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Van Zundert TC, Gatt SP, van Zundert AA. Anesthesia and perioperative pain relief in the frail elderly patient. Saudi J Anaesth 2023; 17:566-574. [PMID: 37779574 PMCID: PMC10540986 DOI: 10.4103/sja.sja_628_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 10/03/2023] Open
Abstract
Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.
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Affiliation(s)
| | - Stephen P Gatt
- Discipline of Anaesthesia, Critical Care and Emergency Medicine, University of New South Wales, Kensington, NSW, Australia and Udayana University, Bali, Indonesia
| | - André A.J. van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, and The University of Queensland, Brisbane, Queensland, Australia
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Hartrick CT. Exploiting Injury-Induced Peripheral Opioid Receptor Changes in Novel Analgesic Development for Chronic Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:883164. [PMID: 35557854 PMCID: PMC9090307 DOI: 10.3389/fpain.2022.883164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
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Schumacher CS, Menendez ME, Pagani NR, Freiberg AA, Kwon YM, Bedair H, Ring D, Rubash HE. Variation in perioperative opioid use after total joint arthroplasty. J Orthop 2021; 25:162-166. [PMID: 34025059 DOI: 10.1016/j.jor.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/02/2021] [Indexed: 12/30/2022] Open
Abstract
Objective We studied variation in perioperative opioid use after total joint arthroplasty with respect to patient and procedure characteristics in order to inform initiatives to optimize pain relief. Methods We recorded perioperative opioid consumption for a cohort of total joint arthroplasty patients to identify factors underlying variation in perioperative opioid use. Results Younger patient age, tobacco use, greater symptoms of depression, private insurance, and knee arthroplasty were associated with increased opioid consumption. Conclusions Awareness of the patient characteristics associated with increased perioperative opioid use can help inform implementation of targeted strategies for safe, optimal pain relief and satisfaction.
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Affiliation(s)
- Charles S Schumacher
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariano E Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Nicholas R Pagani
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Andrew A Freiberg
- Department of Orthopaedic Surgery, Newton-Wellesley Hospital, Newton, MA, USA
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hany Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Harry E Rubash
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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van Zuylen ML, ten Hoope W, Bos EME, Hermanides J, Stevens MF, Hollmann MW. Safety of epidural drugs: a narrative review. Expert Opin Drug Saf 2019; 18:591-601. [DOI: 10.1080/14740338.2019.1617271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- ML van Zuylen
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W ten Hoope
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - EME Bos
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J Hermanides
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MF Stevens
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - MW Hollmann
- Department of Anesthesiology, Amsterdam UMC, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Cohen M, Zuk J, McKay N, Erickson M, Pan Z, Galinkin J. Intrathecal Morphine Versus Extended-Release Epidural Morphine for Postoperative Pain Control in Pediatric Patients Undergoing Posterior Spinal Fusion. Anesth Analg 2017; 124:2030-2037. [PMID: 28448398 DOI: 10.1213/ane.0000000000002061] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine. METHODS The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 μg/kg IT morphine or 150 μg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day. RESULTS There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects. CONCLUSIONS There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after posterior spinal fusion for scoliosis and may be associated with less opioid-induced pruritus.
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Affiliation(s)
- Mindy Cohen
- From the Departments of *Anesthesiology and Surgery, †Orthopedic Surgery, and ‡Statistics Pediatric Research Institute, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
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Side Effects and Efficacy of Neuraxial Opioids in Pregnant Patients at Delivery: A Comprehensive Review. Drug Saf 2016; 39:381-99. [DOI: 10.1007/s40264-015-0386-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Kang SB. Epidural injection of extended-release morphine during colorectal surgery. Ann Coloproctol 2014; 30:159-60. [PMID: 25210682 PMCID: PMC4155132 DOI: 10.3393/ac.2014.30.4.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Peravali R, Brock R, Bright E, Mills P, Petty D, Alberts J. Enhancing the Enhanced Recovery Program in Colorectal Surgery - Use of Extended-Release Epidural Morphine (DepoDur®). Ann Coloproctol 2014; 30:186-91. [PMID: 25210688 PMCID: PMC4155138 DOI: 10.3393/ac.2014.30.4.186] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 03/01/2014] [Indexed: 12/22/2022] Open
Abstract
Purpose DepoDur® is a single-dose extended-release morphine injection into the epidural space. It is not commonly used, but has many advantages over traditional analgesic regimens. We analyzed a number of these advantages in our case series in the context of the colorectal enhanced recovery program (ERP) and aimed to show that the ERP could be further enhanced by using DepoDur®. Methods We conducted a prospective audit of all patients undergoing open and laparoscopic colorectal procedures where DepoDur® was used between July 2010 and April 2012. Validated pain scores were used, and primary outcome measures were resting and dynamic pain, mobilization, and need for additional analgesia. Results Two hundred eighty patients were included in the case series. Good pain control was seen at 24 and 48 hours. Eighty-one percent of the patients required simple analgesia alone at 24 hours, and 62% required simple analgesia (paracetamol +/- nonsteroidal anti-inflammatory drugs) alone at 48 hours. Only a minority required additional oramorph and patient-controlled analgesia at 24 and 48 hours (19% at 24 hours and 38% at 48 hours). Seventy-nine percent of the patients were mobilized at 24 hours, and 88% of the patients were mobilized at 48 hours. Conclusion DepoDur® is an effective alternative to conventional pain management techniques and may have a role in further enhancing the ERP.
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Affiliation(s)
- Rajeev Peravali
- Department of Colorectal Surgery, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Rachael Brock
- Department of Colorectal Surgery, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Elizabeth Bright
- Department of Anaesthetics, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Patricia Mills
- Department of Anaesthetics, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Dawn Petty
- Pain Management Team, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Justin Alberts
- Department of Colorectal Surgery, West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
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McKenzie JC, Goyal N, Hozack WJ. Multimodal pain management for total hip arthroplasty. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.sart.2013.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Offley SC, Coyne E, Horodyski M, Rubery PT, Zeidman SM, Rechtine GR. Randomized trial demonstrates that extended-release epidural morphine may provide safe pain control for lumbar surgery patients. Surg Neurol Int 2013; 4:S51-7. [PMID: 23646274 PMCID: PMC3642756 DOI: 10.4103/2152-7806.109424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/14/2012] [Indexed: 11/29/2022] Open
Abstract
Background: Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery. Methods: Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded. Results: There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection. Conclusion: By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used.
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Affiliation(s)
- Sarah C Offley
- Department of Orthopaedic Surgery, URMC Orthopaedics and Rehabilitation, 601 Elmwood Ave, USA
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Hill L, Schug SA. Recent advances in the pharmaceutical management of pain. Expert Rev Clin Pharmacol 2012; 2:543-57. [PMID: 22112227 DOI: 10.1586/ecp.09.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pain is an unpleasant sensory and emotional experience for patients. Management of pain is the most frequent issue encountered by clinicians and treatment is usually with pharmacological therapy. This review discusses recent pharmaceutical advances in pain management with respect to new modes of analgesic delivery, as well as new analgesic agents and adjuvants that are currently being investigated for their analgesic properties. New modes of administration include transdermal delivery in the form of skin patches, transmucosal delivery, inhalational administration, various patient-controlled devices and extended-release analgesic formulations. Up-to-date research is presented on classical analgesics, such as opioids, anti-inflammatory agents, including cyclo-oxygenase-2 inhibitors and paracetamol (acetaminophen), local anesthetics and ketamine. In addition, newer agents such as antidepressants and antiepileptic drugs as well as medicinal cannabinoids are discussed. As our understanding of the multiple pain pathways involved in the pathogenesis of pain expands, further compounds with analgesic properties will be developed.
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Affiliation(s)
- Lisa Hill
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, GPO Box X2213, Perth, Western Australia 6001, Austrailia.
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Mean analgesic consumption is inappropriate for testing analgesic efficacy in post-operative pain: analysis and alternative suggestion. Eur J Anaesthesiol 2011; 28:427-32. [DOI: 10.1097/eja.0b013e328343c569] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede recovery and delay hospital discharge. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia, but each technique has distinct advantages and disadvantages. Recently, peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. An increasing number of studies have reported multimodal analgesia featuring unilateral peripheral block provide pain relief and functional outcomes similar to that of continuous epidural and superior to systemic analgesia but with fewer side effects. This review discusses the indications, benefits, and side effects associated with conventional and innovative analgesic approaches to facilitate rehabilitation and improve outcome following total joint arthroplasty.
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Affiliation(s)
- Terese T Horlocker
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Vanterpool S, Coombs R, Fecho K. Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis. Ther Clin Risk Manag 2010; 6:271-7. [PMID: 20596504 PMCID: PMC2893759 DOI: 10.2147/tcrm.s10972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND This study retrospectively compared the continuous epidural infusion of morphine with a single epidural injection of extended-release morphine for postoperative pain control after arthroplasty. METHODS Medical records were reviewed for subjects who had total knee or hip arthroplasty (THA) under spinal anesthesia and received either a continuous epidural infusion of morphine (Group EPID; n = 101) or an extended-release epidural morphine (Group EREM; n = 109) for postoperative pain. Data were collected for three postoperative days (POD) on: pain scores; supplemental opioids; medications for respiratory depression, nausea, and pruritus, and distance ambulated during physical therapy. RESULTS Pain scores were similar until subjects were transitioned to another analgesic approach on POD 2; after that time, pain scores increased in Group EPID, although they decreased in Group EREM. Supplemental opioids were used more on POD1 in Group EREM than in Group EPID, although time to first opioid and total daily morphine equivalents were similar. Naloxone and antiemetics, not antipruritics, were used more in Group EREM. Distance ambulated after THA was greater in Group EREM than in Group EPID. CONCLUSIONS These results suggest that EREM is associated with better postoperative ambulation and analgesia during the transition to oral or intravenous analgesics, although a higher incidence of side-effects was evident.
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Affiliation(s)
- Stephanie Vanterpool
- Department of Anesthesiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Lessons learned with extended-release epidural morphine after total hip arthroplasty. Clin Orthop Relat Res 2010; 468:1082-7. [PMID: 20012719 PMCID: PMC2835616 DOI: 10.1007/s11999-009-1181-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 11/16/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED An extended-release epidural morphine (EREM) has been introduced to improve postoperative pain management. Studies have shown the effectiveness of this agent in providing better pain control and patient satisfaction for patients undergoing total joint arthroplasty. We evaluated postoperative pain relief by comparing average daily pain scores and opioid use with those of the control group. Safety was measured by comparing the occurrence of postoperative complications, nausea and vomiting, pruritus, and respiratory depression between the two groups. Between February 2006 and March 2008, we selected 203 patients to receive EREM for THA. These patients were matched in a 2:1 ratio with patients undergoing THA and receiving spinal anesthesia. We retrospectively reviewed all major and minor postoperative complications from a prospective database. Patients receiving EREM had lower pain scores than patients not receiving EREM on Postoperative Day 1 (POD 1) but not POD 2, or POD 3. Patients receiving EREM experienced a slightly higher incidence of pulmonary embolism and supraventricular tachycardia. Patients receiving EREM also experienced more nausea and vomiting and pruritus. We found EREM provided better pain relief on POD 1 at the expense of a slightly higher incidence of side effects compared with spinal anesthesia alone. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Hartrick CT, Tang YS, Hunstad D, Pappas J, Muir K, Pestano C, Silvasi D. Aprepitant vs. multimodal prophylaxis in the prevention of nausea and vomiting following extended-release epidural morphine. Pain Pract 2010; 10:245-8. [PMID: 20230453 DOI: 10.1111/j.1533-2500.2010.00364.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extended-release epidural morphine (EREM) is an effective option for postoperative analgesia following major orthopedic surgery; however, postoperative nausea/vomiting (PONV) is a recognized limitation. The incidence of PONV following prophylactic aprepitant, a neurokinin-1 antagonist, was compared with prophylactic multimodal antiemetic therapy in patients receiving EREM for postoperative analgesia following unilateral primary total knee arthroplasty (TKA). METHODS Prospectively collected quality assurance data were examined with Institutional Review Board approval. A sequential, open-label, active matched case-control study compared PONV following EREM in patients receiving ondansetron and dexamethasone, and either metoclopramide, diphenhydramine, or prochlorperazine every 6 hours for the 48-hour study period, to patients receiving aprepitant 40 mg given as a single oral dose in the preoperative holding area. Cases were matched for procedure (TKA), age, epidural morphine dose, and known major risk factors for PONV (sex, smoking, previous PONV/motion sickness). RESULTS Twelve consecutive patients (3 male; 9 female) receiving aprepitant prior to EREM were matched to 12 patients of the same sex of similar age (range 51 to 84 years.) and EREM dose (range 5 to 12.5 mg) receiving the multimodal regime. The incidence of PONV was significantly less for the aprepitant group where 3 of 12 (25%) had PONV compared with 9 of 12 (75%) in the multimodal group (P = 0.039, Fisher's Exact Test; odds ratio = 0.11; 95% CI: 0.018 to 0.706, P = 0.03). CONCLUSION While aprepitant significantly reduced the incidence of PONV compared with a multimodal antiemetic regime, used alone it did not eliminate PONV.
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Affiliation(s)
- Craig T Hartrick
- Department of Anesthesiology, William Beaumont Hospital-Troy, Troy, Michigan 48085, USA.
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Blackshear RH, Crosson KC. Reduction in Pulmonary Embolism after Total Joint Arthroplasty: Three Years of Experience with Extended-Release Epidural Morphine. Pain Pract 2010; 10:235-44. [DOI: 10.1111/j.1533-2500.2009.00339.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mhuircheartaigh RJN, Moore RA, McQuay HJ. Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain. Br J Anaesth 2009; 103:874-81. [PMID: 19889750 DOI: 10.1093/bja/aep300] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Individual patient information from clinical trials is infrequently available, but can provide insights for clinical trials and practice. METHODS We analysed individual patient information from five randomized trials (913 patients) of i.v. patient-controlled analgesia (IVPCA) plus epidural placebo, morphine sulphate (MS) 5 mg, or extended-release epidural morphine (EREM; DepoDur) at doses of 5-30 mg, to explore effects of a range of epidural morphine doses. Pain and opioid requirement on first and second postoperative days, dose-response, clinically relevant comparisons of IVPCA without epidural morphine, 5 mg MS, and 10 mg EREM, and relationship between patient rating and other measures were described. RESULTS There were three strong findings. Epidural morphine resulted in greater patient satisfaction, despite higher rates of adverse events. Those describing their analgesic medication as 'very good' or 'excellent' used IVPCA opioid less and had pain scores significantly below the global mean, whereas those describing their medication as 'poor' or 'fair' had pain scores significantly above the mean. Epidural morphine meant less need for postoperative IVPCA opioid than epidural placebo. The therapeutic gain with EREM was lower pain scores with less IVPCA opioid. Moderate or severe pruritus was more common with IVPCA plus epidural morphine, whatever the formulation, compared with IVPCA plus placebo. CONCLUSIONS Analysis of individual patient data from high-quality clinical trials provides important insights into characteristics of new agents not immediately apparent from original trials, and also informing clinical practice. Prophylactic epidural morphine provides a better patient experience than IVPCA alone.
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Affiliation(s)
- R J Ni Mhuircheartaigh
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, John Radcliffe Hospital, Level 6 West Wing, Oxford, UK
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Extended-release epidural morphine (DepoDur) following epidural bupivacaine in patients undergoing lower abdominal surgery: a randomized controlled pharmacokinetic study. Reg Anesth Pain Med 2009; 34:316-25. [PMID: 19574865 DOI: 10.1097/aap.0b013e3181ac9e78] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The primary objective was to compare the serum pharmacokinetic profile of a single dose of extended-release epidural morphine (EREM) administered alone versus 15 to 60 mins after an analgesic epidural dose of bupivacaine. METHODS This multicenter study enrolled 144 patients, 18 years or older, with scheduled lower abdominal surgery under general anesthesia. Patients were randomly assigned to a single 15-mg dose of EREM; the same dose administered 15, 30, or 60 mins after epidural bupivacaine (20 mL 0.25%); or epidural placebo (normal saline) administered 15, 30, or 60 mins after bupivacaine. Postoperatively, fentanyl patient-controlled analgesia was offered for breakthrough pain. Multiple serum samples were analyzed for morphine and morphine metabolites. Safety and efficacy were assessed. RESULTS The mean maximum serum concentration and area under the concentration-time curve for morphine and metabolites were not significantly different when EREM was administered alone versus 15, 30, or 60 mins after bupivacaine. Median time to maximum serum concentration and median apparent terminal elimination half-life were also comparable. Total fentanyl patient-controlled analgesia consumption was comparable among all EREM groups (with/without prior bupivacaine) but significantly (P < 0.05) lower compared with the bupivacaine + placebo group. Nausea, vomiting, and dizziness were consistently more frequent in groups receiving EREM after bupivacaine versus EREM alone. CONCLUSIONS The pharmacokinetic and efficacy profiles of a single 15-mg dose of EREM were not significantly altered when administered 15, 30, or 60 mins after an analgesic epidural dose of bupivacaine.
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Viscusi ER, Gambling DR, Hughes TL, Manvelian GZ. Pharmacokinetics of extended-release epidural morphine sulfate: Pooled analysis of six clinical studies. Am J Health Syst Pharm 2009; 66:1020-30. [DOI: 10.2146/ajhp080154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eugene R. Viscusi
- Acute Pain Management, Department of Anesthesiology, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David R. Gambling
- Sharp Mary Birch Hospital for Women, San Diego, CA, and Associate Clinical Professor, Department of Anesthesiology, University of California San Diego, San Diego
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Hartrick CT, Hartrick KA. Extended-release epidural morphine (DepoDur): review and safety analysis. Expert Rev Neurother 2009; 8:1641-8. [PMID: 18986234 DOI: 10.1586/14737175.8.11.1641] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Extended-release epidural morphine (EREM) provides effective postoperative analgesia for 48 h following injection. It is administered as a single bolus into the lumbar epidural space, and is indicated for lower abdominal and lower extremity surgery associated with moderate-to-severe pain. While its efficacy has been well documented in randomized controlled trials, the safety and clinically appropriate dosing are less well defined. A meta-analysis approach was used to assess the adverse effects of EREM (n = 801) in comparison with intravenous opioids and standard epidural morphine. EREM 15 mg or greater was associated with a trend towards a higher incidence of hypoventilation (odds ratio: 0.48; 95% confidence interval [CI]: 0.21-1.09; p = 0.081; number-needed-to-treat [NNT] = 14) compared with placebo. The incidence of pruritus was significantly higher for all EREM doses compared with both placebo (p = 0.004) and standard epidural morphine (p = 0.03). Vomiting was also increased with EREM 15 mg or greater compared with placebo (odds ratio: 0.40; 95% CI: 0.18-0.89; p = 0.02; NNT = 5). A multimodal analgesic regime is recommended to permit the use of lower EREM doses, thus reducing the risk for adverse effects including respiratory depression. Prophylactic time-contingent antiemetics are also recommended when EREM is used.
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Affiliation(s)
- Craig T Hartrick
- Anesthesiology Research, Beaumont Research Institute, Royal Oak, MI 48073, USA.
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Dorr LD, Raya J, Long WT, Boutary M, Sirianni LE. Multimodal analgesia without parenteral narcotics for total knee arthroplasty. J Arthroplasty 2008; 23:502-8. [PMID: 18514865 DOI: 10.1016/j.arth.2007.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 10/04/2007] [Indexed: 02/01/2023] Open
Abstract
Use of parenteral narcotics after total knee arthroplasty is considered by most orthopedic surgeons to be the standard of care. This study tested the hypothesis that a multimodal oral pain medication protocol could control pain and minimize complications of parenteral narcotics. Postoperative oral analgesia was augmented with either continuous epidural infusion or continuous femoral infusion using ropivacaine only. Seventy patients had total knee arthroplasty with a protocol that included preemptive oral analgesics, epidural anesthesia, pericapsular analgesic injection, and postoperative analgesia without parenteral opioids. The average daily pain score was less than 4 out of 10, nausea occurred in 15 patients (21%), emesis in 1 patient (1.4%), and there were no severe complications. This study proved the hypothesis that pain after total knee arthroplasty could be effectively managed without routine use of parenteral opioids.
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Polomano RC, Rathmell JP, Krenzischek DA, Dunwoody CJ. Emerging Trends and New Approaches to Acute Pain Management. Pain Manag Nurs 2008; 9:S33-41. [DOI: 10.1016/j.pmn.2007.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
This paper is the 29th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning 30 years of research. It summarizes papers published during 2006 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurological disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, United States.
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Abstract
The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to achieve an effective and successful perioperative pain management regimen.
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Affiliation(s)
- Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Patient-controlled analgesia (PCA) is a delivery system with which patients self-administer predetermined doses of analgesic medication to relieve their pain. Since its introduction in the early 1980s, the daily management of postoperative pain has been extensively optimised. The use of PCA in hospitals has been increasing because of its proven advantages over conventional intramuscular injections. These include improved pain relief, greater patient satisfaction, less sedation and fewer postoperative complications. All PCA modes contain the following variables: initial loading dose, demand dose, lockout interval, background infusion rate and 1-hour or 4-hour limits. Morphine is the most studied and most commonly used intravenous drug for PCA. In spite of the fact that it is the 'first choice' for PCA, other opioids have been successfully used for this option. The most observed adverse effects of opioid-based PCA are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. Although intravenous PCA is the most studied route of PCA, alternative routes have extensively been described in the literature. PCA by means of peridural catheters and peripheral nerve catheters are the most studied. Recently, transdermal PCA has been described. The use of peripheral or neuraxial nerve blocks is recommended to avoid the so called opioid tolerance observed with the intravenous administration of opioids. Numerous studies have shown the superiority of epidural PCA to intravenous PCA. The beneficial postoperative effects of epidural analgesia are more apparent for high-risk patients or those undergoing higher risk procedures. PCA with peripheral nerve catheters results in increased postoperative analgesia and satisfaction for surgery on upper and lower extremities. Serious complications occur rarely with these catheters. With the introduction of an Acute Pain Service, management of postoperative pain can be improved. This will also help to minimise adverse effects related to PCA and to avoid lethal mishaps.
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Affiliation(s)
- Mona Momeni
- Department of Anaesthesiology, University Hospital St Luc, Brussels, Belgium.
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Angst MS, Drover DR. Pharmacology of drugs formulated with DepoFoam: a sustained release drug delivery system for parenteral administration using multivesicular liposome technology. Clin Pharmacokinet 2007; 45:1153-76. [PMID: 17112293 DOI: 10.2165/00003088-200645120-00002] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Lamellar liposome technology has been used for several decades to produce sustained-release drug formulations for parenteral administration. Multivesicular liposomes are structurally distinct from lamellar liposomes and consist of an aggregation of hundreds of water-filled polyhedral compartments separated by bi-layered lipid septa. The unique architecture of multivesicular liposomes allows encapsulating drug with greater efficiency, provides robust structural stability and ensures reliable, steady and prolonged drug release. The favourable characteristics of multivesicular liposomes have resulted in many drug formulations exploiting this technology, which is proprietary and referred to as DepoFoam. Currently, two formulations using multivesicular liposome technology are approved by the US FDA for clinical use, and many more formulations are at an experimental developmental stage. The first clinically available formulation contains the antineoplastic agent cytarabine (DepoCyt) for its intrathecal injection in the treatment of malignant lymphomatous meningitis. Intrathecal injection of DepoCyt reliably results in the sustained release of cytarabine and produces cytotoxic concentrations in cerebrospinal fluid (CSF) that are maintained for at least 2 weeks. Early efficacy data suggest that DepoCyt is fairly well tolerated, and its use allows reduced dosing frequency from twice a week to once every other week and may improve the outcome compared with frequent intrathecal injections of unencapsulated cytarabine. The second available formulation contains morphine (DepoDur) for its single epidural injection in the treatment of postoperative pain. While animal studies confirm that epidural injection of DepoDur results in the sustained release of morphine into CSF, the CSF pharmacokinetics have not been determined in humans. Clinical studies suggest that the use of DepoDur decreases the amount of systemically administered analgesics needed for adequate postoperative pain control. It may also provide superior pain control during the first 1-2 postoperative days compared with epidural administration of unencapsulated morphine or intravenous administration of an opioid. However, at this timepoint the overall clinical utility of DepoDur has yet to be defined and some safety concerns remain because of the unknown CSF pharmacokinetics of DepoDur in humans. The versatility of multivesicular liposome technology is reflected by the many agents including small inorganic and organic molecules and macromolecules including proteins that have successfully been encapsulated. Data concerning many experimental formulations containing antineoplastic, antibacterial and antiviral agents underscore the sustained, steady and reliable release of these compounds from multivesicular liposomes after injection by the intrathecal, subcutaneous, intramuscular, intraperitoneal and intraocular routes. Contingent on the specific formulation and manufacturing process, agents were released over a period of hours to weeks as reflected by a 2- to 400-fold increase in elimination half life. Published data further suggest that the encapsulation process preserves bioactivity of agents as delicate as proteins and supports the view that examined multivesicular liposomes were non-toxic at studied doses. The task ahead will be to examine whether the beneficial structural and pharmacokinetic properties of multivesicular liposome formulations will translate into improved clinical outcomes, either because of decreased drug toxicity or increased drug efficacy.
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Affiliation(s)
- Martin S Angst
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305-5117, USA.
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Alam M, Hartrick CT. Extended-Release Epidural Morphine (DepoDurtm): An Old Drug with a New Profile. Pain Pract 2005; 5:349-53. [PMID: 17177768 DOI: 10.1111/j.1533-2500.2005.00048.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The FDA has recently approved a novel formulation for epidural morphine administration that allows a single injection to provide 48 hours of analgesia. This may eliminate the need for an indwelling epidural catheter in some circumstances and therefore be particularly well suited to postoperative situations where anticoagulation is required. Other uses that have been less thoroughly studied should be approached with due caution.
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Affiliation(s)
- Masroor Alam
- St. Elizabeth Medical Center, Edgewood, Kentucky 41017, USA.
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