Intrathecal hydrophilic opioids for abdominal surgery: a meta-analysis, meta-regression, and trial sequential analysis

Koning, Mark V.; Klimek, Markus; Rijs, K.; Stolker, Robert Jan; Heesen, M.

doi:10.1016/j.bja.2020.05.061

Cited by 50 publications

(61 citation statements)

References 80 publications

(75 reference statements)

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“…Of these patients, none had life-threatening respiratory failure [ 8 ]. Other studies with various doses of intrathecal hydrophilic opioids found incidences of 3.0% of 1022 patients [ 9 ], 1.5% of 1039 patients [ 10 ], 1.0% of 492 patients [ 11 ], 3.0% of 327 patients [ 5 ], and 0.5% of 944 patients [ 6 ], with varying definitions of respiratory depression. Second, the majority of the data of this review resulted from case reports, which are inherently retrospective of nature, just as our case series.…”

Section: Discussionmentioning

confidence: 99%

“…Due to its hydrophilic properties, intrathecally administered morphine remains in the cerebrospinal fluid for a prolonged period of time, which results in a duration of action up to 36 hours, but simultaneously carries the risk of a delayed respiratory depression [2][3][4]. Several studies suggest a dose-dependent incidence of delayed respiratory depression [5][6][7]. e incidence of respiratory depression after a dose of less than 1 mg intrathecally administered morphine varies between 0.5 and 3.0% in studies including 492 and 5705 patients [5,6,[8][9][10][11].…”

Section: Introductionmentioning

confidence: 99%

“…Several studies suggest a dose-dependent incidence of delayed respiratory depression [5][6][7]. e incidence of respiratory depression after a dose of less than 1 mg intrathecally administered morphine varies between 0.5 and 3.0% in studies including 492 and 5705 patients [5,6,[8][9][10][11]. is variance in the incidence is for an important part caused by the heterogeneity in definition of respiratory depression [4].…”

Section: Introductionmentioning

confidence: 99%

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Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review

Koning

Reussien

Vermeulen

et al. 2022

Pain Research and Management

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Background. The dose of intrathecal morphine is important because of its narrow therapeutic range. Due to a compounding error, pharmacy-compounded, ready-to-use syringes contained 1 mg ml−1 morphine instead of the intended 50 mcg ml−1. Six patients consequently received this twenty-fold dose. This study aims to describe the serious adverse events in these six patients and a systematic review is added to describe the characteristics of serious adverse events after intrathecal morphine. Methods. A retrospective case series described all six patients that received the erroneous morphine intrathecally for analgesia after laparoscopic segmental colonic resections. The patients’ charts were reviewed for the occurrence, timing, duration and management of adverse events, the vital signs at the night after surgery, and length of hospital stay. A systematic review investigated characteristics of serious adverse events after intrathecal morphine in a perioperative setting. Results. Four patients had a serious adverse event, which was respiratory depression combined with somnolence (n = 3) and hypotension (n = 1). The review yielded 63 cases with serious adverse events, predominantly somnolence and/or respiratory depression. The onset occurred between 2 and 24 hours after injection. The severity of symptoms varied and life-threatening respiratory depression only occurred after a dose >900 mcg or when potentiating medication was used. Naloxone did not affect analgesia. No prolonged sequalae occurred. Conclusion. This study reveals that respiratory depression and somnolence are the predominant serious adverse events after intrathecal morphine in a perioperative setting and demonstrated a large variation in the presentation of symptoms.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review

Koning

Reussien

Vermeulen

et al. 2022

Pain Research and Management

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“…Before induction, all patients received antibiotic prophylaxis, and intravenous (IV) loads of magnesium (30 to 40 mg/kg), dexamethasone (10 mg) and diclofenac (75 mg) according to the presence of a contraindication [ 14 ]. Patients from the opioid-based anesthesia group (OBA) also received a single bolus of intrathecal morphine (4 g/kg with a maximum of 300 g) [ 15 ].…”

Section: Methodsmentioning

confidence: 99%

Opioid-free versus opioid-based anesthesia in pancreatic surgery

et al. 2022

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Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

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“…Before induction, all patients received antibiotic prophylaxis, and intravenous loads of magnesium (30 to 40 mg/kg), dexamethasone (10 mg) and diclofenac (75 mg) according to the presence of a contraindication [14]. Patients from the opioid-based anesthesia group (OBA) also received a single bolus of intrathecal morphine (4 µg/kg with a maximum of 300 µg) [15].…”

Section: Anesthesiamentioning

confidence: 99%

Opioid-Free Versus Opioid-Based Anesthesia in Pancreatic Surgery

Hublet

Galland

Navez

et al. 2021

Preprint

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Background: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption and postoperative nausea and vomiting in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Hence, we retrospectively reviewed a consecutive cohort of patients undergoing pancreatic surgery. Methods: Perioperative data from 77 consecutive patients who underwent pancreatic resection under OBA or OFA were included. Patients received either an OBA with intraoperative remifentanil (n=42) or an OFA (n=35) with a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade, postoperative continuous wound infiltration, and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48h after extubation, length of stay (LOS), adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.Results: Compared to OBA, NRS (3 [2-4] vs 0 [0-2], P<0.001) and opioid consumption (36 [24-52] vs 10 [2-24], P=0.005) were both less in the OFA group. LOS was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P<0.001). OFA (P=0.03), postoperative pancreatic fistula (P=0.0002) and delayed gastric emptying (P<0.0001) were identified as only independent factors for LOS. The comprehensive complication index (CCI) was the lowest with OFA (24.9±25.5 vs 14.1±23.4, P=0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.Conclusions: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

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Intrathecal hydrophilic opioids for abdominal surgery: a meta-analysis, meta-regression, and trial sequential analysis

Cited by 50 publications

References 80 publications

Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review

Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review

Opioid-free versus opioid-based anesthesia in pancreatic surgery

Opioid-Free Versus Opioid-Based Anesthesia in Pancreatic Surgery

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