Advertisement

The Perioperative Use of Epidural Opiates

  • H. Müller
  • U. Börner
  • M. Stoyanov
  • G. Hempelmann
Part of the Anaesthesiologie und Intensivmedizin Anaesthesiology and Intensive Care Medicine book series (A+I, volume 144)

Summary

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.

Keywords

Respiratory Depression Epidural Anaesthesia Epidural Catheter Epidural Morphine Epidural Injection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Atweh SF, Kuhar MJ (1977) Autoradiographic localization of opiate receptors in rat brain, spinal cord and lower medulla. Brain Res 124:53PubMedCrossRefGoogle Scholar
  2. 2.
    Behar M, Olshwang D, Magora F, Davidson JT (1979) Epidural morphine in treatment of pain. Lancet 1:527PubMedCrossRefGoogle Scholar
  3. 3.
    Bromage PR (1979) Subarachnoid and peridural anaesthesia. Lecture 209, ASA Annual Refresher Course Lectures, Lipincott/Harper, HagerstownGoogle Scholar
  4. 4.
    Bullingham RES, McQuay HJ, Moore RA (1980) Unexpectedly high plasma fentanyl levels after epidural use. Lancet 1:1361PubMedCrossRefGoogle Scholar
  5. 5.
    Cookson RF (1980) Analgesic plasma concentrations. Br J Anaesth 52:959PubMedCrossRefGoogle Scholar
  6. 6.
    Covino BG, Vassallo HG (1976) Local anesthetics. Mechanism of action and clinical use. Grune & Stratton, New York - San Francisco - LondonGoogle Scholar
  7. 7.
    Davies GK, Tolhurst-Cleaver CL, James TL (1980) CNS depression from intrathecal morphine. Anesthesiology 52:280PubMedCrossRefGoogle Scholar
  8. 8.
    Dirksen R, Nijhuis GMM (1980) Epidural opiate and perioperative analgesia. Acta anaesth scand 24:367PubMedCrossRefGoogle Scholar
  9. 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. 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
  11. 11.
    Engquist A, Brandt MR, Fernandes A, Kehlet H (1977) The blocking effect of epidural analgesia on the adrenocortical and hyperglycaemic responses to surgery. Acta Anaesth scand 21:333CrossRefGoogle Scholar
  12. 12.
    Freye E (1974) Cardiovascular effects of high dosages of fentanyl, meperidine and naloxone in dogs. Anesth Analg Curr Res 1:40Google Scholar
  13. 13.
    Glynn CJ, Mathers LE, Cousins MJ, Wilson PR, Graham JR (1979) Spinal narcotics and respiratory depression. Lancet 2:356PubMedCrossRefGoogle Scholar
  14. 14.
    Hall GM (1980) Fentanyl and the metabolic response to surgery. Br J Anaesth 52:561PubMedCrossRefGoogle Scholar
  15. 15.
    Heykants J On the pharmacokinetics of fentanyl. Janssen Pharmaceutica (unpublished results)Google Scholar
  16. 16.
    Hug CC, Murphy MR (1979) Fentanyl disposition in cerebrospinal fluid and plasma and its relationship to ventilatory depression in the dog. Anesthesiology 50:342PubMedCrossRefGoogle Scholar
  17. 17.
    Husemeyer RP, O’Connor MC, Davenport HT (1979) Aspects of epidural morphine. Lancet 2:583PubMedCrossRefGoogle Scholar
  18. 18.
    Kim KC, Stoelting RK (1980) Effect of droperidol on the duration of analgesia and development of tolerance to intrathecal morphine. Anesthesiology V 53, 3:219CrossRefGoogle Scholar
  19. 19.
    Lilios A, Andersen FH (1979) Selective spinal analgesia. Lancet 2:357CrossRefGoogle Scholar
  20. 20.
    Michiels M, Hendriks R, Heykants J (1977) A sensitive radioimmunoassay for fentanyl. Plasma levels in dogs and man. Europ J clin Pharmacol 12:153CrossRefGoogle Scholar
  21. 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. 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. 23.
    Müller H, Brähler A, Stoyanov M, Hempelmann G Peridurales Morphin als Adjuvans der geburtshilflichen Periduralanaesthesie. Anaesthesist (in press)Google Scholar
  24. 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. 25.
    Müller H, Börner U, Stoyanov M, Hempelmann G (1980) Intraoperative peridurale Opiatanalgesie. Anaesthesist 12:656Google Scholar
  26. 26.
    Perriss BW (1979) Epidural opiates in labour. Lancet 2:422PubMedCrossRefGoogle Scholar
  27. 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. 28.
    Samii K (1980) Postoperative analgesia with intrathecal morphine. Lecture at the 7th World Congress of Anesthesiologists, HamburgGoogle Scholar
  29. 29.
    Schleimer R, Benjamini E, Eisele J, Henderson G (1978) Pharmacokinetics of fentanyl as determined by radioimmunoassay. Clin Pharmacol Therap 23:188Google Scholar
  30. 30.
    Scott J, Huskisson EC (1976) Graphic representation of pain. Pain 2:175PubMedCrossRefGoogle Scholar
  31. 31.
    Stoeckel H, Hengstmann JH, Schüttler J (1979) Pharmacokinetics of fentanyl as a possible explanation for recurrence of respiratory depression. Br J Anaesth 51:741PubMedCrossRefGoogle Scholar
  32. 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
  33. 33.
    Yaksh TL (1978) Analgetic actions of intrathecal opiates in cat and primate. Brain Res 153:205PubMedCrossRefGoogle Scholar
  34. 34.
    Yaksh TL, Reddy SVR (1981) Studies in the primate on the analgetic effects associated with intrathecal actions of opiates, α-adrenergic agonists and baclofen. Anesthesiology 54:451PubMedCrossRefGoogle Scholar
  35. 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
  36. 36.
    Weddel SJ, Ritter RR (1980) Epidural morphine: Serum levels and pain relief. Anesthesiology V 53, 3:419CrossRefGoogle Scholar
  37. 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
  38. 38.
    Wolfe MJ, Davies GK (1980) Analgesic action of extradural fentanyl. Br J Anaesth 52:357PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1982

Authors and Affiliations

  • H. Müller
  • U. Börner
  • M. Stoyanov
  • G. Hempelmann

There are no affiliations available

Personalised recommendations