Anaesthesia and intensive care
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Misuse of prescription opioids forced an inevitable response from authorities to intervene with consequences felt by all. In the Australian community one person will die for approximately every 3600 adults prescribed opioids, while in the hospital setting a postoperative patient managed primarily with opioids, as opposed to epidural analgesia, has an additional risk of death as high as between one in 56 to 477. Opioids maintain a valid role in acute pain management when use is reasoned and with full awareness of the harms and how they are to be avoided, such as in those at risk of ongoing use, the opioid naïve, and when opioid-induced ventilatory impairment may occur. Clinicians managing acute pain can focus on assessing pain versus nociception, strategically apply antinociceptive medications and neural blockade when indicated, assess pain with an emphasis on the degree of bothersomeness and functional impairment and, finally, optimise the use of framing and placebo-enhancing communication to minimise reliance on medications.
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Anaesth Intensive Care · Mar 2022
Case ReportsCaudal catheter placement for repeated epidural morphine doses after neonatal upper abdominal surgery.
Effective pain control after major surgery in neonates presents many challenges. Parenteral opioids (and co-analgesics) are often used but inadequate analgesia and oversedation are not uncommon. Although continuous thoracic epidural analgesia is highly effective and opioid-sparing, its associated risks and the need for staff with specialised skills and/or neonatal intensive care unit staff buy-in may preclude this option even in many academic centres. We present the case of a six-day-old infant who underwent upper abdominal surgery and received intermittent morphine doses via a tunnelled caudal epidural catheter, which provided satisfactory analgesia and facilitated early extubation.
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Anaesth Intensive Care · Mar 2022
ReviewThe complications of opioid use during and post-intensive care admission: A narrative review.
Opioids are a commonly administered analgesic medication in the intensive care unit, primarily to facilitate invasive mechanical ventilation. Consensus guidelines advocate for an opioid-first strategy for the management of acute pain in ventilated patients. ⋯ Consequently, there is a challenge of optimising analgesia while minimising these adverse effects. This narrative review will discuss the characteristics of opioid use in the intensive care unit, outline the potential short-term and long-term adverse effects of opioid therapy in critically ill patients, and outline a multifaceted strategy for opioid minimisation.
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Anaesth Intensive Care · Mar 2022
ReviewNew pharmacological perspectives and therapeutic options for opioids: Differences matter.
Opioids remain the major drug class for the treatment of acute, chronic and cancer pain, but have major harmful effects such as dependence and opioid-induced ventilatory impairment. Although no new typical opioids have come onto the market in the past almost 50 years, a plethora of new innovative formulations has been developed to meet the clinical need. This review is intended to shed light on new understanding of the molecular pharmacology of opioids, which has arisen largely due to the genomic revolution, and what new drugs may become available in the coming years. ⋯ That gene splice variants of the mu opioid receptor produce multiple receptor isoforms in different brain regions, and may change with pain chronicity and phenotype, presents new challenges but also opportunities for precision pain medicine. Finally, that opioids also have pro-inflammatory effects not aligned with mu opioid receptor binding affinity implicates a fresh understanding of their role in chronic pain, whether cancer or non-cancer. Hopefully, a new understanding of opioid analgesic drug action may lead to new drug development and better precision medicine in acute and chronic pain relief with less patient harm.
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Opioid-induced ventilatory impairment is the primary mechanism of harm from opioid use. Opioids suppress the activity of the central respiratory centres and are sedating, leading to impairment of alveolar ventilation. Respiratory physiological changes induced with acute opioid use include depression of the hypercapnic ventilatory response and hypoxic ventilatory response. ⋯ Obstructive sleep apnoea and opioid-induced ventilatory impairment are frequently associated, with this interrelationship being complex and often unpredictable. Monitoring the patient for opioid-induced ventilatory impairment poses challenges in the areas of reliability, avoidance of alarm fatigue, cost, and personnel demands. Many situations remain in which patients cannot be provided effective analgesia without opioids, and for these the clinician requires a comprehensive knowledge of opioid-induced ventilatory impairment.