PAIN
Volume 153, Issue 4 , Pages 784-793, April 2012

Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: A meta-analysis of randomized trials☆

  • Daniel M. Pöpping

      Affiliations

    • Department of Anesthesiology and Intensive Care, University Hospital Münster, Münster, Germany
    • Corresponding Author InformationCorresponding author. Address: Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum, Albert-Schweitzer-Str. 33, D-48149Münster, Germany. Tel.: +49 (0) 251 83 47255; fax: +49 (0) 251 88704.
    • ,
  • Nadia Elia

      Affiliations

    • Institute of Social and Preventive Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
    • Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
    • ,
  • Emmanuel Marret

      Affiliations

    • Department of Anesthesiology and Intensive Care, Tenon University Hospital, UMPC University Paris, France
    • ,
  • Manuel Wenk

      Affiliations

    • Department of Anesthesiology and Intensive Care, University Hospital Münster, Münster, Germany
    • ,
  • Martin R. Tramèr

      Affiliations

    • Division of Anesthesiology, University Hospitals of Geneva, Geneva, Switzerland
    • Faculty of Medicine, University of Geneva, Geneva, Switzerland

Received 1 June 2011; received in revised form 21 November 2011; accepted 28 November 2011. published online 09 January 2012.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Summary 

Morphine, and to a lesser extent fentanyl, added to intrathecal bupivacaine prolong postoperative analgesia. With morphine, the risk of respiratory depression cannot be ruled out.

Abstract 

Opioids are widely used as additives to local anesthetics for intrathecal anesthesia. Benefit and risk remain unclear. We systematically searched databases and bibliographies to February 2011 for full reports of randomized comparisons of any opioid added to any intrathecal local anesthetic with the local anesthetic alone in adults undergoing surgery (except cesarean section) and receiving single-shot intrathecal anesthesia without general anesthesia. We included 65 trials (3338 patients, 1932 of whom received opioids) published between 1983 and 2010. Morphine (0.05–2mg) and fentanyl (10–50μg) added to bupivacaine were the most frequently tested. Duration of postoperative analgesia was prolonged with morphine (weighted mean difference 503min; 95% confidence interval [CI] 315 to 641) and fentanyl (weighted mean difference 114min; 95% CI 60 to 168). Morphine decreased the number of patients needing opioid analgesia after surgery and decreased pain intensity to the 12th postoperative hour. Morphine increased the risk of nausea (number needed to harm [NNH] 9.9), vomiting (NNH 10), urinary retention (NNH 6.5), and pruritus (NNH 4.4). Fentanyl increased the risk of pruritus (NNH 3.3). With morphine 0.05 to 0.5mg, the NNH for respiratory depression varied between 38 and 59 depending on the definition of respiratory depression chosen. With fentanyl 10 to 40μg, the risk of respiratory depression was not significantly increased. For none of these effects, beneficial or harmful, was there evidence of dose-responsiveness. Consequently, minimal effective doses of intrathecal morphine and fentanyl should be sought. For intrathecal buprenorphine, diamorphine, hydromorphone, meperidine, methadone, pentazocine, sufentanil, and tramadol, there were not enough data to allow for meaningful conclusions.

Keywords: Intrathecal, Local anesthetic, Opioid, Postoperative analgesia, Single-shot spinal anesthesia

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☆ Presented in part as an abstract at the Annual Scientific Meeting of the German Society of Anesthesiology, May 14–17, 2011, Hamburg, Germany; and at the annual scientific meeting of the European Society of Anaesthesiology, June 11–14, 2011, Amsterdam, The Netherlands.

PII: S0304-3959(11)00726-3

doi:10.1016/j.pain.2011.11.028

PAIN
Volume 153, Issue 4 , Pages 784-793, April 2012

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