Abstract
The widespread use of remifentanil during total intravenous anesthesia (TIVA) has raised concerns about the risk of postoperative remifentanil-associated pain. Although a recent meta-analysis suggests that remifentanil-associated pain is unlikely to occur in patients with TIVA because of the protective effect of co-administered propofol, the evidence is not conclusive. We retrospectively assessed 635 patients who received robotic thyroid surgery under TIVA to evaluate the risk of remifentanil-associated pain. Postoperative pain was evaluated using 11-point numeric rating scale (NRS). Time dependent Cox proportional hazards regression analysis was used to determine the risk factors of treatment-requiring pain (NRS > 4) during the first 48 postoperative hours. Postoperative pain rapidly decreased, and treatment-requiring pain remained in 12.8% (81 out of 635) of patients at 48 hours postoperatively. After adjusting for the time-dependent analgesic consumption, intraoperative use of remifentanil > 0.2 mcg/kg/min was a positive predictor of postoperative pain with a hazard ratio of 1.296 (95% C.I., 1.014–1.656, P = 0.039) during 48 hours after surgery. In conclusion, excessive use of remifentanil during TIVA was associated with increased risk of pain after robotic thyroid surgery. Prospective trials are required to confirm these results and determine whether decreasing remifentanil consumption below the threshold can reduce postoperative pain.
Highlights
Remifentanil is one of the most commonly used analgesic in recent anesthesia practice due to its rapid onset and offset
We retrospectively evaluated patients who underwent robotic thyroid surgery to assess whether excessive remifentanil use in total intravenous anesthesia (TIVA) increases postoperative pain
A total of 709 patients were reviewed for eligibility and 635 patients were included in the regression analysis after excluding 74 patients who took analgesic medication due to acute and chronic pain (5 cases), participated in another clinical trial (60 cases), and in whom numeric rating scale (NRS) record was missing (9 cases)
Summary
Remifentanil is one of the most commonly used analgesic in recent anesthesia practice due to its rapid onset and offset. With the widespread use of remifentanil, there are concerns about new problems related to postoperative pain. Due to the short duration of action, the analgesic effect of remifentanil rapidly disappears with the termination of infusion, raising the issue of proper postoperative analgesia. The association between excessive remifentanil use during surgery and acute opioid tolerance (AOT) and/or opioid-associated hyperalgesia (OIH) after surgery has been suggested by many prospective studies and subsequent meta-analysis and systematic reviews [1,2,3,4,5].
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