Combination of a reduced dose of an intrathecal local anesthetic with a small dose of an opioid: A meta-analysis of randomized trials

Abstract

a b s t r a c tWe tested whether the combination of a reduced dose of a local anesthetic (LA) with an opioid compared with a standard dose of the same LA alone guaranteed adequate intraoperative anesthesia and postoperative analgesia and decreased LA-related adverse effects. We systematically searched (to November 2012) for randomized comparisons of combinations of a reduced dose of an LA with a concomitant opioid (experimental) with a standard dose of the LA alone (control) in adults undergoing surgery with singleinjection intrathecal anesthesia without general anesthesia. We included 28 trials (1393 patients). In experimental groups, the median decrease in LA doses was 40% (range, 12%-70%). There was no difference between experimental and control groups in the need for intraoperative opioids or general anesthesia for failed block or in the duration of postoperative analgesia. With experimental interventions, there was evidence of a reduction in the duration of motor blockade postoperatively (average, À50 minutes), time to discharge from hospital or PACU (À33 minutes), time to ambulation (À28 minutes), and time to urination (À14 minutes). There was also evidence of a decrease in the risk of shivering (risk ratio [RR]: 0.26; 95% confidence interval [CI]: 0.12-0.56), nausea (RR: 0.45; 95% CI: 0.31-0.66), and arterial hypotension (RR: 0.52; 95% CI: 0.35-0.78). The risk of pruritus was increased (RR: 11.7; 95% CI: 6.2-21.9). Adding an opioid to a reduced dose of an intrathecal LA can decrease LA-related adverse effects and improve recovery from the spinal block without compromising intraoperative anesthesia or duration of postoperative analgesia. Ó

Prophylactic Ondansetron for the Prevention of Intrathecal Fentanyl- or Sufentanil-Mediated Pruritus

“…The incidence of pruritus in nonobstetric surgery patients after intrathecal morphine ranges from 15% to 70% 32-34 and after intrathecal fentanyl or sufentanil, from 53% to 79%. [23][24][25]29 A meta-analysis of 28 trials by Pöpping et al 9 demonstrated that intrathecal fentanyl and sufentanil allowed for a lower dose of intrathecal local anesthetic and hastening recovery from motor block but at the price of an increased risk of pruritus (RR, 11.8; 95% CI, 6.2-21.9).…”

“…1-4 Moreover, adding an opioid to neuraxial blockade reduces local anesthetic dose, which limits hemodynamic consequences and shortens recovery time. [5][6][7][8][9] Given increasing demand for effective, low-dose neuraxial techniques, selection of intrathecal opioid has been the topic of several recent studies. [10][11][12][13] Fentanyl and sufentanil are lipophilic opioids with similar chemical structure and intrathecal pharmacokinetics.…”

Comparison of pain relief between patient-controlled epidural analgesia and patient-controlled intravenous analgesia for patients undergoing spinal fusion surgeries

“…In addition, PCEA has the advantages of small dosage, reliable analgesic effect, long duration, limited range of action and relatively small systemic effects, which can be used for postoperative analgesia, cancer carbuncle of chest, abdomen and lower extremity and traumatic pain (multiple rib fractures, pelvic fractures) [20,21]. Especially, the combined use of local anesthetic and opioid analgesics, also called balanced analgesia method, can reduce the doses of each drug and reduce the side effects of drugs, which can effectively inhibit metabolic and endocrine responses resulting from nociceptive stimulation [22,23]. Some previous studies have revealed that after some thoracic and gynecological operations, PCEA presented more merits in postoperative analgesia than PCIA and could effectively relieve pain both on coughing and at rest [24,25].…”

Effects of Patient-Controlled Epidural Analgesia and Patient-Controlled Intravenous Analgesia on Analgesia in Patients Undergoing Spinal Fusion Surgery

“…33 The balanced analgesia method uses opioid analgesics as additives with local anesthetic to reduce the dosage and lower the side effects of individual drugs, efficiently preventing endocrine stress responses and adverse physiological responses from noxious stimulation. 34,35 In this study, we also compared the patients' clinical data, and our results revealed that patients in the PCEA group had shorter surgery time and duration of anesthesia compared with patients in the PCIA group. VAS scores, a measure of the degree of pain, were significantly lower in the PCEA group in comparison with the PCIA group at 3, 6, 12, 24, and 48 hours after spinal fusion surgery.…”