การให้ยามอร์ฟีนทางระบบประสาทส่วนกลางกับการกดการหายใจ
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เผยแพร่แล้ว:
ส.ค. 28, 2020
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การบริหารยาทางระบบประสาทส ่วนกลาง, มอร์ฟีน, โอปิออยด์, ภาวะกดการหายใจ
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บทคัดย่อ
มอร์ฟีนถือเป็นยาที่มีบทบาทอย่างมากในการควบคุม อาการปวดภายหลังการผ่าตัด โดยการบริหารยามอร์ฟีนทาง ระบบประสาทส่วนกลาง(neuraxialopioids) เป็นหนึ่งในวิธี การระงับปวดที่ได้รับการยอมรับและเป็นมาตรฐาน เนื่องด้วย สามารถระงับปวดได้ดีประสิทธิภาพเหนือกว่าการบริหารยา มอร์ฟีนด้วยรูปแบบอื่น ปลอดภัยและลดผลข้างเคียงจากยา เช่น ลดการทำงานของลำไส้(reduction of bowel motility) อย่างไรก็ตามข้อพึงระวังสำหรับการให้ยามอร์ฟีน ได้แก่ภาวะ กดการหายใจ ซึ่งถือเป็นผลข้างเคียงที่รุนแรงถึงแก ่ชีวิต โดยพบอุบัติการณ์อยู่ในช่วงร้อยละ 0-23 จากข้อมูลปัจจุบัน พบว่ากลไกกดการหายใจเกิดจากการกระตุ้นตัวรับโอปิออยด์ บริเวณ ventral medullary area และกลุ ่มประสาท preBotzinger complex บริเวณสมองส่วน medulla ทั้งนี้ อุบัติการณ์ของภาวะกดการหายใจจะเพิ่มขึ้นตามปริมาณ มอร์ฟีนที่ให้และความเสี่ยงที่เกิดจากผู้ป่วย เช่น ผู้ป่วยที่มี โรคนอนกรน โรคอ้วน เป็นต้น ด้วยเหตุนี้แนวทางปฏิบัติ สำหรับการระงับปวดด้วยวิธีนี้จึงแนะนำให้ขนาดยามอร์ฟีน ทางระบบประสาทส่วนกลางในระดับต่ำสุดที่มีประสิทธิภาพ ในการระงับปวด ทั้งนี้อยู่ในช่วง0.075-0.15 มิลลิกรัมทางช่อง ไขสันหลัง(intrathecal) และ2.5-3.75 มิลลิกรัมทางช่องเหนือ ไขสันหลัง(epidural)รวมถึงต้องมีการติดตามผู้ป่วยอย่างต่อ เนื่องและเหมาะสมภายหลังการได้รับยา ทั้งนี้เพื่อป้องกัน ติดตามและรักษาภาวะกดการหายใจได้อย่างทันท่วงท
Article Details
ประเภทบทความ
บทฟื้นฟูวิชาการ
เอกสารอ้างอิง
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postoperative paincontinues to beundermanaged. Anesth
Analg 2003;97:534-40.
2. Pert CB, Snyder SH. Opiate receptor: demonstration in
nervous tissue. Science1973;179:1011-4.
3. Wang JK, NaussLA,Thomas JE. Painrelief by intrathecally
applied morphinein man. Anesthesiology1979;50:149-51.
4. Behar M, Olshwang D, Magora F, et al. Epidural morphine
intreatmentof pain.Lancet1979;313:527-9.
5. DeSousa KA, Chandran R. Intrathecal morphine for
postoperativeanalgesia: Current trends.World J Anesthesiol
2014;3:191-202.
6. DahlJB,JeppesenIS,Jorgensen H,etal. Intraoperativeand
postoperative analgesic efficacy and adverse effects of
intrathecalopioidsin patientsundergoing cesareansection
with spinal anesthesia: a qualitative and quantitative
systematic review of randomized controlled trials.
Anesthesiology1999;91:1919-27.
7. Cohen SE, Woods WA.Theroleofepidural morphineinthe
postcesarean patient: efficacy and effects on bonding.
Anesthesiology1983;58:500-4.
8. Rosaeg OP, Lui AC, Cicutti NJ, et al. Peri-operative
multimodal pain therapy for caesarean section: analgesia
and fitness for discharge. CanJ Anesth1997;44:803-9.
9. StoeltingRK. Intrathecalmorphine-anunderusedcombination
for postoperative pain management. Anesth Analg 1989;
68:707-9.
10. Bujedo BM. Spinal opioid bioavailability in postoperative
pain. Pain Pract2014;14:350-64.
11. Bernards CM, Shen DD, Sterling ES, et al. Epidural,
cerebrospinalfluid,and plasma pharmacokineticsofepidural
opioids(part1): differencesamong opioids. Anesthesiology
2003;99:455-65.
12. Bernards CM, Hill HF. Physical and chemical properties of
drug molecules governing their diffusionthroughthespinal
meninges. Anesthesiology1992;77:750-6.
13. Weddel SJ, Ritter RR. Serum levels following epidural
administration of morphine and correlation with relief of
postsurgical pain. Anesthesiology1981;54:210-4.
14. Moulin DE, Inturrisi CE, Foley KM. Cerebrospinal fluid
pharmacokineticsof intrathecalmorphinesulfateand D-Ala2-
D-Leu5-enkephalin. Annalsofneurology1986;20:218-22.
15. Hanna MH, Peat SJ, Woodham M, et al. Analgesic efficacy
and CSF pharmacokinetics of intrathecal morphine6-glucuronide: comparison with morphine. Br J Anaesth
1990;64:547-50.
16. Davies GK, Tolhurst-Cleaver CL, James TL. Respiratory
depression after intrathecal narcotics. Anaesthesia 1980;
35:1080-3.
17. Nordberg G, HednerT, Mellstrand T,etal. Pharmacokinetic
aspects of intrathecal morphine analgesia. Anesthesiology
1984;60:448-54.
18. Sjostrom S,Tamsen A, Persson MP,etal. Pharmacokinetics
of intrathecal morphine and meperidine in humans.
Anesthesiology1987;67:889-95.
19. Gourlay GK, Cherry DA, Cousins MJ. Cephalad migrationof
morphinein CSFfollowing lumbarepiduraladministrationin
patients withcancer pain. Pain1985;23:317-26.
20. IonescuTI,Taverne RH, Drost RH,etal. Epidural morphine
anesthesia for abdominal aortic surgery-pharmacokinetics.
Reg Anesth1989;14:107-14.
21. Bellanca L, Latteri MT, Latteri S, et al. Plasma and CSF
morphine concentrations after i.m. and epidural
administration. Pharmacol Res Commun1985;17:189-96.
22. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphineand
respiratory depression: finding the right balance. Drugs
2011;71:1807-19.
23. Macintyre PE, Loadsman JA, Scott DA. Opioids, ventilation
and acute pain management. Anaesth Intensive Care
2011;39:545-58.
24. Hurle MA, Mediavilla A, Florez J. Morphine, pentobarbital
and naloxoneintheventral medullarychemosensitiveareas:
differential respiratory and cardiovascular effects.
J Pharmacol Exp Ther1982;220:642-7.
25. Mueller RA,Lundberg DB, Breese GR, HednerJ, HednerT,
Jonason J. The neuropharmacology of respiratory control.
Pharmacol Rev1982;34:255-85.
26. Pokorski M, Grieb P, Wideman J. Opiate system influences
central respiratorychemosensors. Brain Res1981;211:221-6.
27. Li Y, van den Pol AN. Mu-opioid receptor-mediated
depression of the hypothalamic hypocretin/orexin arousal
system. J Neurosci2008;28:2814-9.
28. Sieker HO, Hickam JB. Carbon dioxide intoxication: the
clinical syndrome, its etiology and management with
particular reference to the use of mechanical respirators.
Medicine1956;35:389-423.
29. Overdyk FJ, Hillman DR. Opioid modeling of central
respiratory drive must take upper airway obstruction into
account. Anesthesiology2011;114:219-20.
30. LoadsmanJA, Hillman DR. Anaesthesiaand sleep apnoea.
Br J Anaesth2001;86:254-66.
31. Gustafsson LL, Schildt B, Jacobsen K. Adverse effects of
extradural and intrathecal opiates: report of a nationwide
survey in Sweden1982. Br J Anaesth1998;81:86-93.
32. Stenseth R, Sellevold O, Breivik H. Epidural morphine for
postoperative pain: experience with 1085 patients. Acta
Anaesthesiol Scand 1985;29:148-56.
33. Koren G, Sandler AN, Klein J, et al. Relationship between
the pharmacokinetics and the analgesic and respiratory
pharmacodynamics of epidural sufentanil. Clin Pharmacol
Ther1989;46:458-62.
34. Brockway MS, Noble DW, Sharwood-Smith GH, et al.
Profound respiratory depression after extradural fentanyl.
Br J Anaesth1990;64:243-5.
35. Bujedo BM. Recommendations for spinal opioids clinical
practiceinthe managementof postoperative pain.J Anesth
Clin Res2013;2.
36. Bailey PL, Rhondeau S, Schafer PG, et al. Dose-response
pharmacologyof intrathecal morphineinhumanvolunteers.
Anesthesiology1993;79:49-59.
37. Kafer ER, Brown JT, Scott D, et al. Biphasic depression of
ventilatory responses to CO2 following epidural morphine.
Anesthesiology1983;58:418-27.
38. HorlockerTT, Burton AW, Connis RT,etal. Practice guidelines
for the prevention, detection,andmanagementof respiratory
depressionassociated withneuraxialopioid administration.
Anesthesiology2009;110:218-30.
39. Gehling M, Tryba M. Risks and side-effects of intrathecal
morphinecombined withspinalanaesthesia:ameta-analysis.
Anaesthesia2009;64:643-51.
40. Meylan N, Elia N, Lysakowski C, et al. Benefit and risk of
intrathecal morphine without local anaesthetic in patients
undergoing major surgery: meta-analysis of randomized
trials. Br J Anaesth2009;102:156-67.
41. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and
timing of respiratory depression in 1524 postoperative
patients treated withsystemicorneuraxial morphine. J Clin
Anesth2005;17:537-42.
42. Duale C, Frey C, Bolandard F, et al. Epidural versus
intrathecal morphine for postoperative analgesia after
Caesareansection. Br J Anaesth2003;91:690-4.
43. Sarvela J, Halonen P, Soikkeli A, et al. A double-blinded,
randomized comparisonof intrathecaland epiduralmorphine
forelectivecesarean delivery. Anesth Analg 2002;95:436-40.
44. Ng K, Parsons J, Cyna AM, et al. Spinal versus epidural
anaesthesiaforcaesareansection.CDSR 2004(2):Cd003765.
45. Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg
subarachnoid morphine to hyperbaric bupivacaine for
cesarean delivery: a prospective study of 856 cases. Reg
Anesth1991;16:137-40.
46. Ladha KS, Kato R, Tsen LC, et al. A prospective study of
post-cesarean deliveryhypoxiaafter spinalanesthesia with
intrathecal morphine 150 mg. Int J Obstet Anesth 2017;32:
48-53.
47. Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A
retrospective assessment of the incidence of respiratory
depression after neuraxial morphine administration for
postcesarean delivery analgesia. Anesth Analg 2013;117:
1368-70.
48. Fuller JG, McMorland GH, Douglas MJ, et al. Epidural
morphine for analgesia after caesarean section: a report of
4880 patients. CanJ Anaesth1990;37:636-40.
49. Kato R, Shimamoto H, Terui K, et al. Delayed respiratory
depression associated with 0.15 mg intrathecal morphine
for cesarean section: a review of 1915 cases. J Anesth
2008;22:112-6.
50. Gwirtz KH, Young JV, Byers RS,etal.Thesafetyand efficacy
of intrathecalopioid analgesiaforacute postoperative pain:
seven years’ experience with 5969 surgical patients at
Indiana University Hospital. Anesth Analg 1999;88:599-604.
51. Flisberg P, Rudin A, Linner R, et al. Pain relief and safety
after major surgery. A prospective study of epidural and
intravenous analgesia in 2696 patients. Acta Anaesthesiol
Scand 2003;47:457-65.
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neuraxial morphineforcesarean deliveryanalgesia. Anesth
Analg 2019;129:458-74.
experience: results from a national survey suggest
postoperative paincontinues to beundermanaged. Anesth
Analg 2003;97:534-40.
2. Pert CB, Snyder SH. Opiate receptor: demonstration in
nervous tissue. Science1973;179:1011-4.
3. Wang JK, NaussLA,Thomas JE. Painrelief by intrathecally
applied morphinein man. Anesthesiology1979;50:149-51.
4. Behar M, Olshwang D, Magora F, et al. Epidural morphine
intreatmentof pain.Lancet1979;313:527-9.
5. DeSousa KA, Chandran R. Intrathecal morphine for
postoperativeanalgesia: Current trends.World J Anesthesiol
2014;3:191-202.
6. DahlJB,JeppesenIS,Jorgensen H,etal. Intraoperativeand
postoperative analgesic efficacy and adverse effects of
intrathecalopioidsin patientsundergoing cesareansection
with spinal anesthesia: a qualitative and quantitative
systematic review of randomized controlled trials.
Anesthesiology1999;91:1919-27.
7. Cohen SE, Woods WA.Theroleofepidural morphineinthe
postcesarean patient: efficacy and effects on bonding.
Anesthesiology1983;58:500-4.
8. Rosaeg OP, Lui AC, Cicutti NJ, et al. Peri-operative
multimodal pain therapy for caesarean section: analgesia
and fitness for discharge. CanJ Anesth1997;44:803-9.
9. StoeltingRK. Intrathecalmorphine-anunderusedcombination
for postoperative pain management. Anesth Analg 1989;
68:707-9.
10. Bujedo BM. Spinal opioid bioavailability in postoperative
pain. Pain Pract2014;14:350-64.
11. Bernards CM, Shen DD, Sterling ES, et al. Epidural,
cerebrospinalfluid,and plasma pharmacokineticsofepidural
opioids(part1): differencesamong opioids. Anesthesiology
2003;99:455-65.
12. Bernards CM, Hill HF. Physical and chemical properties of
drug molecules governing their diffusionthroughthespinal
meninges. Anesthesiology1992;77:750-6.
13. Weddel SJ, Ritter RR. Serum levels following epidural
administration of morphine and correlation with relief of
postsurgical pain. Anesthesiology1981;54:210-4.
14. Moulin DE, Inturrisi CE, Foley KM. Cerebrospinal fluid
pharmacokineticsof intrathecalmorphinesulfateand D-Ala2-
D-Leu5-enkephalin. Annalsofneurology1986;20:218-22.
15. Hanna MH, Peat SJ, Woodham M, et al. Analgesic efficacy
and CSF pharmacokinetics of intrathecal morphine6-glucuronide: comparison with morphine. Br J Anaesth
1990;64:547-50.
16. Davies GK, Tolhurst-Cleaver CL, James TL. Respiratory
depression after intrathecal narcotics. Anaesthesia 1980;
35:1080-3.
17. Nordberg G, HednerT, Mellstrand T,etal. Pharmacokinetic
aspects of intrathecal morphine analgesia. Anesthesiology
1984;60:448-54.
18. Sjostrom S,Tamsen A, Persson MP,etal. Pharmacokinetics
of intrathecal morphine and meperidine in humans.
Anesthesiology1987;67:889-95.
19. Gourlay GK, Cherry DA, Cousins MJ. Cephalad migrationof
morphinein CSFfollowing lumbarepiduraladministrationin
patients withcancer pain. Pain1985;23:317-26.
20. IonescuTI,Taverne RH, Drost RH,etal. Epidural morphine
anesthesia for abdominal aortic surgery-pharmacokinetics.
Reg Anesth1989;14:107-14.
21. Bellanca L, Latteri MT, Latteri S, et al. Plasma and CSF
morphine concentrations after i.m. and epidural
administration. Pharmacol Res Commun1985;17:189-96.
22. Sultan P, Gutierrez MC, Carvalho B. Neuraxial morphineand
respiratory depression: finding the right balance. Drugs
2011;71:1807-19.
23. Macintyre PE, Loadsman JA, Scott DA. Opioids, ventilation
and acute pain management. Anaesth Intensive Care
2011;39:545-58.
24. Hurle MA, Mediavilla A, Florez J. Morphine, pentobarbital
and naloxoneintheventral medullarychemosensitiveareas:
differential respiratory and cardiovascular effects.
J Pharmacol Exp Ther1982;220:642-7.
25. Mueller RA,Lundberg DB, Breese GR, HednerJ, HednerT,
Jonason J. The neuropharmacology of respiratory control.
Pharmacol Rev1982;34:255-85.
26. Pokorski M, Grieb P, Wideman J. Opiate system influences
central respiratorychemosensors. Brain Res1981;211:221-6.
27. Li Y, van den Pol AN. Mu-opioid receptor-mediated
depression of the hypothalamic hypocretin/orexin arousal
system. J Neurosci2008;28:2814-9.
28. Sieker HO, Hickam JB. Carbon dioxide intoxication: the
clinical syndrome, its etiology and management with
particular reference to the use of mechanical respirators.
Medicine1956;35:389-423.
29. Overdyk FJ, Hillman DR. Opioid modeling of central
respiratory drive must take upper airway obstruction into
account. Anesthesiology2011;114:219-20.
30. LoadsmanJA, Hillman DR. Anaesthesiaand sleep apnoea.
Br J Anaesth2001;86:254-66.
31. Gustafsson LL, Schildt B, Jacobsen K. Adverse effects of
extradural and intrathecal opiates: report of a nationwide
survey in Sweden1982. Br J Anaesth1998;81:86-93.
32. Stenseth R, Sellevold O, Breivik H. Epidural morphine for
postoperative pain: experience with 1085 patients. Acta
Anaesthesiol Scand 1985;29:148-56.
33. Koren G, Sandler AN, Klein J, et al. Relationship between
the pharmacokinetics and the analgesic and respiratory
pharmacodynamics of epidural sufentanil. Clin Pharmacol
Ther1989;46:458-62.
34. Brockway MS, Noble DW, Sharwood-Smith GH, et al.
Profound respiratory depression after extradural fentanyl.
Br J Anaesth1990;64:243-5.
35. Bujedo BM. Recommendations for spinal opioids clinical
practiceinthe managementof postoperative pain.J Anesth
Clin Res2013;2.
36. Bailey PL, Rhondeau S, Schafer PG, et al. Dose-response
pharmacologyof intrathecal morphineinhumanvolunteers.
Anesthesiology1993;79:49-59.
37. Kafer ER, Brown JT, Scott D, et al. Biphasic depression of
ventilatory responses to CO2 following epidural morphine.
Anesthesiology1983;58:418-27.
38. HorlockerTT, Burton AW, Connis RT,etal. Practice guidelines
for the prevention, detection,andmanagementof respiratory
depressionassociated withneuraxialopioid administration.
Anesthesiology2009;110:218-30.
39. Gehling M, Tryba M. Risks and side-effects of intrathecal
morphinecombined withspinalanaesthesia:ameta-analysis.
Anaesthesia2009;64:643-51.
40. Meylan N, Elia N, Lysakowski C, et al. Benefit and risk of
intrathecal morphine without local anaesthetic in patients
undergoing major surgery: meta-analysis of randomized
trials. Br J Anaesth2009;102:156-67.
41. Shapiro A, Zohar E, Zaslansky R, et al. The frequency and
timing of respiratory depression in 1524 postoperative
patients treated withsystemicorneuraxial morphine. J Clin
Anesth2005;17:537-42.
42. Duale C, Frey C, Bolandard F, et al. Epidural versus
intrathecal morphine for postoperative analgesia after
Caesareansection. Br J Anaesth2003;91:690-4.
43. Sarvela J, Halonen P, Soikkeli A, et al. A double-blinded,
randomized comparisonof intrathecaland epiduralmorphine
forelectivecesarean delivery. Anesth Analg 2002;95:436-40.
44. Ng K, Parsons J, Cyna AM, et al. Spinal versus epidural
anaesthesiaforcaesareansection.CDSR 2004(2):Cd003765.
45. Abouleish E, Rawal N, Rashad MN. The addition of 0.2 mg
subarachnoid morphine to hyperbaric bupivacaine for
cesarean delivery: a prospective study of 856 cases. Reg
Anesth1991;16:137-40.
46. Ladha KS, Kato R, Tsen LC, et al. A prospective study of
post-cesarean deliveryhypoxiaafter spinalanesthesia with
intrathecal morphine 150 mg. Int J Obstet Anesth 2017;32:
48-53.
47. Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A
retrospective assessment of the incidence of respiratory
depression after neuraxial morphine administration for
postcesarean delivery analgesia. Anesth Analg 2013;117:
1368-70.
48. Fuller JG, McMorland GH, Douglas MJ, et al. Epidural
morphine for analgesia after caesarean section: a report of
4880 patients. CanJ Anaesth1990;37:636-40.
49. Kato R, Shimamoto H, Terui K, et al. Delayed respiratory
depression associated with 0.15 mg intrathecal morphine
for cesarean section: a review of 1915 cases. J Anesth
2008;22:112-6.
50. Gwirtz KH, Young JV, Byers RS,etal.Thesafetyand efficacy
of intrathecalopioid analgesiaforacute postoperative pain:
seven years’ experience with 5969 surgical patients at
Indiana University Hospital. Anesth Analg 1999;88:599-604.
51. Flisberg P, Rudin A, Linner R, et al. Pain relief and safety
after major surgery. A prospective study of epidural and
intravenous analgesia in 2696 patients. Acta Anaesthesiol
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