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| LETTER TO EDITOR |
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| Year : 2022 | Volume
: 42
| Issue : 5 | Page : 253-254 |
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Ketamine treats nalbuphine sebacate-induced hyperalgesia
Su-Zhen Wu1, Jen-Yin Chen2, Zhi-Fu Wu3
1 Department of Anesthesiology, Chi Mei Medical Center, Liouying, Taiwan
2 Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
3 Department of Anesthesiology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung; Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| Date of Submission | 15-Dec-2020 |
| Date of Decision | 09-Jan-2021 |
| Date of Acceptance | 13-Jan-2021 |
| Date of Web Publication | 04-May-2021 |
Correspondence Address:
Zhi-Fu Wu
No. 100, Tzyou 1st Road, Sanmin District, Kaohsiung City 80756
Taiwan
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmedsci.jmedsci_418_20
How to cite this article:
Wu SZ, Chen JY, Wu ZF. Ketamine treats nalbuphine sebacate-induced hyperalgesia. J Med Sci 2022;42:253-4 |
Dear Editor,
We read the article, Nalbuphine sebacate interferes with the analgesic effect of fentanyl, there is a case suffered from nalbuphine sebacate (Naldebain®)-induced hyperalgesia after surgery and rescue fentanyl 100 μg, tenoxicam 20 mg, and tramadol 100 mg were in vain.[1] Here, we present a case who experienced postoperative severe pain after Naldebain® administration and relieved after ketamine treatment.
A 36-year-old female, with a height of 165.3 cm and a weight of 71.5 kg, had a right-side ovarian tumor. She underwent right salpingo-oophocystectomy with exploratory laparotomy. Thirteen hours before anesthesia, intramuscular Naldebain® 150 mg was administered. Anesthesia was induced with fentanyl 100 μg, rocuronium 10 mg, and propofol 120 mg and maintained with desflurane under entropy. During 3 h of the operation, fentanyl 100 mcg, morphine 10 mg, ketorolac 30 mg, and exhaled 8%–10% desflurane concentration were administered to manage her hyperdynamics (blood pressure: 160/85 mmHg, heart rate: around 80–100 bpm, and response entropy/state entropy: 56/53). In the postanesthetic care unit, the patient complained severe sharp wound pain with a Numerical Rating Scale (NRS) score of 8/10. After rescue morphine 5 mg, NRS is still 5/10. Ketamine 15 mg was given 20 min after rescue morphine, and pain relieved to 3/10, without any side effects. In the general ward, the numeric rating scale (NRS) was around 3/10 without received any pain killer.
A previous report that nalbuphine did not attenuate the antinociceptive effect of morphine at a dose of 5 mg/kg in rats.[2] However, Wu et al.[1] reported that Naldebain® may induced hyperalgesia perioperatively. Moreover, acute opioid tolerance and opioid-induced hyperalgesia have been reported in the clinical use of opioids for anesthesia and postoperative pain management.[3] Possible action mechanisms include increased presynaptic glutamate release and postsynaptic N-methyl-D-aspartate (NMDA) receptor activation.[3],[4] Huang et al.[5] reported that NMDA receptor antagonist, ketamine and dextromethorphan, can reduce neuroplasticity through inhibition of NMDA receptors. It is consistent with our present case.
In conclusion, anesthesiologists must notice the administration of Naldebain® before surgery; it may interfere with the analgesic effect of fentanyl[1] and then the management of hemodynamics and postoperative pain. We prefer multimodal analgesia, including local anesthetic infiltration and ketamine, to only opioid administration.
Consent
The consent for publication was gained.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Wu TS, Wu HC, Wu ZF, Huang YH. Nalbuphine sebacate interferes with the analgesic effect of fentanyl. J Med Sci 2020;40:101.  [Full text] |
| 2. | Lee SC, Wang JJ, Ho ST, Tao PL. Nalbuphine coadministered with morphine prevents tolerance and dependence. Anesth Analg 1997;84:810-5. |
| 3. | Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: Molecular mechanisms and clinical considerations. Clin J Pain 2008;24:479-96. |
| 4. | Gu X, Wu X, Liu Y, Cui S, Ma Z. Tyrosine phosphorylation of the N-Methyl-D-Aspartate receptor 2B subunit in spinal cord contributes to remifentanil-induced postoperative hyperalgesia: The preventive effect of ketamine. Mol Pain 2009;5:76. |
| 5. | Huang NC, Sun WZ, Wong CS. Prevention of chronic postsurgical pain: The effect of preventive and multimodal analgesia. Asian J Anesthesiol 2018;56:74-82. |
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