The Korean Journal of Pain

  • 제27권3호
  • /
  • Pages.200-209
  • /
  • 2014
  • /
  • 2005-9159(pISSN)
  • /
  • 2093-0569(eISSN)
대한통증학회 (The Korean Pain Society)
권호 표지
DOI QR코드

DOI QR Code

Current Evidence for Spinal Opioid Selection in Postoperative Pain

  • Bujedo, Borja Mugabure (Department of Anaesthesiology, Critical Care and Pain Medicine, Donostia University Hospital)
  • 투고 : 2014.01.16
  • 심사 : 2014.04.16
  • 발행 : 2014.07.01
PDF 다운로드
⟨ 이전 논문 다음 논문 ⟩

초록

Background: Spinal opioid administration is an excellent option to separate the desirable analgesic effects of opioids from their expected dose-limiting side effects to improve postoperative analgesia. Therefore, physicians must better identify either specific opioids or adequate doses and routes of administration that result in a mainly spinal site of action rather than a cerebral analgesic one. Methods: The purpose of this topical review is to describe current available clinical evidence to determine what opioids reach high enough concentrations to produce spinally selective analgesia when given by epidural or intrathecal routes and also to make recommendations regarding their rational and safety use for the best management of postoperative pain. To this end, a search of Medline/Embase was conducted to identify all articles published up to December 2013 on this topic. Results: Recent advances in spinal opioid bioavailability, based on both animals and humans trials support the theory that spinal opioid bioavailability is inversely proportional to the drug lipid solubility, which is higher in hydrophilic opioids like morphine, diamorphine and hydromorphone than lipophilic ones like alfentanil, fentanyl and sufentanil. Conclusions: Results obtained from meta-analyses of RTCs is considered to be the 'highest' level and support their use. However, it's a fact that meta-analyses based on studies about treatment of postoperative pain should explore clinical surgery heterogeneity to improve patient's outcome. This observation forces physicians to use of a specific procedure surgical-based practical guideline. A vigilance protocol is also needed to achieve a good postoperative analgesia in terms of efficacy and security.

키워드

참고문헌

  1. Macintyre PE, Walker SM. The scientific evidence for acute pain treatment. Curr Opin Anaesthesiol 2010; 23: 623-8. https://doi.org/10.1097/ACO.0b013e32833c33ed
  2. Espitalier F, Tavernier E, Remerand F, Laffon M, Fusciardi J, Giraudeau B. Heterogeneity in meta-analyses of treatment of acute postoperative pain: a review. Br J Anaesth 2013; 111: 897-906. https://doi.org/10.1093/bja/aet250
  3. Kehlet H, Wilkinson RC, Fischer HB, Camu F; Prospect Working Group. PROSPECT: evidence-based, procedurespecific postoperative pain management. Best Pract Res Clin Anaesthesiol 2007; 21: 149-59. https://doi.org/10.1016/j.bpa.2006.12.001
  4. Wang JK, Nauss LA, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology 1979; 50: 149-51. https://doi.org/10.1097/00000542-197902000-00013
  5. Behar M, Magora F, Olshwang D, Davidson JT. Epidural morphine in treatment of pain. Lancet 1979; 1: 527-9.
  6. Bernards CM. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesthesiol 2002; 16: 489-505. https://doi.org/10.1053/bean.2002.0255
  7. Bernards CM. Recent insights into the pharmacokinetics of spinal opioids and the relevance to opioid selection. Curr Opin Anaesthesiol 2004; 17: 441-7. https://doi.org/10.1097/00001503-200410000-00015
  8. Bujedo BM. Spinal opioid bioavailability in postoperative pain. Pain Pract 2014; 14: 350-64. https://doi.org/10.1111/papr.12099
  9. Angst MS, Ramaswamy B, Riley ET, Stanski DR. Lumbar epidural morphine in humans and supraspinal analgesia to experimental heat pain. Anesthesiology 2000; 92: 312-24. https://doi.org/10.1097/00000542-200002000-00011
  10. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphine and respiratory depression: finding the right balance. Drugs 2011; 71: 1807-19. https://doi.org/10.2165/11596250-000000000-00000
  11. Gourlay GK, Murphy TM, Plummer JL, Kowalski SR, Cherry DA, Cousins MJ. Pharmacokinetics of fentanyl in lumbar and cervical CSF following lumbar epidural and intravenous administration. Pain 1989; 38: 253-9. https://doi.org/10.1016/0304-3959(89)90210-8
  12. Eisenach JC, Hood DD, Curry R, Shafer SL. Cephalad movement of morphine and fentanyl in humans after intrathecal injection. Anesthesiology 2003; 99: 166-73. https://doi.org/10.1097/00000542-200307000-00027
  13. Ummenhofer WC, Arends RH, Shen DD, Bernards CM. Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Anesthesiology 2000; 92: 739-53. https://doi.org/10.1097/00000542-200003000-00018
  14. Fernandez Robles CR, Degnan M, Candiotti KA. Pain and genetics. Curr Opin Anaesthesiol 2012; 25: 444-9. https://doi.org/10.1097/ACO.0b013e3283556228
  15. Bujedo BM, Santos SG, Azpiazu AU. A review of epidural and intrathecal opioids used in the management of postoperative pain. J Opioid Manag 2012; 8: 177-92. https://doi.org/10.5055/jom.2012.0114
  16. Smith HS. Combination opioid analgesics. Pain Physician 2008; 11: 201-14.
  17. Popping DM, Elia N, Marret E, Wenk M, Tramer MR. Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: a meta-analysis of randomized trials. Pain 2012; 153: 784-93. https://doi.org/10.1016/j.pain.2011.11.028
  18. Popping DM, Elia N, Wenk M, Tramer MR. Combination of a reduced dose of an intrathecal local anesthetic with a small dose of an opioid: a meta-analysis of randomized trials. Pain 2013; 154: 1383-90. https://doi.org/10.1016/j.pain.2013.04.023
  19. van Dongen RT, Crul BJ, van Egmond J. Intrathecal coadministration of bupivacaine diminishes morphine dose progression during long-term intrathecal infusion in cancer patients. Clin J Pain 1999; 15: 166-72. https://doi.org/10.1097/00002508-199909000-00002
  20. Mercadante S, Intravaia G, Villari P, Ferrera P, Riina S, David F, et al. Intrathecal treatment in cancer patients unresponsive to multiple trials of systemic opioids. Clin J Pain 2007; 23: 793-8. https://doi.org/10.1097/AJP.0b013e3181565d17
  21. de Leon-Casasola OA, Parker B, Lema MJ, Harrison P, Massey J. Postoperative epidural bupivacaine-morphine therapy. Experience with 4,227 surgical cancer patients. Anesthesiology 1994; 81: 368-75. https://doi.org/10.1097/00000542-199408000-00015
  22. Mugabure Bujedo B. A clinical approach to neuraxial morphine for the treatment of postoperative pain. Pain Res Treat 2012; 2012: 612145.
  23. de Leon-Casasola OA, Lema MJ. Postoperative epidural opioid analgesia: what are the choices? Anesth Analg 1996; 83: 867-75.
  24. Gambling D, Hughes T, Martin G, Horton W, Manvelian G. A comparison of Depodur, a novel, single-dose extendedrelease epidural morphine, with standard epidural morphine for pain relief after lower abdominal surgery. Anesth Analg 2005; 100: 1065-74. https://doi.org/10.1213/01.ANE.0000145009.03574.78
  25. Hartrick CT, Hartrick KA. Extended-release epidural morphine (DepoDur): review and safety analysis. Expert Rev Neurother 2008; 8: 1641-8. https://doi.org/10.1586/14737175.8.11.1641
  26. Mhuircheartaigh RJ, Moore RA, McQuay HJ. Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain. Br J Anaesth 2009; 103: 874-81. https://doi.org/10.1093/bja/aep300
  27. Sumida S, Lesley MR, Hanna MN, Murphy JD, Kumar K, Wu CL. Meta-analysis of the effect of extended-release epidural morphine versus intravenous patient-controlled analgesia on respiratory depression. J Opioid Manag 2009; 5: 301-5.
  28. Meylan N, Elia N, Lysakowski C, Tramer MR. Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials. Br J Anaesth 2009; 102: 156-67. https://doi.org/10.1093/bja/aen368
  29. Remy C, Marret E, Bonnet F. Effects of acetaminophen on morphine side-effects and consumption after major surgery: meta-analysis of randomized controlled trials. Br J Anaesth 2005; 94: 505-13. https://doi.org/10.1093/bja/aei085
  30. Gehling M, Tryba M. Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis. Anaesthesia 2009; 64: 643-51. https://doi.org/10.1111/j.1365-2044.2008.05817.x
  31. Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg 2005; 101: S30-43. https://doi.org/10.1213/01.ANE.0000177101.99398.22
  32. Hamber EA, Viscomi CM. Intrathecal lipophilic opioids as adjuncts to surgical spinal anesthesia. Reg Anesth Pain Med 1999; 24: 255-63. https://doi.org/10.1097/00115550-199924030-00015
  33. Ginosar Y, Riley ET, Angst MS. The site of action of epidural fentanyl in humans: the difference between infusion and bolus administration. Anesth Analg 2003; 97: 1428-38.
  34. Niemi G, Breivik H. Thoracic epidural fentanyl has spinal cord analgesic effects. Acta Anaesthesiol Scand 2013; 57: 1089-91. https://doi.org/10.1111/aas.12146
  35. Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al. Efficacy of postoperative patientcontrolled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005; 103: 1079-88. https://doi.org/10.1097/00000542-200511000-00023
  36. Niemi G, Breivik H. Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind, cross-over study with and without adrenaline. Acta Anaesthesiol Scand 1998; 42: 897-909. https://doi.org/10.1111/j.1399-6576.1998.tb05348.x
  37. Niemi G, Breivik H. Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl. A randomized, doubleblind crossover study with and without fentanyl. Acta Anaesthesiol Scand 2001; 45: 221-32. https://doi.org/10.1034/j.1399-6576.2001.450214.x
  38. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012; 116: 248-73. https://doi.org/10.1097/ALN.0b013e31823c1030
  39. American Society of Anesthesiologists Task Force on Neuraxial Opioids, Horlocker TT, Burton AW, Connis RT, Hughes SC, Nickinovich DG, et al. Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration. Anesthesiology 2009; 110: 218-30.
  40. Bujedo BM. Recommendations for spinal opioids clinical practice in the management of postoperative pain. J Anesthesiol Clin Sci 2013; 2: 28. https://doi.org/10.7243/2049-9752-2-28

피인용 문헌

  1. Acute pain service: past, present and future vol.5, pp.1, 2015, https://doi.org/10.2217/pmt.14.48
  2. Neuraxial Anesthesia in the Geriatric Patient vol.5, pp.2296-858X, 2018, https://doi.org/10.3389/fmed.2018.00254
  3. Comparison between Vapocoolant Spray and Eutectic Mixture of Local Anesthetics Cream in Reducing Pain during Spinal Injections vol.2018, pp.1687-6970, 2018, https://doi.org/10.1155/2018/5050273
  4. Collaborative working in cancer pain management pp.2047-8933, 2020, https://doi.org/10.7748/cnp.2019.e1560
  5. Why do Pain Physicians Not Routinely Use Mixed Opioids for the Prevention of Neuraxial Opioid-induced Pruritus? vol.10, pp.None, 2014, https://doi.org/10.2174/1876386301710010014
  6. Post-operative analgesia techniques after total knee arthroplasty: A narrative review vol.14, pp.1, 2020, https://doi.org/10.4103/sja.sja_494_19