Funk Robert D, Hilliard Paul, Ramachandran Satya Krishna
Ann Arbor, Mich. From the Department of Anesthesiology, University of Michigan.
Plast Reconstr Surg. 2014 Oct;134(4 Suppl 2):32S-39S. doi: 10.1097/PRS.0000000000000680.
Opioids remain the most common analgesic tool for the surgeon, owing to their cost-effectiveness in both the inpatient and outpatient setting. Aside from these attributes, opioids have significant side effects that are associated with morbidity and mortality. Specifically, obese patients, patients with sleep apnea, and the elderly may be at an increased risk of experiencing sedation and respiratory depression in response to opioids. Opioid reduction strategies prove useful for decreasing total opioid dose and, in turn, their associated adverse effects. Such strategies may include adjuvant nonopioid analgesics such as α-2 agonists, gabapentinoids, and N-methyl-D-aspartate receptor agonists as well as local, regional, or neuraxial anesthesia and modification of surgical technique where possible for operative patients. Patients may also present to surgeons while taking chronic opioids, including high-dose opioids and opioid agonist/antagonists. These clinical scenarios are associated with extreme challenges in postoperative analgesic management. With all opioid prescribing, other sedative medications should be limited or avoided as the risk for additive sedation is significant. This review aims to describe systematic methods to reduce opioid side effects and identify specific risk-reduction strategies within each risk group.
由于阿片类药物在住院和门诊环境中都具有成本效益，因此仍然是外科医生最常用的镇痛工具。除了这些特性外，阿片类药物还具有与发病率和死亡率相关的显著副作用。具体而言，肥胖患者、睡眠呼吸暂停患者和老年人在使用阿片类药物时可能会增加出现镇静和呼吸抑制的风险。减少阿片类药物的策略被证明有助于降低阿片类药物的总剂量，进而减少其相关的不良反应。此类策略可能包括辅助性非阿片类镇痛药，如α-2激动剂、加巴喷丁类药物和N-甲基-D-天冬氨酸受体激动剂，以及局部、区域或神经轴麻醉，并在可能的情况下对外科手术患者的手术技术进行改进。患者在就诊时也可能正在服用慢性阿片类药物，包括高剂量阿片类药物和阿片类激动剂/拮抗剂。这些临床情况在术后镇痛管理中面临极大挑战。在所有阿片类药物处方中，由于相加镇静的风险很大，其他镇静药物应限制使用或避免使用。本综述旨在描述减少阿片类药物副作用的系统方法，并确定每个风险组内具体的风险降低策略。
