University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA.
Tabriz University of Medical Sciences, Tabriz, Iran.
Pain Physician. 2023 Jul;26(4):319-326.
Intrathecal opioids have long been used as analgesia for intractable cancer pain or as part of spinal anesthesia during obstetric operations. More recently, they have been used preoperatively as a pain management adjuvant for open cardiac and thoracic procedures.
This study aims to analyze the impact of administering intrathecal opioids before cardiac and thoracic surgeries on postoperative pain and mechanical ventilation.
Systematic review and meta-analysis.
University, School of Medicine, and several university-affiliated hospitals.
Five outcomes were studied, including the primary outcome of time to extubation, secondary outcomes of analgesia requirements at 24 and 48 hours, resting pain scores at 1 and 24 hours post-extubation, ICU length of stay in hours, and hospital length of stay in days. A search of multiple databases provided 28 studies reporting 4,000 total patients. Outcomes were measured using continuous mean difference with a 95% confidence interval, and the studies were examined for heterogeneity and sensitivity analysis.
The primary outcome analysis suggested that time to extubation was 42 minutes shorter in the intrathecal opioid group (ranging from 82 to 1 minute, P = 0.04). There was also a decrease in postoperative analgesia requirements at both 24 hours (mean difference (MD) = -8.95 mg morphine equivalent doses (MED) [-9.4, -8.5], P < 0.001) and 48 hours (MD = -17.7 mg MED [-23.1, -12.4], P < 0.001) with I2 of 94% and 85% respectively, an improvement of pain scores at both 1 hour (MD = -2.24 [-3.16, -1.32], P < 0.001) and 24-hours (MD = -1.64 [-2.48, -0.80], P =< 0.001) I2 of 94% and 85%, no change in both ICU length of stay (MD = -0.27 hours [-0.55, 0.01], P = 0.06) I2 = 77% and hospital length of stay (MD = -0.30 days [-0.66, 0.06], P = 0.11) I2 = 32%.
The major limitation of this meta-analysis was the inconsistent dosages of intrathecal opioids utilized. Some used the same dose for each patient, while other studies used weight-based doses. The differences in the outcomes observed may then be a result of the different amounts of opioids administered rather than the technique itself. Another limitation was the inconsistent timing of reports for pain scores and postoperative analgesic requirements. Further studies were analyzed at the 2 time periods for both secondary outcomes, making it difficult to attribute the 2 effects solely to the intervention.
We conclude that preoperative injection of intrathecal opioids is significantly associated with decreased time to extubation, decreased postoperative analgesia requirement, and improved pain scores. In controlled conditions with adequate staff education, this method of analgesia may make it possible to extubate the patients after the surgery in the operating room and fast-track their discharge from the hospital.
鞘内注射阿片类药物长期以来一直被用于治疗难治性癌痛或作为产科手术中脊髓麻醉的一部分。最近，它们也被用作开胸心脏手术的术前疼痛管理辅助药物。
本研究旨在分析术前给予鞘内阿片类药物对开胸心脏手术后疼痛和机械通气的影响。
系统评价和荟萃分析。
大学、医学院和几家大学附属医院。
研究了 5 个结果，包括主要结果为拔管时间，次要结果为术后 24 小时和 48 小时的镇痛需求、拔管后 1 小时和 24 小时的静息疼痛评分、ICU 住院时间（以小时计）和住院时间（以天计）。通过对多个数据库的搜索，提供了 28 项研究，共报告了 4000 名患者。使用 95%置信区间的连续均值差异进行结果测量，并对研究进行了异质性和敏感性分析。
主要结果分析表明，鞘内阿片类药物组拔管时间缩短了 42 分钟（范围为 82 至 1 分钟，P = 0.04）。术后 24 小时（平均差值（MD）=-8.95mg 吗啡等效剂量（MED）[-9.4，-8.5]，P < 0.001）和 48 小时（MD=-17.7mg MED[-23.1，-12.4]，P < 0.001）的镇痛需求也有所减少，分别为 I2 为 94%和 85%，1 小时（MD=-2.24[-3.16，-1.32]，P < 0.001）和 24 小时（MD=-1.64[-2.48，-0.80]，P =< 0.001）疼痛评分也有所改善，I2 分别为 94%和 85%，ICU 住院时间（MD=-0.27 小时[-0.55，0.01]，P = 0.06）和 I2 = 77%以及住院时间（MD=-0.30 天[-0.66，0.06]，P = 0.11）和 I2 = 32%无变化。
本荟萃分析的主要局限性是鞘内阿片类药物的剂量不一致。一些研究为每个患者使用相同的剂量，而其他研究则使用基于体重的剂量。观察到的结果差异可能是由于给予的阿片类药物量不同，而不是技术本身。另一个限制是疼痛评分和术后镇痛需求报告的时间不一致。对这两个次要结果进行了进一步的分析，这使得很难将这两种效果完全归因于干预措施。
我们的结论是，术前鞘内注射阿片类药物与拔管时间缩短、术后镇痛需求减少和疼痛评分改善显著相关。在有足够工作人员教育的控制条件下，这种镇痛方法可能使患者在手术后可以在手术室拔管，并快速出院。
