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Review
. 2020 Sep;125(3):358-372.
doi: 10.1016/j.bja.2020.05.061. Epub 2020 Jul 11.

Intrathecal hydrophilic opioids for abdominal surgery: a meta-analysis, meta-regression, and trial sequential analysis

Mark V Koning  1 , Markus Klimek  2 , Koen Rijs  2 , Robert J Stolker  2 , Michael A Heesen  3
Affiliations
Review

Intrathecal hydrophilic opioids for abdominal surgery: a meta-analysis, meta-regression, and trial sequential analysis

Mark V Koning et al. Br J Anaesth. 2020 Sep.

Abstract

Background: Intrathecal hydrophilic opioids decrease systemic opioid consumption after abdominal surgery and potentially facilitate enhanced recovery. A meta-analysis is needed to quantify associated risks and benefits.

Methods: A systematic search was performed to find RCTs investigating intrathecal hydrophilic opioids in abdominal surgery. Caesarean section and continuous regional or neuraxial techniques were excluded. Several subgroup analyses were prespecified. A conventional meta-analysis, meta-regression, trial sequential analysis, and provision of GRADE scores were planned.

Results: The search yielded 40 trials consisting of 2500 patients. A difference was detected in 'i.v. morphine consumption' at Day 1 {mean difference [MD] -18.4 mg, (95% confidence interval [CI]: -22.3 to -14.4)} and Day 2 (MD -25.5 mg [95% CI: -30.2 to -20.8]), pain scores at Day 1 in rest (MD -0.9 [95% CI: -1.1 to -0.7]) and during movement (MD -1.2 [95% CI: -1.6 to -0.8]), length of stay (MD -0.2 days [95% CI: -0.4 to -0.1]) and pruritus (relative risk 4.3 [95% CI: 2.5-7.5]) but not in nausea or sedation. A difference was detected for respiratory depression (odds ratio 5.5 [95% CI: 2.1-14.2]) but not when two small outlying studies were excluded (odds ratio 1.4 [95% CI: 0.4-5.2]). The level of evidence was graded as high for morphine consumption, in part because the required information size was reached.

Conclusions: This study showed important opioid-sparing effects of intrathecal hydrophilic opioids. Our data suggest a dose-dependent relationship between the risk of respiratory depression and the dose of intrathecal opioids. Excluding two high-dose studies, intrathecal opioids have a comparable incidence of respiratory depression as the control group.

Clinical trial registration: PROSPERO-registry: CRD42018090682.

Keywords: analgesics; enhanced recovery; intrathecal; laparoscopy; laparotomy; opioids; spinal injections.

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Figures

Fig 1
Fig 1
Flow diagram of study selection.
Fig 2
Fig 2
Risk of bias assessment for included studies.
Fig 3
Fig 3
Forest plot of (a) morphine-equivalent consumption after 24 h and (b) 48 h. CI, confidence interval; SD, standard deviation.
Fig 4
Fig 4
Contour-enhanced funnel plot of A. 24 hour morphine equivalent consumption and B. pain score at rest after 24 hours. NRS, numeric rating scale.
See this image and copyright information in PMC

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