Gradual withdrawal of remifentanil delays initial post-operative analgesic demand after thyroid surgery; double-blinded, randomized controlled trial

Abstract

Background Mismanagement of remifentanil leads to severe side effects such as opioid-induced tolerance and hyperalgesia. Recently studies revealed an alternative withdrawal method to limit these side effects. A gradual withdrawal of remifentanil seems to be associated with less pain. The hypothesis of this double-blinded, randomized controlled trial was that a gradual withdrawal of remifentanil would be associated with less immediate post-operative pain compared to after an abrupt discontinuation of remifentanil in patients who underwent thyroid surgery. Methods This double-blinded, randomized controlled trial was conducted in a tertiary level hospital in Brussels (Belgium) from April until August 2017. 34 patients undergoing thyroid surgery were randomized and 29 patients completed the study. After randomization, patients undergoing thyroid surgery were allocated to two groups: one with an abrupt discontinuation of remifentanil after surgery and one with a gradual withdrawal of remifentanil after surgery. The primary outcome was the initial post-operative demand of analgesic medication. Results Gradual withdrawal of remifentanil was associated with a delayed initial post-operative demand of analgesic medication ( P = 0.006). The first morphine bolus was given after 76.3 +/− 89.0 min in the group with a gradual withdrawal of remifentanil versus after 9.0 +/− 13.5 min in the group with an abrupt discontinuation of remifentanil. However, overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) were similar in both groups ( P > 0.05). Conclusion Though overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) are not altered, a gradual withdrawal of remifentanil after thyroid surgery is safe and associated with a delayed initial post-operative demand of analgesic drugs. The withdrawal process does, however, require vigilance and training. Trial registration Clinicaltrials.gov NCT03110653 (PI: Luc Barvais; date of registration: 03/31/2017).

Evaluation of analgesic and sedative effects of remifentanil‐based fast‐track anesthesia in children undergoing transthoracic device closure of ventricular septal defects

“…Remifentanil is a highly fat‐soluble μ‐opioid receptor agonist of fentanyl that can be hydrolyzed rapidly in tissues and blood to balance blood and brain concentrations. Because of its fast onset and short duration, remifentanil is a commonly used opioid drug in general anesthesia 16 . In addition, remifentanil also has a neuroprotective effect.…”

“…Because of its fast onset and short duration, remifentanil is a commonly used opioid drug in general anesthesia. 16 In addition, remifentanil also has a neuroprotective effect.…”

Timelog-Based Approach to Early Post-Thoracotomy Pain in Lung Cancer Surgery

“…However, using lower doses of the drug intraoperatively and gradual withdrawal at the end of the operation were reported to reduce additional analgesic demand at early postoperative period. 13,21,22 Inadequate treatment of post-thoracotomy pain may also lead to pulmonary complications (atelectasis, pneumonia, respiratory depression, and reintubation, etc.) due to restricted deep breathing, reduced ability of expectoration and inability to adapt physiotherapy.…”

“…Remifentanil induced postoperative hyperalgesia was avoided by gradually reducing the dose in the last hour of operation as previously recommended. 13 Remifentanil infusion was ceased before awakening.…”

Postoperative Drip-Infusion of Remifentanil Reduces Postoperative Pain—A Retrospective Observative Study

“…A randomized, double-blinded, placebo-controlled, crossover trial included 19 healthy volunteers and suggested that the GWR could reduce RIH in the heat pain test [6]. In addition, Saxena et al [7] conducted a double-blinded, randomized controlled study and concluded that gradual withdrawal of remifentanil after thyroid surgery may delay the initial postoperative requirement of analgesics, but the overall consumption of opioids, pain scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) were similar in both abrupt discontinuation and gradual withdrawal groups. Nonetheless, the withdrawal process requires vigilance and training.…”