lunes, 9 de abril de 2018

Morfina neuroaxial / Neuroaxial morphine

Abril 9, 2018. No. 3048
Morfina espinal en pacientes sometidos a una hemorroidectomía abierta: un análisis prospectivo de control del dolor y complicaciones postoperatorias.
Morphine spinal block anesthesia in patients who undergo an open hemorrhoidectomy: a prospective analysis of pain control and postoperative complications.
Ann Coloproctol. 2014 Jun;30(3):135-40. doi: 10.3393/ac.2014.30.3.135. Epub 2014 Jun 23.
PURPOSE: This study evaluated the use of adding morphine to bupivacaine in spinal anesthesia for pain control in patients who underwent an open hemorrhoidectomy. METHODS: Forty patients were prospectively selected for an open hemorrhoidectomy at the same institution and were randomized into two groups of 20 patients each: group 1 had a spinal with 7 mg of heavy bupivacaine associated with 80 µg of morphine (0.2 mg/mL). Group 2 had a spinal with 7 mg of heavy bupivacaine associated with distilled water, achieving the same volume of spinal infusion as that of group 1. Both groups were prescribed the same pain control medicine during the postoperative period. Pain scores were evaluated at the anesthetic recovery room and at 3, 6, 12, and 24 hours after surgery. Postoperative complications, including pruritus, nausea, headaches, and urinary retention, were also recorded. RESULTS: There were no anthropometric statistical differences between the two groups. Pain in the anesthetic recovery room and 3 hours after surgery was similar for both groups. However, pain was better controlled in group 1 at 6 and 12 hours after surgery. Although pain was better controlled for group 1 after 24 hours of surgery, the difference between the groups didn't achieved statistical significance. Complications were more common in group 1. Six patients (6/20) presented coetaneous pruritus and 3 with (3/20) urinary retention. CONCLUSION: A hemorrhoidectomy under a spinal with morphine provides better pain control between 6 and 12 hours after surgery. However, postoperative complications, including cutaneous pruritus (30%) and urinary retention (15%), should be considered as a negative side of this procedure.
KEYWORDS: Hemorroidectomy; Postoperative pain; Urinary retention
Morfina intratecal aumenta la incidencia de retención urinaria en pacientes ortopédicos bajo anestesia raquídea
Intrathecal morphine increases the incidence of urinary retention in orthopaedic patients under spinal anaesthesia.
Anaesthesiol Intensive Ther. 2014 Jan-Mar;46(1):29-33. doi: 10.5603/AIT.2014.0006.
BACKGROUND: Morphine injected into the subarachnoid space enhances the analgesic effects of spinal anaesthesia, improving the patient's comfort in the postoperative period. However, it is likely to be associated with adverse side effects that reduce patient satisfaction, e.g., urine retention. The aim of the present study was to evaluate the incidence of urine retention in patients receiving spinal anaesthesia combined with intrathecal morphine. METHODS: The postoperative course of 30 patients undergoing orthopaedic surgical procedures was analysed. Patients were divided into two groups: the control group (BSH; 16 individuals anaesthetised with a 0.5% hyperbaric solution of bupivacaine) and the experimental group (BSH + MF; 14 individuals anaesthetised with a 0.5% hyperbaric solution of bupivacaine with the addition of 0.2 mg morphine). The following parameters were analysed: duration of anaesthesia, time to miction, time to urgency and need to introduce a urinary catheter. RESULTS: There were no statistically significant differences in the duration of anaesthesia, incidence of hypogastric discomfort/difficulties in urination, time to hypogastric discomfort or duration of discomfort. Patients receiving intrathecal morphine were characterised by longer time to miction, higher incidence of urinary catheterisation and longer time between anaesthesia and urinary catheterisation. CONCLUSIONS: Patients receiving spinal anaesthesia with a 0.5% hyperbaric solution of bupivacaine combined with intrathecal morphinewere demonstrated to have a higher incidence of urinary catheterisation, longer time to urinary catheterisation and longer time to miction compared to patients receiving only local anaesthetics.
Incidencia de retención urinaria postoperatoria en pacientes sometidos a cirugía electiva de cadera y rodilla
The incidence of postoperative urinary retention in patients undergoing elective hip and knee arthroplasty.
Ann R Coll Surg Engl. 2014 Sep;96(6):462-5. doi: 10.1308/003588414X13946184902523.
INTRODUCTION Postoperative urinary retention requiring urethral catheterisation increases the risk of joint sepsis following arthroplasty. Spinal anaesthesia with opiate administration is used widely in lower limb arthroplasty. We sought to establish whether the choice of opiate agent had any effect on the incidence of postoperative retention and therefore the risk of joint sepsis. METHODS A total of 445 consecutive patients who underwent primary elective lower limb arthroplasty were reviewed retrospectively. Patients had general anaesthesia and femoral nerve block (GA+FNB), spinal anaesthesia and intrathecal fentanyl (SA+ITF) or spinal anaesthesia and intrathecal morphine (SA+ITM). RESULTS Urinary retention was observed in 14% of male and 2% of female patients with GA+FNB, 9% of male and 3% of female patients with SA+ITF, and 60% of male (p=0.0005) and 5% of female patients with SA+ITM. Men who experienced retention were older (68 vs 64 years, p=0.013) and had longer inpatient stays (6.7 vs 4.6 days, p=0.043). Fewer patients in the SA+ITM group required breakthrough analgesia (28% vs 58%, p=0.004). CONCUSIONS The use of ITM in men significantly increases the incidence of urinary retention requiring urethral catheterisation and subsequently increases the risk of deep joint sepsis. Its use should be rationalised against the intended benefits and alternatives sought where possible...
Efectos secundarios relacionados con la morfina intratecal a largo plazo.
Drug-related side effects of long-term intrathecal morphine therapy.
Pain Physician. 2007 Mar;10(2):357-66.
BACKGROUND: The introduction of intrathecal opioid administration for intractable chronic non-malignant pain and cancer pain is considered as one of the most important breakthroughs in pain management. Morphine, the only opioid approved by FDA for intrathecal administration, has been increasingly utilized for this purpose. For over 3 decades, there have been numerous reports on the non-nociceptive side effects associated with ever increasing long-term intrathecal morphine usage. OBJECTIVES: To review the literature on side effects due to long-term intrathecal morphine therapy with discussions of alternate treatment options. DESIGN: English-language publications were identified through MEDLINE search and the bibliographies of identified articles were reviewed. RESULTS: Most side effects of intrathecal morphine therapy are dose dependent and mediated by opioid receptors. Common ones include nausea, vomiting, pruritus, urinary retention, constipation, sexual dysfunction, and edema. Less common ones include respiratory depression, and hyperalgesia. Catheter tip inflammatory mass formation is a less common complication that may not be mediated by opioid receptors. CONCLUSION: The utilization of intrathecal morphine administration for cancer and intractable non-malignant chronic pain represents an important leap forward in pain management. Yet, a wide variety of non-nociceptive side effects may also occur in susceptible patients. The side effects due to intrathecal morphine administration are mostly mediated by opioid receptors. Treatment usually involves the utilization of opioid receptor antagonist, such as naloxone. Patients considering intrathecal opioid pump therapy should be informed and advised about the possible side effects associated with long-term intrathecal morphine administration prior to placement of a permanent morphine infusion pump
Fisiología y farmacología clínica de los opioides epidurales e intratecales
B. Mugabure1, E. Echaniz1 y M. Marín2
Rev. Soc. Esp. Dolor vol.12 no.1 Madrid ene./feb. 2005
La historia de la anestesia intratecal y epidural ha discurrido en paralelo al desarrollo de la anestesia general. La primera reseña publicada sobre el uso de opioides para anestesia intradural la realizó un cirujano rumano, que presentó su experiencia en 1901 en París. Ha pasado casi un siglo hasta conseguir la utilización de opioides por vía epidural. En nuestros días, el uso de opioides intradurales y epidurales constituye una práctica clínica habitual para conseguir analgesia intra y postoperatoria. En los últimos 30 años, el uso de opioides epidurales se ha convertido en rutinario para el tratamiento del dolor del trabajo del parto y del manejo tanto del dolor agudo como crónico. Ha sido ampliamente asumido que cualquier opioide depositado en el espacio epidural o intratecal producirá una analgesia altamente selectiva medular y que esta será superior a la conseguida por otras técnicas analgésicas o vías de administración. Desafortunadamente esto simplemente no es verdad. De hecho, en multitud de ocasiones, los opioides son utilizados vía perimedular a pesar de que la evidencia clínica nos demuestra que no producen un efecto específico medular, o que la analgesia producida no es superior a la conseguida tras su administración intravenosa. Para realizar un uso apropiado de los opioides espinales, debemos comprender adecuadamente la fisiología y la farmacología clínica de estos fármacos y cuál produce analgesia selectiva medular y cuál no. Las diferencias son producto de la biodisponibilidad en los receptores específicos de su biofase medular en la sustancia gris. Esta es menor para los opioides lipofílicos, ya que son aclarados hacia el plasma con mayor rapidez que los hidrofílicos, y consecuentemente producen con mayor antelación efectos adversos supramedulares y su vida media es de menor duración. La morfina es probablemente el opioide con mayor acción selectiva medular tras su administración epidural o intradural. La metadona es otro fármaco al que se le ha observado una selectividad medular moderada tras su administración epidural. Sin embargo, su prolongada vida media puede resultar en su acumulación plasmática y presencia de efectos supraespinales a lo largo del tiempo. La administración epidural de fentanilo ofrece muy pocas ventajas sobre su utilización intravenosa, salvo en obstetricia donde parece producir una analgesia selectiva medular de grado moderado. Finalmente, la administración epidural de sufentanilo o alfentanilo parece producir analgesia por recaptación sistémica y redistribución hacia los receptores opioides cerebrales. Palabras clave: Epidural. Intradural. Opioides. Espinal. Analgesia.

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