Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2004
Recent insights into the pharmacokinetics of spinal opioids and the relevance to opioid selection.
Spinal opioid administration was introduced into clinical practice nearly 25 years ago in the hope of producing intense spinal analgesia that was devoid of the dose-limiting side effects associated with systemic opioid administration. While spinal opioid administration can clearly be an effective analgesic technique, there is a widespread misconception that any opioid administered epidurally or intrathecally will produce analgesia by a selective spinal mechanism. This is simply not true; multiple opioids that are commonly administered spinally produce analgesia by uptake into the systemic circulation with subsequent redistribution to brainstem opioid receptors. In an effort to help clinicians understand why some opioids are not suitable for selective spinal analgesia, this review describes recent insights into the fate of intrathecally and epidurally administered opioids. ⋯ These animal data help to explain multiple clinical studies that have demonstrated that the analgesic effect of spinally administered lipid-soluble opioids is due in part, if not exclusively, to uptake into plasma and distribution to brainstem opioid receptors.
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This review of the most recent publications is aimed to look at the current developments regarding the effects of regional anesthesia on perioperative outcome. ⋯ Despite the controversies, the numerous potential benefits and advantages of regional anesthesia are keys to its continued popularity. With constant search for new scientific clues by improving experimental designs, valuable evidence slowly unfolds. Regional anesthesia certainly takes a leading role in the current trends for a multimodal approach of perioperative pain management.
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Intraoperative neurophysiologic monitoring provides useful information on the functional status of the nervous system. This review focuses on recently published data concerning the impact of monitoring on patient outcome. ⋯ Brain monitoring facilitates anesthetic drug administration. An increasing number of neurosurgical procedures will require some form of intraoperative neurophysiologic monitoring to achieve higher degrees of safety and accuracy. In many instances, the data derived from monitoring will guide and influence surgical decisions. In this context, neurophysiologic monitoring should be regarded as interventional.
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Morphine metabolites have attracted continuing interest for their contribution to the desired and unwanted effects of morphine. Among the metabolites of morphine, morphine-6-glucuronide has been given most scientific attention. It accounts for 10% of the morphine metabolism, acts as an agonist at mu-opioid receptors and exerts antinociceptive effects. This review summarizes the recent findings on morphine-6-glucuronide and discusses its potential use as an analgesic. ⋯ Morphine-6-glucuronide might qualify as an analgesic but it has several pharmacological properties that make it far from ideal for therapeutic use. Whether it will be a useful addition to the currently established analgesics has yet to be demonstrated.
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Quality of recovery is recognized as a valid and important outcomes measurement in clinical care and research. The increasing interest in evaluating quality of recovery reflects the overall increased interest in patient-focused assessments. Assessment of quality of recovery incorporates measuring many dimensions or domains including physiologic endpoints, adverse events and psychosocial status. Unlike 'traditional' outcomes that focus on major morbidity and mortality, quality of recovery assesses 'nontraditional' outcomes focused around patient-oriented endpoints. By adversely influencing the many domains assessed by quality of recovery, postoperative pain may have a general detrimental effect on quality of recovery. ⋯ Higher levels of postoperative pain typically correlate with a decrease in quality of recovery. Different analgesic techniques and regimens may differentially influence quality of recovery, with preliminary evidence suggesting that some regional analgesic techniques may provide superior quality of recovery, quality of life and patient satisfaction. Further studies are needed to elucidate the effects of different analgesic techniques on quality of recovery.