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Ramaiah VK, Kharasch ED. Methadone and Enhanced Recovery After Surgery: Concepts and Protocols. Anesth Analg 2024; 139:670-674. [PMID: 38295148 PMCID: PMC11289168 DOI: 10.1213/ane.0000000000006790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Affiliation(s)
- Vijay K Ramaiah
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Majumdar JR, Grbic J, Carlsson S, Barreiro D, Marte M, Laudone V, Assel MJ, Masson G. Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery. J Perianesth Nurs 2024; 39:638-644.e1. [PMID: 38493405 PMCID: PMC11297671 DOI: 10.1016/j.jopan.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 03/18/2024]
Abstract
PURPOSE In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery. DESIGN The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients. METHODS Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time. FINDINGS Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding. CONCLUSIONS The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.
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Affiliation(s)
- Jennifer R Majumdar
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY; Hunter-Bellevue School of Nursing, Hunter College, City University of New York, New York, NY.
| | - John Grbic
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY; Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY; Urology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Donna Barreiro
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marie Marte
- Advanced Practice Providers, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent Laudone
- Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa J Assel
- Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY
| | - Geema Masson
- Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
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Mu RJ, Liu TL, Liu XD, Liu L. PBPK-PD model for predicting morphine pharmacokinetics, CNS effects and naloxone antagonism in humans. Acta Pharmacol Sin 2024; 45:1752-1764. [PMID: 38570601 PMCID: PMC11272789 DOI: 10.1038/s41401-024-01255-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/27/2024] [Indexed: 04/05/2024] Open
Abstract
Morphine and morphine-6-glucuronide (M6G) produce central nervous system (CNS) effects by activating mu-opioid receptors, while naloxone is used mainly for the reversal of opioid overdose, specifically for the fatal complication of respiratory depression, but also for alleviating opioid-induced side effects. In this study we developed a physiologically-based pharmacokinetic-pharmacodynamic (PBPK-PD) model to simultaneously predict pharmacokinetics and CNS effects (miosis, respiratory depression and analgesia) of morphine as well as antagonistic effects of naloxone against morphine. The pharmacokinetic and pharmacodynamic parameters were obtained from in vitro data, in silico, or animals. Pharmacokinetic and pharmacodynamic simulations were conducted using 39 and 36 clinical reports, respectively. The pharmacokinetics of morphine and M6G following oral or intravenous administration were simulated, and the PBPK-PD model was validated using clinical observations. The Emax model correlated CNS effects with free concentrations of morphine and M6G in brain parenchyma. The predicted CNS effects were compared with observations. Most clinical observations fell within the 5th-95th percentiles of simulations based on 1000 virtual individuals. Most of the simulated area under the concentration-time curve or peak concentrations also fell within 0.5-2-fold of observations. The contribution of morphine to CNS effects following intravenous or oral administration was larger than that of M6G. Pharmacokinetics and antagonistic effects of naloxone on CNS effects were also successfully predicted using the developed PBPK-PD model. In conclusion, the pharmacokinetics and pharmacodynamics of morphine and M6G, antagonistic effects of naloxone against morphine-induced CNS effects may be successfully predicted using the developed PBPK-PD model based on the parameters derived from in vitro, in silico, or animal studies.
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Affiliation(s)
- Rui-Jing Mu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Tian-Lei Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Xiao-Dong Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Li Liu
- Department of Pharmacology, College of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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Jin X, Deng R, Weng Q, Yang Q, Zhong W. Clinical Application of Different Doses of Hydromorphone Slow-Release Analgesia in Lumbar Fusion in Elderly Patients. Pain Ther 2024:10.1007/s40122-024-00632-3. [PMID: 38995609 DOI: 10.1007/s40122-024-00632-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/25/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION The aim of this study is to examine the analgesic efficacy of varying doses of hydromorphone hydrochloride in conjunction with absorbable gelatin sponge for postoperative pain management in elderly individuals undergoing lumbar fusion surgery. Additionally, the study aims to assess the sustained release analgesic properties of this combination and to determine the optimal dosage of hydromorphone hydrochloride for effective pain relief. METHODS A total of 113 elderly patients (aged ≥ 65 years old) meeting the criteria for 1-2-level posterior lumbar fusion surgery at Ganzhou City People's Hospital between July 2022 and August 2023 were randomly assigned to four groups: group A (0.2 mg hydromorphone hydrochloride 1 ml), group B (0.3 mg hydromorphone hydrochloride 1.5 ml), group C (0.4 mg hydromorphone hydrochloride 2 ml), and group D (0.9% normal saline 2 ml) for standard anesthesia induction and maintenance. Prior to suturing the incision, gelfoam was utilized to administer epidural analgesia to each group. Following the surgical procedure, an intravenous analgesia pump was utilized for pain management. The baseline infusion rate was set at 0.5 ml/h. Patient-controlled analgesia (PCA) was administered at a dose of 2 ml, with a lockout interval of 20 min, allowing the patient to self-administer as needed. Pain relief was assessed using the visual analogue scale (VAS) prior to surgery, as well as at 1 day and 3 days post-operation. The frequency of PCA requests within the initial 48-h postoperative period, the remedial analgesia with dezocine, postoperative adverse reactions, and duration of hospitalization were documented for analysis. RESULTS The VAS scores of groups B and C were found to be significantly lower than those of group D 1 day after the operation. Additionally, VAS scores at 3 days post-operation, remedial rate of dezocine and PCA follow-up times at 48 h in groups A, B, and C were significantly lower compared to group D (P < 0.001). There was no statistically significant difference between group B and group C in VAS scores at 1 day and 3 days post-operation, as well as PCA follow-up times at 48 h post-operation (P < 0.001). Furthermore, the VAS scores of groups B and C were lower than those of group A at 1 day and 3 days post-operation (P < 0.05). The PCA frequency of group C was also lower than that of group A at 48 h post-operation (P < 0.05). CONCLUSION The combination of hydromorphone hydrochloride and absorbable gelatin sponge epidural analgesia has been shown to enhance postoperative pain management. A dosage of 0.4 mg of hydromorphone hydrochloride may be considered an appropriate analgesic dose, as it can provide effective pain relief without eliciting adverse reactions. TRIAL REGISTRATION ChiCTR.org.cn(ChiCTR2200064863). Registered on October 20, 2022.
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Affiliation(s)
- Xianwei Jin
- Department of Medicine, Graduate School, Nanchang University, Nanchang, Jiangxi Province, China
| | - Ruiming Deng
- Department of Anesthesiology, The People's Hospital of Ganzhou, No. 16, Meiguan Avenue, Zhanggong District, Ganzhou, 341000, Jiangxi Province, China
| | - Qiaoling Weng
- Department of Anesthesiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Qiao Yang
- Department of Anesthesiology, The Maternal and Child Health Hospital of Ganzhou City, Ganzhou, Jiangxi Province, China
| | - Weibo Zhong
- Department of Anesthesiology, The People's Hospital of Ganzhou, No. 16, Meiguan Avenue, Zhanggong District, Ganzhou, 341000, Jiangxi Province, China.
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Paolini A, Bucci R, Bianchi A, Del Signore F, Parrillo S, Di Giosia A, Ristori C, Tamburro R, Robbe D, Carluccio A, Rosa V, Vignoli M. Use of Caudal Quadratus Lumborum Block with Ropivacaine as Part of an Opioid-Free Analgesic Protocol in Dogs Undergoing Orchiectomy: A Randomized Trial. Animals (Basel) 2024; 14:1885. [PMID: 38997997 PMCID: PMC11240621 DOI: 10.3390/ani14131885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
In veterinary medicine, the use of loco-regional anesthesia techniques is increasing. The Quadratus Lumborum block (QL) is an interfascial loco-regional technique that involves the release of local anesthetic (LA) between the Quadratus Lumborum and the Small Psoas (Pm) muscle. The study aims to evaluate the effect of the QL block on reducing the total amount of opioids in dogs undergoing pre-scrotal orchiectomy. A group of 36 dogs was enrolled in a randomized blinded study. The animals were divided into two groups: 18 in the experimental group (QL) and 18 in the control group (C). The QL group received 0.4 mL kg-1 of ropivacaine 0.5% for each hemiabdomen (total amount of 3 mg kg-1 of ropivacaine, 1.5 mg kg-1 per side). The C group was brought into the operating room (OR) after receiving the same clipping as the QL group. In the intraoperative period, opioid consumption in the QL group was significantly lower than in the C group. No differences were found in the post-operative phase. No side effects were reported when performing the QL technique. The QL block performed at the level of L6 appears to be a valid approach to reducing opioid use in dogs undergoing orchidectomy with a pre-scrotal surgical approach.
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Affiliation(s)
- Andrea Paolini
- Small Animal Surgery and Anesthesia Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Roberta Bucci
- Obstetrics, Gynecology and Veterinary Andrology Clinic Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Amanda Bianchi
- Small Animal Surgery and Anesthesia Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Francesca Del Signore
- Small Animal Imaging Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Salvatore Parrillo
- Obstetrics, Gynecology and Veterinary Andrology Clinic Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Alessandro Di Giosia
- Obstetrics, Gynecology and Veterinary Andrology Clinic Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Claudia Ristori
- Small Animal Surgery and Anesthesia Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Roberto Tamburro
- Small Animal Surgery and Anesthesia Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Domenico Robbe
- Obstetrics, Gynecology and Veterinary Andrology Clinic Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Augusto Carluccio
- Obstetrics, Gynecology and Veterinary Andrology Clinic Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Valeria Rosa
- Small Animal Surgery and Anesthesia Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
| | - Massimo Vignoli
- Small Animal Imaging Service, Department of Veterinary Medicine, University of Teramo, 64100 Teramo, Italy
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Cao X, Gui Q, Wei Y, Lan L, Xiao H, Wen S, Li X. The 50% effective dose of hydromorphone and morphine for epidural analgesia in the hemorrhoidectomy: a double-blind, sequential dose-finding study. BMC Anesthesiol 2024; 24:41. [PMID: 38291353 PMCID: PMC10826036 DOI: 10.1186/s12871-024-02420-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/18/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Although previous studies have showed that epidural morphine can be used as a complement to local anesthetics for analgesia after postcesarean delivery under spinal anesthesia, there is little known about the analgesic dosage of epidural morphine and hydromorphone for hemorrhoidectomy. Therefore, we conducted this study to examine the potency ratio of hydromorphone to epidural morphine as well as effective analgesic dose for 50% patients (ED50) undergoing elective hemorrhoidectomy. METHODS 80 patients under elective hemorrhoidectomy with combined spinal and epidural anesthesia(CSEA) in department of anesthesia, Dongguan Tungwah hospital. To assess the ED50, patients were treated with epidural morphine or epidural hydromorphone randomly using a biased coin method-determined dose with a sequential allocation procedure. Following surgery, standardized multimodal analgesia was administered to all patients. A pain response score of ≤ 3 (on a scale of 0-10) was determined to be the effective dose after 24 h following CSEA. The ED50 in both groups were determined using the probit regression and isotonic regression method. We also measured pain intensity by patient interview using a 10 point verbal numeric rating scale prospectively at 6, 12 and 24 h after CSEA, and adverse effects were also noted. RESULTS The ED50 was 0.350 mg (95% CI, 0.259-0.376 mg) in hydromorphone group and 1.129 mg (95% CI, 0.903-1.187 mg) in morphine group, respectively, estimated by isotonic regression method. Regression analysis with the probit, the ED50 of epidural hydromorphone was 0.366 mg (95% CI, 0.276-0.388 mg) and epidural morphine was 1.138 mg (95% CI, 0.910-1.201 mg). Exploratory findings showed that there was no difference between the most frequent dosages of epidural hydromorphone or epidural morphine in the occurrence of nausea, vomiting and pruritus. When administered with epidural opioids at ED50 doses or higher, 97.5% (39/40) of epidural morphine patients and 97.5% (39/40) epidural hydromorphone of patients were satisfied with their analgesia. CONCLUSION Effective hemorrhoidectomy analgesia requires a 3:1 ratio of epidural morphine to epidural hydromorphone. Both drugs provide excellent patient satisfaction.
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Affiliation(s)
- Xianghua Cao
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China
| | - Qiangjun Gui
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China
| | - Yujiao Wei
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China
| | - Lanhui Lan
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China
| | - Huiling Xiao
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China
| | - Shihong Wen
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, No 58, ZhongShan 2nd road, Guangzhou, China.
| | - Xueping Li
- Department of Anesthesiology, Dongguan Tungwah Hospital, Dongguan, China.
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