The role of the perispinal route for postsurgical pain relief

Epidural and spinal agents for postoperative analgesia

The discovery of opioid receptors and the subsequent development of the technique of epidural and intrathecal opioid administration are undoubtedly two of the most significant advances in pain management in recent decades. The use of spinal opioids is widespread and increasing. The technique is used widely to treat intraoperative, postoperative, traumatic, obstetric, chronic, and cancer pain. Newer developments include the increasing use of combined local anesthetics and opioids or nonopioids and also PCEA, particularly in the obstetric population. Meta-analysis of controlled trials has demonstrated improved pulmonary outcome in patients receiving epidural postoperative analgesia. Although rare, respiratory depression continues to be a major problem of the technique. None of the currently available opioids is completely safe; however, extensive international experience has shown that patients receiving spinal opioids for postoperative analgesia can be safely nursed on regular wards, provided that trained personnel and appropriate guidelines are available. The importance of a good acute pain service to provide the safe and effective use of spinal opioids cannot be overemphasized.

Epidural and intrathecal opioids for postoperative pain management in Europe--a 17-nation questionnaire study of selected hospitals. Euro Pain Study Group on Acute Pain

BACKGROUND

A questionnaire study conducted with the help of selected contact persons in 17 countries in Europe attempted to create a picture of the practice of acute pain management with the use of spinal opioid analgesia (SOA).

METHODS

A questionnaire was mailed to anaesthesiologists in 105 European hospitals. Depending on the population, 5-10 hospitals from each country were selected by a country co-ordinator.

RESULTS

A total of 101 (96.2%) completed questionnaires were returned. During 1 year SOA was used in 55,117 patients (6.6% of all in-patient surgical procedures); of these, 89.2% received epidural opioids and 10.8% intrathecal opioids (ratio 8:1). The most common opioid for SOA was morphine; fentanyl was also used quite frequently; 12 different opioids and 8 non-opioids had been used. ASA 1-2 patients receiving epidural morphine were nursed on surgical wards in 58.4% of the hospitals; in 25.7% of hospitals even ASA 3-4 were nursed on surgical wards. Respiratory depression (requiring naloxone treatment) was noted in 45 of the 49,183 patients who received epidural opioids (0.09%); 33 of these patients had received morphine. In more than 75% of hospitals the monitoring variables were respiratory rate, sedation level and pulse oximetry. There was a great difference between hospitals and countries regarding duration of monitoring.

CONCLUSIONS

This questionnaire study showed that SOA was used in about 7% of 836,000 in-patients undergoing surgery at the 105 selected hospitals. Epidural opioids were used eight times more often than intrathecal opioids. Morphine was the commonest opioid for SOA. The duration of monitoring differed greatly between hospitals and countries; the need for official guidelines is emphasized.