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      Comportamiento de la dosis intradural de fentanil en el paciente geriátrico: Its behavior in elderly patients Translated title: Intradural doses of Phentanyl

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          Abstract

          Introducción: El fentanilo es uno de los fármacos más usados para producir analgesia tras su administración intratecal, especialmente asociado a anestésicos locales. La disminución del dolor postoperatorio es la piedra angular de una evolución adecuada pues se ha observado que este solo hecho reduce problemas en diferentes órganos y sistemas, especialmente en el paciente anciano. Objetivos: Determinar el comportamiento de la dosis intradural de fentanilo asociado a bupivacaina en el paciente anciano. Material y Método: Se realizó un estudio observacional, prospectivo, de casos control, en 100 pacientes. Se conformaron cuatro grupos con 25 pacientes en cada uno, procediéndose de la siguiente manera: Grupo A: no se empleo fentanil. Grupo B: 12.5 µg de fentanil. Grupo C: 25 µg de fentanil. Grupo D: 50 µg de fentanil. En todos los grupos se empleó bupivacaina al 0.5% 7.5 miligramos como anestésico local. Las variables utilizadas fueron; edad, sexo, tipo de cirugía, efectos adversos o complicaciones intraoperatorias y analgesia postoperatoria. Resultados: Fue frecuente el grupo de edades entre 60 y 70 años. No existió diferencia significativa en cuanto al sexo, la cirugía ortopédica de miembros inferiores y la urológica fueron frecuentes en igual número, los efectos adversos y complicaciones se observaron en la medida en que se fue incrementando la dosis de fentanil, el prurito, la somnolencia y la bradicardia fueron los que mas incidieron, no se presento en ninguno de los pacientes depresión respiratoria, vómitos, ni retención urinaria. Conclusiones: La calidad de la analgesia se incremento en la medida en que se aumento la dosis de Fentanil.

          Translated abstract

          Introduction: Phentanyl if one of the more used drugs to produce analgesia after its intrathecal administration, especially in association with local anesthetics. Decrease of postoperative pain is the rule of a proper evolution since it is observed that this only fact reduce problems in different organs and systems, especially in elderly patient. Objectives: To determine behavior of intradural dose of Phentanyl associated to Bupivacaine in these patients. Material and Methods: We performed a prospective observational study of index cases in 100 patients. Four groups were created including 25 patients each, proceeding as follow: Group A: no-Phentanyl. Group B: 12.5 ?g of Phentanyl. Group C: 25 ?g of Phentanyl. Group D: 50 ?g of Phentanyl. In all groups we used Bupivacaine (0.5%-7.5 mg) as local anesthetic. Variable used were: age, sex, surgery, side effects or intraoperative complications and postoperative analgesia. Results: The more frequent age group was between 60 and 70 years. There wasn't a significant difference regards sex; orthopedic surgery of lower limbs, and the urologic one were the more frequent in a similar number, side effects and complications were seen according to an increase in Phentanyl dose; pruritus, drowsiness and bradycardia had the greatest incidence. There wasn't respiratory depression, vomiting and urinary retention. Conclusions:Analgesia quality was increased according to a rise of Phentanyl dose.

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          Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil.

          Despite widespread use, little is known about the comparative pharmacokinetics of intrathecally administered opioids. The present study was designed to characterize the rate and extent of opioid distribution within cerebrospinal fluid, spinal cord, epidural space, and systemic circulation after intrathecal injection. Equal doses of morphine and alfentanil, fentanyl, or sufentanil were administered intrathecally (L3) to anesthetized pigs. Microdialysis probes were used to sample cerebrospinal fluid at L2, T11, T7, T3, and the epidural space at L2 every 5-10 min for 4 h. At the end of the experiment, spinal cord and epidural fat tissue were sampled, and each probe's recovery was determined in vitro. Using SAAM II pharmacokinetic modeling software (SAAM Institute, University of Washington, Seattle, WA), the data were fit to a 16-compartment model that was divided into four spinal levels, each of which consisted of a caternary arrangement of four compartments representing the spinal cord, cerebrospinal fluid, epidural space, and epidural fat. Model simulations revealed that the integral exposure (area under the curve divided by dose) of the spinal cord (i.e., effect compartment) to the opioids was highest for morphine because of its low spinal cord distribution volume and slow clearance into plasma The integral exposure of the spinal cord to the other opioids was relatively low, but for different reasons: alfentanil has a high clearance from spinal cord into plasma, fentanyl distributes rapidly into the epidural space and fat, and sufentanil has a high spinal cord volume of distribution. The four opioids studied demonstrate markedly different pharmacokinetic behavior, which correlates well with their pharmacodynamic behavior.
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            The role of intrathecal drugs in the treatment of acute pain.

            Intrathecal opioids are widely used as useful adjuncts in the treatment of acute and chronic pain, and a number of non-opioid drugs show promise as analgesic drugs with spinal selectivity. In this review we examine the historical development and current use of intrathecal opioids and other drugs that show promise for treating pain in the perioperative period. The pharmacology and clinical use of intrathecal morphine and other opioids is reviewed in detail, including dosing guidelines for specific surgical procedures and the incidence and treatment of side effects associated with these drugs. Available data on the use of non-opioid drugs that have been tested intrathecally for use as analgesics are also reviewed. Evidence-based guidelines for dosing of intrathecal drugs for specific surgical procedures and for the treatment of the most common side effects associated with these drugs are presented.
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              Recent insights into the pharmacokinetics of spinal opioids and the relevance to opioid selection.

              Spinal opioid administration was introduced into clinical practice nearly 25 years ago in the hope of producing intense spinal analgesia that was devoid of the dose-limiting side effects associated with systemic opioid administration. While spinal opioid administration can clearly be an effective analgesic technique, there is a widespread misconception that any opioid administered epidurally or intrathecally will produce analgesia by a selective spinal mechanism. This is simply not true; multiple opioids that are commonly administered spinally produce analgesia by uptake into the systemic circulation with subsequent redistribution to brainstem opioid receptors. In an effort to help clinicians understand why some opioids are not suitable for selective spinal analgesia, this review describes recent insights into the fate of intrathecally and epidurally administered opioids. A series of animal studies published over the last 4 or more years have provided the first measurements of opioid concentration in the epidural space, intrathecal space, spinal cord and peri-spinal tissues following intrathecal and epidural opioid administration. These studies characterize, for the first time, the factors governing the rate and extent to which different opioids redistribute from the epidural and intrathecal spaces to reach target opioid receptors in the spinal cord dorsal horn. The findings indicate that increasing lipid solubility decreases the spinal cord bioavailability of spinally administered opioids. These animal data help to explain multiple clinical studies that have demonstrated that the analgesic effect of spinally administered lipid-soluble opioids is due in part, if not exclusively, to uptake into plasma and distribution to brainstem opioid receptors.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Journal
                scar
                Revista Cubana de Anestesiología y Reanimación
                Rev cuba anestesiol reanim
                Editorial Ciencias Médicas (Ciudad de la Habana )
                1726-6718
                April 2009
                : 8
                : 1
                : 0
                Affiliations
                [1 ] Hospital Universitario Manuel Ascunce Domenech Cuba
                Article
                S1726-67182009000100003
                c69a6498-749e-438c-826e-505b992855d0

                http://creativecommons.org/licenses/by/4.0/

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                SciELO Cuba

                Self URI (journal page): http://scielo.sld.cu/scielo.php?script=sci_serial&pid=1726-6718&lng=en
                Categories
                ANESTHESIOLOGY

                Anesthesiology & Pain management
                Geriatric anesthesia,Intradural Phentanyl,Anestesia geriátrica,Fentanil intradural

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