This report describes the use of a continuous intrathecal sufentanil infusion to provide postoperative analgesia after major intraabdominal surgery.
Case Report
A 47-yr-old female with a medical history of ovarian cancer presented for exploratory laparotomy and tumor debulking. She had undergone a laparotomy and debulking procedure in 1991, followed by several courses of chemotherapy. The patient’s medical history was otherwise unremarkable; her only preoperative medication was estrogen replacement. On physical examination, the patient weighed 75 kg and was 165 cm tall. General endotracheal anesthesia was planned for intraoperative management, with an epidural catheter for postoperative pain management.
With the patient in the sitting position, an 18-gauge Touhy needle was advanced under local anesthesia at the T12-L1 interspace; before loss of resistance was noted, clear fluid returned via the Touhy needle, indicating unintentional dural puncture. The needle was withdrawn and repositioned at the L1-2 interspace. After loss of resistance to air, a 20-gauge epidural catheter was easily advanced 5 cm into the epidural space. The patient was returned to a semirecumbent position on the stretcher, and aspiration of the catheter revealed freely flowing clear fluid. One mL of lidocaine 1% was injected via the catheter, with evidence of subarachnoid block. Rather than subject the patient to the risk of a third procedure, it was decided to manage the catheter as an intrathecal catheter.
General anesthesia was induced with IV sodium thiopental 400 mg and fentanyl 250 μ g. The patient’s trachea was intubated easily, and anesthesia was maintained with isoflurane, oxygen, cisatracurium, and fentanyl. At laparotomy, a widely disseminated tumor was found, with dense adhesions involving most of the small bowel, precluding resection. The patient tolerated the procedure well; total blood loss was <200 mL, and intraoperative fluid replacement totaled 3000 mL crystalloid. She received a total of 500 μg IV fentanyl.
Immediately before extubation, 5 μg sufentanil diluted to a total volume of 2 mL with sterile saline was injected via the intrathecal catheter. The patient emerged smoothly, the trachea was extubated, and she was moved to the postanesthesia care unit (PACU) for recovery.
On PACU arrival, the patient’s only complaint was discomfort resulting from the nasogastric tube. A continuous sufentanil infusion (250 μg sufentanil in 250 mL sterile saline, final concentration, 1 μg/mL) was connected to the intrathecal catheter and begun at a rate of 5 μg/h (APM II infusion pump; Abbott Laboratories, Abbott Park, IL). The patient required no further analgesia in the PACU (pain score, 1 on a scale of 0 - 10), and was transferred to an intensive care unit (ICU) 1.5 h after PACU admission. Orders included continuous Sao2 monitoring, and hourly respiratory rate checks. Nasal oxygen, 2 L/m PRN, was ordered to maintain Sao2 more than 92%.
The patient’s recovery was uneventful. She received droperidol 0.625 mg IV for nausea approximately 6 h after PACU discharge. She required no further analgesics until the first postoperative day, when she received a bolus of 5 μg intrathecal sufentanil for complaints of abdominal pain with coughing and deep breathing exercises. Her respiratory rate varied between 18 and 20 breaths/min, Sao2 between 92% and 100%, and pain score at rest between 1 and 2 throughout the duration of the infusion. On the second postoperative day, 45 h after the initial sufentanil bolus, preservative-free morphine, 0.25 mg, was injected via the intrathecal catheter, and the catheter was removed. The total dose of sufentanil infused was 244 μg. She received three doses of diphenhydramine 50 mg IV for pruritus while the sufentanil infusion was running. A mild headache was treated conservatively with oral analgesics and resolved by the fifth postoperative day. She was discharged to home on the sixth postoperative day.
Discussion
Intrathecal sufentanil is an effective analgesic. It has been used as a single injection drug and via continuous infusion for labor analgesia (1–5) and with local anesthetics for spinal anesthesia (6). Few reports have examined intrathecal sufentanil for postoperative analgesia, probably because of its relatively short duration of action (84 min as a labor analgesic) (2). Single injection sufentanil after total hip replacement has been reported (7). A 12 h trial of intrathecal sufentanil via patient-controlled analgesia for postoperative pain (8) reported good analgesia.
Sufentanil is well suited for use via continuous intrathecal infusion for postoperative analgesia for several reasons. First is its efficacy as an analgesic. Second, its rapid onset allows easy titration to individual patient tolerance and the desired clinical endpoint. Third, its short duration of action means that the opioid’s desired analgesic effect will continue as long as the infusion is running; likewise, any undesirable side effects will be short-lived with discontinuation of the infusion.
Potential problems may be associated with intrathecal sufentanil. Pruritus is common, affecting 80–100% of patients (4,9). Nausea has also been reported; although the incidence is much less than pruritus (4,7), it likely varies depending on the population. Nausea was not prominent in this patient, but may have been lessened because of the presence of continuous nasogastric suction.
The most serious side effect of intrathecal sufentanil is respiratory depression, which has been reported in parturients (10–12), and after a single 5 μg bolus (13) in an elderly surgical patient. Respiratory depression after bolus doses occurs shortly after injection, usually within 30 min. There is insufficient information to characterize the risk and nature of respiratory depression during a continuous infusion. In the case reported above, the patient was admitted to an ICU for the duration of the infusion, and was monitored with continuous pulse oximetry and hourly respiratory rate checks. She experienced no clinical respiratory depression. Previous reports indicate that respiratory depression from intrathecal sufentanil is preceded by somnolence (10,13), and desaturation can be avoided with nasal oxygen therapy (14). Until the risk of respiratory depression can be better characterized, patients receiving intrathecal sufentanil infusions should be managed in a setting such as an ICU where close monitoring of respiration is possible.
In summary, a report of the use of a continuous intrathecal sufentanil infusion for postoperative analgesia is presented. In this patient, the infusion provided excellent postoperative analgesia for intraabdominal surgery with minimal side effects. Although greater experience with the technique is necessary to characterize its risks and benefits, the technique canbe considered for use in appropriate patients and circumstances.
References
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