are opioids the worse pain killers? xavier capdevila m.d.,ph.d. head of department department of...
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Are Opioids the Worse Pain Killers?
Xavier Capdevila M.D.,Ph.D.Head of Department
Department of Anesthesiology and Critical Care MedicineLapeyronie 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
Cumulative 24 h consumption of i.v. morphine (in milligrams) for break-through 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
All surgeries
« Respiratory depression remains a major safety concern »
Postoperative sedationNausea and vomiting
0minutes
5
D+15
0 4hours
D+7D0
Naloxone
0
100
200
300
400
500
600
Pain inflammation
Carrageenan
Time (days)
Paw
pre
ssur
e (g
)
Inflammation + Fentanyl
orFentanyl
NaCl
Naive rats
*
*
Angst M.S, Koppert W., Pain 2003
//
2 4 8 160.5 240
20
40
60
80
100
//
*
*
1
Desflurane
Remifentanil
Post - extubation time (h)
Guignard et al. Anesthesiology 2000
Visual Analog Scale
(mm)
Remifentanil vs. desflurane Remifentanil vs. desflurane based anesthesiabased anesthesia
Guignard et al. Anesthesiology 2000
0
20
40
60
0.5 10 4 12 20
/
2
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//
Morphine (mg)
Post - extubation time (h)
Desflurane
Remifentanil P < 0.05 vs. desflurane
OpiatesStress Surgery
SurgeryOpiatesHypnotics
opioids
opioids
opioids
CAM: cellular adhesivity moleculCMH: histocompatibility major complexKIR: killer inhibitor-receptor
μ3
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.
24
British Journal of Cancer (2007) 97, 1523 – 1531
Morphine during two weeksAssociation M+C: better analgesia , better survival
25
Anesth Analg 2010;110:1630–5
319 Patients
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 whenfeasible, 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 ».