Transcript Are Opioids the Worse Pain Killers

Are Opioids the Worse Pain Killers?
Xavier Capdevila M.D.,Ph.D.
Head of Department
Department of Anesthesiology and Critical Care Medicine
Lapeyronie University Hospital and Montpellier School of Medicine
Montpellier , France
Conflicts of interest:
•
Pajunk
•
B Braun
•
GE Healthcare
•
Baxter
•
Janssen
•
Abbott
Nineteen articles; 603 patients
Ilfeld et al Anesthesiology 2008
Patients given 4 days of perineural ropivacaine attained
the 3 discharge criteria in a median (25th-75th
centiles) of 25 ( 21-47)h compared with 71 (46-89)h in
the selected center. Decrease in time until discharge
readiness of 46h
Ilfeld et al Pain 2010
Patients given 4 days of perineural ropivacaine attained the
3 discharge criteria in a median (25th-75th centiles) of 47 (
29-69)h compared with 62 (45-79)h in that multicentric
trial. Decrease in time until discharge readiness of 15h
A Comprehensive Anesthesia Protocol that Emphasizes Peripheral Nerve
Blockade for Total Knee and Total Hip Arthroplasty
JAMES R. HEBL, SANDRA L. KOPP, MIR H. ALI, TERESE T. HORLOCKER, JOHN A. DILGER, MD,
ROBERT L. LENNON, BRENT A. WILLIAMS, ARLEN D. HANSSEN AND MARK W. PAGNANO
THE JOURNAL OF BONE & JOINT SURGERY ·VOLUME 87-A · SUPPLEMENT 2 · 2005
All surgeries
Cumulative 24 h consumption of i.v. morphine (in milligrams) for breakthrough pain after operation
Pain intensity (0–10-point scale, ranging from 0, no pain, to 10, maximum pain) at
rest at 2, 4, 12, and 24 h after operation
« Respiratory depression remains a major safety concern »
Nausea and vomiting
Postoperative sedation
NaCl
or
Carrageenan
Fentanyl
Naloxone
Paw pressure (g)
600
500
400
300
200
*
100
*
0
04
hours
D0
05
minutes
D+7
D+15
Time (days)
Naive rats
Pain inflammation
Inflammation + Fentanyl
Angst M.S, Koppert W., Pain 2003
100
Desflurane
80
Visual Analog
Scale (mm)
*
Remifentanil
60
*
//
40
20
0
//
0.5 1 2
4 8
16
24
Post - extubation time (h)
Guignard et al. Anesthesiology 2000
Remifentanil vs. desflurane
based anesthesia
60
Remifentanil
Morphine (mg)
P < 0.05 vs. desflurane
40
Desflurane
20
/
/
0
0
0.5
/
1 2 4
12
20
Post - extubation time (h)
Guignard et al. Anesthesiology 2000
Surgery
Opiates
Hypnotics
Opiates
Stress
Surgery
OPIOIDS
OPIOIDS
OPIOIDS
μ3
CAM: cellular adhesivity molecul
CMH: histocompatibility major complex
KIR: killer inhibitor-receptor
Effects of fentanyl on natural killer cell activity and on resistance to tumor
metastasis in rats. Dose and timing study. Shavit Y, Ben-Eliyahu S, Zeidel A, Beilin B.
Neuroimmunomodulation. 2004;11(4):255-60
Fentanyl suppresses NKCC and increases the risk of tumor metastasis.
Suppression of NK cells at a time when surgery may induce tumor dissemination can be critical for
metastases.
Acute administration of a moderate dose of opiates during surgery should be applied cautiously in
cancer patients
Forty patients were included : half were assigned to each
protocol of anesthesia.
In each anesthetic group, half the patients were undergoing
surgery for malignant diseases.
Blood samples were collected during the perioperative
period.
Morphine in clinically relevant doses promotes
tumor neovascularization in a human breast
tumor xenograft model in mice leading to
increased tumor progression.
British Journal of Cancer (2007) 97, 1523 – 1531
Morphine during two weeks
Association M+C: better analgesia , better survival
24
Anesth Analg 2010;110:1630–5
319 Patients
25
Fifty patients had surgery with paravertebral
anesthesia and analgesia combined with general
anesthesia, and 79 patients had general
anesthesia combined with postoperative
morphine analgesia.
Nowadays , opioids are useful in the
perioperative period as first line
analgesics in very painfull surgeries,
however regional techniques should be
often preferred in order to limit adverse
events and immunomodullary
dysfunctions.
Anesthesia and Analgesia
June 2010 • Volume 110 • Number 6
« Even though the evidence is inconclusive and at times conflicting, we
ignore the possibility that anesthesia may contribute to the recurrence
of cancer, months or even years after cancer surgery.
So what should we do? An obvious choice is to use regional anesthesia when
feasible, alone or in combination with general anesthesia, to minimize the
amount of opioid administered, and to consider using NSAIDs, especially
specific COX-2 inhibitors. Of course, what we really need are good prospective,
randomized,and controlled clinical trials ».