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Nassif YJ, Zanin ME, Martinez-Sobalvarro JV, de Barros CM, Pacheco-Neto M, Dos Reis TM, Cardoso-Podestá MHM, Torres LH. Effectiveness of epidural morphine for the treatment of cancer pain in patients with gastrointestinal neoplasm-a systematic review. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:3819-3827. [PMID: 38180558 DOI: 10.1007/s00210-023-02925-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients.
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Affiliation(s)
- Yasmim Jianjulio Nassif
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil
| | - Maria Elisa Zanin
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil
| | - Joselin Valeska Martinez-Sobalvarro
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil
- Department of Pharmacy, Health Sciences Sector, Federal University of Paraná, Curitiba, Brazil
| | - Carlos Marcelo de Barros
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil
- Department of Anesthesiology, Pain and Palliative Care, Santa Casa of Alfenas, Alfenas, Brazil
| | | | - Tiago Marques Dos Reis
- Department of Clinical and Toxicological Analysis, School of Pharmaceutical Sciences, Federal University of Alfenas, Alfenas, Brazil
| | - Márcia Helena Miranda Cardoso-Podestá
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil
| | - Larissa Helena Torres
- Department of Food and Drugs, School of Pharmaceutical Sciences, Federal University of Alfenas, Rua Gabriel Monteiro da Silva, 700, Centro-Alfenas, MG, CEP: 37130-001, Brazil.
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Guay J, Nishimori M, Kopp S. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery. Cochrane Database Syst Rev 2016; 7:CD001893. [PMID: 27419911 PMCID: PMC6457860 DOI: 10.1002/14651858.cd001893.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016. OBJECTIVES To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery. SEARCH METHODS We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update. SELECTION CRITERIA We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids. DATA COLLECTION AND ANALYSIS We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale. MAIN RESULTS We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited. AUTHORS' CONCLUSIONS An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
| | - Mina Nishimori
- Seibo International Catholic HospitalDepartment of Anesthesiology2‐5‐1, Naka‐OchiaiShinjyukuTokyoJapan161‐8521
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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Chaudhary A, Bogra J, Singh PK, Saxena S, Chandra G, Verma R. Efficacy of spinal ropivacaine versus ropivacaine with fentanyl in transurethral resection operations. Saudi J Anaesth 2014; 8:88-91. [PMID: 24665247 PMCID: PMC3950461 DOI: 10.4103/1658-354x.125951] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: The low-dose ropivacaine provides differential spinal block to reduce adverse hemodynamic effects in elderly patients. Addition of intrathecal fentanyl with ropivacaine may enhance analgesia and early postoperative mobility. The present study was performed to evaluate the efficacy of intrathecal ropivacaine alone and in combination with fentanyl in transurethral resection operation. Methods: Sixty male patients aged >50 years of ASA I-III scheduled for elective transurethral resection were included in a prospective, randomized, double-blinded study and they were divided in two groups of 30 each. Group A (n = 30) received intrathecal injection of ropivacaine 2 ml (0.75%) and Group B (n = 30) ropivacaine 1.8 ml (0.75%) with fentanyl 10 μg. The characteristics of onset and regression of sensory and motor blockade, hemodynamic stability, and side effects were observed. Student's t test (for parametric data) and Mann-Whitney U test (for non-parametric data) were used for statistical analyses. Results: There were no significant differences between the two groups for patient demographic data, intraoperative hemodynamic parameters, side effects, and satisfaction to patients and surgeon. The highest level of sensory block was at T10 in group A and T9 in group B (P = 0.001). Duration of motor block was longer in group B being 210.51 ± 61.25 min than in group A being 286.25 ± 55.65 min (P < 0.001). Conclusion: The addition of fentanyl to ropivacaine may offer the advantage of shorter duration of complete motor block, hemodynamic stability, and without any increase in the frequency of major side effects.
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Affiliation(s)
- A Chaudhary
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
| | - J Bogra
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
| | - P K Singh
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
| | - S Saxena
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
| | - G Chandra
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
| | - R Verma
- Department of Anesthesia, KG's Medical University, Lucknow, Uttar Pradesh, India
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Zhu Z, Wang C, Xu C, Cai Q. Influence of patient-controlled epidural analgesia versus patient-controlled intravenous analgesia on postoperative pain control and recovery after gastrectomy for gastric cancer: a prospective randomized trial. Gastric Cancer 2013; 16:193-200. [PMID: 22806415 DOI: 10.1007/s10120-012-0168-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 05/11/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-controlled epidural analgesia (PCEA) has not been widely used after gastrectomy, although, in other abdominal surgery, it benefits patients more than patient-controlled intravenous analgesia (PCIA). We attempted to determine the effect of PCEA compared with PCIA on postoperative pain control and recovery after gastrectomy for gastric cancer. METHODS A randomized controlled clinical trial that included patients undergoing D2 radical gastrectomy for gastric cancer was conducted for this study. Patients were randomized to a morphine-bupivacaine PCEA group and a morphine PCIA group. Postoperative outcomes such as pain, fasting blood glucose (FBG), time to first passage of flatus, complications, and time staying in hospital after surgery were compared with an intention-to-treat analysis. RESULTS Between March 2010 and October 2010, 67 patients were randomized and 60 were evaluated. The PCEA group showed lower pain scores both at rest and on coughing after the operation (P < 0.05). FBG after the operation was significantly lower in the PCEA group than that in the PCIA group (P < 0.05). Time to first passage of flatus after surgery was shorter in the PCEA group (P < 0.05), while there were no significant differences regarding the incidence of complications between the two groups in terms of the clinical records. The length of hospital stay in the PCEA group was 10.7 ± 1.7 days, which was significantly shorter than that in the PCIA group (11.9 ± 1.8 days, P < 0.05). CONCLUSIONS After gastrectomy for gastric cancer, PCEA, compared with PCIA, offered safer pain relief with superior pain control and resulted in a lower stress response and a quicker return of bowel activity.
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Affiliation(s)
- Zhenxin Zhu
- Gastro-intestine Surgery Department, Shanghai Changzheng Hospital, 415 FengYang Road, Shanghai, 200003, People's Republic of China
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Cadavid AM, Montes DM, González MV, Urrea LM, Lescano WJ. Tolerabilidad y eficacia de morfina versus hidromorfona en analgesia epidural posquirúrgica con bupivacaína. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2010. [DOI: 10.1016/s0120-3347(10)83005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Abstract
Despite numerous publications, new guidelines for the treatment of acute pain and efforts from a number of initiatives, there is still a tremendous need for improvement in postoperative pain therapy. One of the reasons for the shortcomings in the care of patients with postoperative pain is the lack of applicability of guidelines in daily clinical practice. Therefore, simple but effective and easy to implement concepts need to be developed. In the following review, different concepts that have been developed over recent years are presented and evaluated for their effectiveness. One of these is the notion of balanced analgesia, currently probably one of the most widely used perioperative therapy concepts. The idea of this concept is to reduce the doses of analgesics, e.g. opioids, through combinations of different classes of analgesics, thereby reducing their side effects. However, recent studies and essential meta-analyses indicate pitfalls using this concept. The pros and cons will be discussed and ideas on how to deal with balanced analgesia in daily practice will be given. Another pain concept of "procedure-specific postoperative pain therapy", is an appealing idea of an international initiative from surgeons and anaesthesiologists and an essential part of the German S3 guidelines for acute pain released last year. Critical evaluation of the available recommendations for procedure-specific analgesia together with the presentation of relatively simple but evidence-based algorithms for specific procedures may help to implement this concept in clinical routine.
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Königsrainer I, Bredanger S, Drewel-Frohnmeyer R, Vonthein R, Krueger WA, Königsrainer A, Unertl KE, Schroeder TH. Audit of motor weakness and premature catheter dislodgement after epidural analgesia in major abdominal surgery. Anaesthesia 2008; 64:27-31. [PMID: 18671685 DOI: 10.1111/j.1365-2044.2008.05655.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. Additionally, to prevent outward movement, the catheters were inserted deeper into the epidural space (mean (SD) 5.2 (1.5) cm in Period Two vs 4.6 (1.3) cm in Period One). Lower leg motor weakness declined from 14.7% to 5.1% (odds ratio 0.35; 95% confidence interval 0.16-0.74) between the two periods. Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.
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Affiliation(s)
- I Königsrainer
- Department of General-, Visceral- and Transplantation Surgery, University Hospital Tübingen, Tübingen, Germany
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Addition of remifentanil to patient-controlled tramadol for postoperative analgesia: a double-blind, controlled, randomized trial after major abdominal surgery. Eur J Anaesthesiol 2008; 25:968-75. [PMID: 18533063 DOI: 10.1017/s0265021508004663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE We have investigated whether, after major abdominal surgery, the addition of remifentanil to tramadol for intravenous patient-controlled analgesia improved analgesia and lowered pain scores, compared to a patient-controlled analgesia containing only tramadol. METHODS Sixty-two patients were allocated randomly to receive an intravenous patient-controlled analgesia with tramadol alone (T), or tramadol plus remifentanil (TR), in a double-blind randomized study. Whenever patients complained of pain, they were allowed to use bolus doses of tramadol (0.2 mg kg-1) or tramadol (0.2 mg kg-1) plus remifentanil (0.2 microg kg-1) mixture every 10 min without a time limit and background infusion. Discomfort, sedation, pain scores, total and bolus patient-controlled analgesia tramadol consumption, and side-effects were recorded for up to 24 h after the start of patient-controlled analgesia. RESULTS Pain scores at rest were statistically significantly lower in the TR group at 6, 12 and 24 h than in T group (P < 0.05). Pain scores at movement and patient comfort scores were also found to be significantly lower in the TR group at 2, 6, 12 and 24 h than in the T group (P < 0.05). Although the TR group consumed less tramadol, there were no statistically significant differences in the cumulative tramadol consumptions between the groups at any time. However, the number of patients requiring rescue analgesia and average supplementary doses used was significantly higher in the T group than in the TR group (P < 0.05). CONCLUSIONS After major abdominal surgery, adding remifentanil (0.2 microg kg(-1)) to tramadol (0.2 mg kg(-1)), with 10-min lockout times, for patient-controlled analgesia offered better postoperative pain relief and patient comfort, without causing any sedation or respiratory depression.
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Abstract
This paper is the 28th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning over a quarter-century of research. It summarizes papers published during 2005 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity, neurophysiology and transmitter release (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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