Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewManagement of adverse effects of intrathecal opioids in acute pain.
Intrathecal opioids have been used for several decades in different clinical settings. They are easy to administer and provide many benefits in clinical practice, such as better quality of spinal anaesthesia, prolonged postoperative analgesia, decreased postoperative analgesic requirements and early mobilisation. ⋯ In contrast, intrathecal hydrophilic opioids may have potentially serious adverse effects, the most feared of which is respiratory depression. In this review, we will focus on the contemporary evidence regarding intrathecal hydrophilic opioids and present their adverse effects and how to manage them.
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Central neuraxial blocks (CNBs), which include spinal, epidural, and combined spinal epidural injections, are indispensable techniques in the anesthesiologist's armamentarium. Indeed, in scenarios such as when dealing with the obstetric population, patients with obesity, or patients having respiratory compromise (e.g., lung disease or scoliosis), CNBs are the mainstay for anesthesia and/or analgesia. Traditionally, CNBs are performed using anatomical landmarks, which are simple, easy to master, and exceptionally successful in most cases. ⋯ Any limitation of an anatomic landmark-based approach is an opportunity for an ultrasound-guided (USG) technique. This has become particularly true for CNBs, where recent advances in ultrasound technology and research data have addressed many of the shortcomings of the traditional anatomic landmark-based approaches. This article reviews the ultrasound imaging of the lumbosacral spine and its application for CNBs.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewCurrent indications for spinal anesthesia-a narrative review.
Spinal anesthesia is a commonly performed regional anesthesia technique by most anesthesiologists worldwide. This technique is learned early during training and is relatively easy to master. ⋯ This review attempts to highlight the current indications of this technique. Understanding the finer aspects and knowledge gaps will help postgraduates and practicing anesthesiologists in designing patient-specific techniques and interventions.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewIntrathecal drug delivery in the management of chronic pain.
Targeted intrathecal drug delivery (TIDD) has the objective of bringing the drug(s) close to the receptors influencing pain modulation, and thus reducing the dose and the side effects. Intrathecal drug delivery knew its real start with the development of permanent implantation of intrathecal and epidural catheters, combined with internal or external ports, reservoirs, and programmable pumps. TIDD is a valuable treatment for patients with cancer suffering refractory pain. ⋯ Only two drugs are approved by the US Food and Drug Administration for TIDD administration for chronic pain: morphine and ziconotide as monotherapy. In pain management, off-label use of medication and combination therapy is often reported. The specific action of the intrathecal drugs, the efficacy and safety, is described, as well as the modalities for trialing intrathecal drug delivery and the implantation methods.
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Best Pract Res Clin Anaesthesiol · Jun 2023
ReviewIntrathecal opioids for the management of post-operative pain.
Intrathecal opioids are highly effective in the management of post-operative pain. The technique is simple with a very low risk of technical failure or complications, and it does not require additional training or expensive equipment such as ultrasound machines and, therefore, is widely practised around the world. The high-quality pain relief is not associated with sensory, motor or autonomic deficits. ⋯ With these dose reductions, the risks have decreased; current evidence shows that the risk of the much-feared respiratory depression with low-dose ITM (up to 150 mcg) is no greater than that with systemic opioids used in routine clinical practice. Patients receiving low-dose ITM can be nursed in regular surgical wards. The monitoring recommendations from societies such as the European Society of Regional Anaesthesia and Pain Therapy (ESRA), the American Society of Regional Anesthesia and Pain Medicine and the American Society of Anesthesiologists need to be updated so that the requirements for extended or continuous monitoring at postoperative care units (PACUs), step-down units, high-dependency units, and intensive care units can be eliminated, thereby reducing additional costs and inconvenience and making this simple, versatile and highly effective analgesia technique available to a wider patient population in resource-limited settings.