1 / 35

Intrathecal Narcotics for Post-operative Analgesia

Intrathecal Narcotics for Post-operative Analgesia. Kristopher R Davignon, MD Dept of Anessthesia Grand Rounds March 2007. Intrathecal Narcotics. Opioids were know to the ancient Sumerians as of 4000 B.C. 1971 Opioid receptor discovered 1973 Receptors found in the brain

chaz
Download Presentation

Intrathecal Narcotics for Post-operative Analgesia

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Intrathecal Narcotics for Post-operative Analgesia Kristopher R Davignon, MD Dept of Anessthesia Grand Rounds March 2007

  2. Intrathecal Narcotics • Opioids were know to the ancient Sumerians as of 4000 B.C. • 1971 Opioid receptor discovered • 1973 Receptors found in the brain • 1976 Receptors found in the spinal cord • 1979 Early reports of intrathecal opioids producing analgesia

  3. Intrathecal Narcotics • Thoracic and Upper Abdominal Procedures • Elective Total Hip Arthroplasty • 350,000 Procedures per year in the US • + 5 min to consent • + 15 min for procedure

  4. Overview and Goals • Anatomy, Physiology & Pharmacology • Complications • Evidence Based Practice • Dose-Response • Future Directions

  5. Anatomy, Physiology & Pharmacology

  6. Anatomy, Physiology & Pharmacology • Drug disposition depends primarily on lipid solubility • Any drug rapidly redistributes • opioid is detectable in the cisterna magna within 30 min of lumbar intrathecal administration

  7. Opiods Morphine Meperidine Hydromorphone Sufentanil & Fentanyl Methadone Non Opiods Clonidine Neostigmine Adenosine Epinephrine Ketorolac Midazolam Anatomy, Physiology & Pharmacology Preservative

  8. Anatomy, Physiology & Pharmacology • Lipophilic opioids • Rapidly traverse the dura; sequestered in epidural fat (and enter systemic circulation) • Rapidly penetrate the spinal cord and bind receptors and nonspecific sites

  9. Anatomy, Physiology & Pharmacology • Hydrophilic opiods • Limited binding to epidural fat and nonspecific receptors • Slower transfer to systemic circulation • Higher CSF concentrations accounting for rostral spread

  10. Anatomy, Physiology & Pharmacology

  11. “Complications” • Pruritus • Mechanism unclear – likely opiod receptor mediated (not histamine) • Incidence 30-100% • Rx: Antihistamines, 5-HT3 antagonist, opiod antagonists (or agonist-antagonists), propofol

  12. “Complications” • Urinary Retention • Not dose dependent • Can last 14-16 hours • Most frequent with Morphine • 35 % incidence • Mechanism related to sacral parasympathetic outflow inhibition • Allows increase in maximal bladder capacity

  13. “Complications” • Nausea and Vomiting • Incidence 30 % • Most profound with Morphine • Likely due to cephalad migration of drug to area postrema

  14. “Complications” • Respiratory Depression • Incidence is dose dependent • Very Rare 0.09% to 0.4% • Likely no more clinically relevant than for IV narcotics • Monitoring for 18-24 hours when using lipophilic opiods

  15. “Complications” • PDPH • Age, Gender, History of PDPH, Obesity • Multiple dural puncture, Needle size, Needle design

  16. “Complications” • PDPH • Rx: • hydration • Caffeine • Sumatriptan • ACTH • EBP

  17. “Complications” • Neuropraxia/Paralysis • Epidural hematoma • Epidural abcess

  18. Evidence Based Practice • What types of surgery is amenable to intrathecal narcotics? • What doses should we use? • What outcomes can we affect?

  19. Types of Surgery • Thoracic • Including Cardiac • Intra-abdominal • Including C/S, AAA, Open Cholecystectomy • Lower Extremity • Including THA & TKA

  20. Narcotic Only (worst) • Narcotic + LA (best) • LA Only

  21. “the Dose” • 1) Optimal dose depends on the surgical procedure • 2) Incidence of side effects increases in proportion to dose (especially with doses > 300 ųg)

  22. “the Dose”

  23. Dosing for THA • Use lowest dose possible! • Studies have used doses as low as 0.025 mg • Older studies used doses as high as 0.5mg • Ideal dose seems to be 0.1 mg • Lower doses don’t provide good analgesia • Higher doses plagued with pruritis

  24. Dosing for THA

  25. Dosing for THA

  26. Affecting Outcomes

  27. Do Improved Pain Scores Matter?

  28. Future Directions • Anticoagulants • Use of stents and anti-platelet agents • Aggressive DVT prophlaxis • Absence of laboratory evidence of these agents • Sustained release neuraxial narcotic • Depodur

  29. Future Directions • Depodur (morphine sulfate extended release liposome injection)

  30. Future Directions

  31. Future Directions • Better Pain Scores for 48 hours • Studied in Hip Arthroplasty, Cesarean Section, Lower Abdominal Surgery • No significant difference in side effects from IV narcotic

  32. Conclusions • Pain management in the in-patient setting is becoming a priority for adminstrative organizations • A majority of in-patient pain management is post-operative • Neuraxial narcotics consistently reduce patient’s VAS

More Related