Article Notes

Cisatracurium has the lowest risk of anaphylaxis of all non-depolarising neuromuscular blocking drugs.

  Daniel Jolley

In Australia and New Zealand rocuronium is associated with a higher risk of anaphylaxis when compared to vecuronium or the benzylisoquinolinium NMBDs. This is not the case in North America or Europe.

  Daniel Jolley

Intraoperative parecoxib 40mg reduces postoperative shivering, comparable to tramadol.

  Daniel Jolley

Why is this important?

Despite growth of regional and non-opioid analgesic options, opioids remain the mainstain of peri-operative management of moderate to severe pain. IV patient-controlled analgesia (PCA) is a safe, common and reliable delivery mechanism.

What did they do?

Dinges et al. performed a network meta-analysis of 63 studies covering 16 different PCA opioids, comparing side-effects at equianalgesic doses. Morphine was used as the baseline comparator.

And they found?

Although there were some small difference in the incidence of nausea & vomiting (fentanyl having lowest N&V risk, buprenorphine highest) and pruritus (nalbuphine, butorphanol, methadone, and pethidine/meperidine resulting in least pruritis), there were significant differences for sedation and satisfaction.

Pethidine/meperidine, fentanyl & oxymorphone showed the lowest sedation scores, although respiratory depression events were too infrequent to show differences. Oxycodone, alfentanil, remifentanil, fentanyl & pethidine/meperidine resulted in the highest patient satisfaction and tramadol was the least satisfying.

Take-home message

Although some PCA-opioids perform better than others in small ways, overall side-effect profiled are very similar and comparably safe. Oxycodone, alfentanil and remifentanil however result in significantly higher patient satisfaction.

The big picture...

Rather than focusing on the small differences among opioids, there is almost certainly more to be gained by a disciplined, multi-modal analgesic focus that reduces opioid use and thus side-effects.

  Daniel Jolley

Fentanyl PCA has a slightly lower incidence of nausea & vomiting than other opioids.

  Daniel Jolley

Tramadol when delivered by PCA results in significantly lower patient satisfaction than other opioids.

  Daniel Jolley

Oxycodone, alfentanil and remifentanil PCAs result in significantly higher patient satisfaction than other opioids, although side-effect profiles are similar.

  Daniel Jolley

Restrictive fluid management intraoperatively in liver transplantation does not appear to reduce kidney injury or mortality, but may modestly reduce pulmonary complications and duration of mechanical ventilation.

  Daniel Jolley

Although suprascapular nerve block reduces nausea & vomiting and improves patient satisfaction after shoulder surgery when compared to morphine alone, it results only in clinically insignificant objective improvement of analgesia.

  Daniel Jolley

Although there is some evidence that ketamine may reduce emergence delirium in children, it is generally low quality and inconsistent, and practice change is not recommended.

  Daniel Jolley