Department of Anesthesiology and Intensive Care, University Hospital Münster, Münster, Germany Institute of Social and Preventive Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland Department of Anesthesiology and Intensive Care, Tenon University Hospital, UMPC University Paris, France Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Pain. 2012 Apr;153(4):784-793. doi: 10.1016/j.pain.2011.11.028. Epub 2012 Jan 9.
Opioids are widely used as additives to local anesthetics for intrathecal anesthesia. Benefit and risk remain unclear. We systematically searched databases and bibliographies to February 2011 for full reports of randomized comparisons of any opioid added to any intrathecal local anesthetic with the local anesthetic alone in adults undergoing surgery (except cesarean section) and receiving single-shot intrathecal anesthesia without general anesthesia. We included 65 trials (3338 patients, 1932 of whom received opioids) published between 1983 and 2010. Morphine (0.05-2mg) and fentanyl (10-50 μg) added to bupivacaine were the most frequently tested. Duration of postoperative analgesia was prolonged with morphine (weighted mean difference 503 min; 95% confidence interval [CI] 315 to 641) and fentanyl (weighted mean difference 114 min; 95% CI 60 to 168). Morphine decreased the number of patients needing opioid analgesia after surgery and decreased pain intensity to the 12th postoperative hour. Morphine increased the risk of nausea (number needed to harm [NNH] 9.9), vomiting (NNH 10), urinary retention (NNH 6.5), and pruritus (NNH 4.4). Fentanyl increased the risk of pruritus (NNH 3.3). With morphine 0.05 to 0.5mg, the NNH for respiratory depression varied between 38 and 59 depending on the definition of respiratory depression chosen. With fentanyl 10 to 40 μg, the risk of respiratory depression was not significantly increased. For none of these effects, beneficial or harmful, was there evidence of dose-responsiveness. Consequently, minimal effective doses of intrathecal morphine and fentanyl should be sought. For intrathecal buprenorphine, diamorphine, hydromorphone, meperidine, methadone, pentazocine, sufentanil, and tramadol, there were not enough data to allow for meaningful conclusions.
阿片类药物被广泛用作鞘内麻醉的局部麻醉剂的添加剂。其益处和风险仍不清楚。我们系统地检索了数据库和文献，以获取 2011 年 2 月前关于任何阿片类药物与单独局部麻醉剂鞘内麻醉的成年人手术（不包括剖宫产）的随机比较的完整报告，这些患者接受单次鞘内麻醉而未接受全身麻醉。我们纳入了 1983 年至 2010 年期间发表的 65 项试验（3338 例患者，其中 1932 例接受阿片类药物）。测试最频繁的是吗啡（0.05-2mg）和芬太尼（10-50μg）与布比卡因联合使用。术后镇痛时间延长，吗啡（加权平均差异 503 分钟；95%置信区间[CI]315-641）和芬太尼（加权平均差异 114 分钟；95%CI60-168）。吗啡减少了术后需要阿片类药物镇痛的患者数量，并降低了术后 12 小时的疼痛强度。吗啡增加了恶心（危害比[NNH]9.9）、呕吐（NNH 10）、尿潴留（NNH 6.5）和瘙痒（NNH 4.4）的风险。芬太尼增加了瘙痒的风险（NNH 3.3）。吗啡 0.05-0.5mg 时，呼吸抑制的 NNH 因所选呼吸抑制定义而异，在 38-59 之间。芬太尼 10-40μg 时，呼吸抑制的风险没有显著增加。对于这些有益或有害的作用，都没有证据表明存在剂量反应性。因此，应寻求鞘内吗啡和芬太尼的最小有效剂量。对于鞘内丁丙诺啡、二氢吗啡酮、氢吗啡酮、哌替啶、美沙酮、戊唑辛、舒芬太尼和曲马多，没有足够的数据得出有意义的结论。
