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Up to date in clinical management of neuraxial opioids for the treatment of postoperative pain. Mugabure Bujedo, S. Hospital Universitario Donostia. Palabras clave: Analgesia espinal. Opioides epidurales. Opioides intratecales. Dolor postoperatorio. Opioids are the strongest drugs currently used for the treatment of pain.

Over the last 40 years, because of the discovery of the spinal cord opioid receptors, the use of spinal opioids has become a standard for producing intense segmental analgesia without side effects associated with systemic administration.

There is a widespread misconception that any opioid administered epidurally or intrathecally will always produce analgesia by a selective mechanism without central adverse effects. This is simply not true because multiple of these opioids produce analgesia by uptake into the systemic circulation or cerebrospinal fluid CSF , with subsequent redistribution to brain opioid receptors. The findings indicate that increasing lipid solubility decreases the spinal cord bioavailability, therefore morphine is the most spinally selective opioid currently used in the epidural and intrathecal spaces.

Extended release epidural morphine EREM utilizes a proprietary liposomal carrier to provide prolonged analgesia without the need for an indwelling catheter. Fentanyl is the best option for ambulatory surgery and it becomes apparent that epidural fentanyl acts predominantly spinally when administered as a bolus, and predominantly supraspinally as a continuous infusion. Epidural methadone and hydromorphone are valid alternatives for improve analgesia in the postoperative setting.

All opioids injected intrathecally can be expected to produce analgesia, at last in part, by a spinal mechanism. The principal difference among opioids is in their duration of analgesic action, speed of re-distribution and the mechanism by which the drug reaches brainstem sites.

In general, lipophilic opioids produce short durations of action hours , which makes them attractive for short-term postoperative states. Key words: Spinal analgesia. Epidural opioid. Intrathecal opioid. Postoperative pain. La historia de la anestesia intratecal y epidural ha discurrido en paralelo a la de la anestesia general. Todos los opioides producen analgesia por el mismo mecanismo molecular 5. Todo ello conlleva a disminuir la excitabilidad neuronal.

Fue imposible comprobar 7 de ellas por falta de trabajos. Bernards y cols. Ummenhofer y cols. Un reciente estudio ha demostrado su efectividad en 3. Concluyeron por tanto, que la oxicodona es igual de efectiva que la morfina epidural, cuando se administra al doble de dosis, con menos efectos adversos pero con una mayor variabilidad individual Autores como Tan y cols.

Coda y cols. Van der Nieuwenhuyzen y cols. Concluyeron que no les fue posible demostrar un efecto espinal de este opioide. Concluyeron que 1 mg de metadona es muy inferior a la misma dosis de morfina intradural. El resto de efectos fueron similares entre los grupos. Se obtuvo la densidad y sus variaciones con la temperatura de todos los AL y de sus combinaciones con opioides a 20 o C, 25 o C y 37 o C.

Recomendaciones sobre la vigilancia en pacientes que reciben opioides neuraxiales. A history of neuroaxial administration of local analgesics and opioids. Eur J Anesthesiology ;21 4 Analgesia mediated by a direct spinal action of narcotics. Science ; Pain relief by intrathecally applied morphine in man. Anesthesiology ; Epidural morphine in treatment of pain.

Lancet ; Bernards CM. Understanding the physiology and farmacology of epidural and intrathecal opiods. Best Practice and Reseach Clinical Anaesthesiology ;16 4 Algia Hospital ; Inturrisi CE.

Clinical Pharmacology of opioids for pain. Clin J Pain ;18 4 Rev Soc Esp Dolor ;16 5 Simonet G, Rivat C. Opioid-induced hyperalgesia: abnormal or normal pain. Neuroreport ; Koppert W, Schmelz M. The impact of opioid-induced hyperalgesia for postoperative pain.

Best Pract Res Clin Anesthesiol ;21 1 Lavand'nhomme P. Perioperative pain. Curr Opin Anaesthesiol ; Postoperative hyperalgesia: its clinical importance and relevance. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement.

Anesthesiology ;93 2 Remifentanil-induced postoperative hyperalgesia and its prevention with small-dose ketamina. Anesthesiology ; 1 Effects of COX inhibition on experimental pain and hyperalgesia during and after remifentanil infusion in humans. Pain ; ahead of print. Fentanyl enhancement of carrageenan-induced hyperalgesia in rats: prevention by the N-Methyl-D-Aspartate receptor antagonist ketamina. Ketamine improves the management of exaggerated postoperative pain observed in perioperative fentanyl treated rats.

Anesthesiology ; 2 Intraoperative high dose fentanyl induces postoperative fentanyl tolerance. Can J Anaesth ; Nitrous oxide revisited: evidence for potent antihyperalgesic properties. Anesthesiology ; 4 Gabapentin prevents delayed and long-lasting hyperalgesia induced by fentanyl in rats.

Anaesthesiology ; 3 Does intrathecal fentanyl produce acute cross-tolerance to i. Br J Anaesth ; Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain ; Weinbroum AA. A single small dose of postoperative ketamine provides rapid and sustained improvement in morphine analgesia in the presence of morphine-resistant pain. Anesth Analg ; Smith MT. Neuroexcitatory effects of morphine and hydromorphone: evidence implicating the 3-glucuronide metabolites.

Mechanisms of nocicepcion evoked by intrathecal high-dose morphine. Neurotoxicology ; Opioid induced hyperalgesia. A Qualitative systematic review. Anesthesiology ; Devulder J. Hyperalgesia induced by high-dose inthratecal sufentanil in neuropathic pain. J Neurosug Anesthesiol ;9 2 Do opioids induce hiperalgesia in humans? An evidence-based structured review.

Pain Med ; 10 5

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