Nalbuphine versus dexmedetomidine for treatment of combined spinal-epidural post-anesthetic shivering in pregnant women undergoing cesarean section

Efficacy of intravenous nalbuphine for managing post-anaesthesia shivering: A systematic review and meta-analysis of randomised controlled trials with trial sequential analysis

Background and Aims

Post-anaesthesia shivering is distressing and is observed after spinal and general anaesthesia. Nalbuphine, a partial mu-opioid receptor antagonist with kappa-opioid receptor agonist properties, has been successfully used to manage post-anaesthesia shivering.

Methods

After registering the review with the International Prospective Register of Systematic Reviews (PROSPERO), we searched PubMed/Medline, Scopus, Ovid, Cochrane Library and clinicaltrials.gov with keywords for randomised controlled trials. The risk of bias-2 (RoB-2) scale was used to assess the quality of evidence. We also used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) guidelines to evaluate the strength of evidence and trial sequential analysis to validate the conclusions.

Results

Of the 240 articles, 10 were considered eligible for review (700 patients, 350- nalbuphine, 350- control or placebo). When compared to placebo, the success rate of nalbuphine controlling shivering was significantly better (risk ratio [RR]: 2.37, 95% confidence interval [CI]:1.91, 2.94; P = 0.04, I² = 94%), but comparable to the control group drugs (opioids, dexmedetomidine, ondansetron, pethidine). Compared to placebo, shivering recurrence was significantly less with nalbuphine than with placebo (RR: 0.47, 95% CI: 0.26, 0.83; P = 0.01, I² = 61%), but comparable with the control group. The incidence of postoperative nausea/vomiting (PONV) was significantly less with nalbuphine when compared to the control group (RR: 0.67, 95% CI: 0.47, 0.95; P = 0.02, I² = 37%), but PONV in the nalbuphine group was comparable to placebo (RR: 1.20, 95% CI: 0.68, 2.12; P = 0.54, I² = 0%). Other outcomes, like the grade of shivering and hypotension, were comparable between the nalbuphine and control groups.

Conclusion

Nalbuphine successfully controls post-anaesthesia shivering and reduces the recurrence of shivering.

Comparison of the Effect of Forced-air Warming and Warmed Intravenous Fluid on the Comfort and Prevention of Shivering After Spinal Anesthesia in Patients Undergoing Orthopedic Surgery

PURPOSE

This study aimed to compare the effect of forced-air warming and warmed intravenous fluid on the comfort and prevention of shivering after spinal anesthesia in patients undergoing orthopaedic surgery.

DESIGN

Randomized controlled clinical trial.

METHODS

A total of 120 patients were randomly divided into three groups: forced-air warming (38°C), warmed intravenous fluid (37°C), and the control group. Patients' comfort and severity of shivering were measured and recorded five times (immediately and 15 minutes after spinal anesthesia, end of the surgery, time of entrance to the recovery room, and 15 minutes after entering the recovery room), and compared with each other.

FINDINGS

There was a significant difference between the three groups in terms of comfort at all points of evaluation times (P < .001). The comfort score in the control group was significantly higher than the two intervention groups (P < .001). Moreover, the comfort score in the warmed intravenous fluid group was significantly higher than the forced-air warming group (P < .001). In addition, there was a significant difference in shivering severity between the three groups at the end of the surgery, entrance to the recovery room, and 15 minutes after surgery (P < .001). The majority of patients in the forced-air warming group (90%) had no shivering at all three times, while the warmed IV fluid and control groups was 65% and 30% respectively.

CONCLUSIONS

Non-pharmacological methods such as forced-air warming and warmed intravenous fluid can provide comfort and prevent shivering in orthopaedic patients undergoing spinal anesthesia. However, the use of forced-air warming is more effective than warmed intravenous fluid in providing comfort and preventing shivering in these patients. It is recommended that these methods be used in the operating room to provide comfort and prevent shivering in these patients.

Nalbuphine alleviates inflammation by down-regulating NF-κB in an acute inflammatory visceral pain rat model

Introduction

Nalbuphine can relieve patients’ inflammation response after surgery compared to other opioid drugs. However, its molecular mechanism has not been clear. Activation of NF-κB signaling pathway under oxidative stress and inflammation can maintain pain escalation.

Methods

We firstly investigated the effect of nalbuphine on writhing test and mechanical allodynia using a rat model of inflammatory visceral pain (acetic acid (AA) administrated). Cytokines (including tumor necrosis factor (TNF)-α, Interleukin (IL)-1β, IL-2, and IL-6 in plasma were tested with ELISA technology. Expression levels of TNF-α, IκBα and p-NF-κB p65 at the spinal cord (L3–5) were measured by western blot or RT-qPCR.

Results

We found that the paw withdrawal threshold (PWT) values of rats were reduced in the model group, while the numbers of writhing, levels of IL-1β, IL-2, IL-6, and TNF-α in plasma, and p-NF-κB protein and its gene expressions in the lumbar spinal cord were up-regulated. Subcutaneously injection of nalbuphine (10 μg/kg) or PDTC (NF-κB inhibitor) attenuated acetic acid-induced inflammatory pain, and this was associated with reversal of up-regulated IL-1β, IL-2, IL-6, and TNF-α in both plasma and spinal cord. Furthermore, acetic acid increased p-NF-κB and TNF-α protein levels in the white matter of the spinal cord, which was attenuated by nalbuphine. These results suggested that nalbuphine can significantly ameliorate inflammatory pain via modulating the expression of NF-κB p65 as well as inflammation factors level in the spinal cord.

Conclusion

In conclusion, nalbuphine inhibits inflammation through down-regulating NF-κB pathway at the spinal cord in a rat model of inflammatory visceral pain.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-022-00573-7.

Comparison of dexmedetomidine and meperidine for the prevention of shivering following coronary artery bypass graft: study protocol of a randomised controlled trial

INTRODUCTION

Shivering is a common complication in the postoperative period. The incidence of shivering has been reported to range from 5% to 65% under general anaesthesia and as 33% during epidural anaesthesia. Shivering can increase perioperative risk in patients. Both dexmedetomidine and meperidine are effective agents for the prevention of postanaesthetic shivering. However, few studies have compared the anti-shivering effects of different agents following coronary artery bypass graft (CABG). This study aims to compare the effects of dexmedetomidine and meperidine on the incidence of shivering in patients undergoing CABG.

METHODS AND ANALYSIS

A total of 180 patients aged 18-75 years, with an American Society of Anesthesiologists (ASA) grade of II-IV, undergoing elective CABG will be enrolled and randomly assigned to the dexmedetomidine, meperidine and control groups (placebo) in an intended 1:1:1 allocation ratio. The patients will be followed up for 7 days after surgery. The primary outcome is the incidence of shivering within 24 hours postoperatively. The secondary outcomes are the number of remedial drugs used after surgery, the incidence of postoperative hypotension and bradycardia, sedation scores, endotracheal extubation time, intensive care unit length of stay, incidence of postoperative delirium within 7 days after surgery, incidence of postoperative arrhythmias, incidence of postoperative nausea and vomiting, average hospital length of stay and mortality rate 30 days after surgery.

ETHICS AND DISSEMINATION

The study protocol was approved by the ethics committee of The First Affiliated Hospital of Shandong First Medical University on 20 January 2021 (YXLL-KY-2021(002)) and registered at ClinicalTrials.gov. The results of this study will be presented at national and international scientific meetings and conferences. We plan to publish the data in peer-reviewed international scientific journals.

TRIAL REGISTRATION NUMBER

NCT04735965.

Analysis of Anesthesia Effect of Dexmedetomidine in Clinical Operation of Replantation of Severed Finger

Brachial plexus block commonly used in finger replantation has the advantages of simple operation, small side effects, and stable circulation, but it has inherent problems such as imperfect block range, slow onset of anesthesia, and short maintenance time of anesthesia. In order to explore the reliable clinical anesthesia effect, this paper uses experimental investigation methods to study the effect of dexmedetomidine in clinical surgery of replantation of severed fingers. Moreover, this paper uses comparative test methods, uses statistical methods to process test data, and uses intuitive methods to display test results. Finally, this paper verifies the reliability of dexmedetomidine in replantation of severed finger through comparative analysis and verifies that the anesthesia method proposed in this paper has certain user satisfaction through parameter survey.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Effects of epidural anesthesia combined with dexmedetomidine on blood pressure, sedation, analgesia and serum β-endorphin levels in patients with hip fractures

OBJECTIVE

To investigate the effect of dexmedetomidine (DEX) combined with epidural anesthesia on blood pressure, sedation, analgesia and serum β-endorphin levels in patients with hip fractures.

METHODS

A total of 260 patients with hip fractures were randomly divided into the control group and the experimental group by random number table, with 130 cases in each group. During the perioperative period, the control group was anesthetized with sufentanil combined midazolam, while the experimental group was anesthetized with sufentanil with DEX. In this study, we observed the vital signs and evaluated Ramsay scores at 15 minutes (T1), 30 minutes (T2), 60 minutes (T3), and 90 minutes (T4) after anesthesia. The analgesic effect was obtained using Visual Analogue Scale (VAS) scores at 2 hours (H1), 6 hours (H2), 12 hours (H3), and 24 hours (H4) after operation. The collected blood was used to determine the levels of nitric oxide (NO), endorphin (β-EP), substance P (SP), gamma-interferon (IFN-γ), and tumor necrosis factor-α (TNF-α) by enzyme-linked immuno sorbent assay (ELISA). We also recorded the incidence of adverse reactions during the observation period.

RESULTS

Compared with the control group, the experimental group had higher systolic blood pressure (SBP) at T1, T2 and T3, higher diastolic blood pressure (DBP) at T2, higher rate-pressure product (RPP) at T3 and T4, and lower heart rate (HR) at T1, T2 and T3 (all P<0.05). Compared with the control group, the experimental group had higher Ramsay scores at T2 and T3 (P<0.05). The control group had a difference in Ramsay scores at T2 and T3 compared to T1 (P<0.05). Ramsay scores of the experimental group at T4 were different from that at T1 (P<0.05). Compared with the control group, the experimental group had higher visual analogue scale (VAS) scores at H1, H2, and H3 (P<0.05), while the VAS scores at H3 were lower than those at H1, and the VAS scores at H4 were lower than those at H3 (P<0.05). After operation, the levels of NO, β-EP, SP and IFN-γ in the experimental group were lower than those in the control group (P<0.05), but the level of TNF-α was higher than that in the control group (P<0.05). The number of PCIA analgesic compressions and the dosage of sufentanil in the experimental group were different from those in the control group (P<0.05). There was no statistical difference in the adverse reactions between experimental group and control groups (P>0.05).

CONCLUSION

Compared with midazolam, the effect of DEX combined with epidural anesthesia for the hip fracture was better. It can maintain patient's vital signs and up-regulate β-endorphin for rapid analgesia and sedation.

Randomized Double-Blinded Comparative Study of Intravenous Nalbuphine and Tramadol for the Treatment of Postspinal Anesthesia Shivering

Context:

Shivering is one of the most commonly recognized complications of the central neuraxial blockade. For optimal perioperative care, control of postspinal anesthesia shivering is essential.

Aims:

The present study designed to compare the clinical efficacy, hemodynamic parameters, and side effects of nalbuphine and tramadol for control of postspinal anesthesia shivering.

Settings and Design:

This was a prospective, randomized, double-blind study.

Materials and Methods:

This study was conducted on 90 American Society of Anesthesiologists Physical Status I and II patients of either gender, aged between 18 and 60 years, who subsequently developed shivering grade 3 or 4, scheduled for different surgical procedures under spinal anesthesia. The patients were randomized into two groups of 45 patients each to receive either nalbuphine 0.06 mg.kg⁻¹ (Group N) or tramadol 1 mg.kg⁻¹ (Group T). Grade of shivering, onset of shivering, time interval for cessation of shivering, response rate at 5 and 30 min, rescue dose, hemodynamic parameters, and side effects were observed at scheduled intervals.

Statistical Analysis Used:

Independent t-test and Chi-square/Fisher's exact test were used to analyze the data.

Results:

The time taken for cessation of shivering was significantly less with nalbuphine in comparison with tramadol (P < 0.05). It was observed that the response time at 5 and 30 min and rescue dose requirement for control of shivering were not much difference (P > 0.05).

Conclusions:

Both nalbuphine and tramadol are effective; however, the time taken for cessation of shivering is significantly less with nalbuphine when compared to tramadol. Furthermore, tramadol causes significantly more nausea and vomiting; however, nalbuphine causes significantly more sedation.

Effects of anesthetic agents on contractions of the pregnant rat myometrium in vivo and in vitro

BACKGROUND

Several anesthetic agents are used in cesarean sections for both regional and general anesthesia purposes. However, there are no data comparing the in vivo effects of propofol, sevoflurane, and dexmedetomidine on the contraction of the myometrium in pregnant rats. The aim of this study was to investigate the effect of these anesthetic agents on myometrial contraction and elucidate the underlying mechanisms.

METHODS

Contraction force and frequency changes in response to propofol, dexmedetomidine, or sevoflurane were evaluated in vivo and in vitro. To test the effect of arachidonic acid on myometrial contraction enhanced by dexmedetomidine, changes in myometrial contraction with dexmedetomidine after administration of indomethacin were evaluated. The amount of phosphorylated myosin phosphatase target subunit 1 (MYPT1) in the membrane fraction was expressed as a percentage of the total fraction by Western blot analysis.

RESULTS

This study demonstrated that dexmedetomidine enhances oxytocin-induced contraction in the myometrium of pregnant rats, whereas propofol and sevoflurane attenuate these contractions. The dexmedetomidine-induced enhancement of myometrial contraction force was abolished by the administration of indomethacin. Propofol did not affect oxytocin-induced MYPT1 phosphorylation, whereas sevoflurane attenuated oxytocin-induced MYPT1 phosphorylation.

CONCLUSIONS

Inhibition of myofilament calcium sensitivity may underlie the inhibition of myometrial contraction induced by sevoflurane. Arachidonic acid may play an important role in the enhancement of myometrial contraction induced by dexmedetomidine by increasing myofilament calcium sensitivity. Dexmedetomidine may be used as a sedative agent to promote uterine muscle contraction and suppress bleeding after fetal delivery.