Dr. M. Ramli Ahmad - The Role of Opioid in Epidural
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Transcript of Dr. M. Ramli Ahmad - The Role of Opioid in Epidural
CURRICULUM VITAENama : Dr. dr. Muh. Ramli Ahmad, Sp.An-KAP-KMNNIP : 19590323 198702 1 001Status Dosen : Dosen Biasa NegeriTempat/Tanggal lahir : Bone. 23 Maret 1959Pangkat/Golongan : Pembina Utama Muda / IV cJabatan Struktural : KPS Bagian Ilmu Anestesi, Perawatan Intensif & Manajemen Nyeri Fakultas Kedokteran UNHASAlamat : Jl. A.P.Pettarani Blok GA7 No.9
Komp IDI Panakukang Makassar Telp/HP : 0411-456144 / HP: 0811442733 / Flx: 0411-5068281Alamat Kantor : Bagian Ilmu Anestesiologi, Perawatan Intensif & Manajemen Nyeri Fakultas Kedokteran UNHAS
RS. Dr. Wahidin Sudirohusodo Jl. Perintis Kemerdekaan Km.11 Tamalanrea Makassar 90245Riwayat Pendidikan : Jenjang S1, Bidang Kedokteran, Tamat tahun 1986Profesi, Bidang Kedokteran Umum, Tamat tahun 1986 Fakultas Kedokteran Universitas HasanudddinSpesialis, Bidang Anestesiologi, Tamat tahun 1996, Fakultas Kedokteran Universitas AirlanggaKonsultan Pediatric Tahun 2009Konsultan Manajemen Nyeri Tahun 2010S3 Kedokteran Pasca Sarjana Universitas Hasanuddin Makassar-Indonesia Tahun 2012
The Role of Opioidin Epidural Analgesia
Muh. Ramli AhmadDepartment of Anesthesiolgy, IC and Pain Management
Faculty of Medicine, Hasanuddin UniversityMakassar, Indonesia
Introduction• Epidural Analgesia Small catheter inserted
into epidural space, where nerve roots come out from the spinal cord.
• Target delivery of opioid to spinal cord opioid receptors, less dose required → less systemic side effects, better analgesia
• Central neuraxial block
Introduction (cont.)
• Epidural opioids have the advantage of producing analgesia without motor or sympathetic blockade
• Opioids may be used alone• More commonly as adjuncts to local
anaesthetics with which they have a synergistic effect.
• Drugs used: local anaesthetic +/-fentanyl +/-morphine +/- Meperidine
Spinal cord opioid receptor
Adverse effects of epidural analgesia
• Neurological injury• Epidural haematoma• Epidural abscess• Respiratory depression• Hypotension• Postural puncture headache• Treatment failure
BASIC CONCEPT EPIDURAL ANALGESIA
BASIC CONSEP EPIDURAL ANALGESIA
Epidural Autonomic Organ Innervation:
BASIC CONCEPT EPIDURAL ANALGESIA
Reuben SS, Acute Pain Management 2009
Neural Patway
Humoral Patway
Humoral stress response
Epidural Analgesia
BASIC CONCEPT EPIDURAL ANALGESIA
Dimodifikasi dari Reuben SS, Acute Pain Management 2009Pebedahan/ luka operasi
NYERI
Proses Humoral (Mediator Inflamasi)
Pelepasan TNF-, IL-1β, IL-6, dan IL-10
SensitisasiPerifer
Proses Neural (Nosisepsi)
AktivasiCOX-2Otak
Aktivasi COX-2 Sirkulasi
Alur Nosisepsi dan Humoral
Transduksi
Modulasi
Transmisi
Persepsi
SensitisasiSentral
COX-2Medulla Spinalis
BASIC CONCEPT EPIDURAL ANALGESIA
Epidural BlockLocal Anesthetic
NeuroendocrineStress Response
ACTHADHGHTSH
Central COX-2
inhibition
CytokinesIL-1βIL-2IL-6TNF
NorepinephrineEpinephrineCortisolAldosteroneRenin
Sympathetic efferent
Modify by AHT
Humoral stress response
COX-2
Lipophilic OpioidsRapid Onset, Short Duration, Low CSF Solubility
Advantages Rapid Analgesia Ideal for
Continuous Infusion or PCEA
a low risk of delayed respiratory depression
Disadvantages Systemic
Absorption Brief Single Dose
Analgesia Limited Thoracic
Analgesia with Lumbar Administration
ANAESTHESIA TUTORIAL OF THE WEEK 230 4th JULY 2011
Hydrophilic OpioidsSlow Onset, Long Duration, High CSF Solubility
Advantages Prolonged Single
Dose Analgesia Thoracic Analgesia
with Lumbar Administration
Minimal Dose Compared with IV Administration
Disadvantages Delayed Onset of
Analgesia Unpredictable
Duration Delayed Respiratory
Depression
ANAESTHESIA TUTORIAL OF THE WEEK 230 4th JULY 2011
Opioid for Epidural Analgesia• Spinal cord opioid
receptor• Opioid Lipid solubility
– Lipophilic opioid : fentanyl– Hydrophilic opioid :
morphine • amount of opioid needed
to provide a given level of analgesia – Intravenous > epidural >
intratechal
ANAESTHESIA TUTORIAL OF THE WEEK 230 4th JULY 2011
The “Fate” of agent for epidural analgesia solution
EPIDURAL INJECTION
Epidural Venous diffusion through Plexus the duramater
Diffusion across the subdural space dural cuffs surrounding Systemic spinal nerve roots Circulation CSF
Centripetal diffusiontoward the neuraxis
Bind receptors In brain
Spinal root block
LongitudinalSpread up & down
1
2
Epidural analgesia
• Level I evidence – Provide superior analgesia than PCA.– Improve oxygenation and reduce
pulmonary infection and other pulmonary complication compared with iv opioid.
– Is not assoicated with increase risk of anastomotic leakage after bowel surgery
Level I evidence-thoracic epidural analgesia
• For open abdominal aortic surgery reduces the duration of tracheal intubation and mechanical ventilation and incidence of MI
• Used for CABG reduces postoperative pain, risk of dyrhythmias, pulmonary complications and time to extubation compared with ivi opioid analgesia
• Improves bowel recovery after abdominal surgery and colorectal surgery.
• Extended > 24 hours reduces the incidence of postoperative MI
• Reduces need for ventilation in patient with muliple rib fracture and reduce incidence of pneumonia
Morphine• The 1st reported & mostly studied opioid for
epidural analgesia• Lipid insoluble opioid (hydrophilic)• Slow onset (30 min.)* & long duration (12-24 hrs.)*
• Increased risk of delayed side effects after intratechal bolus, therefore;– Continuous administration have some clinical
advantages– And also, the recent study shows that quality of
analgesia appears to be more complete when using continuous technique
*: After epidural adminbistration
Meperidine
• Metabolit toxic - Normeperidine seizures - Exkresi melalui renal. local anesthetic properties• Inotropik negatif • Menyebabkan tachycardia (anticholinergic)• Interaksi dengan MAO inhibitors,
menyebabkan MAO syndrome • Berguna untuk mengatasi shivering
FentanylHighly lipophylic• Strong opioid agonist• 80x more potent than morphine• Available in parenteral, transdermal,
transbuccal preparation• Transdermal formulation onset 6 – 12
hour ,duration 3 – 6 days.
Fentanyl
• Highly potent lipid soluble opioid (lipophilic)• Rapid onset (10 min.)* & short duration (2-4 hrs.)*
• Preferentially undergo vascular absorption rather than meningeal penetration– No clinical advantages to administer via epidural
route compared to the IV route
IV fentanyl provides equivalent analgesia to the epidural routes, but slightly increased incidence of nausea & vomitting
- Guinard et al.-
*: After epidural adminbistration
ADJUVANT AGENTS IN NEURAXIAL BLOCKADE ANAESTHESIA TUTORIAL OF THE WEEK 230 4th JULY 2011
Epidural Opioids: intermittent dose, onset, duration
Epidural opioid dosesdrug Single dose Onset
( min )Duration
( h )Infusion solution ( μg/ml )
Continuous Infusion
Fentanyl 50 – 100 μg 5 - 10 2.5 - 4 5-10 25 – 100 μg/h
Sufentanyl 10 – 50 μg 5 2 - 4 1 10 – 20 μg/h
Meperidine 20 – 50 mg 5 -15 6 2500 10 – 30 mg/h
Methadone 2 – 8 mg 10 6 - 10 10 – 15 0.1 – 0.3 mg/h
Morphine 1 – 5 mg 30 -60 18 10 0.05 – 0.1 mg/h
Hydromorphone 0.5 – 1 mg 10 - 15 10 -12 5 -10 0.05 – 0.1 mg/h
Level of catheter insertion
Thoracotomy Th 5 -7
Upper abdominal incision Th 7 – 9
Lower abdominal laparatomy Th 10 – 11
Pelvic sugery/ Lower limb surgery L 2-4
Level of insetion shoud be in the middle of dermatome of planned incision.
Opioid and Local anesthetic combination
• synergistically.• decreased concentration of the local anesthetic and
a lower dose of the opioid may be possible. • Provides better analgesia with fewer side effects
Common opioids concentration Common LA concentrationMorphine 10 mcg/mlHydromorphone 10mcg/mlFentanyl 2-5mcg/mlMeperidine 2mg/ml
Common infusion rate : 5 – 14 cc / hr
Bupivacaine 0.1% (1mg/ml).Bupivacaine 0.05% (0.5mg/ml)Ropivacaine 0.2% (2mg/ml)
Recommended Level, Agents and days for removal of Epidural
Grass JA, Problems in Anesthesia1998,10(1):45-70
Anesth Analg 1997;85:3804)
PERBANDINGAN EFEKTIFITAS KOMBINASI BUPIVAKAIN + PETIDIN DENGAN BUPIVAKAIN+FENTANIL PADA
ANALGESIA EPIDURAL
Muhammad Ramli Ahmad, Abd Azis
Kombinasi bupivacaine + petidin sama Efektifnya dengan kombinasi bupivacaine + fentanyl pada analgesia epidural
HASIL PENELITIAN
Karakterisitik Kelompok Petidin(n=30)
Kelompok Fentanyl(n=30)
Nilai p
Jenis Kelamin Laki-laki : 4 (13,3%)Perempuan : 26 (86,7%)
Laki-laki : 13 (43,3%)Perempuan : 17 (56,7%)
0,110
Umur 40,5±13,1 49,5±16,5 0,062Operasi Obgyn 13 (43,3%) Obsgyn 6
(20%)
0,366
Digestif 8 (26,7%) Digestif 17 (56,7%)
Ortopedi 8 (26,7%) Ortopedi 6 (20%)
Urologi 1 (3,3%) Urologi 1 (3,3%)
Data disajikan dalam bentuk prosentase. Nilai p diuji dengan X2Test. Nilai p<0,05 dinyatakan signifikan
Tabel. Karakteristik sampel
Tabel. Perbandingan derajat nyeriPetidin (n=30) Fentanyl (n=30) p
2 jam pascabedah
Nyeri ringan : 30 (100%) Nyeri ringan : 30(100%)0,161
24 jam pascabedah
Tidak nyeri :16 (53,3%) Nyeri ringan :14 (46,7%)
Tidak nyeri : 19 (63,3%)Nyeri ringan: 11 (36,7%) 0,415
Akhir pelepasan kateter epidural
Tidak nyeri :18 (60%) Nyeri ringan :12 (40%)
Tidak nyeri : 21(70%)Nyeri ringan : 9(30%) 0,421
Data disajikan dalam bentuk prosentase. Nilai p diuji dengan Mann Whitney U Test. Nilai p<0,05 dinyatakan signifikan
CLOPEDIN
CONCLUSIONS• Opioids are commonly added to local anaesthetic
for operations performed under epidural.• Neuraxial opioids improve the quality of
intraoperative analgesia, delay regression of sensory blockade prolong postoperative analgesia.
• Multiple trials have shown that the addition of opioids to local anaesthetic solutions significantly improves pain relief after thoracic, abdominal and orthopaedic surgery.
Thank you! FOR YOUR ATTENTION