To the Editor,We read with great interest the article of von Dincklage et al. () in a recent issue of the Journal. The authors concluded after investigating 110 patients undergoing primary total hip arthroplasty that greater levels of intraoperative analgesia are associated with lower levels of persistent pain and less analgesic consumption 6 months after total hip arthroplasty. The authors should be congratulated for performing a well‐designed study and for examining a very important topic in perioperative medicine (Niraj et al., ; Piraccini et al., ).Although the authors performed a well‐conducted study, there are some concerns that are important but not discussed by the authors. First, remifentanil has been shown to cause postoperative hyperalgesia and the authors’ findings are contrary to a large body of literature in the topic (Fletcher and Martinez, ; Koo et al., ; Lee et al., ). We were wondering if the use of a binary outcome for ‘regular’ pain medication after 6 months is appropriate, as the variation in dose can be very important especially when related to opioids. In addition, the use of linear regression for pain intensity is likely not appropriate given the ordinal nature of this variable. Lastly, it would be important for the authors to report any interaction terms that could have altered the analysis.We would welcome some comments from the authors. These comments would further determine the validity of this important clinical study.Referencesvon Dincklage, F., Jakuscheit, A., Weth, J., Lichtner, G., Jurth, C., Rehberg‐Klug, B. (2017). Higher doses of intraoperative analgesia are associated with lower levels of persistent pain and less analgesic consumption six months after total hip arthroplasty. Eur J Pain 22, 691–699.Fletcher, D., Martinez, V. (2014). Opioid‐induced hyperalgesia in patients after surgery: a systematic review and a meta‐analysis. Br J Anaesth 112, 991–1004.Koo, C.H., Cho, Y.J., Hong, D.M., Jeon, Y., Kim, T.K. (2016). Influence of high‐dose intraoperative remifentanil with intravenous ibuprofen on postoperative morphine consumption in patients undergoing pancreaticoduodenectomy: a randomized trial. J Clin Anesth 35, 47–53.Lee, M., Zhu, F., Moodie, J., Zhang, Z., Cheng, D., Martin, J. (2017). Remifentanil as an alternative to epidural analgesia for vaginal delivery: A meta‐analysis of randomized trials. J Clin Anesth 39, 57–63.Niraj, G., Kelkar, A., Kaushik, V., Tang, Y., Fleet, D., Tait, F., Mcmillan, T., Rathinam, S. (2017). Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center. J Clin Anesth 36, 174–177.Piraccini, E., Byrne, H., Calli, M., Poggi, P., Maitan, S. (2017). Pectoral nerves and serratus plane block for persistent postsurgical pain after video‐assisted thoracic surgery. Eur J Pain 21, 1618–1619.
European Journal of Pain – Wiley
Published: Jan 1, 2018
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