgSO4 and 10 μg ketamine respectively. Paw withdrawal mechanical thresholds and paw withdrawal thermal latency tests were performed at -24 h, 2 h, 6 h, 24 h, 48 h, 72 h and 7 day after the surgical procedure. After behavior assessment on the 7th day, remifentanil was given again to ascertain whether or not NMDA antagonists could suppress the re-exposure of remifentanil-induced hyperalgesia.. Remifentanil administration plus surgical incision induced significant postoperative hyperalgesia, as indicated by decreased paw withdrawal mechanical thresholds and paw withdrawal thermal latency to mechanical and thermal stimulation. In addition to ketamine, intrathecal MgSO4 (100, 300 μg) dose-dependently reduced remifentanil-induced mechanical and thermal hyperalgesia. Ketamine had less mechanical hyperalgesia in 6 h (p = 0.018), 24 h (p = 0.014) and 48 h (p = 0.011) than 300 μg MgSO4. There was no difference in inhibiting thermal hyperalgesia between the group ketamine and group MgSO4 (300 μg). The rats were given remifentanil again 7 days later after the first exposure of remifentanil. The hyperalgesic effect induced by re-exposure of remifentanil was not reversed in any groups of MgSO4 or ketamine.. In addition to ketamine, intrathecal administration of MgSO4 dose-dependently reduced remifentanil-induced hyperalgesia in a surgical incision mode. Re-exposure to remifentanil 1 week later again produced hyperalgesia, and this was not altered by the prior intrathecal treatments in any 4 groups treated with MgSO4 or ketamine.

Topics: Animals; Dose-Response Relationship, Drug; Hyperalgesia; Injections, Spinal; Ketamine; Magnesium Sulfate; Male; Pain Measurement; Pain Threshold; Pain, Postoperative; Piperidines; Rats; Remifentanil

Tremendous experimental and clinical studies identify that remifentanil anesthesia might elicit postoperative opioid-induced hyperalgesia (OIH) and aggravate nociceptive hypersensitivity, whereas definite mechanisms remain equivocal. WNT signaling and fractalkine pathway have been manifested to participate in varieties of pain pathogenesis, respectively, but no report is on whether they could lead to OIH. This study intended to investigate the effect of WNT3a/β-catenin on fractalkine and its receptor CX3CR1 in OIH in rats model of incision pain.. A WNT scavenger Fz-8/Fc and a neutralizing antibody against CX3CR1 (anti-CX3CR1) were injected intrathecally after remifentanil infusion. Exogenous WNT agonist delivery was utilized in naïve rats. PWT and PWL were documented for postsurgical 48h to assess mechanical and thermal hyperalgesia. Also, expressions of WNT3a, FZ1, FZ8, β-catenin, fractalkine and CX3CR1 in spinal dorsal horn were measured by Western blot and RT-qPCR after nociceptive testing.. We found that postsurgical mechanical and thermal hyperalgesia could be engendered after remifentanil exposure, which was accompanied by a dramatical rise of spinal WNT3a, FZ8, β-catenin, fractalkine and CX3CR1 levels. Moreover, OIH was attenuated by intrathecal application of Fz-8/Fc and anti-CX3CR1. Up-regulation of spinal fractalkine and CX3CR1 expression after remifentanil anesthesia was reversed by Fz-8/Fc. Also, WNT agonist administration could directly generate hypernociception and elevate fractalkine/CX3CR1 level in naïve rats, which was prevented by anti-CX3CR1.. These present findings demonstrated that the involvement of spinal WNT3a/FZ8/β-catenin in OIH through modulating fractalkine/CX3CR1 in rats.

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Animals; beta Catenin; Chemokine CX3CL1; CX3C Chemokine Receptor 1; Frizzled Receptors; Hyperalgesia; Pain, Postoperative; Piperidines; Rats, Sprague-Dawley; Receptors, Chemokine; Remifentanil; Spinal Cord; Wnt Signaling Pathway; Wnt3A Protein

AMPAkines augment the function of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors in the brain to increase excitatory outputs. These drugs are known to relieve persistent pain. However, their role in acute pain is unknown. Furthermore, a specific molecular and anatomic target for these novel analgesics remains elusive.. The authors studied the analgesic role of an AMPAkine, CX546, in a rat paw incision (PI) model of acute postoperative pain. The authors measured the effect of AMPAkines on sensory and depressive symptoms of pain using mechanical hypersensitivity and forced swim tests. The authors asked whether AMPA receptors in the nucleus accumbens (NAc), a key node in the brain's reward and pain circuitry, can be a target for AMPAkine analgesia.. Systemic administration of CX546 (n = 13), compared with control (n = 13), reduced mechanical hypersensitivity (50% withdrawal threshold of 6.05 ± 1.30 g [mean ± SEM] vs. 0.62 ± 0.13 g), and it reduced depressive features of pain by decreasing immobility on the forced swim test in PI-treated rats (89.0 ± 15.5 vs. 156.7 ± 18.5 s). Meanwhile, CX546 delivered locally into the NAc provided pain-relieving effects in both PI (50% withdrawal threshold of 6.81 ± 1.91 vs. 0.50 ± 0.03 g; control, n = 6; CX546, n = 8) and persistent postoperative pain (spared nerve injury) models (50% withdrawal threshold of 3.85 ± 1.23 vs. 0.45 ± 0.00 g; control, n = 7; CX546, n = 11). Blocking AMPA receptors in the NAc with 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo[f]quinoxaline-2,3-dione inhibited these pain-relieving effects (50% withdrawal threshold of 7.18 ± 1.52 vs. 1.59 ± 0.66 g; n = 8 for PI groups; 10.70 ± 3.45 vs. 1.39 ± 0.88 g; n = 4 for spared nerve injury groups).. AMPAkines relieve postoperative pain by acting through AMPA receptors in the NAc.

Topics: Analgesics; Animals; Behavior, Animal; Depression; Dioxoles; Disease Models, Animal; Male; Neuralgia; Nucleus Accumbens; Pain, Postoperative; Piperidines; Rats; Rats, Sprague-Dawley; Receptors, AMPA

Activation of N-methyl-d-aspartate (NMDA) receptor by reactive oxygen species (ROS) in the spinal cord plays an important role in the development of hyperalgesia in several neuropathic pain models. The study examined the involvement of ROS-NMDA signaling pathway in remifentanil-induced postoperative hyperalgesia.. Nociceptive responses were measured by paw withdrawal mechanical threshold (PWT) and paw withdrawal thermal latency (PWL) before and up to day 5 after remifentanil infusion. Spinal delivery of MitoSOX red was performed to detect mitochondrial ROS. Changes in expression of NMDA receptor subunits (NR1 and NR2B) in the spinal cord were analyzed by immunofluorescence and Western blotting. Intraperitoneal injection of phenyl-N-tert-butylnitrone (PBN), a non-selective ROS scavenger, was administrated to investigate the role of ROS in remifentanil-induced postoperative hyperalgesia.. Intraoperative infusion of remifentanil induced postoperative mechanical allodynia and thermal hyperalgesia. ROS production, phosphorylated NR1 and NR2B subunits of NMDA receptor were found to be significantly increased in the spinal dorsal horn after intraoperative remifentanil infusion. However, remifentanil-induced postoperative hyperalgesia was suppressed by pretreatment of PBN. In addition, reduction of ROS by PBN prevented enhanced phosphorylation of NR1 and NR2B subunits.. These findings indicated that ROS-dependent activation of NMDA receptor in the spinal cord might be a potential mechanism underlying remifentanil-induced postoperative hyperalgesia.

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Animals; Cyclic N-Oxides; Hyperalgesia; Male; Mitochondria; Pain Threshold; Pain, Postoperative; Phosphorylation; Piperidines; Rats, Sprague-Dawley; Reactive Oxygen Species; Receptors, N-Methyl-D-Aspartate; Remifentanil; Spinal Cord

Remifentanil may induce hyperalgesia. Recent studies implicate a close relationship between post-surgical hyperalgesia and phosphorylation and activation of p38 mitogen-activated protein kinase (p38MAPK) in the spinal microglia. This study aimed to investigate whether the combination of post-surgical and remifentanil-induced hyperalgesia worsens post-operative pain and whether phosphorylated p38MAPK (phospho-p38MAPK) in the spinal dorsal horn in rats is involved in remifentanil-induced postoperative hyperalgesia.. Sprague-Dawley rats were randomly divided into six groups: control, incision only, remifentanil only, remifentanil + incision, remifentanil + incision + SB203580, and remifentanil + incision + DMSO. The p38MAPK inhibitor SB203580 and DMSO were injected intrathecally. A right plantar surgical incision was performed in the incision groups, and remifentanil was infused for 60 min in the remifentanil groups. Mechanical paw withdrawal threshold (PWT) and thermal paw withdrawal latency (PWL) of the bilateral hind paws were measured and the number of phospho-p38MAPK-positive cells in rat spinal dorsal horn sections was counted.. Intravenous remifentanil infusion decreased bilateral plantar PWL values from 1 h to 3 days after surgery, however there was no additive effect with incision-induced values. There was a significant increase in the number of dorsal horn phospho-p38MAPK-positive cells in the remifentanil + incision group compared to the incision group, but no increase in the number of these cells when remifentanil was given alone. Intrathecal pretreatment with SB203580 attenuated remifentanil + incision-induced postoperative hyperalgesia and significantly reduced activation of phospho-p38MAPK in spinal dorsal horn.. Incision-induced and remifentanil-induced increases in hyperalgesia were not additive when incision and remifentanil were used together. Data on phospho-38MAPK activation in remifenanil-induced hyperalgesia were contradictory and need further clarification.

Topics: Analgesics, Opioid; Analysis of Variance; Animals; Anti-Inflammatory Agents, Non-Steroidal; Disease Models, Animal; Enzyme Activation; Hyperalgesia; Imidazoles; Male; p38 Mitogen-Activated Protein Kinases; Pain Measurement; Pain Threshold; Pain, Postoperative; Piperidines; Pyridines; Rats; Rats, Sprague-Dawley; Remifentanil; Spinal Cord Dorsal Horn; Time Factors

Remifentanil and nitrous oxide (N2O) are 2 commonly used anesthetic agents. Both these agents are known risk factors for postoperative nausea and vomiting (PONV). However, remifentanil and N2O have not been directly compared in a published study. Remifentanil can induce acute tolerance or hyperalgesia, thus affecting postoperative pain. The objective of this retrospective study is to compare the effects of remifentanil and N2O on PONV and pain in patients receiving intravenous patient-controlled analgesia (IV-PCA) after thyroidectomy.We analyzed the electronic medical records of 992 patients receiving fentanyl-based IV-PCA after thyroidectomy at Chung-Ang University Hospital from January 1, 2010 to April 30, 2016. We categorized the patients according to anesthetic agents used: group N2O (n = 745) and group remifentanil (n = 247). The propensity score matching method was used to match patients in the 2 groups based on their covariates. Finally, 128 matched subjects were selected from each group.There were no differences between groups for all covariates after propensity score matching. The numeric rating scale for nausea (0.55 ± 0.88 vs 0.27 ± 0.76, P = 0.01) was higher and complete response (88 [68.8%] vs 106 [82.8%], P = 0.001) was lower in group N2O compared with group remifentanil on postoperative day 0. However, the visual analog scale score for pain (3.47 ± 2.02 vs 3.97 ± 1.48, P = 0.025) was higher in group remifentanil than group N2O on postoperative day 0.In patients receiving IV-PCA after thyroidectomy, postoperative nausea was lower but postoperative pain was higher in group remifentanil.

Topics: Adult; Analgesia, Patient-Controlled; Analgesics, Non-Narcotic; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Humans; Hypnotics and Sedatives; Male; Middle Aged; Nitrous Oxide; Pain Measurement; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propensity Score; Remifentanil; Retrospective Studies; Thyroidectomy; Treatment Outcome

To analyze the effectiveness and usefulness of contact topical anesthesia in strabismus surgery in adult patients.. A prospective study was conducted on 20 patients undergoing strabismus surgery using contact topical anesthesia and sedation with remifentanil. The intensity of pain was recorded using a numeric pain rating scale at the time of anesthesia implementation, during the surgical procedure, 30 min afterwards, and during the first postoperative day. The incidence of oculocardiac reflex, postoperative nausea and vomiting, corneal ulcers, patient satisfaction (numerically from 0 to 10) and the degree of residual ocular deviation were also assessed.. The operation was performed successfully in all patients. Average pain intensity was 1.40 ± 1.73 during anesthesia implementation, 4.20 ± 2.57 during the surgical procedure, 2.50 ± 2.54 30 min after surgery, and 3.55 ± 2.89 during the first postoperative day. Oculocardiac reflex was observed in 7 patients (35%), postoperative nausea and vomiting in 4 (20%), and corneal ulcer in 4 (20%). The patient satisfaction was 9.53 ± 2.51. More than two-thirds (70%) of patients had a residual ocular deviation less than 10 prism diopters.. Contact topical anesthesia is a safe and effective alternative for strabismus surgery in adult patients. Contact topical anesthesia provides adequate pain control, lower incidence of postoperative nausea and vomiting and oculocardiac reflex, and optimal setting of ocular alignment.

Topics: Administration, Ophthalmic; Adult; Aged; Aged, 80 and over; Anesthesia, Local; Anesthetics, Local; Bupivacaine; Conscious Sedation; Corneal Ulcer; Female; Humans; Hypnotics and Sedatives; Lidocaine; Male; Middle Aged; Pain Measurement; Pain, Postoperative; Patient Satisfaction; Piperidines; Postoperative Nausea and Vomiting; Prospective Studies; Reflex, Oculocardiac; Remifentanil; Strabismus; Treatment Outcome; Young Adult

To investigate whether pupil diameter (PD) measured during scotopic conditions is influenced by pain in conscious patients in the early postoperative period.. Prospective, observational, cohort study.. Single-center, postanesthesia care unit (PACU).. Patients scheduled for a surgery during general anesthesia.. Baseline PD was measured the day before surgery. Patients were observed on admission to the PACU, immediately after extubation, during the different steps of analgesic intervention (demand, relief, plus intermediate measures when relevant), and either at discharge or 3 hours after admission.. PD, pain (numerical rating scale), and alertness (Observer's Assessment of Alertness/Sedation scale).. Of 103 patients enrolled, 80 required analgesia in the PACU and completed follow-up. Pain intensity evolved in line with expectations (temporary increase then relief), and alertness increased with time. PD increased from low mean values at admission to the PACU (40% of baseline) to a plateau throughout the rest of the study period (80% of baseline) and was not related to pain intensity. Multivariate analyses suggested that the factors influencing PD (or its value related to baseline) were time since extubation and the type of opioid (remifentanil, sufentanil, or sufentanil at high doses) administered during surgery.. Because of a residual effect of intraoperative opioids and a level of nociceptive stimulation lower than in surgical conditions, PD is not significantly influenced by early postoperative pain or pain relief.

Topics: Aged; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, General; Cohort Studies; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Humans; Intraoperative Care; Male; Middle Aged; Multivariate Analysis; Pain, Postoperative; Piperidines; Prospective Studies; Pupil; Remifentanil; Sufentanil; Time Factors

Remifentanil has a rapid onset and short duration of action, predictable pharmacokinetic/pharmacodynamic profile, and unlike fentanyl, does not accumulate with repeated or prolonged administration. This study evaluated predictors of remifentanil use in surgical patients with renal or hepatic impairment, or obesity in the United States who received remifentanil, fentanyl, or the combination.. Data (2010) from the US Healthcare National Inpatient Database, State Inpatient Database, State Ambulatory Surgery Database, and private hospital and Medicaid databases were used in this analysis. Patients included had presence of hepatic or renal disease, and/or obesity and were >5 and ≤80 years of age.. In 2010, 9,274 patients with renal impairment, 1,896 with hepatic impairment, and 6,278 with obesity were identified. The percentage of surgical patients diagnosed with renal disease, hepatic disease, or obesity who received remifentanil was 41, 28, and 35%, respectively; 29, 17, and 22% received both remifentanil and fentanyl, and 30, 55, and 43% received fentanyl alone, respectively. In patients with renal or hepatic disease the probability of remifentanil use was greater for persons aged >50 years, with Medicare as primary payer, or who were diagnosed with obesity (p < 0.05 all comparisons). In obese patients, the probability of remifentanil use was greater for persons aged >50 years or female (both p < 0.05). For all 3 disease states, the probability of remifentanil use was lower for those receiving epidural anesthesia or with Medicaid as primary payer (p < 0.05 all comparisons).. Remifentanil in combination with fentanyl is used less than fentanyl in surgical patients with hepatic impairment or obesity. This is inconsistent with the fact that the pharmacokinetic/pharmacodynamic features of remifentanil suggest it is the preferred intraoperative opioid in these patients. Predictors of remifentanil use in patients with renal or hepatic impairment, or obesity include older age, obesity, and Medicare as primary payer. Remifentanil in combination with fentanyl was significantly less utilized than fentanyl in persons with Medicaid as primary payer even though there was a disproportionate enrollment of beneficiaries with renal or hepatic disease, or obesity in state Medicaid programs.

Topics: Adult; Aged; Analgesics, Opioid; Anesthetics, Intravenous; Drug Therapy, Combination; Female; Fentanyl; Humans; Kidney Diseases; Liver Diseases; Male; Middle Aged; Obesity; Pain, Postoperative; Piperidines; Predictive Value of Tests; Remifentanil; Retrospective Studies; United States

Several studies have demonstrated that intraoperative remifentanil infusions have been associated with opioid-induced hyperalgesia (OIH). Activation of delta opioid receptor (DOR) and augmentation of N-methyl-d-aspartate (NMDA) receptor expression and function may play an important role in the development of OIH. The aim of this study was to investigate whether DOR inhibition could prevent remifentanil-induced hyperalgesia via regulating spinal NMDA receptor expression and function in vivo and in vitro.. A rat model of remifentanil-induced postoperative hyperalgesia was performed with the DOR agonist deltorphin-deltorphin II or the DOR antagonist naltrindole injected intrathecally 10 min before remifentanil infusion. Mechanical and thermal hyperalgesia were measured at -24h, 2, 6, 24 and 48 h after remifentanil infusion. Western blot was applied to detect the membrane and total expression of DOR and NMDA receptor subunits (NR1, NR2A and NR2B) in spinal cord L4-L6 segments. In addition, whole-cell patch-clamp recording was used to investigate the effect of DOR inhibition on NMDA receptor-induced current in spinal cord slices in vitro.. We found that membrane trafficking of DOR, NR1 and NR2B subunits in the spinal cord increased after remifentanil administration and surgery. The DOR antagonist naltrindole could attenuate mechanical and thermal hyperalgesia without affecting baseline nociceptive threshold, reduce membrane expression of DOR and decrease the membrane and total expressions of NR1 and NR2B subunits. Furthermore, the amplitude and the frequency of NMDA receptor-induced current were significantly increased by remifentanil incubation in neurons of the dorsal horn, which was reversed by the application of naltrindole.. The above results indicate that inhibition of DOR could significantly inhibit remifentanil-induced hyperalgesia via modulating the total protein level, membrane trafficking and function of NMDA receptors in the dorsal horn of spinal cord, suggesting that naltrindole could be a potential anti-hyperalgesic agent for treating OIH.

Topics: Anesthetics, Intravenous; Animals; Disease Models, Animal; Hot Temperature; Hyperalgesia; Lumbar Vertebrae; Male; Naltrexone; Narcotic Antagonists; Oligopeptides; Pain Threshold; Pain, Postoperative; Piperidines; Posterior Horn Cells; Random Allocation; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Receptors, Opioid, delta; Remifentanil; Spinal Cord; Tissue Culture Techniques; Touch

Hyperalgesia is one of the negative consequences following intraoperative analgesia with remifentanil. Peroxynitrite is a critical determinant in nociceptive process. Peroxynitrite inactivates iron-sulfur cluster that results in mitochondrial dysfunction and the release of iron, leading to mitochondrial iron accumulation. Iron accumulation mediated by divalent metal transporter 1 (DMT1) plays a key role in N-methyl-D-aspartate neurotoxicity. This study aims to determine whether peroxynitrite contributes to remifentanil-induced postoperative hyperalgesia via DMT1-mediated iron accumulation.. Behavior testing was performed in rat model at different time points. Three-nitrotyrosine, nitrated manganese superoxide dismutase, and DMT1 with/without iron-responsive element [DMT1(+)IRE and DMT1(-)IRE] in spinal cord were detected by Western blot and immunohistochemistry. Spinal iron concentration was measured using the Perl stain and atomic absorption spectrophotometer. Hydrogen-rich saline imparting selectivity for peroxynitrite decomposition and iron chelator was applied in mechanistic study on the roles of peroxynitrite and iron, as well as the prevention of hyperalgesia.. Remifentanil induced thermal and mechanical hyperalgesia at postoperative 48 h. Compared with control, there were higher levels of 3-nitrotyrosine (mean ± SD, hyperalgesia vs. control, 1.22 ± 0.18 vs. 0.25 ± 0.05, n = 4), nitrated manganese superoxide dismutase (1.01 ± 0.1 vs. 0.19 ± 0.03, n = 4), DMT1(-)IRE (1.42 ± 0.19 vs. 0.33 ± 0.06, n = 4), and iron concentration (12.87 ± 1.14 vs. 5.26 ± 0.61 μg/g, n = 6) in remifentanil-induced postoperative hyperalgesia, while DMT1(+)IRE was unaffected. Eliminating peroxynitrite with hydrogen-rich saline protected against hyperalgesia and attenuated DMT1(-)IRE overexpression and iron accumulation. Iron chelator prevented hyperalgesia in a dose-dependent manner.. Our study identifies that spinal peroxynitrite activates DMT1(-)IRE, leading to abnormal iron accumulation in remifentanil-induced postoperative hyperalgesia, while providing the rationale for the development of molecular hydrogen and "iron-targeted" therapies.

Topics: Animals; Cation Transport Proteins; Hyperalgesia; Iron; Iron-Regulatory Proteins; Male; Pain, Postoperative; Peroxynitrous Acid; Piperidines; Rats; Rats, Sprague-Dawley; Remifentanil; Spinal Cord

Topics: Analgesics, Opioid; Humans; Hyperalgesia; Pain, Postoperative; Piperidines

Topics: Analgesics, Opioid; Humans; Hyperalgesia; Pain, Postoperative; Piperidines

The aim of this study was to compare the speed of anesthetic recovery and the perioperative analgesic requirements in patients who received total intravenous anesthesia (TIVA) with either remifentanil-propofol or fentanyl-propofol for lumbar spine surgery.. Retrospective cohort study.. Operating room, postanesthesia care unit, and general surgical ward.. One hundred six patients (53 in each group) with American Society of Anesthesiologists status I, II, or III who received either remifentanil-propofol TIVA or fentanyl-propofol TIVA for elective lumbar vertebral disc surgery.. Patient demographics, total duration of anesthesia relative to surgical duration, time to emergence from anesthesia after completion of surgery, length of stay in the postanesthesia care unit, and requirements for opioid analgesia, nonopioid analgesia, and antiemetics in the perioperative period.. No differences in anesthesia time, emergence time, or length of stay in the postanesthesia care unit were found between the remifentanil-propofol and fentanyl-propofol groups. Postoperative opioid and nonopioid analgesic use was significantly higher in the remifentanil-propofol group.. Remifentanil and fentanyl are equally efficient with regard to the speed of patient turnover when used as part of TIVA for lumbar disc surgery, but remifentanil use is associated with increased perioperative analgesic requirements.

Topics: Adult; Aged; Analgesics; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Cohort Studies; Female; Fentanyl; Humans; Lumbar Vertebrae; Male; Middle Aged; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Retrospective Studies

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.. 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.. 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.. Intrathecal injection of KN93 attenuates postoperative hyperalgesia induced by intraoperative infusion of remifentanil in rats through inhibiting spinal CaMKII phosphorylation.

Topics: Animals; Benzylamines; Calcium-Calmodulin-Dependent Protein Kinase Type 2; Dose-Response Relationship, Drug; Hyperalgesia; Injections, Spinal; Male; Pain, Postoperative; Piperidines; Protein Kinase Inhibitors; Rats; Rats, Sprague-Dawley; Remifentanil; Spinal Cord; Sulfonamides

Varying levels of female sex hormones during the menstrual cycle were found to influence the central nervous system. The goal of the present study was to investigate whether the median (50%) effective effect-concentration (EC50) of propofol inducing loss of consciousness (LOC) varies between the luteal and the follicular phases of the menstrual cycle.. Twenty-two patients (follicular phase) and 20 patients (luteal phase) undergoing gynaecological procedures under general anaesthesia were enrolled on the study. Anaesthesia was conducted with a target-controlled infusion (TCI) of propofol. The initial target effect-site propofol concentration (Ceprop) was 3.5 µg ml(-1) and was adjusted stepwise by 0.5 µg ml(-1) at 4 min intervals by an up-down sequential method to reach LOC. Anaesthesia was maintained with a propofol TCI guided by the bispectral index. The correlation between female sex hormones and predicted Ceprop at the time of LOC was analysed and emergence time from anaesthesia was recorded.. Propofol EC50 to induce LOC was higher in patients in the follicular phase than those in the luteal phase (4.17 vs 3.58 µg ml(-1), P<0.05). Progesterone correlated significantly with Ceprop at LOC. Emergence time was also longer in the follicular group than in the luteal group (6.5 vs 5.0 min, P<0.05).. During general anaesthesia, patients in the luteal phase of the menstrual cycle had a lower propofol EC50 for LOC and a shorter emergence time compared with those in the follicular phase. Differences in progesterone levels between menstrual phases may contribute to these anaesthetic effects. Registry number of clinical trial ChiCTR-RCH-12002755.

Topics: Adult; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Consciousness Monitors; Data Interpretation, Statistical; Female; Gonadal Steroid Hormones; Gynecologic Surgical Procedures; Humans; Luteal Phase; Menstrual Cycle; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Progesterone; Propofol; Remifentanil; Unconsciousness; Young Adult

Topics: Acetaminophen; Analgesia; Analgesics, Non-Narcotic; Analgesics, Opioid; Child; Cleft Lip; Cleft Palate; Data Collection; Humans; Ireland; Pain, Postoperative; Piperidines; Remifentanil; United Kingdom

Combination of local and regional anesthetic agents are widely used in emergency and surgical setting and the interaction between the medications used in general anesthesia and these local and/or regional anesthetic becomes a growing concern in current patient management system. The interaction between general anesthetic agents and the local anesthetic agents given epidurally, spinally, intravenously or intramuscularly and the effects of BIS monitorisation on combined propofol-remifentanil anesthesia are examined in several studies. In literature, there is no research investigating the effect of lidocaine infusion on remifentanil and anesthetic dosage used in hypotensive anesthesia. The aim of this study is to examine this effect.. We studied 39, ASA I-II patients undergoing elective transsphenoidal endoscopic hypophyseal adenoma excision procedure. After preoperative examination and informed consent of the patient, monitorisation with non invasive blood pressure measurement, electrocardiography, pulse oxymeter and Bispectral Index (BIS) was performed. 0.9% NaCl infusion was started via a 20 G route. Lidocaine (1%) was given as 1.5 mg.kg(-1) hour-1 infusion after 1.5 mg.kg(-1) bolus dosage given in 10 minutes. Lidocaine infusion was started at the same time with anesthesia induction and was stopped after surgery. 0.9% NaCl was given as bolus dosage and as infusion in control group. Induction was maintained via propofol (1%) with 10 mg (1 ml) doses given in 5 seconds and it was applied in every 15 seconds until BIS < 45'. During maintenance of anesthesia desflurane-remifentanil-oxygen (50%)-air (50%) mixture was used. Desflurane was titrated by BIS measurement between 40 and 5012. Remifentanil infusion was started after propofol induction with 0.1 µg.kg(-1).min(-1) dosage and it was titrated between 0.1-0.5 µg.kg(-1).min(-1) levels. For intubation, rocuronium with 0.8 mg kg(-1) dosage was given during induction. After the surgical procedure, it was antagonised with neostigmine and atropine. For postoperative analgesia 1 g paracetamole was given IV after the surgery within 15 minutes and it was reapplied with 1 gr doses in every 6 hours. After extubation, the pain of the patients was examined at 15. minute at the recovery room with VRS (VRS; 0-no pain, 1-slight pain, 2-moderate pain, 3-severe pain). If VRS was greater than 2, 50 mg dolantine was given IM. For prevention of nausea and vomitting, 8 mg ondansetron was given IV. Perioperative total doses of remifentanil, desflurane (ml) (anesthesia machine records) and lidocaine (mg) were recorded after the surgery. Perioperative hemodynamic parameters (systolic, diastolic, mean blood pressures, heart rates) were recorded after monitorisation (basal), after intubation, after the start of the surgery and after extubation.. There were no statistically significant difference between two groups with respect to patient characteristics (age, gender, weight, length, Basal Mass Index = BMI) (p > 0.05). The duration of anesthesia and surgery were also not different statistically (p > 0.05). There were no statistically significant difference between two groups with respect to remifentanil dose (p > 0.05). There were no statistically significant difference between two groups with respect to eye opening and extubation times (p > 0.05). When usage rates and amounts of dolantine, paracetamole and novalgine were compared, we found no statistically significant difference between two groups (p > 0.05). Basal mean arterial blood pressure measurements of the patients and mean arterial blood pressure measurements of the patients after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal heart rate measurements and the heart rates after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05). Basal BIS measurements and BIS measurements after induction, after intubation, 1 minute, 5 minutes, 10 minutes, 15 minutes after discharge of surgery and after extubation showed no statistically significant difference (p > 0.05).. We found no statistically significant difference between two groups about different parameters. But new investigations with different local anesthetic agents may show sigificant difference and usage of these local anesthetic agents may be advised.

Topics: Adenoma; Adolescent; Adult; Aged; Anesthetics, Combined; Anesthetics, Intravenous; Anesthetics, Local; Blood Pressure; Blood Pressure Monitors; Consciousness Monitors; Drug Administration Schedule; Electrocardiography; Endoscopy; Female; Heart Rate; Humans; Hypotension; Infusions, Parenteral; Intraoperative Neurophysiological Monitoring; Lidocaine; Male; Middle Aged; Operative Time; Oximetry; Pain, Postoperative; Piperidines; Pituitary Neoplasms; Predictive Value of Tests; Remifentanil; Time Factors; Treatment Outcome; Young Adult

Hyperalgesia and neuroinflammation are associated with glia, which consists of macroglia and microglia. In this study, we used a selective cannabinoid receptor type 2 (CB2) agonist JWH015 to investigate remifentanil-induced postoperative hyperalgesia.. Mechanical allodynia and thermal hyperalgesia after postoperative hyperalgesia and intrathecal injection of JWH015 were assessed by the paw withdrawal mechanical threshold and paw withdrawal thermal latency tests. We used immunohistochemistry and immunoblotting to investigate the effect of JWH015 on CB2 receptor, NR2B subunits, activated glial cells, and proinflammatory cytokine expression in rats after remifentanil-induced postoperative hyperalgesia.. Postoperative hyperalgesia was induced by intraoperative infusion of remifentanil. Glial cells were activated, and expression levels of several genes were significantly increased, including interleukin 6, tumor necrosis factor α, CB2, and the NR2B subunit phosphorylated at Tyr-1472 (p-NR2B). Intrathecal injection of JWH015 significantly inhibited glial cell activation, suppressed expression of interleukin 6, tumor necrosis factor α, and p-NR2B, and stimulated CB2 expression, thus attenuating postoperative hyperalgesia. However, these phenomena were abolished in the group that was preadministered with AM630.. The activation of glia, the production of proinflammatory cytokines, and the expression of CB2 and p-NR2B in the spinal dorsal horn increase significantly during the process of remifentanil-induced hyperalgesia. These changes can be regulated by pretreatment with JWH015, which may be the main mechanism underlying the antihyperalgesia effects of JWH015.

Topics: Anesthetics, Local; Animals; Astrocytes; Behavior, Animal; Blotting, Western; Cannabinoid Receptor Agonists; Cytokines; Hyperalgesia; Immunohistochemistry; Indoles; Injections, Spinal; Macrophage Activation; Male; Neuroglia; Pain, Postoperative; Phosphorylation; Piperidines; Posterior Horn Cells; Rats; Rats, Sprague-Dawley; Receptor, Cannabinoid, CB2; Receptors, N-Methyl-D-Aspartate; Remifentanil; Spinal Cord

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.

Topics: Analgesics, Opioid; Animals; Cyclin-Dependent Kinase 5; Hyperalgesia; Injections, Spinal; Male; Motor Activity; Pain Threshold; Pain, Postoperative; Phosphorylation; Piperidines; Protein Kinase Inhibitors; Purines; Rats; Rats, Sprague-Dawley; Receptor, Metabotropic Glutamate 5; Receptors, N-Methyl-D-Aspartate; Remifentanil; Roscovitine; Spinal Cord

Many studies have confirmed that brief remifentanil exposure can enhance pain sensitivity. We previously reported that activation of glycogen synthase kinase-3β (GSK-3β) contributes to remifentanil-induced hyperalgesia via regulating N-methyl-D-aspartate receptor plasticity in the spinal dorsal horn. In this study, we demonstrated that GSK-3β inhibition prevented remifentanil-induced postoperative hyperalgesia via regulating α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) expression and function in the spinal dorsal horn.. Using a rat model of remifentanil-induced incision hyperalgesia, mechanical and thermal pain was tested 1 day before infusion and 2 hours, 6 hours, 1 day, 2 days, 3 days, 5 days, and 7 days after infusion. Western blot analysis was used to detect AMPAR subunit (GluR1 and GluR2) trafficking, AMPAR phosphorylation status, and GSK-3β activity in the spinal dorsal horn. Furthermore, whole-cell patch-clamp recording was used to analyze the effect of GSK-3β inhibition on AMPAR-induced current in the spinal dorsal horn.. Membrane AMPAR subunit GluR1 was upregulated in the spinal cord in remifentanil-induced postoperative hyperalgesia rats (275 ± 36.54 [mean ± SD] vs 100 ± 9.53, P = 0.0009). Selective GSK-3β inhibitors, LiCl and TDZD, treatment ameliorates remifentanil-induced postoperative hyperalgesia, and this was associated with the downregulated GluR1 subunit in the membrane fraction (254 ± 23.51 vs 119 ± 14.74, P = 0.0027; 254 ± 23.51 vs 124 ± 9.35, P = 0.0032). Moreover, remifentanil incubation increased the amplitude and the frequency of AMPAR-induced current in dorsal horn neurons (61.09 ± 9.34 pA vs 32.56 ± 6.44 pA, P = 0.0009; 118.32 ± 20.33 milliseconds vs 643.67 ± 43.29 milliseconds, P = 0.0002), which was prevented with the application of LiCl and TDZD, respectively. Remifentanil-induced postoperative pain induced an increase in pGluR1 Ser845 and Rab5, which was prevented with the application of LiCl and TDZD.. These results indicate that amelioration of remifentanil-induced postoperative hyperalgesia by GSK-3β inhibition is attributed to downregulated AMPAR GluR1 expression in the membrane fraction and inhibition of AMPAR function via altering pGluR1 and Rab5 expression in the spinal dorsal horn.

Topics: Animals; Enzyme Inhibitors; Gene Expression Regulation; Glycogen Synthase Kinase 3; Glycogen Synthase Kinase 3 beta; Hyperalgesia; Male; Organ Culture Techniques; Pain, Postoperative; Piperidines; Posterior Horn Cells; Rats; Rats, Sprague-Dawley; Receptors, AMPA; Remifentanil

Remifentanil administration may subsequently cause paradoxical hyperalgesia in animals and humans, but mechanisms remain unclear. Manganese superoxide dismutase (MnSOD) nitration and inactivation caused by generation of reactive oxygen species and activation of N-methyl-D-aspartate (NMDA) receptors are involved in the induction and maintenance of central neuropathic pain. Hydrogen which selectively removes superoxide has gained much attention in recent years. In this study, we investigated antinociceptive effects of hydrogen-rich saline (HRS) on remifentanil-induced postsurgical hyperalgesia in a rat model of incisional pain. HRS was injected intraperitoneally 10 min before remifentanil infusion (1 μg kg(-1) min(-1) for 60 min). A selective NR2B antagonist Ro25-6981 was used to investigate whether antihypernociception of HRS is associated with NMDA receptor (NMDAR). Nociception was evaluated by the paw withdrawal mechanical threshold and thermal latency respectively. Then we assessed MnSOD, NR2A and NR2B in spinal cord dorsal horn via Western blot and immunohistochemistry after nociceptive tests. Here, we found that the analgesic effect of remifentanil was followed by long-term hyperalgesia lasting at least postoperative 7 days, which was accompanied with increase in NR2B expression and trafficking from cytoplasm to surface and MnSOD nitration in dorsal horn. Pretreatment with HRS (10 ml/kg) significantly attenuated mechanical and thermal hyperalgesia, blocked NR2B trafficking and MnSOD nitration in dorsal horn after remifentanil infusion. Ro25-6981 not 5 μg but 10 and 50 μg dosage-dependently attenuated hyperalgesia, and inhibited MnSOD nitration. Hyperalgesia and MnSOD nitration were attenuated after the combination of HRS (2.5 ml/kg) and Ro25-6981 (5 μg). In conclusion, HRS (10 ml/kg) might reverse remifentanil-induced hyperalgesia, through regulating NR2B-containing NMDAR trafficking to control MnSOD nitration and enhance MnSOD activity.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Animals; Excitatory Amino Acid Antagonists; Hot Temperature; Hydrogen; Hyperalgesia; Injections, Intraperitoneal; Male; Nociception; Pain, Postoperative; Phenols; Piperidines; Random Allocation; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Remifentanil; Sodium Chloride; Spinal Cord Dorsal Horn; Superoxide Dismutase; Touch

To determine the changes of Mu-opioid receptor (Mor) and neuron-restrictive silencer factor (NRSF) in periaquductal gray (PAG) in mouse models of remifentanil-induced postoperative hyperalgesia.. Thirty-two Kun-Ming mice were randomly divided into 4 groups (8 mice in each group): Group C (mice underwent a sham procedure and saline was infused subcutaneously over a period of 30 min), Group I (mice underwent a surgical incision and the same volume of saline), Group R (mice underwent a sham procedure and remifentanil was infused subcutaneously at the moment of surgical incision over a period of 30 min), and group IR (mice underwent a surgical incision and remifentanil). Paw withdrawal mechanical threshold (PWMT) and paw withdrawal thermal latency (PWTL) tests were performed 24 h before the operation and 2, 6, 24, and 48 h after the operation. The specimens were collected after behavioral testings at 48 h. The expressions of Mor and NRSF in mice's PAG neurons were determined by Western blot.. Mechanical allodynia and thermal hyperalgesia developed in Group I, R and IR (P<0.01). Intraoperative infusion of remifentanil enhanced mechanical allodynia and thermal hyperalgesia in mice with planta incision (P<0.01). In Group R and Group IR, the expression of Mor was significantly lower (P<0.01) and NRSF was significantly higher (P<0.01) when compared with Group C and Group I.. Intraoperative infusion of remifentanil induces postoperative hyperalgesia in mouse models, accompanied with decreased expressions of Mor and increased of NRSF level in PAG neurons, which may be involved in remifentanil induced hyperalgesia.

Topics: Animals; Disease Models, Animal; Hyperalgesia; Mice; Pain, Postoperative; Periaqueductal Gray; Piperidines; Receptors, Opioid, mu; Remifentanil; Repressor Proteins

Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound-guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair.. After approval of the ethical committee and the relatives of the patients, 15 infants who had undergone thoracotomy were enrolled in the study. The patients received 0.5 ml·kg(-1) a bolus 0.25% bupivacaine with epinephrine 1 : 200 000 at T5-6 level after standard general anesthesia induction. Anesthesia depth with Index of Consciousness (IOC) and tissue oxygen saturation with cerebral (rSO2-C) and somatic thoracodorsal (rSO2-S) were monitored. Intraoperative hemodynamic and postoperative hemodynamic and pain scores were evaluated for 24 h after surgery. Face, Legs, Activity, Cry, Consolability (FLACC) score was utilized to measure postoperative pain in the intensive care unit. Rescue 0.05 mg·kg(-1) IV morphine was applied to patients in whom FLACC was >3.. The median age of the patients was 4.5 (1-11) months, and the median intraoperative endtidal isoflurane concentration was 0.6% (0.3-0.8). The amount of remifentanil used intraoperatively was 4.5 (2.5-14) μg·kg(-) (1) ·h(-1). Intraoperative heart rate and blood pressure values significantly decreased compared with values detected at 5th, 10th, and 15th min after TPVB application, after incision prior and after cross-clamp (P < 0.01). The median time of first dose of morphine application after block was 320 (185-430) min. The median morphine consumption in 24 h was 0.16 (0.09-0.4) mg·kg(-1). The median length of postoperative intensive care unit and in-hospital stay times was 23 (1-67) h and 4 (1-10) days, respectively.. We believe that TPVB, as part of a balanced anesthetic and analgesic regime, provides effective pain relief in patients undergoing aortic coarctation repair.

Topics: Analgesics, Opioid; Anesthesia, Spinal; Anesthetics, Intravenous; Aortic Coarctation; Blood Pressure; Cardiac Surgical Procedures; Cohort Studies; Female; Heart Rate; Humans; Infant; Male; Monitoring, Intraoperative; Morphine; Oxygen; Pain, Postoperative; Piperidines; Preanesthetic Medication; Prospective Studies; Remifentanil; Ultrasonography, Interventional

Topics: Analgesics, Opioid; Anesthetics; Breast Neoplasms; Chronic Pain; Female; Humans; Hyperalgesia; Methyl Ethers; Pain, Postoperative; Piperidines; Propofol

Topics: Analgesics, Opioid; Anesthetics; Breast Neoplasms; Chronic Pain; Female; Humans; Hyperalgesia; Methyl Ethers; Pain, Postoperative; Piperidines; Propofol

Intraoperative nerve lesions can lead to chronic postoperative pain. There are conflicting data as to whether or not anaesthetics administered intraoperatively are beneficial. We investigated if remifentanil administered at the time of nerve injury was able to attenuate neuropathic hypersensitivity.. Rats were anaesthetized with isoflurane, endotracheally intubated, and a tail vein catheter was inserted. Rats received an i.v. infusion of either saline or low- or high-dose remifentanil (2 or 20 μg kg(-1) min(-1), respectively) for 20 min. During this time, rats received a spinal nerve L5 transection to induce neuropathic pain or a sham procedure. Behavioural tests to assess mechanical and cold allodynia and heat hyperalgesia were performed on postoperative days 1, 3, 7, 14, 21, and 28.. Sham-operated animals exhibited no hypersensitivity regardless of the intraoperative remifentanil dose. In rats which received spinal nerve L5 transection, mechanical and cold allodynia developed with no significant differences between treatment groups. However, thermal hyperalgesia was reduced in rats given high-dose remifentanil: mean (standard deviation) area under the curve 426 (53) compared with 363 (34) and 342 (24) in saline or low-dose remifentanil treated rats, respectively (P<0.05).. High-dose remifentanil administered at the time of transection of the spinal nerve at L5 prevents subsequent thermal hyperalgesia.

Topics: Analgesics, Opioid; Animals; Area Under Curve; Behavior, Animal; Cold Temperature; Data Interpretation, Statistical; Hot Temperature; Hyperalgesia; Male; Neuralgia; Pain, Postoperative; Physical Stimulation; Piperidines; Rats; Rats, Sprague-Dawley; Remifentanil; Spinal Nerves

There is currently no evidence about the genetic bases of postoperative pain variability in children.. We prospectively followed a cohort of 168 children after orthopedic or abdominal surgery, who were under morphine patient-controlled analgesia. The children and their parents were genotyped for 6 candidate-gene polymorphisms (single-nucleotide polymorphisms [SNPs]) implicated in nociception and opiate metabolism: ABCB1C3435T, COMTVal158Met, NTRK1His40Tyr, OPRMA118G, POMCArg236Gln, and a haplotype of CYP2D6. Postoperative pain was assessed using the Faces Pain Scale (FPS), at rest and during mobilization, 11 times during the first 24 postoperative hours.. At rest, and to a lesser extent, at mobilization, having at least 4 pain peaks of FPS score >6 in 24 hours was more frequent in children with ABCB1_CC than in children with ABCB1_CT and ABCB1_TT (adjusted risk ratio = 4.5; 95% confidence interval [CI],1.5-13.4; corrected CI for multiple comparisons, 0.98-20.55) and was more frequent in children with OPRM_GA than those with OPRM_AA (adjusted risk ratio = 3.5; 95% CI, 1.1-11.2; corrected CI, 0.70-17.30). After adjusting for parental mating type and correcting for multiple comparisons, mean FPS scores across the 24 postoperative hours were higher for OPRM_GA than for OPRM_AA at rest (P < 0.0002), higher for NTRK1_ CT or NTRK1_ TT than NTRK1_ CC during mobilization (P = 0.002), and lower for COMT_GG than COMT_AA and COMT_GA, during mobilization (P = 0.005).. ABCB1 and OPRM genotypes are associated with clinically meaningful pain variability, whereas NTRK1 and COMT are linked to subclinical effects. This first but small cohort study provides clues to further explore the genetic foundations of pediatric pain.

Topics: Adolescent; Analgesia; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Child; Child, Preschool; Cohort Studies; Female; Genetic Predisposition to Disease; Genotype; Humans; Longitudinal Studies; Male; Morphine; Pain; Pain Measurement; Pain, Postoperative; Piperidines; Polymorphism, Single Nucleotide; Prospective Studies; Remifentanil; Sufentanil; Switzerland; Treatment Outcome

Although remifentanil provides perfect analgesia during surgery, postoperative hyperalgesia after remifentanil administration might be a challenge to anesthesiologists. The trafficking and activation of N-methyl-D-aspartate (NMDA) receptors have a pivotal role in the development and maintenance of remifentanil-induced postoperative hyperalgesia. However, the underlying mechanisms of hyperalgesia are poorly elucidated. We designed the present study to examine the hypothesis that glycogen synthase kinase (GSK)-3β could contribute to remifentanil-induced postoperative hyperalgesia via regulating NMDA receptor trafficking in the spinal cord.. Using a rat model of remifentanil-induced postoperative hyperalgesia, we first tested thermal and mechanical hyperalgesia at baseline (24 hours before incision) and 2, 6, 24, and 48 hours after remifentanil infusion. GSK-3β mRNA and protein expression and NMDA receptor subunits (NR1, NR2A, and NR2B) trafficking in the spinal cord L4-L6 segments were then measured using real-time polymerase chain reaction and Western blot analysis. Furthermore, we investigated the effects of TDZD-8, a selective GSK-3β inhibitor, on remifentanil-induced postoperative hyperalgesia and NMDA receptor subunits trafficking.. Remifentanil induced significant postoperative hyperalgesia, as indicated by increased paw withdrawal latencies and thresholds to thermal and mechanical stimulation, which were markedly improved by pretreatment with TDZD-8. Moreover, remifentanil infusion increased the expression of GSK-3β mRNA and protein as well as the GSK-3β activity in the spinal cord. More importantly, intraoperative infusion of remifentanil increased NMDA receptor subunits (NR1 and NR2B) trafficking from the intracellular pool to surface pool in the spinal cord, which was significantly attenuated by TDZD-8.. The above results suggest that activation of GSK-3β contributes to remifentanil-induced postoperative hyperalgesia via regulating NMDA receptor subunits (NR1 and NR2B) trafficking in the spinal cord. Inhibition of GSK-3β may be an effective novel option for the treatment of remifentanil-induced postoperative hyperalgesia.

Topics: Analgesics, Opioid; Animals; Blotting, Western; Glycogen Synthase Kinase 3; Glycogen Synthase Kinase 3 beta; Hot Temperature; Hyperalgesia; Male; Pain, Postoperative; Physical Stimulation; Piperidines; Rats; Rats, Sprague-Dawley; Real-Time Polymerase Chain Reaction; Receptors, N-Methyl-D-Aspartate; Remifentanil; RNA, Messenger; Spinal Cord; Thiadiazoles

In rodents, surgery and/or remifentanil induce postoperative pain hypersensitivity together with glial cell activation. The same stimulus also produces long-lasting adaptative changes resulting in latent pain sensitization, substantiated after naloxone administration. Glial contribution to postoperative latent sensitization is unknown. In the incisional pain model in mice, surgery was performed under sevoflurane+remifentanil anesthesia and 21 days later, 1 mg/kg of (-) or (+) naloxone was administered subcutaneously. Mechanical thresholds (Von Frey) and glial activation were repeatedly assessed from 30 min to 21 days. We used ionized calcium binding adaptor molecule 1 (Iba1) and glial fibrillary acidic protein (GFAP) to identify glial cells in the spinal cord and dorsal root ganglia by immunohistochemistry. Postoperative hypersensitivity was present up to 10 days, but the administration of (-) but not (+) naloxone at 21 days, induced again hyperalgesia. A transient microglia/macrophage and astrocyte activation was present between 30 min and 2 days postoperatively, while increased immunoreactivity in satellite glial cells lasted 21 days. At this time point, (-) naloxone, but not (+) naloxone, increased GFAP in satellite glial cells; conversely, both naloxone steroisomers similarly increased GFAP in the spinal cord. The report shows for the first time that surgery induces long-lasting morphological changes in astrocytes and satellite cells, involving opioid and toll-like receptors, that could contribute to the development of latent pain sensitization in mice.

Topics: Anesthetics, Intravenous; Animals; Astrocytes; Behavior, Animal; Ganglia, Spinal; Hyperalgesia; Male; Mice; Pain, Postoperative; Piperidines; Remifentanil; Spinal Cord

Although the need for increased postoperative analgesia in smokers has been described, the effect of secondhand smoke on postoperative analgesia requirements has not been studied. We examined the effects of secondhand smoke on fentanyl consumption and postoperative pain.. In this study, 101 patients (American Society of Anesthesiology physical status I and II) who underwent abdominal hysterectomy were divided into 3 groups according to history of exposure to cigarette smoke as per medical records which was retrospectively confirmed by measurement of serum cotinine: smokers (n = 28), nonsmokers (n = 31), and secondhand smokers (n = 32). All patients received propofol-remifentanil total intravenous anesthesia and used fentanyl patient controlled analgesia for postoperative pain. The fentanyl consumption visual analogue scale-pain intensity (VAS-PI) score and side effects were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 h after surgery.. Fentanyl consumption at all the evaluation time points was significantly higher in secondhand smokers than in nonsmokers (P < 0.05). However, fentanyl consumption in secondhand smokers was lower than that in smokers in the PACU and at 24 h (P < 0.05). VAS-PI scores during movement and at rest in the PACU and at 4, 6, and 24 h after surgery were higher in secondhand smokers than in nonsmokers (P < 0.05). There were no statistically significant differences between the groups with regard to side effects such as nausea, vomiting, and dizziness (P > 0.05).. Secondhand smoking was associated with increased postoperative fentanyl consumption, and increased VAS-PI scores. These findings may be beneficial for managing postoperative pain in secondhand smokers.

Topics: Adult; Aged; Anesthetics, Intravenous; Female; Fentanyl; Humans; Middle Aged; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Retrospective Studies; Tobacco Smoke Pollution

Topics: Analgesics, Opioid; Female; Humans; Male; Middle Aged; Oral Surgical Procedures; Pain, Postoperative; Piperidines; Postoperative Care; Remifentanil; Time Factors

Tissue injury and/or opioids induce plastic changes in the spinal cord resulting in pain hypersensitivity; the contribution of the dorsal root ganglia (DRG) is poorly understood. We evaluated DRG phenotypic changes induced by surgery and/or remifentanil in a mice model of postoperative pain using as neuronal markers ERK1/2 and c-Fos; prodynorphin mRNA and dynorphin levels were also determined. We hypothesized that a correlation between nociception and DRG reactivity would occur. Surgery and/or remifentanil induced mechanical hypersensitivity, correlated with ERK1/2 phosphorylation and c-Fos expression in the DRG; changes were greater in the remifentanil + incision group and still present on day 14 (p < 0.01 vs. control). Intrathecal PD98059 (ERK1/2 inhibitor) partially reversed the mechanical hypersensitivity (44%, p < 0.05) observed in the remifentanil + incision group. In this group, significant increases in prodynorphin mRNA (at 2, 7, and 14 days, p < 0.01) roughly coincided with increases in dynorphin (days 2 and 14, p < 0.001) in the DRG. Remifentanil or incision (alone) also induced an up-regulation in prodynorphin mRNA expression on days 7 and 14 (p < 0.01, p < 0.05, respectively), partially correlating with dynorphin levels. On day 21, all molecular changes returned to control levels in all experimental conditions, concurring with the complete recovery of nociceptive thresholds. Surgery and/or remifentanil induce up-regulation of c-Fos and pERK in the DRG, approximately correlating with nociceptive behavior, also associated with an increased expression of prodynorphin/dynorphin. These changes support the role of the DRG in the development and maintenance of pain hypersensitivity after surgery. The findings could contribute to the development of new therapeutic agents focused on peripheral targets.

Topics: Analgesics, Opioid; Animals; Behavior, Animal; Dynorphins; Enkephalins; Ganglia, Spinal; Hyperalgesia; Male; Mice; Mitogen-Activated Protein Kinase 1; Mitogen-Activated Protein Kinase 3; Pain, Postoperative; Piperidines; Protein Precursors; Proto-Oncogene Proteins c-fos; Remifentanil; RNA, Messenger

Numerous studies have demonstrated that prolonged opioid exposure can enhance pain sensitivity that presents as opioid-induced hyperalgesia (OIH). Activation of spinal α2-adrenergic receptor may play an important role in the development of OIH. Dexmedetomidine is an α2-adrenergic agonist that has been shown to synergize with opioids. The aim of this study was to investigate the antihyperalgesia effects of dexmedetomidine on remifentanil-induced postinfusion hyperalgesia in a rat model of incision pain. We also evaluated whether the antihyperalgesic effects of dexmedetomidine were associated with suppression of NMDAR excitability, as measured by a reduction in spinal cord NR2B phosphorylation. Dexmedetomidine (12.5 μg/kg, 25 μg/kg, 50 μg/kg) was administered subcutaneously 30 min before plantar incision. Pretreatment with dexmedetomidine significantly decreased remifentanil-induced hyperalgesia, as indicated by increased paw withdrawal latencies and thresholds to thermal and mechanical stimulation respectively. Correlated with the pain behavior changes, Western blotting experiments also revealed that dexmedetomidine could decrease NR2B subunit phosphorylation (Tyr1472 site) in the dorsal horn, which was upregulated after remifentanil infusion. These results suggest that dexmedetomidine can efficiently alleviate OIH and it may be an effective novel option for the treatment of OIH. Our data also provide evidence that dexmedetomidine's anti-hyperalgesic effect may depend on its ability to modulate spinal cord NMDAR activation via suppression of NR2B phosphorylation.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Animals; Blotting, Western; Dexmedetomidine; Disease Models, Animal; Hyperalgesia; Male; Pain, Postoperative; Phosphorylation; Piperidines; Rats; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Remifentanil; Spinal Cord; Tyrosine

Topics: Cholecystectomy, Laparoscopic; Female; Humans; Ketamine; Male; Pain, Postoperative; Piperidines; Propanolamines

Minimal access cardiac surgery via minithoracotomy aims faster recovery and shorter hospital length of stay. Pain control is essential in order to achieve this goal. A study was conducted to assess the quality of post-operative analgesia and complications related to the analgesia techniques after cardiac surgery by minithoracotomy.. A descriptive, observational and retrospective study was conducted on the patients subjected to minimal access cardiac surgery in our centre between the years 2009 to 2011. The patients were divided into two groups according to the type of analgesia received: analgesia through a paravertebral catheter, with an infusion of local anaesthetics (PVB group), and intravenous analgesia with opioids (IOA group). The aim of the study was to compare the analgesic quality and the complications associated to the analgesic technique, extubation time, post-surgical complications, and length of hospital stay between both techniques.. A total of 37 patients underwent to a modified minimally invasive Heart-Port access cardiac surgery. Fifteen patients received analgesia through a paravertebral block and the other 22 IV analgesia with opioids. Data are shown as means and standard deviation (SD). Mean tracheal extubation time less than 4 hours was observed in 60% of the patients in the PVB group, compared to 22% in the IOA group (P<.05). Length of stay in ICU for the PVB group was 1.2 (0.7) days compared to 2.2 (0.7) days in the IOA group (P<.05). Mean hospital stay was 4.8 (1.2) days for the PVB group, and 5.6 (2.8) for the IOA group (P>.05. No complications associated to the continuous paravertebral block were observed.. PVB analgesia is an acceptable safe technique in cardiac surgery via thoracotomy which enables early extubation with optimal pain control when compared with IV analgesia with opioids.

Topics: Acetaminophen; Adult; Amides; Analgesia; Analgesics; Analgesics, Opioid; Anesthesia, Inhalation; Anesthesia, Intravenous; Cardiac Surgical Procedures; Catheterization; Female; Humans; Infusions, Intravenous; Lidocaine; Male; Methyl Ethers; Middle Aged; Minimally Invasive Surgical Procedures; Morphine; Nerve Block; Pain, Postoperative; Piperidines; Remifentanil; Retrospective Studies; Ropivacaine; Sevoflurane; Thoracotomy

Radical cystectomy is associated with significant morbidity, with rates of gastrointestinal complications as high as 30%. Alvimopan is a mu opioid receptor antagonist that has been shown in randomized control trials to accelerate gastrointestinal recovery in patients undergoing bowel resection with primary anastamosis. We report our experience with gastrointestinal recovery for patients undergoing cystectomy with urinary diversion treated with alvimopan.. Between January 2008 and August 2011, 50 consecutive patients underwent radical cystectomy with urinary diversion at our institution. The first 27 patients in our study did not receive alvimopan preoperatively. The latter 23 patients received perioperative alvimopan and were without postoperative nasogastric decompression. Return of bowel function, initiation of diet, and gastrointestinal complications were evaluated.. Times to first flatus (3.1 versus 5.6 days, p < 0.001, 95% CI 1.66-3.26) and bowel movement (3.8 versus 6.0 days, p < 0.001, 95% CI 1.35-2.99) were significantly shorter in those patients who received alvimopan. Additionally, the initiation of clear liquid diet (4.1 versus 6.3 days, p < 0.001, 95% CI 1.20-3.12), regular diet (5.7 versus 7.3 days, p = 0.023, 95% CI 0.57-2.63) and hospital discharge (7.4 versus 9.5 days, p = 0.04, 95% CI 0.03-4.21) were accelerated in the alvimopan cohort. There were no incidences of prolonged ileus in patients who received perioperative alvimopan (0% versus 25.9%, p = 0.012).. In our experience, the use of alvimopan perioperatively significantly accelerates the rate of gastrointestinal recovery and hospital discharge, eliminates the need for nasogastric tube decompression, and reduces the incidence of postoperative ileus in patients following radical cystectomy and urinary diversion.

Topics: Aged; Analgesics, Opioid; Cystectomy; Eating; Female; Gastrointestinal Agents; Gastrointestinal Tract; Humans; Ileus; Intubation, Gastrointestinal; Length of Stay; Male; Pain, Postoperative; Piperidines; Receptors, Opioid, mu; Recovery of Function; Retrospective Studies; Time Factors; Urinary Diversion

We audited the recovery characteristics of 51 patients who had undergone orthognathic maxillofacial surgery at a single center. Patients whose anesthesia had been maintained with intravenous propofol and remifentanil (n  =  21) had significantly higher pain scores during the first 4 hours after surgery than those whose anesthesia was maintained with volatile inhalational agents and longer-acting opioids (n  =  30) (P  =  .016). There was a nonsignificant trend towards shorter recovery times in the former group, while there were no differences in early postoperative opioid usage, hemodynamic parameters, or postoperative nausea and vomiting . Given that our data were collected retrospectively and without the ability to control for potential confounders, we interpret the results with caution. Notwithstanding these limitations, we believe this is the first report comparing the effects of different opioid-based anesthetic regimens on early recovery from orthognathic surgery, and we believe this report may be used as the starting point for a controlled study.

Topics: Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Dental; Anesthesia, Inhalation; Anesthetics, Combined; Anesthetics, Intravenous; Dental Audit; Female; Heart Rate; Hemodynamics; Humans; Male; Orthognathic Surgical Procedures; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil; Retrospective Studies; Statistics, Nonparametric

The prevalence of moderate-to-severe pain after inguinal hernia repair (IHR) in adults is ≈ 10%. Two studies with very long follow-up periods (16.8 and 49 yr, respectively) have, however, suggested that the risk of developing chronic pain is much lower in children. The purpose of the present study was to examine the prevalence of chronic pain 6-48 months after IHR in children.. Postal questionnaires were sent to 156 children who had undergone IHR between the age of 6 months and 12 yr. The children were asked to recall the duration of postoperative pain, if necessary with help from their parents, and to describe the intensity and character of their pain, if the pain was still present. Children with chronic pain were offered quantitative sensory testing (QST), and a surgical examination, including ultrasound, in order to exclude hernia recurrence.. Ninety-eight children, mean (sd) age 7.8 (2.6) yr, answered the questionnaire. Their age at the time of surgery was mean (sd) 4.6 (2.4) yr, and the follow-up period was mean (sd) 3.2 (1.3) yr. Five children (5.1%, 95% confidence interval: 0.75-9.5) had pain located in the inguinal region, and three of these children underwent further examination. There was no hernia recurrence, but QST revealed pinprick hyperalgesia and decreased pressure pain thresholds on the operated side in all three children.. The prevalence of chronic pain after IHR in children is 5.1%, which is lower than the prevalence reported after adult hernia repair.

Topics: Anesthesia, Intravenous; Anesthetics, Intravenous; Child; Child, Preschool; Chronic Pain; Female; Hernia, Inguinal; Herniorrhaphy; Humans; Infant; Male; Nerve Block; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Surveys and Questionnaires

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Female; Humans; Hyperalgesia; Male; Nitrous Oxide; Pain, Postoperative; Piperidines; Propofol

Endothelin-1 is known to be a potent vasoconstrictor. Administration of endothelin-1 to the central nervous system (CNS) induces antinociceptive effects. Nociceptive stimuli affect dorsal root ganglion (DRG) neurons and neurons/astrocytes/microglia in the dorsal horn of the spinal cord. Surgical incision in the plantar aspect of the rat hindpaw is a model for postoperative pain, and withdrawal thresholds reportedly decrease around the incision. We hypothesized that intrathecal endothelin-1 would have antinociceptive effects in this model, and affect DRG neurons and microglia/neurons in the dorsal horn. Intrathecal endothelin-1 partially restored the withdrawal threshold (which was decreased by plantar incision). BQ-123, and BQ-788 (specific endothelin ET(A)- and ET(B)-receptor antagonists, respectively) attenuated the increase in withdrawal threshold induced by endothelin-1. Phosphorylation of extracellular signal-regulated kinase (ERK) in DRG neurons and microglial activation/ERK phosphorylation in the dorsal horn were observed following the incision. Endothelin-1 decreased the incision-induced increase in the numbers of phosphorylated ERK-positive neurons in DRG and activated microglia in the dorsal horn, without affecting the numbers of phosphorylated ERK-positive neurons in the dorsal horn. BQ-123 or BQ-788 partially suppressed these endothelin-1-induced alterations. Our results show that the pain threshold, which is decreased by surgical stimuli, is partially restored by intrathecal endothelin-1 through both endothelin ET(A)- and ET(B)- receptors in DRG neurons and microglia in the spinal cord. Endothelin-1 administration to the CNS may be worth considering as a new candidate for the treatment of postoperative pain and to mitigate prolonged periods of pain.

Topics: Analgesics; Animals; Behavior, Animal; Disease Models, Animal; Endothelin-1; Extracellular Signal-Regulated MAP Kinases; Flavonoids; Ganglia, Spinal; Injections, Spinal; Male; Microglia; Oligopeptides; Pain Measurement; Pain Threshold; Pain, Postoperative; Peptides, Cyclic; Phosphorylation; Piperidines; Posterior Horn Cells; Protein Kinase Inhibitors; Rats; Rats, Sprague-Dawley; Receptor, Endothelin A; Receptor, Endothelin B; Time Factors

The TCI is a mode of administration that provides greater security by allowing more accurate titration of the anesthetic agent. It leads to a better adaptation to the desired effects, and provide a great interest for the realization of anesthetic induction and the prediction of waking for a well- determined population.. The aim of our prospective study was to evaluate the feasibility of TCI in patients with morbid obesity undergoing laparoscopic surgery for obesity.. Thirty patients were included in this study. Age and BMI means were 32 years and 49.31 kg / m2. Our protocol was proposed to associate an hypnotic agent (propofol) to an opioid one (remifentanil) using the technique of the TCI, with respectively Schnider and Minto models.. The induction protocol has brought good conditions for laryngoscopy with no hypertensive peak or desaturation episode. The period of unconsciousness was 89 seconds with an average target concentration of propofol of 5.1 mg / ml. We also noted hemodynamic stability in 79% of patients at induction. During both preparation phase and final installation of the patients, a low ERC to 2 hg / ml was consistent with a suitable hemodynami profile. We obtained hemodynamic stability by adapting target concentration of remifentanil at different operating times (Surgical incision: 3.64 hg / ml, insufflation of the peritoneum: 5.37 hg / ml, jejuno-jejunal resection anastomosis: 9 hg / ml, gastric resection and gastrojejunal anastomosis: 14.2 hg / ml). During this period, no episodes of bradycardia or hypotension were noticed. During the recovery phase and while doing the distribution of CEP and CER according to the BMI of patients, we identified two groups: Group 1 (BMI <49 kg / m2): fast time extubation (11 min) and target concentrations of propofol and remifentanil respectively at 1.3 mg / ml and 1.25 hg / ml which is similar to most publications on this subject and Group 2 (BMI> 49 kg / m2): time-delayed extubation (23 min) with very low values of CEP and CER inconsistent with the literature data.

Topics: Adult; Analgesics, Opioid; Anesthetics, Intravenous; Feasibility Studies; Humans; Infusions, Intravenous; Laparoscopy; Middle Aged; Obesity, Morbid; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

We report the anesthetic management of a narcoleptic patient performed using sevoflurane-remifentanil with bispectral index (BIS) monitoring. A 22-year-old man, who was diagnosed with narcolepsy at the age of 17, requested endoscopic sinus surgery, under general anesthesia, for chronic allergic rhinitis. On the morning of the day of operation, he took his daily dose of modafinil, used to control narcolepsy. Anesthesia was induced by 5% sevoflurane and maintained with sevoflurane and continuous infusion of remifentanil and 60% oxygen in conjunction with BIS monitoring. BIS values were between 47 and 58. Duration of surgery was 150 min. After surgery, the patient emerged from anesthesia within 10 min and was extubated. His recovery was uneventful. We found the use of BIS monitoring for titrating sevoflurane concentration in a narcoleptic patient is useful for preventing not only oversedation but also intraoperative awareness caused by the preoperative medication.

Topics: Anesthesia; Anesthetics, Inhalation; Anesthetics, Intravenous; Anti-Inflammatory Agents, Non-Steroidal; Benzhydryl Compounds; Central Nervous System Stimulants; Consciousness Monitors; Endoscopy; Flurbiprofen; Humans; Hypnotics and Sedatives; Male; Methyl Ethers; Modafinil; Narcolepsy; Pain, Postoperative; Piperidines; Remifentanil; Rhinitis, Allergic, Perennial; Sevoflurane; Sinusitis; Young Adult

It is well known that buprenorphine compete with remifentanil for receptor binding. I have examined the effect of buprenorphine administration on postoperative analgesia following remifentanil-based anesthesia.. In this study, I enrolled 30 patients who had undergone open reduction and internal fixation for fractures at the extremities under general anesthesia. Anesthesia was maintained with continuous infusion of remifentanil, and buprenorphine was administered at the end of surgery. Postoperative pain and side effects were evaluated in all patients.. Seventeen patients (57%) required additional analgesic treatment within 1 hour of initial administration of buprenorphine. Buprenorphine therapy in patients who had undergone lower limb surgery was not as effective as that in patients who had undergone upper limb surgery. Incidence of nausea and vomiting in the study population was high(37%).. Buprenorphine is effective to some degree as a postoperative analgesic following remifentanil-based anesthesia, but is not sufficient in cases of severe postoperative pain.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia, General; Buprenorphine; Female; Fracture Fixation, Internal; Humans; Lower Extremity; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Upper Extremity

The aim of this study was to test if intraoperative administration of N(2)O during propofol-remifentanil anaesthesia prevented the onset of postoperative opioid-induced hyperalgesia (OIH).. Fifty adult ASA I-II patients undergoing elective open septorhinoplasty under general anaesthesia were studied. Anaesthesia was with propofol, adjusted to bispectral index (40-50), and remifentanil (0.30 μg kg(-1) min(-1)). Patients were assigned to one of the two groups: with N(2)O (70%) and without N(2)O (100% oxygen). Mechanical pain thresholds were measured before surgery and 2 and 12-18 h after surgery. Pain measurements were performed on the arm using hand-held von Frey filaments. A non-parametric analysis of variance was used in the von Frey data analysis. P<0.05 was considered statistically significant.. Baseline pain thresholds to mechanical stimuli were similar in both groups, with mean values of 69 [95% confidence interval (CI): 50.2, 95.1] g in the group without N(2)O and 71 (95% CI: 45.7, 112.1) g in the group with N(2)O. Postoperative pain scores and cumulative morphine consumption were similar between the groups. The analysis revealed a decrease in the threshold value in both groups. However, post hoc comparisons showed that at 12-18 h after surgery, the decrease in mechanical threshold was greater in the group without N(2)O than the group with N(2)O (post hoc analysis with Bonferroni's correction, P<0.05).. Intraoperative 70% N(2)O administration significantly reduced postoperative OIH in patients receiving propofol-remifentanil anaesthesia.

Topics: Adolescent; Adult; Analgesics, Opioid; Anesthetics, Intravenous; Female; Humans; Hyperalgesia; Lidocaine; Male; Middle Aged; Nitrous Oxide; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil

This paper discusses the efficacy and difficulty of the management of monitored anesthesia care (MAC) for inguinal hernia repairs using tumescent local anesthesia(TLA).. Eighty patients were retrospectively divided into four groups (all n = 20) according to the drugs used; group P (propofol), group PF (propofol and fentanyl), group PFM (propofol, fentanyl and midazolam), group PR (propofol and remifentanyl). The four groups were analyzed in terms of the applied dose, airway use, wake-up test to determine whether hernia was repaired, postoperative pain and nausea.. More propofol was administered in group P than in group PFM and PR. Although, airway was used for nine patients, there was no difference between the four groups. Postoperative pain and nausea also do not differ between the groups. One patient in group P showed unsuccessful repair with wake-up test.. MAC shows a beneficial effect on inguinal hernia repairs under TLA. The rate of airway use was as high as eleven percent, and maintenance of the patients' airway requires attention. In terms of wake-up test, propofol combined with opioid administration may be more effective than propofol administration alone. There was no significant difference between the groups in pain and nausea, regardless at the use of fentanyl or remifentanil.

Topics: Aged; Aged, 80 and over; Anesthesia, Local; Female; Fentanyl; Hernia, Inguinal; Humans; Male; Midazolam; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Postoperative Nausea and Vomiting; Propofol; Remifentanil; Retrospective Studies

We gave general anesthesia for the lower right lobe resection in an infant with congenital cystic adenomatoid malformation (CCAM). Anesthesia was performed with sevoflurane inhalation, intravenous infusion of remifentanil and intermittent injection of fentanyl. Intraoperative anesthetic course was uneventful except for failure of one lung ventilation. After all surgical procedures, intercostal nerve block under direct vision by surgeon and intravenous infusion of fentanyl were performed for postoperative analgesia. Emergence from anesthesia was prompt, and the tracheal tube could be removed without any troubles. Remifentanil is an effective and safe opioid to use for thoracic surgery even in infants.

Topics: Anesthesia, General; Cystic Adenomatoid Malformation of Lung, Congenital; Female; Fentanyl; Humans; Infant; Methyl Ethers; Pain, Postoperative; Piperidines; Pneumonectomy; Remifentanil; Sevoflurane

There is a controversy about the development of acute opioid tolerance during remifentanil infusion for postoperative pain. We investigated whether intraoperative remifentanil infusion leads to rapid development of tolerance. We also investigated whether adjuvant analgesic is effective or not.. One hundred and thirty patients scheduled for TKA were divided into 4 groups; Non-remifentanil infusion group (30 patients; group A). This group was given a bolus of fentanyl 0.2 mg at the induction of anesthesia. In remifentanil anesthesia group (100 patients), remifentanil was given 0.2-0.3 microg x kg(-1) min(-1) and divided into three groups; 23 patients group B given a bolus of 0.2 mg fentanyl at induction of anesthesia, 38 patients group C given a bolus of fentanyl 0.2 mg at skin closure, and 39 patients group D given a bolus of fentanyl 0.2 mg at skin closure and administrated diclofenac sodium suppository rectally at induction of anesthesia. Intravenous patient controlled analgesia (PCA) of fentanyl was commenced before skin incision for all patients. Pain was scored at rest and during movement for 24 postoperative hours.. Numerical rating scale (NRS) scores during movement after 24 hours in group B were significantly higher than in group A. And, the NRS scores in group D tended to be lower than the other groups, but there were no significant differences.. Intraoperative remifentanil increased postoperative pain during movement. Remifentanil seems to cause acute torelance. NSAIDs given before operation may be useful for postoperative analgesia.

Topics: Aged; Aged, 80 and over; Analgesia, Patient-Controlled; Analgesics, Opioid; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Arthroplasty, Replacement, Knee; Diclofenac; Drug Tolerance; Female; Humans; Infusions, Intravenous; Male; Pain Measurement; Pain, Postoperative; Piperidines; Preoperative Care; Remifentanil; Time Factors

In humans, remifentanil anesthesia enhances nociceptive sensitization in the postoperative period. We hypothesized that activation of extracellular signal-regulated kinases 1 and 2 (ERK1/2) and the expression of c-Fos, prodynorphin (mRNA), and dynorphin in the spinal cord could participate in the molecular mechanisms underlying postoperative opioid-induced sensitization. In a mouse model of incisional pain, we evaluated thermal (Hargreaves test) and mechanical (von Frey) hyperalgesia during the first 21 postoperative days. Moreover, prodynorphin (mRNA, real-time polymerase chain reaction), dynorphin (enzymatic immunoassay), c-Fos expression, and ERK1/2 phosphorylation (both by immunohistochemistry) in the lumbar spinal cord were assessed. Surgery performed under remifentanil anesthesia induced a maximal decrease in nociceptive thresholds between 4 h and 2 days postoperatively (p < 0.001) that lasted 10 to 14 days compared with noninjured animals. In the same experimental conditions, a significant increase in prodynorphin mRNA expression (at 2 and 4 days) followed by a sustained increase of dynorphin (days 2 to 10) in the spinal cord was observed. We also identified an early expression of c-Fos immunoreactivity in the superficial laminae of the dorsal horn of the spinal cord (peak at 4 h; p < 0.001), together with a partial activation of ERK1/2 (4 h; p < 0.001). These findings suggest that activated ERK1/2 could induce c-Fos expression and trigger the transcription of prodynorphin in the spinal cord. This in turn would result in long-lasting increased levels of dynorphin that, in our model, could participate in the persistence of pain but not in the manifestation of first pain.

Topics: Anesthetics, Intravenous; Animals; Dynorphins; Genes, fos; Male; Mice; Mitogen-Activated Protein Kinase 1; Mitogen-Activated Protein Kinase 3; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Spinal Cord

Anticipating postoperative pain is a routine practice in our institution. As part of a quality assurance program we used our computerized anesthetic record system database to evaluate incidence of patients having very severe postoperative pain (grade 4 on a subjective pain scale ranging from 0 to 4) in the Post Anesthetic Care Unit during a two year period. These patients were compared to a control group matched on age, type and date of surgery. Demographic characteristics, type and duration of the surgery, preoperative and intra-operative medications were compared between groups.. 78 patients out of 12,510 (0.6%) with a pain score of 4 were compared to another group of 78. No significant difference was observed with regards of demographic characteristics, duration, type of surgery, and operative pain medications. Pain scores and morphine consumption were significantly higher in the cases study group in comparison to the controlled group, 4 vs 1.6+/-1.1, (p<0.05) and 13.2+/-6 vs. 6.9+/-7mg (p<0.05). Patients in the cases study group had significantly more preoperative psychoactive medication: antidepressant and benzodiazepine 13 vs. 2, (p<0.05).. The incidence of severe postoperative pain scores were less than 1% in our institution. In patients with preoperative opioid treatment, adaptation of analgesic treatment has probably prevented the occurrence of severe pain. Multimodal anticipation of postoperative pain should remain mandatory while efforts should focus to identify such patients before surgery.

Topics: Analgesics, Opioid; Anesthetics, Local; Case-Control Studies; Female; Humans; Incidence; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Sufentanil

Topics: Analgesics, Opioid; Drug Tolerance; Humans; Hyperalgesia; Pain, Postoperative; Piperidines; Remifentanil

The ultra-short-acting mu-opioid receptor (MOR) agonist remifentanil enhances postsurgical pain when used as main anesthetic in animal models and man. Although the mechanism/s involved are poorly characterized, changes in opioid receptor expression could be a relevant feature. Using a mouse model of postoperative pain, we assessed the expression of MOR and delta opioid receptors (DORs) and the efficacy of Herpes Simplex vector-mediated proenkephalin release (SHPE) preventing postoperative nociceptive sensitization induced by remifentanil or surgical incision. We determined MOR and DOR expressions in the dorsal root ganglia and the spinal cord after remifentanil or surgery in CD1 mice, using real-time PCR and Western blotting. We also assessed the effect of SHPE on nociception induced by remifentanil, surgery, and their combination (2 and 7 days after manipulation), using thermal and mechanical tests. Both remifentanil and surgery decreased DOR mRNA levels (up to days 2 and 4, respectively) in the dorsal root ganglia, but not in the spinal cord. No changes were observed in MOR mRNA, or in receptor-protein levels (Western) of either receptor. Pre-treatment with SHPE 7 days before manipulation prevented remifentanil-induced thermal hyperalgesia and mechanical allodynia and the increase in incisional pain observed when surgery was performed under remifentanil anesthesia. SHPE also prevented surgically induced allodynia but not hyperalgesia, which was blocked by the additional administration of RB101, an enkephalinase inhibitor. The study suggests that down-regulation of DOR contributes to remifentanil and surgery-induced nociception, and that postoperative pain is completely reversed by increasing enkephalin levels in the spinal cord and the periphery.

Topics: Analgesics; Animals; Disease Models, Animal; Disulfides; Down-Regulation; Enkephalins; Ganglia, Spinal; Male; Methyl Ethers; Mice; Pain Measurement; Pain Threshold; Pain, Postoperative; Phenylalanine; Piperidines; Protein Precursors; Receptors, Opioid, delta; Receptors, Opioid, mu; Remifentanil; RNA, Messenger; Sevoflurane; Spinal Cord; Time Factors

Remifentanil is reported to be cleared rapidly more than other any opioids. It is considered that this characteristic may lead to an increase in postoperative pain and shivering after general anesthesia with remifentanil. This study was aimed to examine the influence of remifentanil to these adverse symptoms in comparison with fentanyl.. The subjects consisted of 41 female patients having undergone a total intravenous anesthesia with remifentanil or/and fentanyl for gynecological laparoscopic surgery.. There was no significant difference in the occurrence of postoperative pain. Shivering occurred significantly more frequently in patients who had received remifentanil anesthesia, associated with a significant lower body temperature after general anesthesia.. Careful management of intraoperative body temperature is important to prevent the occurrence of shivering after total intravenous general anesthesia with remifentanil.

Topics: Anesthesia, General; Anesthesia, Intravenous; Body Temperature; Female; Fentanyl; Gynecologic Surgical Procedures; Humans; Intraoperative Care; Laparoscopy; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Retrospective Studies; Shivering

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Drug Therapy, Combination; Humans; Morphine; Pain, Postoperative; Piperidines; Remifentanil; Time Factors

Topics: Analgesics; Analgesics, Opioid; Anesthetics, Intravenous; Drug Interactions; Drug Tolerance; Humans; Hyperalgesia; Intraoperative Care; Ketamine; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Research Design

Anesthetic goals for procedures involving resections close to the motor cortex include immobility, analgesia, and a level of consciousness that allows for the ability to follow motor commands. Remifentanil as a single agent is an attractive choice, particularly when ventilation is controlled. The successful use of large-dose remifentanil infusion during an awake craniotomy in a 16 year-old man and the subsequent severe acute opioid tolerance is presented.

Topics: Adolescent; Analgesics, Opioid; Anesthesia; Consciousness; Craniotomy; Drug Tolerance; Epilepsy; Fentanyl; Hematoma, Epidural, Cranial; Humans; Male; Morphine; Motor Cortex; Pain, Postoperative; Piperidines; Postoperative Complications; Remifentanil; Wakefulness

Co-administration of ketamine and remifentanil may offer preemptive analgesia and prevention of opioid-induced hyperalgesia, resulting in reduction of postoperative pain.. We retrospectively analyzed data concerning anesthetic management and postoperative pain management in 19 adult patients undergoing elective laparotomy with general anesthesia using ketamine and remifentanil.. Ketamine and remifentanil were co-administered for both induction and maintenance of general anesthesia. Preoperative and total doses of ketamine were 1.4+/-0.5 and 1.9+/-0.4 mg x kg(-1). Infusion rate of remifentanil at the beginning of surgery was 0.24+/-0.02 microg x kg(-1) x min(-1), and minimal and maximal rate were 0.06+/-0.03 and 0.26+/-0.03 microg x kg(-1) min(-1). Pentazocine and nonsteroidal anti-inflammatory drugs (NSAIDs) were used for postoperative pain management. Consumption of pentazocine was 0.51+/-0.33 mg x kg(-1) on 1st postoperative day (1POD), and NSAIDs were co-administered on 1POD for 3 patients. Most patients could stand up and walk on 1POD.. Results in this study suggest that anesthetic management using ketamine and remifentanil may be useful for postoperative pain management, probably by preemptive analgesic effects of both agents and preventive effects of ketamine against opioid-induced hyperalgesia.

Topics: Adult; Aged; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Elective Surgical Procedures; Female; Humans; Hyperalgesia; Ketamine; Laparotomy; Male; Middle Aged; Pain, Postoperative; Pentazocine; Piperidines; Remifentanil; Retrospective Studies

Substance P (SP) signaling facilitates nociceptive sensitization in various inflammatory and chronic pain models and we postulated that SP signaling might also contribute to the development of post-incisional hyperalgesia. These studies used mice with a deletion of the pre-protachykinin A gene (ppt-A(-/-)) which codes for SP to determine the role of SP signaling in post-incisional pain and in the increased cytokine and nerve growth factor (NGF) expression observed in the incised skin. SP deficient ppt-A(-/-) mice displayed reduced mechanical allodynia and heat hyperalgesia compared to the wild-type (wt) mice at all post-incision time points, despite similar baseline values (p<0.001). Furthermore, the NK-1 receptor antagonist LY303870 attenuated mechanical allodynia produced by incision in the wt mice (p<0.001). Incision also up-regulated IL-6, TNF-alpha and KC levels but not IL-1beta after 2h in the wt mice skin. However, ppt-A(-/-) mice had more skin NGF levels 2h post-incision. Subcutaneous hind paw SP injection produced acute and transient elevations of IL-1beta, IL-6, and KC but modest elevations in TNF-alpha levels in the wt mice. Systemic LY303870 reversed the SP-induced elevations of these cytokines. Hind paw injection of IL-6 and NGF dose dependently produced less mechanical allodynia in the ppt-A(-/-) compared to wt mice. Additionally, SP produced mechanical allodynia in a dose-dependent fashion in wt mice. Therefore, SP supports nociceptive sensitization after hind paw incision and potentially participates directly in modulating the intensity of inflammatory response in peri-incisional tissue.

Topics: Analysis of Variance; Animals; Cytokines; Disease Models, Animal; Dose-Response Relationship, Drug; Gene Expression Regulation; Hyperalgesia; Indoles; Male; Mice; Mice, Inbred C57BL; Mice, Knockout; Nerve Growth Factor; Neurokinin-1 Receptor Antagonists; Pain Measurement; Pain Threshold; Pain, Postoperative; Piperidines; Protein Precursors; Signal Transduction; Substance P; Tachykinins; Time Factors

In this study the impact of 25 mg of ketamine racemate given just before surgery on recovery times and postoperative analgesic needs in patients undergoing vaginal hysterectomy and receiving propofol-remifentanil anaesthesia was investigated.. With ethics committee approval 70 female patients aged 25-65 years were enrolled. All patients received a total intravenous anaesthesia with remifentanil and propofol with the propofol infusion being controlled to a Narcotrend index of 40. Patients in the ketamine group (n=35) received additionally a bolus dose of 25 mg ketamine racemate intravenously 3 min before skin incision. In addition to monitoring haemodynamics and circulation parameters, recovery times, postoperative pain and opioid needs were also recorded. Patients were also questioned on their satisfaction with the pain therapy.. All 70 patients completed the study and the groups were similar with respect to demographic data. The haemodynamics of the patients were stable in both groups and the postoperative pain measured over a 24-h period as well as the opioid needs were also comparable. However, recovery times were significantly prolonged in the ketamine group, e.g. the times to extubation were 8.3+/-4.0 min with ketamine compared to 6.1+/-2.1 min in the control group (p<0.01). Undesired side effects were overall rare but occurred to the same extent in both groups.. This study demonstrated that 25 mg ketamine racemate given just before surgery significantly prolongs recovery times without reducing post-operative analgesic needs when applied to patients undergoing vaginal hysterectomy and receiving propofol-remifentanil anaesthesia. A bolus dose of 25 mg ketamine racemate cannot therefore be recommended for preemptive analgesia under these conditions.

Topics: Adult; Aged; Analgesics, Opioid; Anesthesia; Anesthesia Recovery Period; Anesthetics, Dissociative; Anesthetics, Intravenous; Female; Hemodynamics; Humans; Hysterectomy, Vaginal; Ketamine; Middle Aged; Monitoring, Intraoperative; Pain, Postoperative; Piperidines; Premedication; Propofol; Remifentanil; Stereoisomerism; Time Factors

Remifentanil anesthesia enhances postoperative pain in animals and humans. The authors evaluated the impact of the dose (microg x kg(-1) x min(-1)) and duration of remifentanil infusion, and the effects of a second surgery on postoperative pain sensitization.. Mice received different doses of remifentanil over 30 or 60 min. The authors assessed thermal (Hargreaves) and mechanical hyperalgesia (von Frey) at 2, 4, 7, and 10 days. In other experiments, mice had a plantar incision during sevoflurane with or without remifentanil anesthesia that was repeated 27 days later, when nociceptive thresholds returned to baseline. Linear mixed models were used for statistical analysis.. Remifentanil induced dose-dependent pronociceptive effects with calculated ED(50)s of 1.7 (95% confidence interval, 1.3-2.1) and 1.26 (1.0-1.6) microg x kg(-1) x min(-1) for thermal and mechanical hyperalgesia, respectively, which lasted longer with higher doses (P < 0.001). The duration of infusion did not alter the pronociceptive effects of remifentanil when administered at a constant dose of infusion. When given during surgery, high (2.66 microg x kg(-1) x min(-1)) or low (0.66 microg x kg(-1) x min(-1)) remifentanil increased the extent (P < 0.05) and duration (P < 0.01) of thermal and mechanical hyperalgesia. The latter was further enhanced after a second surgery performed in the same experimental conditions (P < 0.05). Surgery or remifentanil infusion, each one individually, induced significant mechanical hyperalgesia, which was greater when repeated (P < 0.05).. In this model of incisional pain, remifentanil induces pronociceptive effects, which are dose dependent but unaltered by the duration of administration. A second surgery performed on the same site and experimental conditions induces greater postoperative hyperalgesia that is enhanced when remifentanil is used as an anesthetic.

Topics: Analgesics, Opioid; Anesthetics, Intravenous; Animals; Dose-Response Relationship, Drug; Hot Temperature; Hyperalgesia; Male; Mice; Nociceptors; Pain Threshold; Pain, Postoperative; Physical Stimulation; Piperidines; Remifentanil

Experimental and clinical studies showed that intraoperative infusion of remifentanil has been associated with postoperative hyperalgesia. Previous reports suggested that spinal N-methyl-D-aspartate (NMDA) receptors may contribute to the development and maintenance of opioid-induced hyperalgesia. In the present study, we used a rat model of postoperative pain to investigate the role of tyrosine phosphorylation of NMDA receptor 2B (NR2B) subunit in spinal cord in the postoperative hyperalgesia induced by remifentanil and the intervention of pretreatment with ketamine.. Intraoperative infusion of remifentanil (0.04 mg/kg, subcutaneous) significantly enhanced mechanical allodynia and thermal hyperalgesia induced by the plantar incision during the postoperative period (each lasting between 2 h and 48 h), which was attenuated by pretreatment with ketamine (10 mg/kg, subcutaneous). Correlated with the pain behavior changes, immunocytochemical and western blotting experiments in our study revealed that there was a marked increase in NR2B phosphorylation at Tyr1472 in the superficial dorsal horn after intraoperative infusion of remifentanil, which was attenuated by pretreatment with ketamine.. This study provides direct evidence that tyrosine phosphorylation of the NR2B at Tyr1472 in spinal dosal horn contributes to postoperative hyperalgesia induced by remifentanil and supports the potential therapeutic value of ketamine for improving postoperative hyperalgesia induced by remifentanil.

Topics: Analgesics, Opioid; Animals; Disease Models, Animal; Excitatory Amino Acid Antagonists; Glutamic Acid; Hyperalgesia; Inflammation Mediators; Ketamine; Male; Nociceptors; Pain, Postoperative; Phosphorylation; Piperidines; Rats; Rats, Sprague-Dawley; Receptors, N-Methyl-D-Aspartate; Remifentanil; Spinal Cord; Synaptic Transmission; Tyrosine

In this study, we explored how a set of remifentanil-propofol response surface interaction models developed from data collected in volunteers would predict responses to events in patients undergoing elective surgery. Our hypotheses were that these models would predict a patient population's loss and return of responsiveness and the presence or absence of a response to laryngoscopy and the response to pain after surgery.. Twenty-one patients were enrolled. Anesthesia consisted of remifentanil and propofol infusions and fentanyl boluses. Loss and return of responsiveness, responses to laryngoscopy, and responses to postoperative pain were assessed in each patient. Model predictions were compared with observed responses.. The loss of responsiveness model predicted that patients would become unresponsive 2.4 +/- 2.6 min earlier than observed. At the time of laryngoscopy, the laryngoscopy model predicted an 89% probability of no response to laryngoscopy and 81% did not respond. During emergence, the loss of responsiveness model predicted return of responsiveness 0.6 +/- 5.1 min before responsiveness was observed. The mean probability of no response to pressure algometry was 23% +/- 35% when patients required fentanyl for pain control.. This preliminary assessment of a series of remifentanil-propofol interaction models demonstrated that these models predicted responses to selected pertinent events during elective surgery. However, significant model error was evident during rapid changes in predicted effect-site propofol-remifentanil concentration pairs.

Topics: Adult; Elective Surgical Procedures; Female; Humans; Laryngoscopy; Male; Middle Aged; Models, Biological; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Remifentanil

Postoperative analgesia may be complicated by the occurrence of acute opiate tolerance and hyperalgesia. We present the case of a patient who underwent gynecological surgery that was complicated by intense pain in the immediate postoperative period. The pain was attributed to the development of acute opiate tolerance caused by the brief infusion of a high dose of remifentanil. The opiate tolerance was complicated by tactile hyperalgesia at the site of the surgical wound. Pain management with the usual dose of nonsteroidal anti-inflammatory drugs associated with a high dose of morphine (50 mg administered in less than 2 hours) produced no analgesic or adverse effects. The pain was finally brought under control by epidural perfusion of ropivacaine and fentanyl and subsequently maintained with multimodal analgesia.

Topics: Acetaminophen; Adnexal Diseases; Amides; Analgesia, Epidural; Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthetics, Local; Anti-Inflammatory Agents, Non-Steroidal; Drug Resistance; Drug Tolerance; Female; Fentanyl; Humans; Hyperalgesia; Hysterectomy; Ketorolac; Middle Aged; Morphine; Pain, Postoperative; Piperidines; Remifentanil; Ropivacaine

Topics: Aged; Anesthesia, General; Anti-Inflammatory Agents, Non-Steroidal; Autonomic Nerve Block; Brachial Plexus; Breast Neoplasms; Contraindications; Etomidate; Female; Histamine H1 Antagonists; Histamine Release; Humans; Lymph Node Excision; Mastectomy; Mastocytosis, Systemic; Methyl Ethers; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Sevoflurane; Trigger Finger Disorder; Tryptases

Freeman-Sheldon syndrome, or distal arthrogryposis type 2A, is a rare congenital myopathy and dysplasia characterised by multiple contractures, abnormalities of the head and face, defective development of the hands and feet and skeletal malformations. The facial muscle contracture produces the typical 'whistling face' appearance. Anaesthetic issues include difficult intravenous access, difficult airway and postoperative pulmonary complications. Although an association with malignant hyperthermia has been suggested, this has not been confirmed. We report the management of a seven-year-old girl with Freeman-Sheldon syndrome undergoing anterior and posterior spinal surgery and describe a successful anaesthetic regimen based on a total intravenous anaesthesia technique with remifentanil and propofol without neuromuscular blocking agents. The child had an uneventful anaesthetic and postoperative course. We believe the presence of the myopathy warranted the use of a 'non-triggering' anaesthetic, as suxamethonium and volatile agents may be associated with significant complications such as muscle rigidity and rhabdomyolysis in myopathic patients, even in the absence of malignant hyperthermia.

Topics: Abnormalities, Multiple; Anesthesia, General; Anesthetics, Intravenous; Arthrogryposis; Blood Pressure; Child; Craniofacial Abnormalities; Electroencephalography; Female; Heart Rate; Humans; Monitoring, Intraoperative; Orthopedic Procedures; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Respiration, Artificial; Scoliosis; Spine; Syndrome

For amputations of the lower limbs the combined blockade of the sciatic nerve (via the transgluteal approach) and the femoral nerve (via the inguinal route) may be a suitable alternative to general or neuroaxial anaesthetic methods. In highly comorbid, high risk patients this catheter-linked regional anaesthesia combines the advantages of avoiding controlled ventilation with decreased cardiovascular depression, as conveyed by the use of general anaesthesia or neuraxial techniques. Furthermore, improved postoperative analgesia may be achieved for several days. In our retrospective study, 65 patients who were scheduled for amputation of the lower limbs were analysed. In 58 patients (89%), a regional anaesthesia technique employing only a catheter technique was performed and only 7 patients (11%) required additional general anaesthesia. For postoperative pain management, local anaesthetics were administered via an indwelling nerve block catheter and excellent pain scores were achieved in these patients. However, successful employment of this technique necessitates sufficiently trained personnel as well as on-going training in the performance of catheter-based local analgesia.

Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Analgesia, Patient-Controlled; Anesthesia, Conduction; Anesthesia, General; Anesthetics, Dissociative; Anesthetics, Intravenous; Anesthetics, Local; Catheterization; Electric Stimulation; Female; Femoral Nerve; Humans; Ketamine; Leg; Male; Midazolam; Middle Aged; Nerve Block; Pain, Postoperative; Piperidines; Remifentanil; Retrospective Studies; Risk Assessment

Topics: Analgesics; Analgesics, Opioid; Femoral Artery; Fentanyl; Humans; Hyperalgesia; Ketamine; Male; Middle Aged; Morphine; Myocardial Revascularization; Pain, Postoperative; Piperidines; Remifentanil

Topics: Analgesia, Epidural; Anesthesia, Intravenous; Antiemetics; Benzhydryl Compounds; Chemical and Drug Induced Liver Injury; Clomipramine; Contraindications; Humans; Hypnotics and Sedatives; Intracellular Signaling Peptides and Proteins; Intraoperative Complications; Kidney Pelvis; Modafinil; Narcolepsy; Neuropeptides; Ondansetron; Orexins; Pain, Postoperative; Piperidines; Preanesthetic Medication; Propofol; Remifentanil; Ureteral Obstruction

To evaluate whether remifentanil based general anesthesia combined with epidural analgesia for postoperative pain, has any advantages with respect to consumption of drugs, blood loss, quality of pain control, hemodynamic profile, in major abdominal surgery, as compared to other combined techniques.. A retrospective study based on chart reviews of patients who have undergone colectomy, radical cystectomy and radical prostatectomy over one year period in our Institution, operated under combined regional-general anesthesia. Twenty-six patients were analyzed and were divided into three groups according to the type of anesthesia received. Group A: combined general-epidural for per-operative and postoperative pain (10 patients). Group B: combined spinal-general anesthesia (8 patients) post-operative analgesia consisted of parenteral mepiridine and paracetamol. Group C: remifentanil based general anesthesia followed by epidural for postoperative analgesia (8 patients).. The demographic data, age and M/F distribution were comparable in the three groups. The remifentanil group showed less utilization of muscle relaxant (Cisatracurium) with respect to other groups (p < 0.001). The amount of intraoperative blood loss was not significantly different among the three groups. The efficacy of the postoperative epidural analgesia was demonstrated by the minimal utilization of analgesics (p < 0.05 and 0.01) in group A and C as compared to group B. In the group of remifentanil, the blood pressure was more stable and maintained at a systolic of 80-100 mmHg as compared to initial hypotension mainly in group C.. The use of remifentanil based general anesthesia offers the advantage of non-accumulation of drugs and hemodynamic stability. Post-operative analgesia can be provided by epidural route which proved to be satisfactory in the remifentanil group. The effect on blood loss was not conclusive in this study.

Topics: Abdomen; Adult; Aged; Analgesia, Epidural; Anesthesia, Conduction; Anesthesia, General; Anesthetics, Intravenous; Anesthetics, Local; Blood Loss, Surgical; Blood Pressure; Dose-Response Relationship, Drug; Female; Heart Rate; Humans; Male; Middle Aged; Neuromuscular Blocking Agents; Pain Measurement; Pain, Postoperative; Piperidines; Preanesthetic Medication; Remifentanil; Retrospective Studies

Pain following brain surgery is a significant problem. Infiltration of the scalp with local intradermal anesthetics was suggested for postoperative pain control but was assessed only in the first hour postoperatively.. To evaluate wound infiltration with a single dose of metamizol (dipyrone) for postoperative pain control in patients undergoing awake craniotomy.. This open, prospective, non-randomized observational study, conducted in anesthesiology and neurosurgical departments of a teaching hospital, included 40 patients undergoing awake craniotomy for the removal of brain tumor. Intraoperative anesthesia included wound infiltration with lidocaine and bupivacaine, conscious sedation using remifentanil and propofol, and a single dose of metamizol (dipyrone) for postoperative pain control. Outcome was assessed by the Numerical Pain Scale on arrival at the postoperative care unit, and 2, 4 and 12 hours after the end of surgery.. On arrival at the postoperative care unit, patients reported NPS scores of 1.2 +/- 1.1 in a scale of 0-10 (mean +/- SD) (median = 1, range 0-4). The scores were 0.8 +/-0.9, 0.9 +/- 0.9 and 1 +/- 0.9 at 2 hours, 4 hours and 12 hours after the end of surgery, respectively. Based on patients' complaints and NPS lower than 3, 27 patients did not require any supplementary analgesia during the first 12 postoperative hours, 11 patients required a single dose of oral metamizol or intramuscular diclofenac, one patient was given 2 mg of intravenous morphine, and one patient required two separate doses of metamizol.. Although the clinical setup prevents the use of placebo local analgesia as a control group, the results suggest the possible role of local intradermal infiltration of the scalp combined with a single dose of metamizol to control postoperative pain in patients undergoing craniotomy.

Topics: Anesthetics, Local; Anti-Inflammatory Agents, Non-Steroidal; Bupivacaine; Conscious Sedation; Craniotomy; Dipyrone; Humans; Hypnotics and Sedatives; Intraoperative Care; Lidocaine; Pain Measurement; Pain, Postoperative; Piperidines; Propofol; Prospective Studies; Remifentanil; Treatment Outcome

Providing analgesia is the most important, yet the most difficult aspect of remifentanil anaesthesia, as its effect wears off quickly after infusion is terminated. Longer-acting opioids such as morphine and fentanyl must be given well before patients wake up. Bolus administration of fentanyl approximately 20 minutes before the end of surgery may provide adequate analgesia at emergence and tracheal extubation. However, fentanyl concentration decreases quite rapidly and patients may need repeated dosing until analgesia is attained. Continuous intraoperative low-dose infusion of fentanyl may lead to better analgesia than bolus dosing, because its context-sensitive half-time increases as the infusion lasts longer. Regional anaesthetic technique, such as epidural analgesia and peripheral nerve block can also be used in patients without coagulation abnormalities. Issue of acute tolerance after intraoperative use of remifentanil still awaits further study before final conclusion is reached. Some data suggest that we should not use an unnecessary and high dose of opioid without clear indication. Theoretically, remifentanil infusion can be used in ICU and surgical wards to manage postoperative pain in ventilated as well as spontaneously breathing patients. However, in some susceptible patients, even a very low-rate infusion can still cause significant respiratory depression more than 30 minutes after starting infusion. Pulse oximetry is not sensitive enough to detect early ventilatory depression when patients breathe oxygen-enriched air. Without continuous observation by trained anaesthetists, infusion of remifentanil should not be used casually particularly in non-ventilated patients.

Topics: Analgesia; Analgesics, Opioid; Anesthetics, Intravenous; Fentanyl; Humans; Morphine; Pain, Postoperative; Piperidines; Remifentanil

Opioid-induced delayed hyperalgesia and allodynia have been reported in human and animal models. The authors evaluated the influence of different opioids used during clinical anesthesia on nociceptive sensitivity and incisional pain in mice. The role of the inducible nitric oxide synthase on surgical pain and opioid-induced pronociception also was investigated.. CD1 mice were used to study the efficacy of opioids inducing pronociception and enhancing incisional pain. The implication of nitric oxide generated from the inducible nitric oxide synthase was investigated using knockout mice (C57/BL6) for its gene. Mice underwent right hind paw surgery under sevoflurane anesthesia combined with subcutaneous administration of saline or the opioids fentanyl (0.05 mg/kg), alfentanil (1 mg/kg), and remifentanil (0.04 mg/kg). Nociception was evaluated daily for 7 days using paw-pressure, plantar, and von Frey tests.. The antinociceptive effect of opioids was followed by long-lasting thermal hyperalgesia and mechanical allodynia (each lasting between 2 and 7 days), but not mechanical hyperalgesia. Intraoperative infusion of opioids significantly enhanced incisional pain in all tests. The most prominent effects were observed with remifentanil. The inducible nitric oxide synthase gene deletion attenuated both remifentanil- and incision-induced pronociceptive effects. In mutant mice for the inducible nitric oxide synthase gene, remifentanil was still efficient in enhancing incisional pain, but the global pronociceptive effect was attenuated significantly as compared with wild-type mice.. The authors' study demonstrates that the intraoperative administration of fentanyl or remifentanil enhances the extent and duration of postoperative pain. The results suggest a role of the nitric oxide systems in the cause of acute postoperative pain and opioid-induced pronociception.

Topics: Analgesics, Opioid; Animals; Fentanyl; Hyperalgesia; Male; Mice; Mice, Inbred C57BL; Nitric Oxide; Nitric Oxide Synthase Type II; Pain, Postoperative; Piperidines; Remifentanil; Species Specificity

Topics: Analgesics; Anesthesia, Conduction; Anesthesia, Intravenous; Child; Child, Preschool; Humans; Infant; Leg; Leg Injuries; Morphine; Orthopedic Procedures; Pain, Postoperative; Piperidines; Remifentanil

Remifentanil (Ultivatrade), a 4-anilidopiperidine derivative of fentanyl, is an ultra-short-acting micro-opioid receptor agonist indicated to provide analgesia and sedation in mechanically ventilated intensive care unit (ICU) patients. Analgesia-based sedation with remifentanil is a useful option for mechanically ventilated patients in the ICU setting. Its unique properties (e.g. organ-independent metabolism, lack of accumulation, rapid offset of action) set it apart from other opioid agents. Remifentanil is at least as effective as comparator opioids such as fentanyl, morphine and sufentanil in providing pain relief and sedation in mechanically ventilated ICU patients. Moreover, it allows fast and predictable extubation, as well as being associated with a shorter duration of mechanical ventilation and quicker ICU discharge than comparators in some studies. In addition, remifentanil is generally well tolerated in this patient population. Thus, remifentanil is a welcome addition to the currently available pharmacological agents employed in the management of mechanically ventilated ICU patients.

Topics: Drug Tolerance; Humans; Hypnotics and Sedatives; Intensive Care Units; Pain, Postoperative; Piperidines; Remifentanil

Topics: Adult; Analgesics, Opioid; Female; Humans; Pain, Postoperative; Piperidines; Remifentanil; Respiration

Patient-controlled analgesia (PCA) using intravenous opioids is increasing in popularity for children aged 5 years and over. To our knowledge there are no reports on the use of PCA in children with remifentanil in the postoperative period. We report successful use of remifentanil for intravenous (IV) PCA in a child scheduled for suprasellar arachnoid cystectomy with Axenfeld-Rieger syndrome who needed good postoperative analgesia because of accompanying serious problems.

Topics: Abnormalities, Multiple; Analgesia, Patient-Controlled; Analgesics, Opioid; Arachnoid Cysts; Child; Eye Diseases; Genes, Dominant; Heart Diseases; Humans; Infusions, Intravenous; Male; Monitoring, Intraoperative; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Syndrome

A 24-year-old female with a history of former heroin addiction underwent open heart surgery for a mechanical tricuspid valve replacement. Anaesthesiological management included a thoracic epidural catheter at the Th(2)/Th(3) segments and balanced general anaesthesia (remifentanil, desflurane/propofol). Additionally, clonidine (2 microg*kg(-1)*h(-1)) was continuously administered. Pain therapy was achieved using 0.375% ropivacaine via a thoracic epidural catheter (4 ml*h(-1)) and metamizole (4 x 1 g/day) intravenously. With this concept we were able to achieve an appropriate anaesthesia and analgesia and the operation was carried out without complications.

Topics: Adrenergic alpha-Agonists; Adult; Amides; Anesthesia, Epidural; Anesthesia, General; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Anti-Inflammatory Agents, Non-Steroidal; Clonidine; Desflurane; Dipyrone; Female; Heart Valve Prosthesis Implantation; Heroin Dependence; Humans; Isoflurane; Pain, Postoperative; Piperidines; Propofol; Remifentanil; Ropivacaine; Tricuspid Valve

Remifentanil, a short-acting opioid, is commonly used in cardiac anesthesia. In this study we sought to demonstrate the feasibility of pain treatment and to determine the remifentanil dose necessary for adequate analgesia in tracheally extubated patients after cardiac surgery. Thirty patients undergoing elective cardiac surgery were included in this study. After surgery, the intraoperatively administered remifentanil was initially continued at 0.05 microg . kg(-1) . min(-1). Before tracheal extubation, a nonsteroidal antiinflammatory drug was administered and remifentanil was reduced to 0.035 microg . kg(-1) . min(-1). Pain assessment using a visual analog scale (VAS) was performed after tracheal extubation, in 2-min intervals for 10 min, every 10 min until the end of the first hour and every 30 min during the ensuing 5 h. A VAS score > or =30 or a respiratory rate <10 breaths/min was followed by an increase or decrease in the remifentanil dose by 0.005 microg . kg(-1) . min(-1), respectively. For rapid dose adaptation during the first 10 min, remifentanil was increased twice by 0.005 microg. kg(-1) . min(-1) and then 3 times by 0.01 microg . kg(-1) . min(-1). With a mean remifentanil dose of 0.051 microg . kg(-1) . min(-1) VAS decreased to 26 +/- 14 after 30 min. Sufficient analgesia was achieved with remifentanil doses ranging from 0.03 to 0.09 microg. kg(-1) . min(-1). A maximum mean remifentanil dose of 0.057microg. kg(-1) . min(-1) was reached after 4 h. The combination of remifentanil with a nonsteroidal antiinflammatory drug provided adequate analgesia in 73% of patients 30 min after tracheal extubation. Rapid dose titration was necessary during the first 10 min in 50% of patients. Increasing the initial remifentanil dose could shorten the titration period but may be associated with respiratory complications.

Topics: Adult; Aged; Analgesics, Opioid; Cardiac Surgical Procedures; Female; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Respiration

We report on a 49-year-old female patient suffering from recurrent carcinoma of the rectum, who underwent a palliative Hartmann operation for an anus praeter reconstruction. After a remifentanil bolus of 90 microg and a propofol bolus of 200 mg, anaesthesia was maintained with 0.25 microg/kg/min remifentanil and 4 mg/kg propofol, and after skin incision with 1.0 microg/kg/min remifentanil and 5 mg/kg/h propofol. Throughout the operation, the patient showed a stable blood pressure of 120-130/80 mmHg but 15 min after skin incision the heart rate suddenly rose to 140 beats/min, so remifentanil was increased to 1.8 microg/kg/min and propofol to 8 mg/kg/h. Over a time period of 15 min the heart rate decreased to 90 beats/min. Subsequently vegetative parameters stayed within the normal range (heart rate 90 beats/min, blood pressure 120-130/80 mmHg) so that continuous administration of remifentanil and propofol could be tapered. After completion of skin sutures, administration of remifentanil and propofol was terminated. After extubation the patient reported having heard conversations contributable to the end of the operation and the sentence: "now we're done" was clearly remembered. The patient stated that she had not been able to move any part of her body, that she had perceived the situation as extremely unpleasant and dangerous and that she had felt severe pain. At the postoperative rounds the patient refused any psychological and psychiatric help.

Topics: Adenocarcinoma; Anal Canal; Anesthesia, General; Anesthetics, Intravenous; Awareness; Female; Hemodynamics; Humans; Middle Aged; Pain, Postoperative; Piperidines; Plastic Surgery Procedures; Propofol; Rectal Neoplasms; Remifentanil

Topics: Adult; Analgesics, Opioid; Anesthesia; Anesthetics, Intravenous; Anticonvulsants; Cardiopulmonary Bypass; Diazepam; Etomidate; Female; Fentanyl; Heart Valve Diseases; Heparin; Humans; Midazolam; Morphine; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Pancuronium; Piperidines; Propofol; Remifentanil; Stiff-Person Syndrome

F 13640 is a newly discovered high-efficacy 5-HT(1A) receptor agonist that produces exceptional analgesia in animal models of tonic and chronic, nociceptive and neuropathic pains by novel molecular and neuroadaptive mechanisms. Here we examined the effects of F 13640 and remifentanil (0.63 mg/kg with either compound) when injected i.p. either before or 15 min after rats underwent orthopedic surgery. Surgery consisted of the drilling of a hole in the calcaneus bone and of an incision of the skin, fascia and plantar muscle of one foot. During surgery, the concentration of volatile isoflurane was progressively incremented depending on the animal's response to surgical maneuvers. Other experiments examined the dose-dependent effects of F 13640 (0.04 to 0.63 mg/kg) on surgical pain as well as on the Minimum Alveolar Concentration of isoflurane. Both F 13640 and remifentanil markedly reduced the intra-operative isoflurane requirement. F 13640 also reduced measures of postoperative pain (i.e., paw elevation and flexion). With these postoperative measures, remifentanil produced short-lived analgesia followed by hyperalgesia. F 13640 significantly reduced both surgical pain and the isoflurane Minimum Alveolar Concentration from 0.16 mg/kg onward. F 13640 produced powerful intra- and postoperative analgesia in rats undergoing orthopedic surgery. Unlike the opioid, remifentanil, F 13640 caused no hyperalgesia with ongoing postoperative pain, and should remain effective with protracted postoperative use.

Topics: Analgesia; Analgesics, Non-Narcotic; Analgesics, Opioid; Analysis of Variance; Anesthetics, Inhalation; Animals; Disease Models, Animal; Dose-Response Relationship, Drug; Hyperalgesia; Isoflurane; Male; Monitoring, Intraoperative; Orthopedic Procedures; Pain; Pain Measurement; Pain Threshold; Pain, Postoperative; Piperazines; Piperidines; Pulmonary Alveoli; Pyridines; Rats; Rats, Sprague-Dawley; Remifentanil; Serotonin Antagonists; Vocalization, Animal

To compare the suppressive effects of tramadol and low-dose ketamine on postoperative hyperalgesia after remifentanil-based anaesthesia.. A total number of sixty ASA I - II adult patients who undergone the operation of cranio-cervical region were assigned to three groups randomly, controlled group (Group C), tramadol group (Group T) and low-dose ketamine group (Group K). Before the end of surgery, Group T was given tramadol 0.3 mg/kg, Group K was given ketamine 0.5 mg/kg and Group C wasn't given any medicine. When the visual analogue scale (VAS) score of the group C was over five, tramadol 0.3 mg/kg was given to the patients. The four-level verbal rating scale after trachea extubation, VAS score, the time of requiring analgesia again by patients and adverse drug reactions such as nausea, vomit, diplopia and hallucination were recorded for 24 hours after surgery.. After operation, the VAS score of Group C was much higher than that of Group K in the first 4 hours and Group T was higher than Group K during 2, 3 and 4 hours (P < 0.05). The time of requiring analgesia by patients in Group C and Group T was earlier than Group K. The adverse drug reaction showed no significant difference in three groups.. Low-dose ketamine had significant suppressive effect on patients with postoperative hyperalgesia and acute opioid tolerance after remifentanil-based anaesthesia.

Topics: Adult; Analgesics, Opioid; Anesthesia; Humans; Hyperalgesia; Ketamine; Male; Middle Aged; Pain, Postoperative; Piperidines; Postoperative Period; Remifentanil; Tramadol

To study the possible pharmacodynamic differences in children under anesthesia based on remifentanil.. This multicenter observational study enrolled 275 patients scheduled for minor pediatric surgery (herniorrhaphy, prepuceplasty, and plastic surgery). The children were grouped by age: 1-3 years, 4-7 years, 8-12 years. Premedication was with midazolam, induction with sevoflurane or propofol, and maintenance with sevoflurane 0.5%-0.8%, N2O/O2 30%/70%, and remifentanil 0.25 microg/kg/min. Postoperative analgesia (metamizol, morphine or regional block) was administered at least 30 minutes before the end of surgery.. No differences were found between age groups with regard to remifentanil requirements, end tidal concentrations of sevoflurane, or mean times until spontaneous ventilation or extubation. Nor were there differences in the percentages of complications (5.4%), of which 4 were cases of intense postoperative muscular rigidity, or in the incidence of nausea-vomiting (3.4%). The quality of recovery from anesthesia (Aldrete test) was better in the 8-12-year-old group (P < 0.05), however, while agitation (Postoperative Agitation Score) and pain (visual analog scale or observational scales) were greater in the group of 1-3-year-olds (P < 0.05). The evaluation of the technique by participating caregivers was excellent for 20%, very good for 41%, good for 29%, adequate for 8% and poor for 2% of the cases.

Topics: Age Factors; Analgesia; Analgesics, Opioid; Anesthesia; Child; Child, Preschool; Female; Humans; Infant; Male; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil

We report two cases of sudden increase in Bispectral Index (BIS) after the injection of low-dose ketamine for the prevention of postoperative hyperalgesia. The two patients were anaesthetised with a continuous infusion of remifentanil associated with propofol for one and isoflurane for the other. Changes in BIS occurred while the two patients were in a stable phase of surgery (beginning of parietal closure and suture of an anastomosis) and had a stable target concentration of anaesthetic agents. No others signs of awakening were observed. The BIS value returned progressively to 40-50 despite no increase in target concentration. None of the patients complained of intra-operative recall.

Topics: Aged; Anesthesia, Inhalation; Anesthesia, Intravenous; Anesthetics, Dissociative; Anesthetics, Inhalation; Anesthetics, Intravenous; Electroencephalography; Female; Humans; Hyperalgesia; Isoflurane; Ketamine; Male; Pain, Postoperative; Piperidines; Propofol; Prostatectomy; Prosthesis Implantation; Remifentanil

N-methyl-D-aspartate (NMDA) receptors have been suggested to be critical for the development of central sensitization, which may amplify postoperative pain. NMDA receptors are formed by GluRzeta (NR1) with any one of four GluRvarepsilon1-4 (NR2A-D) subunits. To clarify the involvement of NMDA receptors in postoperative pain, we examined the effect of the GluRepsilon2-selective antagonist (1S,2S)-1-(4-hydroxyphenyl)-2-(4-hydroxy-4-phenyl piperidino)-1-propanol (CP-101,606) on postoperative pain caused by plantar incision. We also applied the postoperative pain model to GluRepsilon1 and GluRepsilon4 knockout mice. CP-101,606 administered intrathecally 30 min prior to incision significantly increased mechanical withdrawal thresholds 2 h and 1-3 days after surgery and reduced postoperative pain dose-dependently. Neither GluRvarepsilon1 nor GluRepsilon4 knockout mice showed a difference in withdrawal thresholds as compared with wild-type mice. Pretreatment with CP-101,606 did not produce an additive analgesic effect in the mice. These results demonstrate that GluRepsilon2-containing NMDA receptors are involved in postoperative pain and that CP-101,606 may be effective in reducing it.

Topics: Animals; Area Under Curve; Behavior, Animal; Dose-Response Relationship, Drug; Hyperalgesia; Male; Mice; Mice, Inbred C57BL; Mice, Knockout; Pain Measurement; Pain, Postoperative; Physical Stimulation; Piperidines; Postural Balance; Receptors, AMPA; Receptors, N-Methyl-D-Aspartate

Topics: Analgesia; Anesthetics, Intravenous; Humans; Pain, Postoperative; Piperidines; Randomized Controlled Trials as Topic; Remifentanil

We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery.. Patients in Group 1 (n = 20) received alfentanil 20 microg kg(-1) followed by 2 microg kg(-1) min(-1) intravenously; patients in Group 2 (n = 20) received remifentanil 1 microg kg(-1) followed by 0.5 microg kg(-1) min(-1) intravenously. Both groups then received propofol 2 mg kg(-1) followed by 9 mg kg(-1) h(-1) intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS).. Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score > or = 9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores > or = 9 were similar.. Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.

Topics: Adolescent; Adult; Alfentanil; Ambulatory Surgical Procedures; Anesthesia Recovery Period; Anesthesia, Intravenous; Anesthetics, Intravenous; Hemodynamics; Humans; Male; Middle Aged; Pain, Postoperative; Piperidines; Remifentanil; Varicocele

Topics: Adult; Anesthesia, General; Anesthetics, Intravenous; Atracurium; Gastric Bypass; Humans; Intraoperative Complications; Male; Neuromuscular Blocking Agents; Obesity, Morbid; Pain, Postoperative; Piperidines; Remifentanil

Topics: Amides; Analgesia, Epidural; Anesthesia Recovery Period; Anesthesia, Epidural; Anesthesia, Inhalation; Anesthesia, Local; Anesthetics, Inhalation; Anesthetics, Intravenous; Anesthetics, Local; Fentanyl; Humans; Male; Methyl Ethers; Middle Aged; Neuromuscular Nondepolarizing Agents; Pain, Postoperative; Piperidines; Pneumonectomy; Preanesthetic Medication; Pulmonary Emphysema; Remifentanil; Ropivacaine; Sevoflurane

Topics: Adrenergic beta-Antagonists; Analgesics, Opioid; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Pain, Postoperative; Piperidines; Propanolamines; Remifentanil

Topics: Analgesics, Opioid; Craniosynostoses; Humans; Intraoperative Care; Neurosurgical Procedures; Pain, Postoperative; Piperidines; Remifentanil; Research Design

We have used a remifentanil-based anaesthetic for patients undergoing major abdominal surgery who would normally have gone to the intensive care unit in this hospital. Avoiding intensive care unit admission was considered an advantage as a shortage of intensive care unit beds was leading to the cancellation of operations. We first used remifentanil as part of a safety and efficacy study. The aim was to see if the rapid and complete awakening obtained when using this drug would allow us to avoid the need for admission to an intensive care unit and use a high dependency unit instead. This was shown to be practicable. In comparison with a group of patients matched retrospectively for the type of operation before remifentanil was used there was a reduction in the length of time (mean+/- SD) patients' lungs were ventilated (612+/-417 vs. 9.9+/-28.9 min P< 0.0001). There was no saving in cost ( pound808.71+/- pound187.06 vs. pound795.27+/- pound253.49). When remifentanil was used routinely (after the safety and efficacy study), there were significant reductions in the time to tracheal extubation (612+/-417 vs. 4+/-10 min P < 0.0001) and costs (808.71I vs. 392.10 I P < 0.0001) compared with other patients in whom it was not used. Patients waiting for a liver transplant were also being cancelled when a donor organ became available because of the shortage of intensive care unit beds. Based on our other experience with remifentanil, we used a similar anaesthetic technique for these patients. It proved possible to extubate the trachea in 12 of 15 patients at the end of the operation. No patient needed re-intubation. The need for intensive care and therefore cancellation of surgery was reduced. In contrast, only one patient's trachea was extubated immediately after surgery in the group of patients anaesthetized before the introduction of remifentanil. A remifentanil-based technique in combination with a change in organization has therefore enabled us to avoid admission to the intensive care unit for these patients.

Topics: Abdomen; Adult; Aged; Analgesia, Epidural; Anesthesia Recovery Period; Anesthetics, Intravenous; Bed Occupancy; Case-Control Studies; Cost Savings; Critical Care; Drug Costs; Female; Humans; Intensive Care Units; Intubation, Intratracheal; Liver Transplantation; Male; Middle Aged; Pain, Postoperative; Patient Admission; Piperidines; Postoperative Care; Recovery Room; Remifentanil; Respiration, Artificial; Retrospective Studies; Safety; Time Factors

This study prospectively determined whether there was a learning curve with the use of remifentanil, as indicated by decreased hemodynamic variability, improved recovery profile, and decreased incidence of opioid-related adverse events with increasing experience. Patients undergoing diverse surgical procedures (outpatient [n = 1340] and inpatient [n = 560]) were enrolled by investigators (n = 190) who had no previous experience with remifentanil use. Each investigator enrolled 10 patients. A standardized protocol for administration of remifentanil was used. Data were analyzed to determine differences between the first three patients and the last three patients enrolled for each anesthesiologist in the study. There were no differences in hemodynamic variables between the first triad and the last triad in either outpatients or inpatients. Requirements for hypnotic drugs and the doses of remifentanil used were also similar between groups. Analgesic medications administered at the end of surgery and in the postanesthesia care unit (PACU) were similar between groups, except that the last triad in the outpatient group received smaller doses of fentanyl compared with the first triad. Times to response to verbal command, tracheal extubation, and operating room discharge did not differ between groups. However, patients in the last triad undergoing outpatient surgery had shorter times to eligibility for PACU discharge, but times to eligibility for discharge home did not differ. The overall incidence of all adverse events (i.e., hypotension, hypertension, muscle rigidity, respiratory depression, apnea, nausea, and vomiting) was less in the last triad as compared with the first triad. When analyzed separately, only the incidence of vomiting (in the outpatient group) was decreased in the last triad as compared with the first triad. This study suggests that there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of PACU stay.. This study demonstrated that anesthesiologists rapidly acquire the ability to use remifentanil with limited experience. However, there is a learning curve that aids reduction of minor adverse effects associated with the use of analgesic medications administered at the end of surgery in outpatients, which might have reduced the incidence of postoperative vomiting and the duration of postanesthesia care unit stay.

Topics: Adult; Ambulatory Surgical Procedures; Analgesics; Analgesics, Opioid; Anesthesia Recovery Period; Anesthetics, Intravenous; Clinical Competence; Clinical Protocols; Female; Hemodynamics; Humans; Learning; Male; Middle Aged; Pain, Postoperative; Piperidines; Prospective Studies; Remifentanil; Surgical Procedures, Operative

Few studies on analgesia with remifentanil (Rf) in children are available, and there are no data on the use of this drug in pediatric neurosurgery. Rf is a new mu-receptor opioid agonist, acting through the activation of pain inhibitory mechanisms. We conducted a prospective trial on the analgesic effects of Rf in 20 children less than 1 year of age undergoing a neurosurgical procedure for craniosynostosis repair. Rf was administered at doses of 0.25 microgram/kg/min, by continuous infusion, 1 h after admission to the pediatric intensive care unit (PICU). The treatment was prolonged for 12 h after the operation. The postoperative pain was evaluated in our PICU, comparing the changing of behavioral (AFS and CHEOPS score) and hemodynamic (heart rate, respiratory rate, systolic and diastolic blood pressure, oxygen saturation, O(2) and CO(2) partial pressure) parameters, before and after treatment with Rf. This drug showed a satisfactory pain control in all the children treated. No significant side effects were noticed, except for one episode of urinary retention. In conclusion, Rf appears to be safe and effective for the treatment of acute pain in the very young child submitted to craniosynostosis repair.

Topics: Age Factors; Analgesics, Opioid; Brain; Cerebrovascular Circulation; Craniosynostoses; Drug Administration Schedule; Female; Humans; Infant; Intracranial Pressure; Male; Neurosurgical Procedures; Pain Measurement; Pain, Postoperative; Piperidines; Remifentanil; Treatment Outcome

Topics: Analgesics, Opioid; Humans; Muscle Rigidity; Pain, Postoperative; Piperidines; Remifentanil

Sameridine, a new substance with both local anesthetic and opioid effects, was administered intrathecally for the first time to humans, i.e. in patients subjected to arthroscopic knee joint surgery.. A dose-escalating (10, 15, 20 and 25 mg), open study was performed in 33 patients. Only two patients were included in the 25 mg group.. Sameridine provided good quality of surgical anesthesia in all patients except those receiving 10 mg. The maximum level of sensory block, Th5-Th7, was reached within 30 min with a median duration of 3.6-3.9 h. The motor block was more profound with increasing dose, but never lasted longer than the sensory block. The influence on heart rate and blood pressure was minor and atropine and ephedrine were needed in four patients. No clinically significant ECG-changes were detected and no arrhythmias were recorded. Oxygen saturation and respiratory rate did not decrease in a clinically significant way and were not affected by concomitant morphine given i.v. postoperatively. There were few side-effects, the most frequent being mild pruritus (10/33).. Sameridine provided clinically adequate anesthesia for the patients receiving the doses of 15, 20 and 25 mg. Further studies are needed to evaluate the substance and it is of great interest to clinically investigate the opioid component with respect to postoperative analgesia.

Topics: Adolescent; Adult; Anesthesia, Spinal; Anesthetics, Local; Arthroscopy; Electrocardiography; Endoscopy; Hemodynamics; Humans; Injections, Spinal; Intraoperative Complications; Knee Joint; Male; Middle Aged; Neuromuscular Blockade; Pain Measurement; Pain, Postoperative; Piperidines; Respiratory Mechanics

We describe a 73-yr-old woman anaesthetized for a laminectomy. She suffered from hepatic failure with mild encephalopathy complicated by several exacerbations associated with sedative and opioid therapy. The challenge for anaesthesia management was to provide adequate analgesia and avoid causing hepatic encephalopathy during and after the surgery. We used remifentanil to provide intraoperative and postoperative analgesia, because it has a short duration of action and does not require hepatic metabolism. We closely monitored the respiratory and the neurological status throughout the administration and conclude that remifentanil can provide perioperative analgesia in patients at risk of developing hepatic encephalopathy.

Topics: Aged; Analgesia; Analgesics, Opioid; Arachnoid Cysts; Chronic Disease; Contraindications; Female; Humans; Laminectomy; Liver Failure; Pain, Postoperative; Piperidines; Remifentanil

Topics: Analgesics, Opioid; Antipruritics; Humans; Nalbuphine; Pain, Postoperative; Piperidines; Pruritus; Remifentanil

Topics: Alfentanil; Analgesics, Opioid; Anesthesia Recovery Period; Anesthesia, Conduction; Anesthesia, Local; Anesthetics, Inhalation; Anesthetics, Intravenous; Dose-Response Relationship, Drug; Drug Interactions; Half-Life; Humans; Isoflurane; Metabolic Clearance Rate; Pain, Postoperative; Piperidines; Propofol; Receptors, Opioid; Remifentanil; Respiration

Topics: Aminopyrine; Analgesics; Anesthesia, General; Benzophenones; Dipyrone; Drug Combinations; Humans; Pain, Postoperative; Piperidines; Vascular Surgical Procedures

Topics: Adolescent; Adult; Aged; Analgesics; Child; Drug Interactions; Female; Humans; Male; Middle Aged; Muscle Contraction; Muscular Diseases; Pain, Postoperative; Piperidines; Succinylcholine

The incidence of nausea in relation to pain was recorded in 104 patients after abdominal operations. Ten per cent of the patients had episodes of nausea not related to pain. One hundred and fourteen episodes of concomitant pain and nausea were recorded in 61 patients (58.6 per cent). The intravenous injection of morphine or ketobemidone relieved nausea as well as pain in 80 per cent of the episodes. Relief of pain with persistence of nausea was uncommon and if pain relief was inadequate nausea was unabated. Nausea was provoked by 3.4 per cent of the morphine injections, but all patients tolerated similar doses of morphine on other occasions without nausea. Nausea often accompanies pain in the early postoperative period and can be relieved concomitant with the pain by the intravenous use of opiates in adequate doses in a high proportion of cases.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Female; Humans; Male; Meperidine; Middle Aged; Morphine; Nausea; Pain, Postoperative; Piperidines

Topics: Amides; Analgesics; Colic; Drug Evaluation; Female; Fumarates; Headache; Humans; Male; Neuralgia; Pain; Pain, Postoperative; Piperidines; Propionates; Pyridines; Sampling Studies; Suppositories

Topics: Analgesia; Analgesics; Humans; Nitriles; Pain, Postoperative; Piperidines

Topics: Analgesics; Anesthesia; Humans; Pain; Pain, Postoperative; Piperidines