Response to the letter to the editor “Anesthesia technique and quality of recovery after laparoscopic cholecystectomy: Case closed?”

Zaballos, M.; Reyes, A.

doi:10.1016/j.redare.2018.04.010

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The dose was adjusted to maintain the patient's haemodynamic parameters to around 20% of baseline values.As Dr. Castro-Alves mentions, remifentanil can be associated with two very different syndromes: on the one hand acute tolerance, and on the other, hyperalgesia. Acute tolerance is characterised by loss of drug efficacy or desensitisation to opioids, and can be overcome by increasing the dose of the drug. This hyperalgesia can occur after about 2h of continuous infusion of remifentanil.<a class="elsevierStyleCrossRefs" href="#bib0035">2–4</a>Hyperalgesia, meanwhile, is a state of nociceptive sensitisation that the International Association for the Study of Pain defines as an “increased pain from a stimulus that normally provokes pain”. It is not restricted to the use of opioids, but also occurs in trauma and tissue inflammation.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> Hyperalgesia cannot be treated by increasing the dose of the drug, since this can make it worse. The concept of opioid-induced hyperalgesia is well defined in animal studies, but there is no widely accepted definition in humans. This hyperalgesia is characterised by a paradoxical increase in pain associated with hyperalgesia and allodynia.<a class="elsevierStyleCrossRef" href="#bib0035">2</a>In our study, none of the aforementioned phenomena were observed, since postoperative pain was rated 3.5 on average (95% CI: 3–4) on a visual numeric scale (see Table 5 in the original),<a class="elsevierStyleCrossRef" href="#bib0030">1</a> and the opioid dose required in the PACU was 7.7μg (95% CI: 3–12.5μg) (see Table 4 in the original).<a class="elsevierStyleCrossRef" href="#bib0030">1</a> On the other hand, our patients had received NSAIDs during surgery, and these, together with other agents such as ketamine, magnesium sulphate, amantadine and gabapentinoids, among others, modulate the phenomenon of hyperalgesia.<a class="elsevierStyleCrossRefs" href="#bib0035">2,5</a> While there is no specific maximum remifentanil dose associated with acute tolerance and hyperalgesia, it is accepted that administration of more than 0.25μg/kg/min may favour acute tolerance, and 0.2μg/kg/min can induce hyperalgesia. Finally, both phenomena are related to prolonged infusion of remifentanil, which was not the case in our procedures, which lasted around 1h.<a class="elsevierStyleCrossRef" href="#bib0035">2</a>With regard to the variability in pain scores recorded by nurses described by some authors, our unit has prioritised accurate recording of postoperative pain as part of a hospital-wide programme to improve quality of care. We can only assume that pain was recorded correctly, although we cannot prove this since it was not recorded simultaneously by an anaesthesiologist. The number of patients reporting intense pain can be estimated indirectly by calculating the percentage of patients who received opioids in the postoperative period (14%), drawing attention to the low doses used, as reported in the study.Finally, we agree that patients who receive more opioids give lower scores on recovery quality scales. In this regard, as shown in Table 6 in the original article,<a class="elsevierStyleCrossRef" href="#bib0030">1</a> the group receiving propofol received a lower overall dose of fentanyl, both in the operating room and in the PACU: 113±38 vs 200±65μg, and showed slightly higher recovery parameters: 137±13 vs 136±15, although this was not statistically or clinically significant. Our data, therefore, support the relationship between the total opioid dose and quality of recovery, although it is hard to establish definitive conclusions on the basis of such minimal differences between groups.FundingThis study was funded by the Department of Anaesthesia and Resuscitation of the Gregorio Marañón University Hospital in Madrid." 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Prospective, comparative, non-inferiority study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Zaballos" 1 => "A. Reyes" 2 => "J. Etulain" 3 => "C. Monteserín" 4 => "M. Rodríguez" 5 => "E. Velasco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2017.09.010" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "96" "paginaFinal" => "102" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29126612" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Remifentanil tolerance and hyperalgesia: short-term gain, long-term pain?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E.H. Yu" 1 => "D.H. Tran" 2 => "S.W. Lam" 3 => "M.G. Irwin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.13602" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2016" "volumen" => "71" "paginaInicial" => "1347" "paginaFinal" => "1362" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27734470" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative use of remifentanil and opioid induced hyperalgesia/acute opioid tolerance: systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.H. Kim" 1 => "N. Stoicea" 2 => "S. Soghomonyan" 3 => "S.D. Bergese" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3389/fphar.2014.00108" "Revista" => array:5 [ "tituloSerie" => "Front Pharmacol" "fecha" => "2014" "volumen" => "5" "paginaInicial" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24847273" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An evidence based systematic review of remifentanil associated opioid induced hyperalgesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.M. Rivosecchi" 1 => "M.J. Rice" 2 => "P.L. Smithburger" 3 => "M.S. Buckley" 4 => "J.C. Coons" 5 => "S.L. Kane-Gill" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1517/14740338.2014.902931" "Revista" => array:6 [ "tituloSerie" => "Expert Opin Drug Saf" "fecha" => "2014" "volumen" => "13" "paginaInicial" => "587" "paginaFinal" => "603" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24669819" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of COX inhibition on experimental pain and hyperalgesia during and after remifentanil infusion in humans" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. Lenz" 1 => "J. Raeder" 2 => "T. Draegni" 3 => "F. Heyerdahl" 4 => "M. Schmelz" 5 => "A. 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Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 7.