The Perioperative Use of Epidural Opiates
Epidural opiates offer new possibilities for perioperative analgesia. They may be used as a supplementation to anaesthesia, allowing reduced doses of anaesthetics for general anaesthesia and of local anaesthetics for epidural anaesthesia (n = 170). Combined epidural opiate anaesthesia with fentanyl is characterized by a remarkable hemodynamic stability.
In comparison to systemic opiate application for surgical treatment, combined epidural opiate anaesthesia is characterized by immediate postoperative cooperation without pain and signs of respiratory depression. After epidural fentanyl application, CSF concentrations were 17 to 83 times higher than plasma levels (n = 11).
In the postoperative period (n = 554), we prefer epidural morphine because of its long duration of action. If small doses of epidural bupivacaine are added, duration of analgesia is still more prolonged (by 50% as compared to epidural morphine alone), so that in most cases a single epidural injection allows sufficient analgesia for the whole postoperative period.
Concerning the degree of pain reduction, the best results of epidural opiate analgesia were found after lower abdominal surgery. The reduced efficiency of epidural morphine after upper abdominal surgery may be overcome by additional small doses of local anaesthetics. The volume, in which the opiate is diluted, as well as exact reference to the involved spinal segments were not as important as during epidural anaesthesia with local anaesthetics.
High doses or repeated administration of epidural opiates in short intervals may cause early respiratory depression (by systemic absorption) or late respiratory embarrassment. The latter is probably due to spinal ascension of opiates in CSF but may also be explained by an abrupt release of high opiate concentrations via epidural veins into systemic circulation. Repeated intravenous naloxone injections are necessary to counteract late respiratory depression. During antagonization with a systemically applied antagonist spinal analgesia is not affected. Epidural naloxone may eliminate epidural opiate-analgesia for a short period of time (investigations with epidural or intravenous naloxone during epidural opiate analgesia: n = 10).
Epidural opiate analgesia shortly after or in combination with systemic opiates should be avoided. On the other hand, the small doses of opiates for epidural analgesia following inhalation anaesthesia (n = 10) do not cause relevant respiratory or hemodynamic changes.
Frequent side-effects could in part be prevented by additional drugs to the epidural opiate solution. A small dose of epidural droperidol avoids nausea and vomiting. Epidural local anaesthetics suppress itching in most patients. Urinary retention is not an uncommon side effect though diagnosis is easy, because strong pain impulses by extension of the bladder are not suppressed. Orthostatic collapse and allergic reactions are rare side-effects of epidural opiates.
KeywordsRespiratory Depression Epidural Anaesthesia Epidural Catheter Epidural Morphine Epidural Injection
Unable to display preview. Download preview PDF.
- 3.Bromage PR (1979) Subarachnoid and peridural anaesthesia. Lecture 209, ASA Annual Refresher Course Lectures, Lipincott/Harper, HagerstownGoogle Scholar
- 6.Covino BG, Vassallo HG (1976) Local anesthetics. Mechanism of action and clinical use. Grune & Stratton, New York - San Francisco - LondonGoogle Scholar
- 9.Castro J de, d’Inverno E, Lecron L, Levy D, Toppet-Balatoni E (1980) Perspectives d’utilisation de morphinoides en anesthésie locorégionale. Anesth Analg Réanim 37:17Google Scholar
- 10.Castro J de, Water A van de, Wouters L, Xhonneux R, Reneman R, Kay B (1979) Comparative study of cardiovascular, neurological and metabolic side-effects of eight narcotics in dogs. Acta anaest belgica 1:7Google Scholar
- 12.Freye E (1974) Cardiovascular effects of high dosages of fentanyl, meperidine and naloxone in dogs. Anesth Analg Curr Res 1:40Google Scholar
- 15.Heykants J On the pharmacokinetics of fentanyl. Janssen Pharmaceutica (unpublished results)Google Scholar
- 21.Montel H, Starke K (1973) Effects of narcotic analgesics and their antogonists on the rabbit isolated heart and its adrenergic nerves. Br J Pharmac 49:628Google Scholar
- 22.Müller H, Börner U, Stoyanov M, Gleumes L, Hempelmann G Peridurale Opiatapplikation bei Malignom bedingten, chronischen Schmerzen. Prakt Anaesth (in press)Google Scholar
- 23.Müller H, Brähler A, Stoyanov M, Hempelmann G Peridurales Morphin als Adjuvans der geburtshilflichen Periduralanaesthesie. Anaesthesist (in press)Google Scholar
- 24.Müller H, Börner U, Hempelmann G Tissue and cerebrospinal fluid-tolerance of epidural opiate- application. Proceedings of the congress in Nymegen “Analgesia by peridural and spinal opiates”, Nov 20–21 1980 (in press)Google Scholar
- 25.Müller H, Börner U, Stoyanov M, Hempelmann G (1980) Intraoperative peridurale Opiatanalgesie. Anaesthesist 12:656Google Scholar
- 27.Piepenbrock S, Hempelmann G, Peters H (1977) Veränderungen der Hämodynamik, der Herzinotro- pie und des myokardialen Sauerstoffverbrauchs nach Antagonisierung von hohen Dosen Fentanyl mit Naloxone. Prakt Anästh 12:275Google Scholar
- 28.Samii K (1980) Postoperative analgesia with intrathecal morphine. Lecture at the 7th World Congress of Anesthesiologists, HamburgGoogle Scholar
- 29.Schleimer R, Benjamini E, Eisele J, Henderson G (1978) Pharmacokinetics of fentanyl as determined by radioimmunoassay. Clin Pharmacol Therap 23:188Google Scholar
- 32.Yakashita Y, Fukuda K, Morioka T, Kano T, Araki Y (1979) Intrathecal application of morphine. I. As a supplementation of anesthesia and a prolonged relief of postoperative pain. Jap J Anesth 12:1584Google Scholar
- 35.Yaksh TL, Rudy TA (1977) Studies on the direct spinal action of narcotics in the production of analgesia in the rat. Exp Ther 202:411Google Scholar
- 37.Welchew EA (1980) The control of postoperative pain by thoracic epidural fentanyl and its effect upon the stress response. Lecture at the 7th World Congress of Anesthesiologists, HamburgGoogle Scholar