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• W2025672318 abstract "Pain is a common problem in the early postoperative period. Techniques that provide perioperative analgesia to alleviate pain may have a significant effect on postoperative events, such as earlier ambulation and earlier dismissal from the hospital with use of epidural analgesia than with systemic analgesia. Spinal opioids, which can be administered epidurally or intrathecally, provide analgesia that is superior to that achieved with systemically administered narcotics. For procedures on the upper extremities, selective analgesia can be achieved with use of various types of neural blockade—for example, brachial plexus blockade, interscalene blockade, and axillary plexus blockade. Intercostal nerve block, a valuable but underutilized procedure appropriate for unilateral upper abdominal or flank operations or for thoracotomy, has been shown to reduce postoperative narcotic requirements and pulmonary complications. A patient-controlled analgesia device, consisting of an electronically controlled infusion pump with a timing device that can be triggered by the patient for intravenous administration of a narcotic when pain is experienced, avoids the vast fluctuations in analgesia that accompany parenteral administration of drugs. In most patients, postoperative pain can be prevented or diminished, and clinicians should be aware of the available techniques for achieving this goal. Pain is a common problem in the early postoperative period. Techniques that provide perioperative analgesia to alleviate pain may have a significant effect on postoperative events, such as earlier ambulation and earlier dismissal from the hospital with use of epidural analgesia than with systemic analgesia. Spinal opioids, which can be administered epidurally or intrathecally, provide analgesia that is superior to that achieved with systemically administered narcotics. For procedures on the upper extremities, selective analgesia can be achieved with use of various types of neural blockade—for example, brachial plexus blockade, interscalene blockade, and axillary plexus blockade. Intercostal nerve block, a valuable but underutilized procedure appropriate for unilateral upper abdominal or flank operations or for thoracotomy, has been shown to reduce postoperative narcotic requirements and pulmonary complications. A patient-controlled analgesia device, consisting of an electronically controlled infusion pump with a timing device that can be triggered by the patient for intravenous administration of a narcotic when pain is experienced, avoids the vast fluctuations in analgesia that accompany parenteral administration of drugs. In most patients, postoperative pain can be prevented or diminished, and clinicians should be aware of the available techniques for achieving this goal. Despite many recent advances in our knowledge of pharmacology, pain in the early postoperative period remains a common problem.1Marks RM Sachar EJ Undertreatment of medical inpatients with narcotic analgesics.Ann Intern Med. 1973; 78: 173-181Crossref PubMed Scopus (824) Google Scholar Frequently, conventional doses of parenterally administered narcotics are ineffective. A 1973 study reported that three-fourths of hospitalized patients who receive parenterally administered opioid analgesics for moderate or severe pain fail to obtain complete relief with use of these drugs.1Marks RM Sachar EJ Undertreatment of medical inpatients with narcotic analgesics.Ann Intern Med. 1973; 78: 173-181Crossref PubMed Scopus (824) Google Scholar The physiologic consequences of postoperative pain are well substantiated.2Scott DB Acute pain management.in: Cousins MJ Bridenbaugh PO Neural Blockade in Clinical Anesthesia and Management of Pain. Second edition. JB Lippincott Company, Philadelphia1988: 861-883Google Scholar, 3Benedetti C Bonica JJ Bellucci G Pathophysiology and therapy of postoperative pain: a review.Adv Pain Res Ther. 1984; 7: 373-407Google Scholar The stimulation of the sympathetic nervous system that accompanies severe pain leads to tachycardia, hypertension, and increased peripheral vascular resistance, which increases myocardial oxygen consumption and can promote ischemia or infarction. Increased sympathetic outflow also decreases intestinal motility and may promote or prolong postoperative ileus.4Bonica JJ Pathophysiology of pain.Hosp Pract. 1978; 13: 4-14Google Scholar Surgical procedures, particularly thoracic and abdominal operations, have pronounced effects on respiration because of alterations in the action of respiratory muscles. Although quiet respiration may be relatively unaffected, the ability to breathe deeply or cough is considerably diminished. Both vital capacity and functional residual capacity are substantially decreased. Vital capacity decreases by 60% after upper abdominal operations, whereas functional residual capacity decreases by 20%.5Muneyuki M Ueda Y Urabe N Takeshita H Inamoto A Postoperative pain relief and respiratory function in man: comparison between intermittent intravenous injections of meperidine and continuous lumbar epidural analgesia.Anesthesiology. 1968; 29: 304-313Crossref PubMed Scopus (46) Google Scholar Impaired ability to cough and perform deep-breathing maneuvers may lead to retention of secretions and atelectasis and may promote hypoxemia and respiratory infections. Surgical trauma can range from a relatively small insult during a minor elective procedure to a massive insult after major procedures, and it may be complicated by sepsis. The stress response to surgical trauma is in the form of generalized endocrine metabolic activation, with procedures involving the thorax and abdominal cavity eliciting a more pronounced response than other procedures.6Traynor C Paterson JL Ward ID Morgan M Hall GM Effects of extradural analgesia and vagal blockade on the metabolic and endocrine response to upper abdominal surgery.Br J Anaesth. 1982; 54: 319-323Crossref PubMed Scopus (50) Google Scholar, 7Kehlet H Modification of responses to surgery by neural blockade: clinical implications.in: Cousins MJ Bridenbaugh PO Neural Blockade in Clinical Anesthesia and Management of Pain. Second edition. JB Lippincott Company, Philadelphia1988: 145-188Google Scholar Water retention can occur postoperatively as a result of increased vascular permeability and increases in antidiuretic hormone and aldosterone, whereas hyperglycemia may be due in part to pain-related increases in catecholamines and Cortisol. Nitrogen balance may be adversely affected by the stress of surgical intervention and postoperative pain. Immunologic changes are seen with a decrease in lymphocytes and an increase in granulocytes.8Rem J Brandt MR Kehlet H Prevention of postoperative lymphopenia and granulocytosis by epidural analgesia.Lancet. 1980; 1: 283-285Abstract PubMed Scopus (89) Google Scholar Although the exact importance of reducing postoperative pain and surgical stress has not been determined, accumulating evidence is beginning to indicate that techniques chosen to provide perioperative anesthesia and analgesia have a major effect on postoperative events (Table l).9Yeager MP Glass DD Neff RK Brinck-Johnsen T Epidural anesthesia and analgesia in high-risk surgical patients.Anesthesiology. 1987; 66: 729-736Crossref PubMed Scopus (813) Google Scholar, 10Simpson BR Parkhouse J Marshall R Lambrechts W Extradural analgesia and the prevention of postoperative respiratory complications.Br J Anaesth. 1961; 33: 628-641Crossref PubMed Scopus (63) Google Scholar Therefore, we should focus on prevention rather than treatment of pain, and techniques that are continuous rather than intermittent may be preferable. The techniques described herein are adaptable to a variety of situations in addition to those mentioned, and they may be initiated before or at the conclusion of a surgical procedure. In this review, we will discuss the currently available modalities of pain control in use at the Mayo Clinic.Table 1Adverse Physiologic Responses to Pain Affected by Analgesic TechniquesPulmonary Improved results of pulmonary function tests5Muneyuki M Ueda Y Urabe N Takeshita H Inamoto A Postoperative pain relief and respiratory function in man: comparison between intermittent intravenous injections of meperidine and continuous lumbar epidural analgesia.Anesthesiology. 1968; 29: 304-313Crossref PubMed Scopus (46) Google Scholar and decreased incidence of pulmonary complications in patients receiving epidural analgesia versus intramuscular or intravenous analgesia9Yeager MP Glass DD Neff RK Brinck-Johnsen T Epidural anesthesia and analgesia in high-risk surgical patients.Anesthesiology. 1987; 66: 729-736Crossref PubMed Scopus (813) Google Scholar, 10Simpson BR Parkhouse J Marshall R Lambrechts W Extradural analgesia and the prevention of postoperative respiratory complications.Br J Anaesth. 1961; 33: 628-641Crossref PubMed Scopus (63) Google Scholar, 11Rawal N Sjöstrand U Christoffersson E Dahlström B Arvill A Rydman H Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function.Anesth Analg. 1984; 63: 583-592Crossref PubMed Google ScholarPeripheral vasculature Reduction in venous thromboembolism after retropubic prostatectomy by using epidural local anesthetics12Hendolin H Mattila MAK Poikolainen E The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy.Acta Chir Scand. 1981; 147: 425-429PubMed Google Scholar Decrease in incidence of pulmonary embolism after total hip arthroplasty13Modig J Maripuu E Sahlstedt B Thromboembolism following total hip replacement.Reg Anesth. April-June 1986; 11: 72-79Google Scholar, 14Modig J Borg T Karlström G Maripuu E Sahlstedt B Thromboembolism after total hip replacement: role of epidural and general anesthesia.Anesth Analg. 1983; 62: 174-180Crossref PubMed Google Scholar, 15Thorburn J Louden JR Vallance R Spinal and general anaesthesia in total hip replacement: frequency of deep vein thrombosis.Br J Anaesth. 1980; 52: 1117-1120Crossref PubMed Scopus (123) Google Scholar Increase in graft blood flow after vascular procedures in lower extremity16Cousins MJ Wright CJ Graft, muscle, skin blood flow after epidural block in vascular surgical procedures.Surg Gynecol Obstet. 1971; 133: 59-64PubMed Google ScholarGastrointestinal Faster resolution of postoperative ileus with use of epidural analgesia17Aitkenhead AR Wishart HY Peebles Brown DA High spinal nerve block for large bowel anastomosis: a retrospective study.Br J Anaesth. 1978; 50: 177-182Crossref PubMed Scopus (37) Google Scholar, 18Scheinin B Asantila R Orko R The effect of bupivacaine and morphine on pain and bowel function after colonic surgery.Acta Anaesthesiol Scand. 1987; 31: 161-164Crossref PubMed Scopus (118) Google Scholar, 19Wallin G Cassuto J Högstrom S Faxén A Rimbäck G Tollesson P-O The effect of prolonged epidural blockade on postoperative paralytic ileus after upper abdominal surgery (abstract).Acta Anaesthesiol Scand Suppl. 1985; 80: 82Google ScholarCentral nervous system Less postoperative sedation with use of epidural analgesia<sp>20-22 Significantly better analgesia and substantial reduction in the need for systemic narcotics with use of epidural narcotics, local anesthetics, and intercostal nerve block20Cousins MJ Mather LE Intrathecal and epidural administration of opioids.Anesthesiology. 1984; 61: 276-310Crossref PubMed Scopus (943) Google Scholar, 23Bridenbaugh PO DuPen SL Moore DC Bridenbaugh LD Thompson GE Postoperative intercostal nerve block analgesia versus narcotic analgesia.Anesth Analg. 1973; 52: 81-85PubMed Google Scholar, 24Moore DC Bridenbaugh LD Intercostal nerve block in 4333 patients: indications, technique, and complications.Anesth Analg. 1962; 41: 1-11Crossref PubMed Google Scholar, 25Galway JE Caves PK Dundee JW Effect of intercostal nerve blockade during operation on lung function and the relief of pain following thoracotomy.Br J Anaesth. 1975; 47: 730-735Crossref PubMed Scopus (38) Google ScholarConvalescence Earlier ambulation and earlier dismissal from the hospital with epidural analgesia26Broadman LM Hannallah RS Norden JM McGill WA “Kiddie caudals”: experience with 1154 consecutive cases without complications (abstract).Anesth Analg. 1987; 66: S18Crossref PubMed Google Scholar than with systemic narcotics Open table in a new tab Local anesthetics or narcotics may be injected directly into the epidural space to provide relief of postoperative pain. Epidural analgesia was introduced in the 1940s but was not frequently used until the 1960s, when anesthesiologists began administering bupivacaine, an amide local anesthetic, epidurally to relieve the pain associated with labor.27Hehre FW Sayig JM Continuous lumbar peridural anesthesia in obstetrics.Am J Obstet Gynecol. 1960; 80: 1173-1180PubMed Scopus (8) Google Scholar Since then, epidural blockade with local anesthetic agents has become the most widely used technique of neural blockade for relief of pain in obstetrics in the United States, Canada, Australia, and other countries.28Bromage PR An evaluation of bupivacaine in epidural analgesia for obstetrics.Can Anaesth Soc J. 1969; 16: 46-56Crossref PubMed Scopus (45) Google Scholar, 29Paton AS Lumbar epidural analgesia in obstetrics.Med J Aust. 1966; 2: 449-451PubMed Google Scholar The technique was also used for relief of pain after various surgical procedures, but on a limited scale because of the potential for motor blockade and hypotension. In 1979, Wang and associates30Wang JK Nauss LA Thomas JE Pain relief by intrathecally applied morphine in man.Anesthesiology. 1979; 50: 149-151Crossref PubMed Scopus (666) Google Scholar first described the intrathecal administration of morphine in humans for the alleviation of cancer-related pain. Since then, the intrathecal and, to a much greater extent, epidural administration of narcotics has rapidly expanded to include management of postoperative pain. Epidural narcotic analgesia is widely used because it provides intensive analgesia without motor or autonomic blockade. The epidural space extends from the foramen magnum to the sacrococcygeal ligament and contains adipose tissue, a rich network of blood vessels and lymphatic structures, and spinal nerve roots as they pass from the spinal cord to the foramina. The dura lies immediately beyond the epidural space and gives rise to a short dural “cuff” to each pair of spinal nerves. At this point, the dura becomes notably thinner and is closely adherent to the surface of the dorsal root. Within these dural cuffs, cerebrospinal fluid is separated from the epidural space by only the dura. This region provides a route for diffusion of narcotics and local anesthetic agents into the cerebrospinal fluid, where the drugs have immediate access to their sites of action in the spinal cord and nerve roots. Narcotics and local anesthetic agents can also be injected directly into the subarachnoid space to provide analgesia; however, reduced dosages must be used because the intensity of physiologic and pharmacologic effects is dramatically increased by this route. Epidural analgesia is accomplished by percutaneously inserting a hollow steel needle into the epidural space. A nylon catheter is threaded through the needle, which is subsequently removed. The catheter is secured and left in place for the desired duration of use. By gentle traction, it can easily be removed at the point where it exits the skin. In most instances, the catheter is placed in the lumbar epidural space, inasmuch as identification of the epidural space and catheter placement are technically easier at this site. Anatomic considerations make catheterization appreciably more difficult in the thoracic region and may be unnecessary in most clinical situations.31Fromme GA Steidl LJ Danielson DR Comparison of lumbar and thoracic epidural morphine for relief of post-thoracotomy pain.Anesth Analg. 1985; 64: 454-455Crossref PubMed Scopus (37) Google Scholar, 32Larsen VH Iversen AD Christensen P Andersen PK Postoperative pain treatment after upper abdominal surgery with epidural morphine at thoracic or lumbar level.Acta Anaesthesiol Scand. 1985; 29: 566-571Crossref PubMed Scopus (26) Google Scholar Intermittent injection is used in many medical centers, but continuous infusion is becoming the preferred method because it provides a constant level of analgesia, minimizes side effects, and helps prevent tachyphylaxis. Epidural analgesia with use of local anesthetic agents is helpful in patients who have acute trauma or postoperative pain (or both). A nylon catheter is inserted into the epidural space, as described in the foregoing section, and a local anesthetic agent is administered. The drug diffuses through the dura and into the cerebrospinal fluid, where it is taken up by spinal nerve roots and, to some extent, the spinal cord. Local anesthetic blockade of the spinal nerve roots prevents nociceptive transmission from the periphery to the spinal cord. Continuous infusion with use of a computerized infusion pump provides analgesia, helps abolish the stress response, and avoids narcotic side effects such as sedation, nausea, and respiratory depression. Sympathetic blockade improves blood flow to the lower extremities and thereby decreases venous stasis and the frequency of venous thrombosis.13Modig J Maripuu E Sahlstedt B Thromboembolism following total hip replacement.Reg Anesth. April-June 1986; 11: 72-79Google Scholar, 14Modig J Borg T Karlström G Maripuu E Sahlstedt B Thromboembolism after total hip replacement: role of epidural and general anesthesia.Anesth Analg. 1983; 62: 174-180Crossref PubMed Google Scholar, 15Thorburn J Louden JR Vallance R Spinal and general anaesthesia in total hip replacement: frequency of deep vein thrombosis.Br J Anaesth. 1980; 52: 1117-1120Crossref PubMed Scopus (123) Google Scholar, 16Cousins MJ Wright CJ Graft, muscle, skin blood flow after epidural block in vascular surgical procedures.Surg Gynecol Obstet. 1971; 133: 59-64PubMed Google Scholar When used in conjunction with intraabdominal procedures, sympathetic blockade may also improve gastrointestinal motility and decrease the incidence of anastomotic breakdown and ileus.17Aitkenhead AR Wishart HY Peebles Brown DA High spinal nerve block for large bowel anastomosis: a retrospective study.Br J Anaesth. 1978; 50: 177-182Crossref PubMed Scopus (37) Google Scholar, 18Scheinin B Asantila R Orko R The effect of bupivacaine and morphine on pain and bowel function after colonic surgery.Acta Anaesthesiol Scand. 1987; 31: 161-164Crossref PubMed Scopus (118) Google Scholar, 19Wallin G Cassuto J Högstrom S Faxén A Rimbäck G Tollesson P-O The effect of prolonged epidural blockade on postoperative paralytic ileus after upper abdominal surgery (abstract).Acta Anaesthesiol Scand Suppl. 1985; 80: 82Google Scholar Bupivacaine, a long-acting amide local anesthetic, is the preferred and most commonly used agent. When bupivacaine is infused in concentrations of 0.125 to 0.25% at 8 to 12 ml/h, motor blockade is seldom prominent, and toxicity and tachyphylaxis are rare.33Raj PP Knarr DC Vigdorth E Denson DD Pither CE Hartrick CT Hopson CN Edström HH Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery.Anesth Analg. 1987; 66: 401-406Crossref PubMed Scopus (71) Google Scholar Infusion rates of up to 30 mg/h for 5 days seem to produce no toxicity, even when clearance is reduced by 60%.34Denson DD Raj PP Saldahna F Finnsson RA Ritschel WA Joyce III, TH Turner JL Continuous perineural infusion of bupivacaine for prolonged analgesia: pharmacokinetic considerations.Int J Clin Pharmacol Ther Toxicol. 1983; 21: 591-597PubMed Google Scholar Surgical procedures that best lend themselves to this technique include lower extremity and lower abdominal operations. Extensive experience has been gained with use of a constant epidural infusion of a local anesthetic agent after lower extremity revascularization and total knee arthroplasty in patients requiring continuous passive motion.33Raj PP Knarr DC Vigdorth E Denson DD Pither CE Hartrick CT Hopson CN Edström HH Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery.Anesth Analg. 1987; 66: 401-406Crossref PubMed Scopus (71) Google Scholar Although it is possible to provide adequate analgesia for patients who undergo upper abdominal and thoracic surgical procedures, the degree of blockade needed may be associated with excessive sympathetic blockade and hypotension. Therefore, these patients may be better served by epidurally administered narcotics. Relative contraindications to the technique include local infection, sepsis, hypovolemia, and coagulopathy. Untoward effects are infrequent but can include excessive sympathetic blockade that results in hypotension, excessive motor blockade, and intravascular or intrathecal migration of the catheter, which may result in central nervous system or cardiovascular depression. Because of the possibility of this latter complication, supervision by a well-trained nursing staff is important. Urinary retention occurs because the autonomic innervation of the bladder (S-2 through S-4) is sensitive to local anesthetic agents and is commonly affected; thus, intermittent or indwelling catheterization may be necessary. Allergic reactions to amide local anesthetic agents can occur but are infrequent.35Fisher MM Graham R Adverse responses to local anaesthetics.Anaesth Intens Care. 1984; 12: 325-327PubMed Google Scholar Spinal opioids, which may be administered epidurally or intrathecally, provide analgesia that is superior to that from systemically administered narcotics and are associated with a low incidence of side effects when properly monitored.36Reiz S Westberg M Side effects of epidural morphine (letter to the editor).Lancet. 1980; 2: 203-204Abstract PubMed Scopus (158) Google Scholar After injection into the epidural space, narcotics diffuse through the dura and into the cerebrospinal fluid, where they are taken up by the spinal cord. Studies in animals and humans have indicated that presynaptic and postsynaptic narcotic receptors in the substantia gelatinosa of the dorsal horn of the spinal cord are the major site of action of spinally administered opioids.37Yaksh TL Noueihed R The physiology and pharmacology of spinal opiates.Ann Rev Pharmacol Toxicol. 1985; 25: 433-462Crossref PubMed Google Scholar The major advantage of spinal opioid analgesia (as opposed to spinal local anesthesia) is the absence of motor or sympathetic blockade in the presence of intense analgesia. The most common practice is to insert a lumbar epidural catheter, unless anatomic considerations direct insertion elsewhere. Two studies have demonstrated minimal or no difference in analgesic effects or dose with use of thoracic or lumbar epidural administration of morphine for pain after upper abdominal or thoracic surgical procedures.31Fromme GA Steidl LJ Danielson DR Comparison of lumbar and thoracic epidural morphine for relief of post-thoracotomy pain.Anesth Analg. 1985; 64: 454-455Crossref PubMed Scopus (37) Google Scholar, 32Larsen VH Iversen AD Christensen P Andersen PK Postoperative pain treatment after upper abdominal surgery with epidural morphine at thoracic or lumbar level.Acta Anaesthesiol Scand. 1985; 29: 566-571Crossref PubMed Scopus (26) Google Scholar Most often, the catheter is inserted when the patient is in the recovery room immediately postoperatively. An initial loading dose of 0.05 to 0.1 mg/kg of morphine or 1 to 1.5 μg/kg of fentanyl is administered (the amount based on size, age, and physical status of the patient), and an infusion is begun. The continuous infusion of morphine, 0.005 to 0.01 mg/kg per hour, or fentanyl, 0.7 to 2 μg/kg per hour, through this catheter seems to be the most practical method, although some medical centers use intermittent injections. The catheter may be left in place until the patient's pain is alleviated and no longer necessitates this treatment. The duration varies from 12 hours to 7 days and averages slightly more than 48 hours. Because spinal opioids and local anesthetic agents differ in sites of action, combining these agents for epidural infusion would seem logical. In theory, the principal advantage of this combination is a reduction in the dosage requirement for each agent and, therefore, a decrease in the potential toxicity while still providing effective analgesia. The combination of 0.1 mg/ml of morphine or 1 μg/ml of fentanyl with 0.1% bupivacaine has been shown to be safe and effective at lower infusion rates than either agent alone in well-controlled studies.38Gregg R Spinal analgesia.Anesthesiol Clin North Am. March 1989; 7: 79-100Google Scholar Currently, investigations are under way to determine the role of combination drug therapy in management of acute pain. Patients who may benefit most from spinal opioids are those undergoing operations with the greatest effect on pulmonary function, such as thoracotomy and upper abdominal procedures.9Yeager MP Glass DD Neff RK Brinck-Johnsen T Epidural anesthesia and analgesia in high-risk surgical patients.Anesthesiology. 1987; 66: 729-736Crossref PubMed Scopus (813) Google Scholar, 39Lilley J-P Fromme GA Wang JK Management of acute pain.Adv Anesthesiol. 1987; 4: 347-363Google Scholar Those patients with the most severe preexisting respiratory disease seem to derive the greatest benefit from improved analgesia.9Yeager MP Glass DD Neff RK Brinck-Johnsen T Epidural anesthesia and analgesia in high-risk surgical patients.Anesthesiology. 1987; 66: 729-736Crossref PubMed Scopus (813) Google Scholar, 11Rawal N Sjöstrand U Christoffersson E Dahlström B Arvill A Rydman H Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function.Anesth Analg. 1984; 63: 583-592Crossref PubMed Google Scholar Benefits over conventional parenterally administered narcotics include improved analgesia, improved pulmonary function, and earlier ambulation postoperatively. Epidural administration of opioids is commonly used in patients undergoing thoracotomy and in selected patients undergoing abdominal procedures such as repair of an aortic aneurysm or radical retropubic prostatectomy. Many other patients may be suitable candidates as well.40Eisenach JC Grice SC Dewan DM Patient-controlled analgesia following cesarean section: a comparison with epidural and intramuscular narcotics.Anesthesiology. 1988; 68: 444-448Crossref PubMed Scopus (202) Google Scholar Spinal opioids have been used in more than 1,000 patients at several medical centers predominantly for thoracic and abdominal surgical procedures; the results have been excellent and well accepted by patients and physicians.39Lilley J-P Fromme GA Wang JK Management of acute pain.Adv Anesthesiol. 1987; 4: 347-363Google Scholar, 41Bromage PR A postoperative pain management service (letter to the editor).Anesthesiology. 1988; 69: 435Crossref PubMed Scopus (14) Google Scholar, 42Ready LB Chadwick HS A postoperative pain management service (reply to letter to the editor).Anesthesiology. 1988; 69: 436Crossref PubMed Google Scholar, 43Holland AJC Srikantha SK Tracey JA Epidural morphine and postoperative pain relief.Can Anaesth Soc J. 1981; 28: 453-457Crossref PubMed Scopus (8) Google Scholar In one series,39Lilley J-P Fromme GA Wang JK Management of acute pain.Adv Anesthesiol. 1987; 4: 347-363Google Scholar 95% of patients were free of pain and requested no other modes of analgesia. Side effects vary in frequency and may include respiratory depression, urinary retention, nausea, vomiting, and pruritus. Fortunately, the most serious side effect, respiratory depression, is uncommon; clinically significant respiratory depression occurs in 0.2 to 1.0% of patients.39Lilley J-P Fromme GA Wang JK Management of acute pain.Adv Anesthesiol. 1987; 4: 347-363Google Scholar Close monitoring by well-trained nurses is imperative to detect this problem. Respiratory depression is a result of cephalad spread of the narcotic within the cerebrospinal fluid to the brain-stem respiratory control centers and is inversely related to the lipid solubility of the narcotic in use.20Cousins MJ Mather LE Intrathecal and epidural administration of opioids.Anesthesiology. 1984; 61: 276-310Crossref PubMed Scopus (943) Google Scholar, 21Rawal N Wattwil M Respiratory depression after epidural morphine—an experimental and clinical study.Anesth Analg. 1984; 63: 8-14PubMed Google Scholar, 22Renaud B Brichant JF Clerque F Chauvin M Levron JC Viars P Continuous epidural fentanyl: ventilatory effects and plasma kinetics (abstract).Anesthesiology. 1985; 63: A234Crossref PubMed Google Scholar, 44Vestergaard Madsen J Rybro L Schurizek BA Husegaard HC Joensen F Møller V Wernberg M Respiratory depression following postoperative analgesia with epidural morphine.Acta Anaesthesiol Scand. 1986; 30: 417-420Crossref PubMed Scopus (11) Google Scholar, 45Bromage PR Camporesi EM Durant PAC Nielsen CH Rostral spread of epidural morphine.Anesthesiology. 1982; 56: 431-436Crossref PubMed Scopus (226) Google Scholar Increased lipid solubility enhances uptake of the drug by opioid receptors in the spinal cord; therefore, less drug is available to ascend in the cerebrospinal fluid.46Callahan P Pasternak GW Opiates, opioid peptides, and their receptors.J Cardiothorac Anesth. 1987; 1: 569-576Abstract Full Text PDF PubMed Scopus (14) Google Scholar In this regard, fentanyl, a highly lipid-soluble agent, ma" @default.
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• W2025672318 title "Management of Postoperative Pain: Review of Current Techniques and Methods" @default.
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