Effect of Dexmedetomidine Combined With Low-dose Nalmefene on Preventing Remifentanil-induced Postoperative Hyperalgesia

Study Overview
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Brief Summary
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To explore and compare antihyperalgesic effects of Dexmedetomidine,Nalmefene,and a combination of both received before anesthesia induction. To evaluate and examine the incidence of adverse effects with the purpose of selecting the optimum dose.

Detailed Description
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There are a dramatically increasing number of evidences that administration of the potent, ultra-short-acting opioid remifentanil seems to cause opioid-induced hyperalgesia (OIH) more frequently and predictably compared with the others, likely due to its rapid onset and offset. Therefore, prophylaxis of remifentanil induced hyperalgesia is indispensable to postoperative comfort and satisfaction. There is no denying the fact that OIH is related to central glutaminergic system and N-methyl-d-aspartate(NMDA)receptor-activation induced central sensitization. Dexmedetomidine is an 2-adrenergic agonist that has been shown to synergize with opioids. Dexmedetomidine inhibits NMDAR excitability by reducing the phosphorylation of N-methyl-D-aspartate receptor 2B subunit phosphorylation of spinal dorsal horn induced by remifentanil, thereby achieving the goal of reducing OIH. Nalmefene is a pure opioid receptor antagonist that antagonizes the Mu receptor, alleviating the central sensitization of NMDA, thereby reducing OIH. At the same time reported in the literature, opioid receptor has a bimode：On the one hand can be mediated by Gs protein-mediated pain, respiratory depression, nausea and vomiting, etc ; on the other hand can be coupled with Gi / Go protein mediated analgesic effect. Low-dose nalmefene (<1.0ug / kg) and other opioid receptor antagonists can antagonize the role of Gs protein-coupled opioid receptors, blocking the pathway of opioid excitatory effects, thereby reducing the incidence of adverse reactions.The following study is carried out to evaluate whether dexmedetomidine combined with nalmefene can be safely and effectively applied to prevent postoperative hyperalgesia induced by remifentanil in patients undergoing Laparoscopic gynecological surgery.

Official Title
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The Effect of Dexmedetomidine Combined With Low-dose Nalmefene on Preventing Remifentanil-induced Postoperative Hyperalgesia in Patients Undergoing Gynecological Surgery

Conditions
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Pain, Anesthesia

Intervention / Treatment
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* Drug: Normal saline
* Drug: Remifentanil
* Drug: Sufentanil
* Drug: Dexmedetomidine injection
* Drug: Nalmefene


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients are scheduled to undergo Gynecological surgery under a short general anesthesia of 1-3 hours. American Society of Anesthesiologists physical status is I-II. Written informed consent was obtained from all the subjects. Exclusion Criteria: Subject has a diagnosis of Coronary heart disease, bronchial asthma, cardiac, lung, hepatic and renal insufficiency. Subject has a diagnosis of Severe high blood pressure , diabetes, obesity (BMI>30). Subject has a history of chronic pain, a history of alcohol or opioid abuse, pre-existing therapy with opioids, intake of any analgesic drug within 48 h before surgery. .Subject has Pregnancy, psychiatric disease. Subject has any contraindication for the use of patient-controlled analgesia (PCA). Inability to understand the Study Information Sheet and provide a written consent to take part in the study.

Ages Eligible for Study
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Minimum Age: 20 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Placebo Comparator: Normal Saline<br>Normal saline is intravenously administrated before anesthesia induction and intraoperative pain management was with remifentanil | Drug: Normal saline<br>* Normal saline is intravenously administrated before anesthesia induction<br>* Other names: 0. 9% Sodium Chloride Injection;Drug: Remifentanil<br>* Remifentanil is intravenously administrated<br>* Other names: Remifentanil Hydrochloride for Injection;|
| Sham Comparator: Sufentanil<br>Normal saline is intravenously admistrated before anesthesia induction and intraoperative pain management was with sufentanil | Drug: Normal saline<br>* Normal saline is intravenously administrated before anesthesia induction<br>* Other names: 0. 9% Sodium Chloride Injection;Drug: Sufentanil<br>* Sufentanil is intravenously administrated<br>* Other names: Sufentanil injection;|
| Active Comparator: Dexmedetomidine<br>Dexmedetomidine is intravenously administrated at a dose of 0.5ug/kg 10min before anesthesia induction and intraoperative pain management was with remifentanil | Drug: Remifentanil<br>* Remifentanil is intravenously administrated<br>* Other names: Remifentanil Hydrochloride for Injection;Drug: Dexmedetomidine injection<br>* Dexmedetomidine is intravenously administrated before anesthesia induction<br>* Other names: Dexmedetomidine;|
| Active Comparator: Nalmefene<br>Nalmefene is intravenously administrated at a dose of 0.2ug/kg before anesthesia induction and intraoperative pain management was with remifentanil | Drug: Remifentanil<br>* Remifentanil is intravenously administrated<br>* Other names: Remifentanil Hydrochloride for Injection;Drug: Nalmefene<br>* Nalmefene is intravenously administrated before anesthesia induction<br>|
| Active Comparator: Dexmedetomidine-Nalmefene<br>A dose of 0.1ug/kg nalmefene and a dose of 0.25ug/kg dexmedetomidine for 10 minutes before anesthesia induction and intraoperative pain management was with remifentanil | Drug: Remifentanil<br>* Remifentanil is intravenously administrated<br>* Other names: Remifentanil Hydrochloride for Injection;Drug: Dexmedetomidine injection<br>* Dexmedetomidine is intravenously administrated before anesthesia induction<br>* Other names: Dexmedetomidine;Drug: Nalmefene<br>* Nalmefene is intravenously administrated before anesthesia induction<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Mechanical Hyperalgesia Threshold on the Dominant Inner Forearm | The mechanical hyperalgesia threshold was defined as the lowest force (g) necessary to bend a Von Frey filament, which was perceived to be painful by the patient and measured by Von Frey filament at 24 hours postoperatively | 24 hours after surgery | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Normalized Area of Hyperalgesia Around the Incision | The skin around the incision is stimulated in steps of 5 mm at intervals of 1 s starting outside of the hyperalgesic area in the direction of the incision. The distance from the incision to the first point where a 'painful', 'sore' or 'sharper' feeling occurred is measured and noted. This measurement is repeated at predefined radial lines around the incision. To eliminate the variable length of incision, this length is subtracted from the longer diameter leaving four radial distances from the end and from the middle of the incision. The normalized area of hyperalgesia is calculated by summing up the areas of the remaining four triangles measured by and Von Frey filament. | 1hours,3hours，6hours，12hours，24hours after surgery | 
| Pain Score (Numerical Rating Scale) | The pain score at rest was evaluated by pain 11-point numerical rating scale : 0 = no pain, 10 = greatest imaginable pain. | 1hours,3hours，6hours，12hours，24hours after surgery | 
| Time of First Postoperative Analgesic Requirement | First postoperative pain (NRS≥5) is initially controlled by titration of sufentanyl. | postoperative 1 hours | 
| Cumulative Sufentanyl Consumption | Each patient was administered analgesics using a PCA pump containing sufentanil (100μg) in normal saline at a total volume of 100 ml after leaving post-anaesthesia care unit . This device was set to deliver a basal infusion of 2 ml/h and bolus doses of 0.5 ml with a 15-min lockout period. Sufentanyl cumulative consumption is recorded 24 hours postoperatively | 1hours,3hours，6hours，12hours，24hours after surgery | 
| Occurrence of Side Effects | Occurrence of side effects: nausea, vomiting, dizziness, headache, shivering, pruritus，hypotention/hypertention，bradycardia/tachycardia | 24 hours | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Remifentanil, Opioid-induced hyperalgesia, Postoperative pain, pain intensity