Letter to the Director
Response to the letter to the editor “Anesthesia technique and quality of recovery after laparoscopic cholecystectomy: Case closed?”
Réplica a la carta al editor «Técnica de la anestesia y calidad de recuperación después de la colecistectomía laparoscópica ¿caso cerrado?»
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Zaballos, A. Reyes" "autores" => array:2 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Zaballos" "email" => array:1 [ 0 => "mati@plagaro.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Reyes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad Complutense de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Réplica a la carta al editor «Técnica de la anestesia y calidad de recuperación después de la colecistectomía laparoscópica ¿caso cerrado?»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">First, we would like to thank Dr. Castro-Alves for his comments and interest in our article.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Regarding the use and dose of remifentanil, in our article we indicate that a dose of between 0.05 and 0.25<span class="elsevierStyleHsp" style=""></span>μg/kg/min was administered throughout the intervention. The dose was adjusted to maintain the patient's haemodynamic parameters to around 20% of baseline values.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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 2<span class="elsevierStyleHsp" style=""></span>h of continuous infusion of remifentanil.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">2</span></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"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></a> and the opioid dose required in the PACU was 7.7<span class="elsevierStyleHsp" style=""></span>μg (95% CI: 3–12.5<span class="elsevierStyleHsp" style=""></span>μg) (see Table 4 in the original).<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></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"><span class="elsevierStyleSup">2,5</span></a> While there is no specific maximum remifentanil dose associated with acute tolerance and hyperalgesia, it is accepted that administration of more than 0.25<span class="elsevierStyleHsp" style=""></span>μg/kg/min may favour acute tolerance, and 0.2<span class="elsevierStyleHsp" style=""></span>μg/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 1<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">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.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1</span></a> the group receiving propofol received a lower overall dose of fentanyl, both in the operating room and in the PACU: 113<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>38 vs 200<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>μg, and showed slightly higher recovery parameters: 137<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13 vs 136<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>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.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study was funded by the Department of Anaesthesia and Resuscitation of the Gregorio Marañón University Hospital in Madrid.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zaballos M, Reyes A. Réplica a la carta al editor «Técnica de la anestesia y calidad de recuperación después de la colecistectomía laparoscópica ¿caso cerrado?». Rev Esp Anestesiol Reanim. 2018;65:417–418.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Desflurane versus propofol in post-operative quality of recovery of patients undergoing day laparoscopic cholecystectomy. 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. 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