Abstract
Purpose: Epidural morphine is associated with decreased bowel motility and increased transit time. Low doses of intravenous naloxone reduce morphine-induced pruritus without reversing analgesia, but the effect of epidural naloxone on bowel motility has not been studied. Therefore we evaluated bowel motility and analgesia when naloxone was co-administered with morphine into the epidural space.
Methods: Forty-three patients having combined thoracic epidural and general anesthesia for subtotal gastrectomy were randomly assigned to one of two study groups. All received a bolus dose of 3 mg epidural morphine at the beginning of surgery, followed by a continuous epidural infusion containing 3 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (control group, n=18) or a calculated dose of 0.208 µg·kg−1·hr−1 of naloxone (experimental group, n=25) for 48 hr. We measured the time to the first postoperative passage of flatus and feces to evaluate the restoration of bowel function, and visual analog scales (VAS) for pain during rest and movement. Scores were assessed at 2, 4, 8, 16, 24, 36 and 48 hr postoperatively.
Results: The experimental group had a shorter time to the first postoperative passage of flatus (51.9±16.6 hrvs 87.0±19.5 hr,P<0.001) and feces (95.3±25.0 hrvs 132.9±29.4 hr,P<0.001). No differences were found in either resting or active VAS between the two groups.
Conclusion: Epidural naloxone reduces epidural morphine-induced intestinal hypomotility without reversing its analgesic effects.
Résumé
Objectif: L’administration péridurale de morphine est associée à une baisse de la motilité intestinale et à une augmentation de la durée du transit. De faibles doses de naloxone intraveineuse réduisent le prurit induit par la morphine sans renverser l’analgésie, mais l’effet de l’administration péridurale de naloxone sur la motilité intestinale n’a pas encore été étudié. C’est pourquoi nous avons évalué cette action et l’analgésie de la naloxone administrée avec de la morphine dans l’espace péridural.
Méthode: Quarante-trois patients qui recevaient une anesthésie péridurale thoracique et générale combinée, pour une gastrectomie partielle, ont été répartis au hasard en deux groupes. Tous ont reçu un bolus de 3 mg de morphine péridurale au début de l’intervention, suivi d’une perfusion péridurale continue de 3 mg de morphine dans 100 ml de bupivacaïne à 0,125 % sans naloxone (groupe témoin, n=18) ou avec une dose calculée de 0,208 µg·kg−1·h−1 de naloxone (groupe expérimental, n=25) pendant 48 h. Nous avons mesuré le temps écoulé avant la première expulsion des gaz intestinaux et des selles afin d’évaluer la restauration de la fonction intestinale et mesuré les scores de douleur à l’aide de l’échelle visuelle analogique (EVA), au repos et pendant le mouvement. Les scores postopératoires ont été relevés à 2, 4, 8, 16, 24, 36 et à 48 h.
Résultats: Dans le groupe expérimental, le temps précédant le premier passage postopératoire des gaz (51,9±16,6 hvs 87,0±19,5 h,P<0,001) et des selles (95,3 ±25,0 h) a été plus court comparé au groupe témoin (132,9±29,4 h,P<0,001). Aucune différence intergroupe n’a été observée aux scores de l’EVA obtenus au repos ou pendant le mouvement.
Conclusion: La naloxone péridurale réduit l’hypomotilité intestinale induite par la morphine péridurale sans renverser ses effets analgésiques.
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References
Bonnet F, Vesinet C. How can we improve the efficacy of morphine analgesia without increasing adverse effects? (French) Cah Anesthesiol 1994; 42: 191–4.
Wattwil M, Thorén T, Hennerdal S, Garvill JE. Epidural analgesia with bupivacaine reduces postoperative paralytic ileus after hysterectomy. Anesth Analg 1989; 68: 353–8.
Thörn SE, Wattwil M, Näslund I. Postoperative epidural morphine, but not epidural bupivacaine, delays gastric emptying on the first day after cholecystectomy. Reg Anesth 1992; 17: 91–4.
Choi JH, Lee J, Choi JH, Bishop MJ. Epidural naloxone reduces pruritus and nausea without affecting analgesia by epidural morphine in bupivacaine. Can J Anesth 2000; 47: 33–7.
De Winter BY, Boeckxstaens GE, De Man JG, Moreels TG, Herman AG, Pelckmans PA. Effects of mu- and kappa-opioid receptors on postoperative ileus in rats. Eur J Pharmacol 1997; 339: 63–7.
Frame WT, Allison RH, Moir DD, Nimmo WS. Effect of naloxone on gastric emptying during labour. Br J Anaesth 1984; 56: 263–6.
Schang JC, Devroede G. Beneficial effects of naloxone in a patient with intestinal pseudoobstruction. Am J Gastroenterol 1985; 80: 407–11.
Dahl JB, Rosenberg J, Hansen BL, Hjortsø NC, Kehlet H. Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery. Anesth Analg 1992; 74: 362–5.
Glise H, Lindahl BO, Abrahamsson H. Reflex adrenergic inhibition of gastric motility by nociceptive intestinal stimulation and peritoneal irritation in the cat. Scand J Gastroenterol 1980; 15: 673–81.
Gillan MG, Pollock D. Acute effects of morphine and opioid peptides on the motility and responses of the rat colon to electrical stimulation. Br J Pharmacol 1980; 68: 381–92.
Porreca F, Filla A, Burks TF. Spinal cord-mediated opiate effects on gastrointestinal transit in mice. Eur J Pharmacol 1983; 86: 135–6.
Porreca F, Mosberg HI, Hurst R, Hruby VJ, Burks TF. Roles of mu, delta and kappa opioid receptors in spinal and supraspinal mediation of gastrointestinal transit effects and hot-plate analgesia in the mouse. J Pharmacol Exp Ther 1984; 230: 341–8.
Liu SS, Carpenter RL, Mackey DC, et al. Effects of perioperative analgesic technique on rate of recovery after colon surgery. Anesthesiology 1995; 83: 757–65.
de Leon-Casasola OA, Karabella D, Lema MJ. Bowel function recovery after radical hysterectomies: thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: a pilot study. J Clin Anesth 1996; 8: 87–92.
Hjortsø NC, Neumann P, Frosig F, et al. A controlled study on the effect of epidural analgesia with local anaesthetics and morphine on morbidity after abdominal surgery. Acta Anaesthesiol Scand 1985; 29: 790–6.
Thorén T, Wattwil M. Effects on gastric emptying of thoracic epidural analgesia with morphine or bupivacaine. Anesth Analg 1988; 67: 687–94.
Thorén T, Tanghöj H, Wattwil M, Järnerot G. Epidural morphine delays gastric emptying and small intestinal transit in volunteers. Acta Anaesthesiol Scand 1989; 33: 174–80.
Thörn SE, Wattwil M, Källander A. Effects of epidural morphine and epidural bupivacaine on gastroduodenal motility during the fasted state and after food intake. Acta Anaesthesiol Scand 1994; 38: 57–62.
Scheinin B, Asantila R, Orko R. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery. Acta Anaesthesiol Scand 1987; 31: 161–4.
Thorn SE, Wattwil M, Lindberg G, Sawe J. Systemic and central effects of morphine on gastroduodenal motility. Acta Anaesthesiol Scand 1996; 40: 177–86.
Frederickson RC, Burgis V, Edwards JD. Hyperalgesia induced by naloxone follows diurnal rhythm in responsivity to painful stimuli. Science 1977; 198: 756–8.
Jacob JJ, Tremblay EC, Colombel M-C. Enhancement of nociceptive reactions by naloxone in mice and rats. (French) Psychopharmacologia 1974; 37: 217–23.
Chesher GB, Chan B. Footshock induced analgesia in mice: its reversal by naloxone and cross tolerance with morphine. Life Sci 1977; 21: 1569–74.
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Lee, J., Shim, J.Y., Choi, J.H. et al. Epidural naloxone reduces intestinal hypomotility but not analgesia of epidural morphine. Can J Anaesth 48, 54–58 (2001). https://doi.org/10.1007/BF03019815
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DOI: https://doi.org/10.1007/BF03019815