DOI QR코드

DOI QR Code

Magnesium Sulfate Attenuate Opioid Tolerance in Patients undergoing Major Abdominal Surgery

주요 복강수술 환자에서 황산 마그네슘의 아편유사제 내성 감소에 대한 효과

  • Jang, Mi Soon (Department of Anesthesiology and Pain Medicine, College of Medicine, Wonkwang University) ;
  • Son, Yong (Department of Anesthesiology and Pain Medicine, College of Medicine, Wonkwang University) ;
  • Lee, Cheol (Department of Anesthesiology and Pain Medicine, College of Medicine, Wonkwang University) ;
  • Lee, Ju Hwan (Department of Anesthesiology and Pain Medicine, College of Medicine, Wonkwang University) ;
  • Park, Jeong Hyun (Department of Internal Medicine, Sanbon Hospital, College of Medicine, Wonkwang University) ;
  • Lee, Myeong Jong (Department of Anesthesiology and Pain Medicine, Chungju Hospital, College of Medicine, Konkuk University)
  • 장미순 (원광대학교 의과대학 마취통증의학교실) ;
  • 손용 (원광대학교 의과대학 마취통증의학교실) ;
  • 이철 (원광대학교 의과대학 마취통증의학교실) ;
  • 이주환 (원광대학교 의과대학 마취통증의학교실) ;
  • 박정현 (원광대학교 의과대학 산본병원 내과학교실) ;
  • 이명종 (건국대학교 의과대학 충주병원 마취통증의학교실)
  • Received : 2009.02.12
  • Accepted : 2009.04.01
  • Published : 2009.04.01

Abstract

Background: Magnesium is a noncompetitive antagonist of the N-methyl-D aspartate (NMDA) receptor. Magnesium is thought to be involved in opioid tolerance by way of inhibiting calcium entry into cells. Methods: The patients were randomly assigned to three groups according to the anesthetic regimens: Group M received magnesium sulfate and Group C received saline intravenously under remifentanil-based anesthesia. Group S received saline intravenously under sevoflurane based anesthesia in place of remifentanil. The patients in the group M received 25% magnesium sulfate 50 mg/kg in 100 ml of saline, and those patients in groups C and S received an equal volume of saline before induction of anesthesia; this was followed by 10 mg/kg/h infusion of either magnesium sulfate (group M) or an equal volume of saline (groups C and S) until the end of surgery. Pain was assessed on a visual analog scale at 1, 6, 12, 24, and 36 hours after the operation. The time to the first postoperative analgesic requirement and the cumulative analgesic consumption were evaluated in the three groups. Results: The visual analog scales for pain and the cumulative analgesic consumption were significantly greater in group C than in other groups. The time to first postoperative analgesic requirement was significantly shorter in group C than that in the other groups. There were no differences between group M and S for side effects. Conclusions: A relatively high dose and continuous remifentanil infusion is associated with clinically relevant evidence of acute opioid tolerance. NMDA-receptor antagonist, magnesium sulfate as an adjuvant analgesic prevents opioid tolerance in patients who are undergoing major abdominal surgery under high dose and continuous remifentanil infusion-based anesthesia.

Keywords

Acknowledgement

Supported by : 원광대학교

References

  1. Jordan B, Devi LA: Molecular mechanisms of opioid receptor signal transduction. Br J Anaesth 1998; 81: 12-9 https://doi.org/10.1093/bja/81.1.12
  2. Koenig JA, Edwardson JM: Endocytosis and recycling of G protein-coupled receptors. Trends Pharmacol Sci 1997;18: 276-87 https://doi.org/10.1016/S0165-6147(97)01091-2
  3. Watkins LR, McGorry M, Schwartz B, Sisk D, Wiertelak EP, Maier SF: Reversal of spinal cord non-opiate analgesia by conditioned anti-analgesia in the rat. Pain 1997; 71:237-47 https://doi.org/10.1016/S0304-3959(97)03375-7
  4. Shimoyama N, Shimoyama M, Inturrisi CE, Elliott KJ: Ketamine attenuates and reverses morphine tolerance in rodents. Anesthesiology 1996; 85: 1357-66 https://doi.org/10.1097/00000542-199612000-00017
  5. McCarthy RJ, Kroin JS, Tuman KJ, Penn RD, Ivankovich AD: Antinociceptive potentiation and attenuation of tolerance by intrathecal co-infusion of magnesium sulfate and morphine in rats. Anesth Analg 1998; 86: 830-6 https://doi.org/10.1097/00000539-199804000-00028
  6. Telci L, Esen F, Akcora D, Erden T, Canbolat AT, Akpir K: Evaluation of effects of magnesium sulphate in reducing intraoperative anaesthetic requirements. Br J Anaesth 2002;89: 594-8 https://doi.org/10.1093/bja/aef238
  7. Ryu JH, Kang MH, Park KS, Do SH: Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia. Br J Anaesth 2008; 100: 397-403 https://doi.org/10.1093/bja/aem407
  8. Rubeiz GJ, Thill-Baharozian M, Hardie D, Carlson RW: Association of hypomagnesemia and mortality in acutely ill medical patients. Crit Care Med 1993; 21: 203-9 https://doi.org/10.1097/00003246-199302000-00010
  9. Shiga T, Wajima Z, Inoue T, Ogawa R: Magnesium prophylaxis for arrhythmias after cardiac surgery: a meta-analysis of randomized controlled trials. Am J Med 2004; 117:325-33 https://doi.org/10.1016/j.amjmed.2004.03.030
  10. Lee C, Jang MS, Song YK, O S, Moon SY, Kang DB, et al: The effect of magnesium sulfate on postoperative pain in patients undergoing abdominal surgery under remifentanil-based anesthesia. Korean J Anesthesiol 2008; 55: 286-90 https://doi.org/10.4097/kjae.2008.55.3.286
  11. Crawford MW, Hickey C, Zaarour C, Howard A, Naser B:Development of acute opioid tolerance during infusion of remifentanil for pediatric scoliosis surgery. Anesth Analg 2006; 102: 1662-7 https://doi.org/10.1213/01.ane.0000216036.95705.c2
  12. Angst MS, Chu LF, Tingle MS, Shafer SL, Clark JD, Drover DR: No evidence for the development of acute tolerance to analgesic, respiratory depressant and sedative opioid effects in humans. Pain 2009; 142: 17-26 https://doi.org/10.1016/j.pain.2008.11.001
  13. Chia YY, Liu K, Wang JJ, Kuo MC, Ho ST: Intraoperative high dose fentanyl induces postoperative fentanyl tolerance. Can J Anaesth 1999; 46: 872-7 https://doi.org/10.1007/BF03012978
  14. Guignard B, Bossard AE, Coste C, Sessler DI, Lebrault C, Alfonsi P, et al: Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology 2000; 93: 409-17 https://doi.org/10.1097/00000542-200008000-00019
  15. Kissin I, Brown PT, Bradley EL Jr: Magnitude of acute tolerance to opioids is not related to their potency. Anesthesiology 1991; 75: 813-6 https://doi.org/10.1097/00000542-199111000-00013
  16. Kissin I, Brown PT, Robinson CA, Bradley EL Jr: Acute tolerance in morphine analgesia: continuous infusion and single injection in rats. Anesthesiology 1991; 74: 166-71 https://doi.org/10.1097/00000542-199101000-00025
  17. Ho ST, Wang JJ, Huang JC, Lin MT, Liaw WJ: The magnitude of acute tolerance to morphine analgesia: concentration-dependent or time-dependent? Anesth Analg 2002;95: 948-51 https://doi.org/10.1097/00000539-200210000-00029
  18. C$\acute{e}$l$\grave{e}$rier E, Rivat C, Jun Y, Laulin JP, Larcher A, Reynier P, et al: Long-lasting hyperalgesia induced by fentanyl in rats: preventive effect of ketamine. Anesthesiology 2000;92: 465-72 https://doi.org/10.1097/00000542-200002000-00029
  19. Whang R: Magnesium deficiency: Pathogenesis, prevalence, and clinical implications. Am J Med 1987; 82: 24-9 https://doi.org/10.1016/0002-9343(87)90129-X
  20. Lanzinger MJ, Moretti EW, Wilderman RF, El-Moalem HE, Toffaletti JG, Moon RE: The relationship between ionized and total serum magnesium concentrations during abdominal surgery. J Clin Anesth 2003; 15: 245-9 https://doi.org/10.1016/S0952-8180(03)00059-X
  21. Chang CH, Nam SB, Lee JS, Han DW, Lee HK, Shin CS:Change in ionized and total magnesium concentration during spinal surgery. Korean J Anesthesiol 2007; 52(Suppl):37-41 https://doi.org/10.4097/kjae.2007.52.6.S37
  22. Nowak L, Bregestovski P, Ascher P, Herbet A, Prochiantz A: Magnesium gates glutamate-activated channels in mouse central neurones. Nature 1984; 307: 462-5 https://doi.org/10.1038/307462a0
  23. Koinig H, Wallner T, Marhofer P, Andel H, H$\ddot{o}$rauf K, Mayer N: Magnesium sulfate reduces intra- and postoperative analgesic requirements. Anesth Analg 1998; 87:206-10 https://doi.org/10.1097/00000539-199807000-00042
  24. Levaux CH, Bonhomme V, Dewandre PY, Brichant JF, Hans P: Effect of intraoperative magnesium sulphate on pain relief and patient comfort after major lumbar orthopaedic surgery. Anaesthesia 2003; 58: 131-5 https://doi.org/10.1046/j.1365-2044.2003.02999.x
  25. Bahar M, Cohen ML, Grinshpun Y, Datski R, Kaufman J, Zaidman JL, et al: Serum electrolyte and blood gas changes after intrathecal and intravenous bolus injections of magnesium sulphate. An experimental study in a rat model. Anaesthesia 1997; 52: 1065-9
  26. Zarauza R, S$\acute{a}$ez-Fern$\acute{a}$ndez AN, Iribarren MJ, Carrascosa F, Adame M, Fidalgo I, et al: A comparative study with oral nifedipine, intravenous nimodipine and magnesium sulfate in postoperative analgesia. Anesth Analg 2000; 91: 938-43 https://doi.org/10.1097/00000539-200010000-00032
  27. Wilder-Smith CH, Kn$\ddot{o}$pfli R, Wilder-Smith OH: Perioperative magnesium infusion and postoperative pain. Acta Anaesthesiol Scand 1997; 41: 1023-7
  28. Goto T, Marota JJ, Crosby G: Volatile anaesthetics antagonize nitrous oxide and morphine-induced analgesia in the rat. Br J Anaesth 1996; 76: 702-6 https://doi.org/10.1093/bja/76.5.702
  29. Tomi K, Mashimo T, Tashiro C, Yagi M, Pak M, Nishimura S, et al: Alterations in pain threshold and psychomotor response associated with subanaesthetic concentrations of inhalation anaesthetics in humans. Br J Anaesth 1993; 70:684-6 https://doi.org/10.1093/bja/70.6.684
  30. Petersen-Felix S, Arendt-Nielsen L, Bak P, Roth D, Fischer M, Bjerring P, et al: Analgesic effect in humans of suba naesthetic isoflurane concentrations evaluated by experimentally induced pain. Br J Anaesth 1995; 75: 55-60 https://doi.org/10.1093/bja/75.1.55
  31. Galinkin JL, Janiszewski D, Young CJ, Klafta JM, Klock PA, Coalson DW, et al: Subjective, psychomotor, cognitive, and analgesic effects of subanesthetic concentrations of sevoflurane and nitrous oxide. Anesthesiology 1997; 87:1082-8
  32. Fuchs-Buder T, Wilder-Smith OH, Borgeat A, Tassonyi E:Interaction of magnesium sulphate with vecuronium-induced neuromuscular block. Br J Anaesth 1995; 74: 405-9 https://doi.org/10.1093/bja/74.4.405
  33. Wadhwa A, Sengupta P, Durrani J, Ak$\c{c}$a O, Lenhardt R, Sessler DI, et al: Magnesium sulphate only slightly reduces the shivering threshold in humans. Br J Anaesth 2005; 94:756-62 https://doi.org/10.1093/bja/aei105
  34. Kranke P, Eberhart LH, Roewer N, Tramèr MR: Singledose parenteral pharmacological interventions for the prevention of postoperative shivering: a quantitative systematic review of randomized controlled trials. Anesth Analg 2004; 99: 718-27 https://doi.org/10.1213/01.ANE.0000130589.00098.CD