Intrathecal hydrophilic opioids show an IV morphine sparing effect and likely dose-related respiratory depression.

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• Mark V Koning, Markus Klimek, Koen Rijs, Robert J Stolker, and Michael A Heesen.
• Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Anaesthesiology and Critical Care, Rijnstate Hospital, Arnhem, the Netherlands. Electronic address: Markkoning66@hotmail.com.
• Br J Anaesth. 2020 Sep 1; 125 (3): 358-372.

BackgroundIntrathecal hydrophilic opioids decrease systemic opioid consumption after abdominal surgery and potentially facilitate enhanced recovery. A meta-analysis is needed to quantify associated risks and benefits.MethodsA systematic search was performed to find RCTs investigating intrathecal hydrophilic opioids in abdominal surgery. Caesarean section and continuous regional or neuraxial techniques were excluded. Several subgroup analyses were prespecified. A conventional meta-analysis, meta-regression, trial sequential analysis, and provision of GRADE scores were planned.ResultsThe search yielded 40 trials consisting of 2500 patients. A difference was detected in 'i.v. morphine consumption' at Day 1 {mean difference [MD] -18.4 mg, (95% confidence interval [CI]: -22.3 to -14.4)} and Day 2 (MD -25.5 mg [95% CI: -30.2 to -20.8]), pain scores at Day 1 in rest (MD -0.9 [95% CI: -1.1 to -0.7]) and during movement (MD -1.2 [95% CI: -1.6 to -0.8]), length of stay (MD -0.2 days [95% CI: -0.4 to -0.1]) and pruritus (relative risk 4.3 [95% CI: 2.5-7.5]) but not in nausea or sedation. A difference was detected for respiratory depression (odds ratio 5.5 [95% CI: 2.1-14.2]) but not when two small outlying studies were excluded (odds ratio 1.4 [95% CI: 0.4-5.2]). The level of evidence was graded as high for morphine consumption, in part because the required information size was reached.ConclusionsThis study showed important opioid-sparing effects of intrathecal hydrophilic opioids. Our data suggest a dose-dependent relationship between the risk of respiratory depression and the dose of intrathecal opioids. Excluding two high-dose studies, intrathecal opioids have a comparable incidence of respiratory depression as the control group.Clinical Trial RegistrationPROSPERO-registry: CRD42018090682.Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.

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