A Randomized, Double-Blinded Study of Remifentanil Versus Fentanyl for Tonsillectomy and Adenoidectomy Surgery in Pediatric Ambulatory Surgical Patients

Davis, Peter J.; Finkel, Julia C.; Orr, Rosemary J.; Fazi, L; Mulroy, John J.; Woelfel, S. K.; Hannallah, Raafat S.; Lynn, Anne M; Kurth, C. Dean; Moro, Michele; Henson, Lynn Graham; Goodman, David K.; Decker, Meredith

doi:10.1097/00000539-200004000-00017

Cited by 47 publications

(35 citation statements)

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“…23 The use of remifentanil for tonsillectomy, rather than fentanyl, may be associated with higher postoperative pain scores and may therefore need better prophylactic analgesic regimens for control of postoperative pain. 24 Nevertheless, the use of morphine at the end of the surgery in our study may have decreased the requirement for postoperative rescue analgesics. Since there have been concerns regarding cardiovascular events associated with the use of rofecoxib and valdecoxib (the active metabolite of parecoxib), 25 the safety of parecoxib sodium in pediatric patients should be evaluated in larger clinical trials.…”

Section: Discussionmentioning

confidence: 72%

Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial

Zhou

Xia

et al. 2015

Can J Anesth/J Can Anesth

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Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial Le parécoxib sodique réduit le besoin d'opioïdes après une amygdalectomie chez l'enfant: une étude clinique randomisée contrôlée par placebo à double insu AbstractObjective Postoperative pain is a common phenomenon after pediatric tonsillectomy. This prospective randomized double-blind placebo-controlled clinical trial was performed to evaluate the analgesic efficacy of intravenous parecoxib sodium in children undergoing tonsillectomy. Methods Sixty children (American Society of Anesthesiologists physical status I-III, aged three to seven years, and scheduled to undergo elective tonsillectomy under general anesthesia) were randomly allocated into one of two groups to receive intravenous parecoxib sodium 1 mgÁkg -1 (Group P, n = 30) or the same volume of saline (Group S, n = 30) just after induction of general anesthesia. Between-group comparisons were made for the number of patients requiring rescue morphine, total number of doses of postoperative rescue morphine, time to first rescue analgesic, postoperative pain and sedation scores, and adverse effects. Results Rescue morphine was given to more children in Group S (25/30, 83%) than in Group P (17/30, 57%) [relative risk (RR), 1.5; 95% confidence interval (CI), 1.0 to 2.1; P = 0.024]. The mean (SD) time to first rescue analgesic was shorter in Group S than in Group P [132 (54) min vs 193 (78) min, respectively; mean difference, 61; 95% CI, 26.6 to 96.1; P = 0.001]. The median (interquartile range [IQR]) Children's Hospital of Eastern Ontario Pain Scale scores in the postanesthesia care unit were lower in Group P than in Group S (7 [5-8] vs 9 [8-11], respectively; P = 0.001). The incidence of postoperative nausea and vomiting (PONV) was higher in Group S than in Group P [11/30 (37%) vs 4/30 (13%), respectively; RR, 2.8; 95% CI, 1.0 to 7.7; P = 0.037]. Conclusions A single intravenous injection of parecoxib sodium 1 mgÁkg -1 after anesthesia induction is an effective method for the control of postoperative pain. It provides a morphine-sparing effect, prolongs the time to first rescue analgesic, and reduces PONV in children undergoing tonsillectomy. RésuméObjectif La douleur postopératoire est un phénomène courant après une amygdalectomie pédiatrique. Cette étude clinique prospective randomisée contrô lée par placebo et à double insu a été réalisée afin d'évaluer l'efficacité analgésique du parécoxib sodique intraveineux chez des enfants subissant une amygdalectomie. Méthode Soixante enfants (statut physique I-III selon la classification de l'American Society of Anesthesiologists, âgés de trois à sept ans et devant subir une amygdalectomie non urgente sous anesthésie générale) ont été aléatoirement alloués à l'un de deux groupes. Le groupe P (n = 30) a reçu 1 mgÁkg -1 de parécoxib sodique intraveineux, alors que le groupe S (n = 30) a reçu le même volume de sérum physiologique juste après l'induction de l'anesthésie générale. ...

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Section: Discussionmentioning

confidence: 72%

Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial

Zhou

Xia

et al. 2015

Can J Anesth/J Can Anesth

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“…The effect of fentanyl on sevoflurane, which has been shown to be interchangeable with remifentanil in children, has been documented. 5,6 There exists a 1:1.5 potency ratio between fentanyl and remifentanil. 7 Zhang et al have shown that in children aged five to ten, an increase in fentanyl serum levels from 0.62 ± 0.13 µg·L -1 to 1.51 ± 0.18 µg·L -1 produces a decrease in sevoflurane MAC from 1.03 ± 0.07% to 0.64 ± 0.01%.…”

Section: Discussionmentioning

confidence: 99%

“…2,4 In children, remifentanil and fentanyl have been shown to be interchangeable clinically. 5,6 Remifentanil has been shown to have superior recovery characteristics and is effective at dosages much lower than those required for other commonly-used opioids such as fentanyl. 7 The effect of remifentanil in reducing the minimum alveolar concentration MAC-BAR of sevoflurane has been demonstrated in adults.…”

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confidence: 99%

Remifentanil decreases sevoflurane requirements in children

Castanelli

Splinter

Clavel

2005

Can J Anesth/J Can Anesth

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Purpose:To establish the effect of increasing concentrations of remifentanil on sevoflurane requirements in children.Methods: Fifty-eight healthy patients, ASA status I-II aged two to 12 yr, undergoing abdominal wall hernia or hydrocele repairs were serially assigned to one of four test groups to receive remifentanil 0.03 µg·kg -1 ·min -1 , 0.06 µg·kg -1 ·min -1 , 0.12 µg·kg -1 ·min -1 , or 0.25 µg·kg -1 ·min -1 iv. Patients received a bolus of remifentanil 1 µg·kg -1 iv before the infusion began. End-tidal sevoflurane concentration was adjusted according to a Dixon up-and-down approach. Ten minutes after starting the remifentanil infusion, the surgical incision was made. The patient was observed for one minute from the time of incision by a solitary blinded rater for either flexion or withdrawal of one or more extremities in response to skin incision. Results:The mean minimum alveolar concentration of sevoflurane was 2.39 ± 0.58 with 0.03 µg·kg -1 ·min -1 remifentanil, 1.91 ± 0.36 with 0.06 µg·kg -1 ·min -1 remifentanil, and 0.92 ± 0.11 with 0.12 µg·kg -1 ·min -1 remifentanil. Remifentanil 0.25 µg·kg -1 ·min -1 lead to the sevoflurane being decreased to a level associated with spontaneous patient awakening.The effective dose (ED 50 ) values of sevoflurane were 2.44 [95% confidence interval (CI) 2.16-2.72], 2.00 (95% CI 1.78-2.22), and 1.18 (95% CI 0.99-1.36) for remifentanil infusion rates of 0.03 µg·kg -1 ·min -1 , 0.06 µg·kg -1 ·min -1 , and 0.12 µg·kg -1 ·min -1 respectively. Conclusion:The administration of remifentanil produced a dose-dependent decrease in the minimum alveolar concentration of sevoflurane necessary for inhibition of movement reaction in response to surgical incision. The use of remifentanil may allow for flexible analgesic control and rapid recovery in children anesthetized with sevoflurane. (IC de 95 % 1,22) et 1,18 (IC de 95 % 0,36) Objectif

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“…Furthermore, the precise dosage of remifentanil that is associated with tolerance in this population has not been determined. Although the intraoperative infusion of 0.25 µg·kg −1 ·min −1 remifentanil is associated with high postoperative pain-discomfort scores in 2-to 12-yr-old children, 9 the intraoperative infusion of 0.8 µg·kg…”

Section: ·Minmentioning

confidence: 99%

Intraoperative Infusion of 0.6–0.9 µg · kg−1 · min−1 Remifentanil Induces Acute Tolerance in Young Children after Laparoscopic Ureteroneocystostomy

et al. 2013

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Background: Intraoperative infusion of opioids has been associated with increased postoperative pain and analgesic requirements, but the development of tolerance in young children is less clear. This prospective, randomized, doubleblinded study was designed to test the hypothesis that the intraoperative administration of remifentanil results in postoperative opioid tolerance in a dose-related manner in young children. Methods: We enrolled 60 children (aged 1-5 yr) who were undergoing elective laparoscopic ureteroneocystostomy. Patients were randomized and received an intraoperative infusion of 0, 0.3, 0.6, or 0.9 µg·kg −1 ·min −1 remifentanil. Postoperative pain was managed by a parent/nurse-controlled analgesia pump using fentanyl. The primary outcome included the total fentanyl consumptions at 24 and 48 h postsurgery. Secondary outcomes were the postoperative pain scores and adverse effects. Results:The children who received 0.6 and 0.9 µg·kg −1 ·min −1 remifentanil required more postoperative fentanyl than the children who received saline or 0.3 µg·kg −1 ·min −1 remifentanil (all P < 0.001) for 24 h after surgery. The children who received 0.3-0.9 µg·kg −1 ·min −1 intraoperative remifentanil reported higher pain scores at 1 h after surgery than the children who received saline (P = 0.002, P = 0.023, and P = 0.006, respectively). No significant intergroup differences in recovery variables were observed, but vomiting was more frequent in the 0.9 µg·kg ·min−1 remifentanil to young children resulted in acute tolerance for 24 h after surgery in an apparently dose-related manner.T he unique pharmacodynamic and pharmacokinetic characteristics of remifentanil have increased its dominant intraoperative role in children.1,2 The context-sensitive halftime of remifentanil renders the offset for effect dose-independent, thus allowing prolonged infusion of large doses with little risk for delayed awakening or respiratory depression after surgery. 3,4 Similar to other potent opioids, however, intraoperative remifentanil may induce hyperalgesia and tolerance, manifesting as increased postoperative pain and analgesic requirements. [5][6][7] Opioid-induced hyperalgesia is a paradoxical pain sensitization of the nervous system whereby a patient receiving an opioid for the treatment of pain might actually have an increase in pain perception to noxious stimuli. 8 Tolerance is a pharmacologic concept defined as a progressive decrease in response to a drug and which can be overcome by increasing the dose of the drug. Although the difference between hyperalgesia and tolerance is difficult to tease out, opioid-induced hyperalgesia and tolerance may complicate the perioperative course of a patient who receives intraoperative opioid.In young children, however, only a few studies have investigated the development of tolerance after the intraoperative infusion of remifentanil, and the results were anecdotal and Intraoperative Infusion of 0.6-0.9 µg · kg

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A Randomized, Double-Blinded Study of Remifentanil Versus Fentanyl for Tonsillectomy and Adenoidectomy Surgery in Pediatric Ambulatory Surgical Patients

Cited by 47 publications

References 12 publications

Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial

Parecoxib sodium reduces the need for opioids after tonsillectomy in children: a double-blind placebo-controlled randomized clinical trial

Remifentanil decreases sevoflurane requirements in children

Intraoperative Infusion of 0.6–0.9 µg · kg−1 · min−1 Remifentanil Induces Acute Tolerance in Young Children after Laparoscopic Ureteroneocystostomy

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