Rebel Annette, Sloan Paul, Andrykowski Michael
Department of Anesthesiology, University of Kentucky Medical Center, Lexington, Kentucky, USA.
J Opioid Manag. 2009 Nov-Dec;5(6):331-9. doi: 10.5055/jom.2009.0033.
Intrathecal opioids (ITOs) have been used for decades to control postoperative pain. Intrathecal opioid dosing is limited, however, by opioid-related side effects, most importantly respiratory depression. To overcome these limitations, we combined intrathecal morphine with a continuous intravenous (IV) postoperative naloxone infusion to control opioid-related side effects. The purpose of this study is to document the efficacy and safety of high-dose intrathecal morphine combined with postoperative naloxone infusion to provide postoperative analgesia after major surgery. After IRB approval, a retrospective chart analysis was performed on 35 patients who had a radical prostatectomy from 2004 to 2006. All patients received a single injection of ITOs before anesthesia, a typical general Anesthestic, followed by naloxone infusion at 5 microg/kg/h started 1 hour post-ITOs and continued for 22 hours postoperatively. The following information was collected: patient age, height, weight, anesthesia technique/time, and dose of ITOs given. Postoperative pain relief was assessed for 48 hours using the Visual Analog Score (VAS) for pain (0, no pain; 10, worst pain), perioperative opioid use, NSAID consumption, and ability of patient to ambulate. The safety of this novel treatment was assessed with opioid-related side effects and vital signs. All data are reported as mean (SD).
Mean ITOs given were morphine 1.3 (0.3) mg combined with fentanyl 56 (9) microg. The intrathecal morphine dose ranged from 0.8 to 1.7 mg. The mean worst pain VAS in the first 12 hours postoperatively was only 1.0 (1.7). The first NSAID dose was given 6.6 (3.1) hours post-ITOs. The first opioid on the floor was given an average of 22.6 (14.5) hours post-ITOs. A mean of only 5.7 (12.3) morphine equivalents were required on postoperative day 1 (POD 1). On POD 2, the mean worst pain VAS was only 2.6 (2.2) with only 5.7 (6.2) morphine equivalents needed to provide pain relief On POD 1, 25patients required no additional opioids for their entire hospital stay. Overall, 11 of 35 patients did not require any additional postoperative opioids. Thirty-four patients (97 percent) were able to ambulate in the first 12 hours postoperatively. No opioid-induced respiratory depression was observed. Opioid-related side effects (pruritus, nausea) were infrequent and minor.
High-dose ITOs combined with postoperative IV naloxone infusion provided excellent analgesia for radical prostate surgery. IV naloxone infusion appeared to control opioid side effects without diminishing the analgesia. No serious adverse effects were noted.
鞘内注射阿片类药物（ITOs）已用于控制术后疼痛数十年。然而，鞘内阿片类药物的剂量受到阿片类药物相关副作用的限制，其中最重要的是呼吸抑制。为克服这些限制，我们将鞘内吗啡与术后持续静脉输注纳洛酮相结合，以控制阿片类药物相关副作用。本研究的目的是记录大剂量鞘内吗啡联合术后纳洛酮输注用于大型手术后提供术后镇痛的有效性和安全性。经机构审查委员会（IRB）批准，对2004年至2006年期间接受根治性前列腺切除术的35例患者进行了回顾性病历分析。所有患者在麻醉前接受单次鞘内注射阿片类药物，这是一种典型的全身麻醉，随后在鞘内注射阿片类药物后1小时开始以5微克/千克/小时的速度输注纳洛酮，并在术后持续22小时。收集了以下信息：患者年龄、身高、体重、麻醉技术/时间以及给予的鞘内阿片类药物剂量。使用视觉模拟疼痛评分（VAS）（0表示无疼痛；10表示最剧烈疼痛）对术后48小时的疼痛缓解情况、围手术期阿片类药物使用情况、非甾体抗炎药（NSAID）消耗量以及患者的行走能力进行评估。通过阿片类药物相关副作用和生命体征评估这种新治疗方法的安全性。所有数据均以平均值（标准差）报告。
给予的鞘内阿片类药物平均为吗啡1.3（0.3）毫克联合芬太尼56（9）微克。鞘内吗啡剂量范围为0.8至1.7毫克。术后前12小时平均最剧烈疼痛VAS仅为1.0（1.7）。首次给予NSAID的时间为鞘内注射阿片类药物后6.6（3.1）小时。病房首次给予阿片类药物的平均时间为鞘内注射阿片类药物后22.6（14.5）小时。术后第1天（POD 1）平均仅需要5.7（12.3）吗啡当量。在POD 2，平均最剧烈疼痛VAS仅为2.6（2.2），仅需要5.7（6.2）吗啡当量来缓解疼痛。在POD 1，25例患者在整个住院期间不需要额外的阿片类药物。总体而言，35例患者中有11例术后不需要任何额外的阿片类药物。34例患者（97%）在术后前12小时能够行走。未观察到阿片类药物引起的呼吸抑制。阿片类药物相关副作用（瘙痒、恶心）不常见且轻微。
大剂量鞘内阿片类药物联合术后静脉输注纳洛酮为根治性前列腺手术提供了出色的镇痛效果。静脉输注纳洛酮似乎能控制阿片类药物副作用而不减弱镇痛效果。未观察到严重不良反应。
