AT THE ACADEMIC SURGICAL CONGRESS
LAS VEGAS (FRONTLINE MEDICAL NEWS) – Intrathecal hydromorphone, administered alone or with lidocaine, effectively controlled pain and decreased postoperative opioid use after colorectal surgery in a retrospective study.
The technique was so effective that 28% of patients required no postoperative opioids at all, Amit Merchea, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
The intrathecal analgesic was part of an enhanced recovery pathway (ERP) for patients undergoing elective colorectal surgery at the Mayo Clinic, Jacksonville, Fla., where Dr. Merchea practices colorectal surgery.
“Multimodal analgesia is an essential component of an enhanced recovery pathway,” he said. “An ERP that includes the use of single-injection intrathecal analgesia has been shown to decrease morbidity, decrease cost, and shorten length of stay.”
Morphine has been the gold standard for this approach, he said. Dr. Merchea and his colleagues investigated the use of hydromorphone in 601 patients who underwent open or minimally invasive colorectal surgery at the Mayo Clinic from 2012 to 2013.
The patients were a median of 52 years old. The surgical approach was almost evenly split between open and laparoscopic. The median length of hospital stay was 3 days. All received intrathecal hydromorphone either alone (91%) or with a local anesthetic (9%).
Everyone was on the same presurgical and postsurgical pain control regimen, which consisted of celecoxib, gabapentin, and acetaminophen before surgery, followed by nonsteroidal anti-inflammatories and acetaminophen, with oxycodone as needed, after surgery.
Overall, the procedure was well tolerated, with seven cases of pruritus requiring Nubain (nalbuphine), one case of respiratory depression that required naloxone, and one postdural headache that required a patch. The rate of ileus was 16%.
At 4 hours, the median pain score was 3 on a 1- to 10-point scale. At 24 hours, it was a median of 4. By 48 hours, the median pain score was 6. This increase is to be expected as the hydrocodone exists in the intrathecal space for up to 36 hours, Dr. Merchea noted.
The median total oral morphine equivalent (OME) was 24; 170 patients (28%) needed no opioid medications after surgery.
He also presented outcomes by infusion composition. There was no difference in the rate of ileus among those who had hydromorphone alone and those who had it with lidocaine. The length of stay was 3 vs. 3.5 days, respectively. The only significant difference in pain scores was the 48-hour maximum, which was a median of 7 in the combination group and 6 in the hydromorphone-only group.
The combination group, however, required more postoperative opioids (33.8 vs. 22.5 OMEs). Significantly more patients in the hydromorphone-only group were able to go without any postoperative opioids (30% vs. 15%).
Dr. Merchea also broke down the results by hydromorphone dosage, but there were no significant differences in ileus rate, length of stay, or pain scores correlated with dosage. However, those who received higher doses were significantly more likely to need more postoperative opioids than those who had lower doses.
Session moderator Peter Muscarella, MD, of Montefiore Medical Center, New York, asked whether the intrathecal infusion was associated with hypotension. “Some of these procedures with epidural analgesics intraoperatively, we have seen shifts in blood pressure that result in excess fluid administration, sometimes leading to tissue complications.”
Dr. Merchea said hypotension was not an outcome of this trial, but that he has looked at it before. “We have previously reported that epidural analgesia was associated with a 15% occurrence of hypotension, but it had no clinical impact and didn’t warrant giving any additional fluids.”
Dr. Merchea had no relevant financial disclosures.
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