Dose–response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery

Batra, Yatindra Kumar; Lokesh, V.; Panda, Nidhi; Rajeev, Subramanyam; Rao, K. L. N.

doi:10.1111/j.1460-9592.2008.02613.x

Cited by 21 publications

(20 citation statements)

References 26 publications

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“…1) Intrathecal morphine has been used in children following major surgery for many years, administered either as a single bolus55,93,94 or via continuous infusion;95,96 and intrathecal morphine has also been administered to neonates and infants following cardiac surgery17,18,97,98 and major craniofacial surgery99. 2) The use of spinal anesthesia in neonates and infants is increasing14 and the limited duration of action of local anesthesia may be improved by co-administration with spinal opioid19. 3) Although there have been no direct comparisons of dose-response via the two routes, higher bolus doses (15–50 mcg morphine) are administered epidurally/caudally in children11, whereas 4–5 mcg/kg morphine is effective following intrathecal delivery53–55, suggesting that similar target concentrations in the cord are required to achieve analgesia and thus have potential for toxicity regardless of whether initial administration is epidural or intrathecal.…”

Section: Discussionmentioning

confidence: 99%

“…Neonatal spinal anesthesia is increasing in many centres14, but clinical utility is limited by the duration of action of spinal local anesthetics15,16. Addition of spinal analgesics such as opioids,17–19 clonidine,20,21 and neostigmine22 have been used in infants to extend the duration of anesthesia and/or enhance postoperative analgesia. While the virtues of spinally administered analgesics and local anaesthetics to control pain during and after surgery are evident, performance of regional anesthesia in healthy children must require demonstration of a high therapeutic ratio23.…”

Section: Introductionmentioning

confidence: 99%

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Validation of a Preclinical Spinal Safety Model

et al. 2010

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Background Preclinical studies demonstrate increased neuroapoptosis after general anesthesia in early life. Neuraxial techniques may minimize potential risks, but there has been no systematic evaluation of spinal analgesic safety in developmental models. We aimed to validate a preclinical model for evaluating dose-dependent efficacy, spinal cord toxicity, and long term function following intrathecal morphine in the neonatal rat. Methods Lumbar intrathecal injections were performed in anesthetized rats aged postnatal day (P)3, 10 and 21. The relationship between injectate volume and segmental spread was assessed post mortem and by in-vivo imaging. To determine the antinociceptive dose, mechanical withdrawal thresholds were measured at baseline and 30 minutes following intrathecal morphine. To evaluate toxicity, doses up to the maximum tolerated were administered, and spinal cord histopathology, apoptosis and glial response were evaluated 1 and 7 days following P3 or P21 injection. Sensory thresholds and gait analysis were evaluated at P35. Results Intrathecal injection can be reliably performed at all postnatal ages and injectate volume influences segmental spread. Intrathecal morphine produced spinally-mediated analgesia at all ages with lower dose requirements in younger pups. High dose intrathecal morphine did not produce signs of spinal cord toxicity or alter long-term function. Conclusions The therapeutic ratio for intrathecal morphine (toxic dose / antinociceptive dose) was at least 300 at P3, and at least 20 at P21 (latter doses limited by side effects). This data provides relative efficacy and safety data for comparison with other analgesic preparations and contributes supporting evidence for the validity of this preclinical neonatal safety model.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Validation of a Preclinical Spinal Safety Model

et al. 2010

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“…Low-dose intrathecal fentanyl (such as 0.2 μg kg −1 body weight) enhances the quality and extends the duration of spinal anaesthesia [59]. When used at high doses, fentanyl and morphine can give rise to a risk of delayed respiratory depression.…”

Section: Adjuncts To Local Anaesthetics In Paediatric Spinal Anaesthesiamentioning

confidence: 99%

Spinal Anaesthetic Management in Paediatric Surgery

Caliskan¹

2017

Pediatric and Neonatal Surgery

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The first paediatric cases involving the use of spinal anaesthesia were published at the end of the nineteenth century. However, the technique did not receive much interest in paediatric anaesthesia until the 1980s. In the last three decades, paediatric spinal anaesthesia has received widespread approval as an alternative technique to general anaesthesia in school-/preschool-aged children, particularly in term and preterm neonates with high risk associated with general anaesthesia. The development of new and safer local anaesthetics mainly through better understanding of the pharmacokinetics and dynamics and dedicated paediatric tools are the keys to this success. Paediatric spinal anaesthesia is an easy and effective technique, and its high efficiency and safety are supported by the presence of numerous publications from the medical literature. However, it remains limited to situations in which general anaesthesia poses a major risk. Despite these advances, it is important to understand the correct technique and the anatomy of children at different ages. Also, the appropriate equipment, the pharmacokinetics and toxicities of local anaesthetics and the indications and complications of paediatric regional blocks should be well known. The goal of this chapter is to review and discuss some of these topics of paediatric spinal anaesthesia for paediatric surgery.

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“…In infants undergoing lower abdominal and urological surgery, addition of fentanyl 1 mcg/kg (but not lower doses) to intrathecal local anaesthetic prolonged the duration of analgesia and reduced supplemental analgesic requirements (Batra et al, 2008 Level II).…”

Section: Intrathecal Opioidsmentioning

confidence: 99%

“…Rapid redistribution contributes to offset of action, fentanyl is metabolised by CYP3A4 to inactive metabolites, and clearance is only 70-80% of adult levels in neonates but rapidly matures (Tibboel et al, 2005). Fentanyl has been administered by multiple routes for perioperative pain management in neonates (Simons & Anand, 2006) and children , including: IV infusion or PCA (Antila et al, 2006 Level II; Butkovic et al, 2007 Level III-1); intrathecal (Batra et al, 2008 Level II) injection; epidural infusion (Lerman et al, 2003 Level II) and patient-controlled epidural analgesia (PCEA) (Saudan et al, 2008 Level III-3). Prolonged IV infusion of fentanyl during neonatal intensive care has been associated with more rapid dose escalation than morphine, but both can produce opioid withdrawal symptoms following rapid cessation (Simons & Anand, 2006).…”

Section: Fentanylmentioning

confidence: 99%

Safety of opioid patch initiation in Australian residential aged care

Gadzhanova

Roughead

Pont

2015

Medical Journal of Australia

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Objective: To explore opioid use by aged care facility residents before and after initiation of transdermal opioid patches. Design: A cross‐sectional cohort study, analysing pharmacy data on individual patient supply between 1 July 2008 and 30 September 2013. Setting: Sixty residential aged care facilities in New South Wales. Participants: Residents receiving an initial opioid patch during the study period. Main outcome measure: The proportion of residents who were opioid‐naive in the 4 weeks prior to patch initiation was determined. In addition, the patch strength at initiation and the daily dose of transdermal patches and of additional opioids 1 month after initiation were determined. Results: An opioid patch was initiated in 596 of 5297 residents (11.3%: 2.6% fentanyl, 8.7% buprenorphine) in the 60 residential aged care facilities. The mean age at initiation was 87 years, and 74% of the recipients were women. The proportion of recipients who were opioid‐naive before patch initiation was 34% for fentanyl and 49% for buprenorphine. Most were initiated at the lowest available patch strength, and the dose was up‐titrated after initiation. Around 15% of fentanyl users and 10% of buprenorphine users needed additional regular opioids after patch initiation. Conclusions: The results suggest some inappropriate initiation of opioid patches in Australian residential aged care facilities. Contrary to best practice, a third of residents initiated on fentanyl patches were opioid‐naive in the 4 weeks before initiation.

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Dose–response study of intrathecal fentanyl added to bupivacaine in infants undergoing lower abdominal and urologic surgery

Abstract: The addition of 1 mug.kg(-1) IT fentanyl to spinal bupivacaine prolonged the duration of spinal block in infants undergoing lower abdominal and urologic procedures.

Cited by 21 publications

References 26 publications

Validation of a Preclinical Spinal Safety Model

Validation of a Preclinical Spinal Safety Model

Spinal Anaesthetic Management in Paediatric Surgery

Safety of opioid patch initiation in Australian residential aged care

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