A Comparison of a Fentanyl, Morphine, and Hydromorphone Patient-Controlled Intravenous Delivery for Acute Postoperative Analgesia: A Multicenter Study of Opioid-Induced Adverse Reactions

Abstract

Patient-controlled analgesia (PCA) is a widely used delivery system for intravenous (IV) administration of opioids during acute post-operative pain management. Various opioids have been used for IV PCA including morphine, meperidine, hydromorphone, and fentanyl. Morphine is by far the most commonly used opioid in this setting, yet the selection of morphine as the primary opioid is based largely on tradition. Meperidine should not be considered in the PCA armamentarium due to the associated risk of central nervous system toxicity from its metabolite normeperidine. The objective of this study is to compare the rate of opioid-induced adverse reactions among three IV PCA opioids, fentanyl, morphine, and hydromorphone, in acute post-operative pain management. Although morphine is the most frequently used opioid, the results from three US hospitals indicate that fentanyl IV PCA had a significantly lower rate of common opioid induce adverse reactions (nausea/vomiting, pruritus, urinary retention, or sedation), when compared to IV PCA morphine and hydromorphone in acute post-operative pain management. The median pain score on post-operative day-1 and -2 was significantly lower in fentanyl IV PCA group. The quantity of opioid in each group was not significantly different when converted to an analgesic equivalence. Morphine and hydromorphone IV PCA were no different in rates of adverse reactions in any area; although, the hydromorphone group trended toward a lower pruritus and urinary retention rate compared to morphine, but this was not statistically significant. The rate of respiratory depression was not significantly different between the three opioids. Fentanyl IV PCA is an under used opioid for post-operative acute-pain management and should be considered more often due to the lower adverse reaction profile.

A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty

“…Other analgesic techniques, such as epidural infusions and continuous femoral blocks, may also be used [8]. However, multimodal analgesia has been established as the preferred method for postoperative pain control [9,10], and studies have shown that multimodal analgesia that includes infiltration of a local anesthetic administered during total knee arthroplasty provides better postsurgical pain control than monotherapy-based regimens. This approach is also associated with a reduction in the use of opioid analgesics, leading to fewer opioidrelated adverse events (AEs) [8,[11][12][13][14] such as respiratory depression, hypotension, nausea, vomiting, central nervous system depression, pruritus, and constipation.…”

Bupivacaine Extended-Release Liposome Injection for Prolonged Postsurgical Analgesia in Patients Undergoing Hemorrhoidectomy: A Multicenter, Randomized, Double-blind, Placebo-controlled Trial

“…Although they are effective, opioids have drawbacks that include respiratory depression, hypotension, nausea, vomiting, central nervous system depression, pruritus, and constipation. 15,16 Concerns about opioid-related complications can result in substantial undertreatment of acute pain and inappropriate postsurgical pain management. [17][18][19][20][21][22][23][24][25] A local analgesic providing adequate postsurgical pain relief for a longer duration than currently available agents could be a useful therapeutic option for the management of postsurgical pain.…”

Patient-Controlled Analgesia (PCA) in Acute Pain: Pharmacological and Clinical Aspects

“…The major drugs used in this system are the opioid analgesics, such as morphine, hydromorphone, fentanyl, sufentanil and tramadol [31]. Meperidine is no longer considered a valid option for PCA as its toxic metabolite may be accumulated, especially in patients with abnormal kidney function [32].…”

“…As the M6G has renal elimination, the use of morphine should be done with caution in patients with impaired renal function and the elderly [34,35]. The low therapeutic index of morphine in IV-PCA was shown in preclinical models, indicating that morphine cannot be the best option for all patients for pain relief in the postoperative period [31].…”