Recording Your Continuing Professional Education s1

SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF

The Activities on these Portfolio Pages correspond with the learning objectives of the Guided Learning unit published in Nursing Times 104: 30 (29 July 2008) and 104; 31 (5 August 2008). The full reference list for this unit follows Activity 4.

Before starting to work through these Activities, save this document onto your computer, then print the completed work for your professional portfolio. Alternatively, simply print the pages if you prefer to work on paper, using extra sheets as necessary.

Recording your continuing professional education To make your work count as part of your five days’ CPD for each registration period, make a note in the box below of the date and the total number of hours you spent on reading the unit and any other relevant material, and working through the Activities.

Hours: Date:

ACTIVITY 1

Learning objective: Understand the role of spinal opioids in postoperative pain management.

Activity: Consider which patients are suitable for spinal anaesthesia and analgesia and examine the advantages and disadvantages of these methods.

RESPONSE

Begin your response here.

Nursing Times Portfolio Pages: Spinal opioids in postoperative pain relief 1

ACTIVITY 2 addition, evaluate the impact unrelieved postoperative pain may have on a patient, both in physiological and Learning objective: Understand the psychological terms. importance of postoperative monitoring.

Activity: Explain what observations are RESPONSE required postoperatively and why. In Begin your response here.

ACTIVITY 3 suitable for spinal anaesthesia and analgesia and examine the advantages and disadvantages of these methods. Learning objective: Understand the role of spinal opioids in postoperative pain management. RESPONSE

Activity: Consider which patients are Begin your response here.

ACTIVITY 4 experience is this always the case? If not, why? Learning objective: Be aware of the incidence and treatment of adverse effects of spinal opioids. RESPONSE Activity: Postoperative patients should not experience moderate or severe pain Begin your response here. on movement after surgery. In your

FULL REFERENCE LIST following knee arthroplasty. British Journal of Anaesthesia; 85: 2, 233-7.

Australian and New Zealand College of Coventry, D.M. (2007) Local Anaesthetic Anaesthetists and Faculty of Pain Techniques. In Aitkenhead, A.R. et al Medicine (ANZCA) (2005) Acute Pain th nd Textbook of Anaesthesia (5 ed). Management: Scientific Evidence (2 ed). Edinburgh: Churchill Livingstone. www.anzca.edu.au/resources/books-and- publications/acutepain.pdf Drakeford, M.K. et al (1991) Spinal narcotics for postoperative analgesia in Baxendale, B.R. (2007) Preoperative total joint arthroplasty. The Journal of Assessment and Premedication. In Bone and Joint Surgery; 73: 3, 424-428. Aitkenhead, A.R. et al Textbook of th Anaesthesia (5 ed). Edinburgh: Churchill Ene, K.W. et al (2007) Intrathecal Livingstone. analgesia for postoperative pain relief after radical prostatectomy. Acute Pain; 9: 65- Beaussier, M. et al (2006) Postoperative 70. analgesia and recovery course after major colorectal surgery in elderly patients: A Fogarty, D.J., Milligan, K.R. (1995) randomised comparison between Postoperative analgesia following total hip intrathecal morphine and intravenous PCA replacement: A comparison of intrathecal morphine. Regional Anaesthesia and Pain morphine and diamorphine. Journal of the Medicine; 31: 6, 531-538. Royal Society of Medicine; 88: 70-72.

Blay, M. et al (2006) Efficacy of low-dose Gwirtz, K.H. et al (1999) The safety and intrathecal morphine for postoperative efficacy of intrathecal opioid analgesia for analgesia after abdominal aortic surgery: A acute postoperative pain: Seven years’ double-blind randomised study. Regional experience with 5969 surgical patients in Anaesthesia and Pain Medicine; 31: 2, 127- an Indiana University Hospital. 133. Anaesthesia and Analgesia; 88: 599-604.

Bowrey, S. et al (2005) A comparison of Hindle, A. (2008) Intrathecal opioids in the 0.2mg and 0.5mg intrathecal morphine for management of acute postoperative pain. postoperative analgesia after total knee Continuing Education in Anaesthesia, replacement. Anaesthesia; 60: 449-452. Critical Care and Pain; 8: 3, 81-85.

Brennan, F.B. et al (2007) Pain Horlocker, T.T. (2003) Regional management: A fundamental human right. anesthesia and anticoagulation in patients Pain Medicine; 105: 1, 205-221. undergoing cardiothoracic and vascular surgery. Seminars in Cardiothoracic and Candido K.D., Stevens, R.A. (2003) Post- Vascular Anesthesia; 7: 4, 417-426. dural puncture headache: Pathophysiology, prevention and treatment. Best Practice & Jacobson, L. et al (1989) Intrathecal Research Clinical Anaesthesiology; 17: 3, methadone and morphine for postoperative 451-469. analgesia: A comparison of the efficacy, duration and side effects. Anaesthesiology; Cole, P.J. et al (2000) Efficacy and 70: 742-746. respiratory effects of low-dose spinal morphine for postoperative analgesia Jacobson, L. et al (1988) A dose-

SPINAL OPIOIDS IN POSTOPERATIVE PAIN RELIEF response study of intrathecal morphine: patients undergoing hip arthroplasty. Efficacy, duration, optimal dose and side Anaesthesia & Analgesia; 97: 1709-15. effects. Anaesthesia & Analgesia; 67: 1082-1088. Naumann, C. et al (1999) Drug adverse events and system complications of Janowski, C.J. (2002) Neuraxial intrathecal opioid delivery for pain: Origins, Anesthetic Techniques. In Raj, P.P. detection, manifestations and Textbook of Regional Anaesthesia. management. Neuromodulation; 2: 2, 92- Philadelphia: Churchill Livingstone. 107.

Kanner, R.M. (2003) Pain Management Neal, J.M. (1998) Update on postdural Secrets (2nd ed). Philadelphia: Hanley and puncture headache. Techniques in Belfus. Regional Anaesthesia and Pain Management; 2: 202-210 Kehlet, H., Holte, K. (2001) Effect of postoperative analgesia on surgical Pickering, S.A.W. et al (2003) outcome. British Journal of Anaesthesia; Electromagnetic augmentation of antibiotic 87: 1 62-72. efficacy in infection of orthopaedic implants. The Journal of Bone & Joint Surgery; 85-B: Koivuranta, M. et al (1997) A survey of 4, 588-593. postoperative nausea and vomiting. Anaesthesia; 52: 5, 443-449. Power, I., Atcheson, R. (2007) Postoperative pain. In Aitkenhead, A.R. et Kong, S.K. et al (2002) Use of intrathecal al (2007) Textbook of Anaesthesia (5th ed). morphine for postoperative pain relief after Edinburgh: Churchill Livingstone. elective laparoscopic colorectal surgery. Anaesthesia; 57: 1168-1173. Rathmell, J.P. et al (2005) The role of intrathecal drugs in the treatment of acute Lena, P. et al (2003) Intrathecal morphine pain. Anaesthesia & Analgesia; 101: S30- and clonidine for coronary artery bypass 43. grafting. British Journal of Anaesthesia; 90: 3, 300-3. Rathmell, J.P. et al (2003) Intrathecal morphine for postoperative analgesia: A Macintyre, P.E., Ready, B.L. (2001) Acute randomised, controlled, dose-ranging study Pain Management, A Practical Guide (2nd after hip and knee arthroplasty. ed). Anaesthesia & Analgesia; 97: 1452-7. London: WB Saunders. Rawal, N. (2007) Regional anesthesia McQuay, H.J., Moore, A. (1998) An complications related to acute pain Evidence-Based Resource For Pain Relief. management. In Finucane, B.T. (ed) (2007) Oxford: Oxford University Press. Complications of Regional Anesthesia (2nd edition) New York: Springer. Motamed, C. et al (2000) Analgesic effects of low dose intrathecal morphine and Rawal, N. (2003) Intraspinal Opioids. In bupivacaine in laparoscopic Rowbotham, D.J., Macintyre, P.E. (2003) cholecystectomy. Anaesthesia; 55: 118- Clinical Pain Management: Acute Pain. 124. London: Arnold.

Murphy, P.M. et al (2003) Optimizing the Rawal, N. (1999) Epidural and spinal dose of intrathecal morphine in older agents for postoperative analgesia.

Surgical Clinics of North America; 79: 2, & Analgesia; 88: 822-6. 313-344. Stoelting, R.K., Hillier, S.C. (2006) Rawal, N., Allvin, R. (1996) Epidural and Pharmacology & Physiology in Anesthetic intrathecal opioids for postoperative pain Practice (4th ed), Philadelphia: Lippincott, management in Europe – A 17 nation Williams and Wilkins. questionnaire study of selected hospitals. Acta Anaesthesiologica Scandinavica; 40: Tan, P.H. et al (2001) Intrathecal 1119-1126. bupivacaine with morphine or neostigmine for postoperative analgesia after total knee Riad, T. et al (2002) Intrathecal morphine replacement surgery. Canadian Journal of compared with diamorphine for Anaesthesia; 48: 6, 551-6. postoperative analgesia following unilateral knee arthroplasty. Acute Pain; 4: 5-8. Togal, T. et al (2004) Combination of low- dose (0.1mg) intrathecal morphine and Safa-Tisseront, V. et al (2001) patient-controlled intravenous morphine in Effectiveness of epidural blood patch in the the manangement of postoperative pain management of post dural puncture following abdominal hysterectomy. Pain headache. Anesthesiology; 95: 2, 334-339. Clinic; 16: 3, 335-341.

Sakai, T. et al (2003) Mini-dose (0.05mg) Urban, M.K. et al (2002) Reduction in intrathecal morphine provides effective postoperative pain after spinal fusion with analgesia after transurethral resection of instrumentation using intrathecal morphine. the prostate. Regional Anaesthesia and Spine; 27: 5, 535-37. Pain; 50: 10, 1027-1030. Viscomi, C.M. (2004) Spinal Anesthesia. In Slappendel, R. et al (1999) Optimization of Rathmell, J.P. et al (eds) The Requisites in the dose of intrathecal morphine in total hip Anesthesiology. Philadelphia: Elsevier. surgery: A dose finding study. Anaesthesia

ADDITIONAL MATERIAL AND TABLES

Table 1. Definition of terms

Term Definition Mode of delivery Spinal Sensory and motor blockade induced One-off injection anaesthesia by the injection of local anaesthetic into the cerebrospinal fluid (CSF) Spinal analgesia The administration of opioid analgesia One-off injection into the CSF often given in combination with spinal anaesthesia Epidural analgesia The administration of local anaesthetic Continuous infusion with or without opioid analgesia into via indwelling the epidural space to induce sensory epidural catheter and preferably not motor blockade. Usually used in the postoperative period

Anatomy Pain pathways Spinal cord/CSF Nociceptor (pain) input is conducted from The brain and spinal cord are covered by peripheral sites to the spinal cord via the three layered meninges - the dura, primary afferent A delta and C nerve arachnoid and pia mater. The pia mater fibres. These synapse in the dorsal horn is the innermost layer which adheres to of the spinal cord and pain impulses are the surface of the brain and spinal cord. then transmitted upwards in groups of The dura mater forms the outermost neurones (anterior and lateral meninges and the arachnoid mater lies spinothalamic tracts) to the brain via the just below the dura - both form the dural ascending pathway (Power and sac. The intrathecal or subarachnoid Atcheson, 2007). The dorsal horns space is beyond the dura and contains contain a high concentration of opioid cerebrospinal fluid (Viscomi, 2004). The receptors. These are present pre- and epidural space contains fat, nerve roots post-synaptically and have an inhibitory and blood vessels lying outside the effect on pain transmission. Pain meninges between the dura mater and impulses may be blocked by local the bones and ligaments of the spinal anaesthetics, opioids and other drugs canal. Local anaesthetic or analgesic acting at other receptors, for example, drugs may be administered via a needle clonidine or ketamine (Rawal, 1999). into the CSF (to produce spinal Analgesia is derived by specific opioid anaesthesia or analgesia) or into the receptor binding in the dorsal horn of the epidural space (to provide epidural spinal cord and by non-specific sites in anaesthesia or analgesia). the white matter.

Table 2. Spinal opioid dose ranges

Opioid Dose range Duration of action Morphine 50–500 mcg Up to 24 hours Fentanyl 5-25 mcg 1-4 hours Diamorphine 500-1000 mcg 12-18 hours

Table 3. Suggested optimal dose of spinal morphine

Procedure Dose Total knee arthroplasty M 300mcg (Riad et al, 2002) M 300mcg (Tan et al, 2001) M 300mcg (Cole et al, 2000) M 500mcg (Bowrey et al, 2005) Hip arthroplasty M 100mcg (Murphy et al, 2003) M 100mcg (Slappendel et al, 1999) M 200mcg (Niemi et al, 1993) M 1.0mg (Fogarty and Milligan, 1995) Hip and knee surgery M 200mcg plus morphine PCA (Rathmell et al, (studies combined 2003) patients in sample M 300mcg or 1mg (Jacobson et al, 1988) group) M 400–500mcg (Gwirtz et al, 1999) M 500mcg (Drakeford et al, 1991) M 500mcg or 1mg (Jacobson et al, 1989) Colorectal surgery M 300mcg plus morphine PCA (Beaussier et al, 2006) Abdominal M 100mcg plus morphine PCA (Togal et al, 2004) hysterectomy M 400-500mcg (Gwirtz et al, 1999) Laparoscopic colorectal M 200mcgmorphine (Kong et al, 2002) surgery Laparoscopic M 75 or 100mcg (Motamed et al, 2000) cholecystectomy Spinal fusion M 20mcg/kg (Urban et al, 2001) Transurethral resection M 50mcg (Sakai et al, 2003) of prostate M 200-300mcg (Gwirtz et al, 1999) Radical prostatectomy M 100-200mcg (Ene et al, 2007) Coronary artery bypass M 4mcg/kg morphine + clonidine 1mcg/kg (Lena et surgery al 2003) Nephrectomy M 600–650mcg (Gwirtz et al, 1999) Abdominal aortic M 200mcgplus IV nefopam and morphine (Blay et surgery al, 2006)

Interpreting the studies to procedure. Typically, patients undergoing total knee replacement There are a number of problems in surgery required a greater dose of the interpretation of these findings, morphine to achieve effective principally because study analgesia than those having total methodology was inconsistent. hip replacement (Rathmell et al, Specifically, pain assessment 2003). This is likely related to the measurement tools were not greater degree of mobility required standardised and included in the prosthetic knee joint than is assessment at rest and on needed in a prosthetic hip joint. movement (Tan et al, 2001; Scrutiny of the type of surgeries in Fogarty and Milligan, 1995; Niemi Table 3 reveals that it has not et al, 1993). In addition, rescue been widely used for patients analgesia was given on patient undergoing major abdominal request in some studies and surgery that involves a midline according to pre-assigned pain laparotomy. The few studies in this scores in others. The area have concluded that it has a administration of supplementary limited role because analgesia will analgesia at a pre-determined be typically required via the pain score (such as VAS >40) is a parenteral route for 4-5 days. more valid and reliable These studies failed to show any measurement of additional beneficial effect of spinal analgesic need (Bowrey et al, analgesia on the postoperative 2005; Tan et al, 2001). recovery course (Beaussier et al, 2006). It is also apparent that the dose requirement varies from procedure

Box 1. Contraindications for spinal anaesthetic and a spinal opioid (Coventry, 2007)

 Untrained medical or nursing staff  Patient unwilling to consent  Generalised or local sepsis  Anticoagulant therapy  Thrombocytopenia or clotting disorder  Central or spinal neurological disease/raised intracranial pressure

Box 2. Clinical requirements for the use of spinal opioids (based on guidance developed at Cardiff and Vale NHS Trust, 2006)

 Appropriate protocols for the administration and postoperative patient monitoring  Regular review (at least daily) by member of the acute pain service or anaesthetist  24-hour access to on-call anaesthetist should the need arise for advice on treatment of side- effects or inadequate analgesia  Provision of rescue analgesia and treatment for side-effects  Standardised prescriptions  Education for nursing and medical staff  Provision for suitable titration onto alternative analgesic once the effect of spinal opioid has diminished  Patients able to tolerate oral analgesia within 18-24 hours after surgery.

Box 3. Nursing care (based on adult guidance developed by the acute pain service at Cardiff and Vale NHS Trust, 2006)

 Patent IV cannula  Observations of blood pressure, pulse, pain, sedation, nausea, respiratory rate and oxygen saturation level should be initiated half-hourly for two hours, then two-hourly thereafter up to 24 hours  Regular paracetamol, IV/PR or PO should be prescribed 1g qds  If indicated, regular NSAID for example, diclofenac 50mg tds can be administered  If rescue analgesia is needed within the first 24 hours then consider giving tramadol 50-100mg qds or codeine phosphate 30-60mg qds.