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Utilización clínica racional de los opioides espinales en el tratamiento del dolor agudo postoperatorio

ALGIA HOSPITAL 09/2007; 2(3):160-171.

ABSTRACT En los últimos 30 años, tras el descubrimiento de los receptores
opioides medulares, la práctica clínica ha conllevado el
uso de fármacos opioides espinales con el propósito de producir
una intensa analgesia desprovista de los efectos adversos
de su utilización sistémica. Existe el concepto erróneo de que
la administración epidural o intratecal de opioides producirá
siempre una analgesia selectiva espinal junto con un menor
riesgo de secundarismos, como la depresión respiratoria. Esta
creencia no es cierta, ya que varios de ellos pueden alcanzar
los centros cerebrales por redistribución sanguínea produciendo
tanto analgesia como efectos adversos. Los estudios demuestran
que la liposolubilidad es inversamente proporcional a su
selectividad medular, siendo ésta mayor para el más fármaco
hidrosoluble, la morfina. El fentanilo es el opioide más recomendable
en cirugía ambulatoria. Parece acontecer un mayor
efecto espinal tras su administración epidural en forma de bolos,
y supraespinal en el modo de infusión continua.

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    ABSTRACT: Opioids are the strongest drugs currently used for the treatment of pain. Over the last 40 years, because of the discovery of the spinal cord opioid receptors, the use of spinal opioids has become a standard for producing intense segmental analgesia without side effects associated with systemic administration. There is a widespread misconcep-tion that any opioid administered epidurally or intrathecally will always produce analgesia by a selective mechanism without central adverse effects. This is simply not true be-cause multiple of these opioids produce analgesia by up-take into the systemic circulation or cerebrospinal fluid (CSF), with subsequent redistribution to brain opioid recep-tors. The findings indicate that increasing lipid solubility de-creases the spinal cord bioavailability, therefore morphine is the most spinally selective opioid currently used in the epidural and intrathecal spaces. Extended release epidural morphine (EREM) utilizes a proprietary liposomal carrier to provide prolonged analgesia without the need for an in-dwelling catheter. Fentanyl is the best option for ambulato-ry surgery and it becomes apparent that epidural fentanyl acts predominantly spinally when administered as a bolus, and predominantly supraspinally as a continuous infu-sion.Epidural methadone and hydromorphone are valid al-ternatives for improve analgesia in the postoperative set-ting. All opioids injected intrathecally can be expected to pro-duce analgesia, at last in part, by a spinal mechanism. The principal difference among opioids is in their duration of analgesic action, speed of re-distribution and the mecha-nism by which the drug reaches brainstem sites. In general, lipophilic opioids produce short durations of action (1-4 hours), which makes them attractive for short-term postop-erative states. However, morphine doses of only 100 to 200 µg produce potent analgesia lasting as long as 24 hours. © 2012 Sociedad Española del Dolor. Published by Arán Ediciones, S.L.
    Revista de la Sociedad Española del Dolor 03/2012; 19(2):72-94.

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