Multimodal anesthesia for spinal surgery

1. Multimodal anesthesia
Upper Chesapeake Medical Center Spine Conference
Friday July 7th, 2017

2. An unpleasant sensation occurring in varying degrees of severity as a consequence of injury,
disease, or emotional disorder

3. pain
• Definition: an internal
and personal
phenomenon
consisting of an
unpleasant sensory
and emotional
experience. This
experience is
associated with actual
or potential tissue
damage or described
in terms of such
damage
3

4. Visual analogue scale
4

7. 7

8. 8
Endogenous morphine
Secreted in response to pain, strenous exercise, orgasm or excitement

9. Opium poppy
fruit latex from
cut
• Opium poppy fruit exuding latex from a cut
• BotanicalOpium
• Source plant(s) Papaver somniferum
• Part(s) of plant latex
• Geographic origin Indochina
• Active ingredients Morphine, Codeine
• Main producers Afghanistan
(primary), Pakistan, Northern India,
Thailand, Laos, Myanmar, Mexico,
Colombia, Hungary
• Main consumers worldwide (#1: U.S.)
9

10. opioids
1. Cortex: analgesia, euphoria,
sedation, addiction
2. Hypothalamus/Pituatary:
decrease testosterone
3. Brainstem: N/V, Mioisis,
respiratory depression
4. SC: analgesia
5. GI: gastroparesis, decreased
peristalsis
6. UG: increased tone ureter,
detrussor, urinary sphincter
7. CVS: decreased peripheral
resistance, decreased HR
10

11. Friedrich Wilhelm Adam Sertürner 1804
• 1783-
1841
• isolated morphine from
opium in 1804 and sold
it in 1817
• first
person to
isolate
the active
ingredient
associate
d with a
medicinal
plant or
herb
11

12. MORPHEUS
• God of dreams
12
Morpheus: greek god
Of dreams

13. 13
Gold standard
Natural substance
Acts on CNS
Gastric emptying/peristalsis
Heroin is a precursor
Morphine/heroin most addictive
Psychological and physical dependence
Tolerance
analgesia, sedation, euphoria, physical dependence, and respiratory depression
Peak Levels: IV/SQ 20 min PO 30 min
Metabolized in liver
Controlled substance Harrison Narcotic Tax Act of 1914

14. heroin
• Diacetylmorphine discovered 1874 from morphine commercially
available in 1898 Bayer
• 1.5-2 times more potent than morphine
• Lipid soluble therefore crosses BBB faster more addictive
• Overtook morphine for choice drug of abuse once available
14

16. oxycodone
• OxyContin is Purdue Pharma slow release
oxycodone
• Opioid synthesized in Germany 1916 thought to
replace Heroin/Morphine
• High risk of withdrawal
• Peak plasma level one hour, 10 min onset
• Excreted in urine/sweat watch for CRI
• 50% weaker than Morphine
• Abuse potential for snorting unlike Morphine and
Heroin (must be injected)
• Less stigma involved than Heroine/morphine
• Street price $1 per mg
• Percocet: Endo pharmaceuticals
16

17. 17
MORPHINE WITHDRAWAL
-14 hours Drug craving, anxiety, irritability, perspiration, and mild to moderate dysphoria
4-18 hours Yawning, heavy perspiration, mild depression lacrimation, crying, running nose, dysphoria
16-24 hours Rhinorrhea, dilated pupils, piloerection (gooseflesh), muscle twitches, hot flashes, cold flashes, achi
muscles, loss of appetite and the beginning of intestinal cramping.
24-36 hours severe cramping and involuntary leg movements “kick the habit”, loose stool, insomnia, elevation of
sure, moderate elevation in body temperature, increase in frequency of breathing and tidal volume, tachycardia
e), restlessness, nausea
6-72 hours fetal position, vomiting, free and frequent liquid diarrhea
AL 7-10 days
CHOLOGICAL: severe depression, anxiety, insomnia, mood swings, amnesia (forgetfulness), low self-esteem, conf
anoia

19. A paradoxical response whereby the patient receiving opioids for the treatment of
pain can become more sensitive to certain painful stimuli

20. 20
Cold pressor test:
methadone
People are sensitive

22. Opiate adverse effects
postoperatively
Constipation
Hyperalgesia
Confusion
Respiratory depression
Urinary dysfunction
Tolerance
Nausea
Light headedness

23. 23

32. Inflammation:
Pain
Redness
Swelling
heat

33. Side
effects
spine
Non-union
Platelet function

35. Neuromodulating
agents
Gabapentin: 1200 mg 1 hour preop?
renal issues
Pregabalin: 150 mg 1 hour preop
Decreased opiate use, continue for one
Week postop

38. 600 mg optimal dose for
gabapentin?

39. Neuroaxial blockade
• Epidural/intrathecal
opioids
• Respiratory depression
• Direct steroidal
application to inflamed
root

40. 4g /day

43. Fatty liver in obesity

44. 200/500mg

45. options
• Celebrex 200mg
• Gabapentin/pregabalin
• Extended release oxycodone
• Acetaminophen
• Lidocaine
• Ketamine?
• Clonidine?
• Tramadol
• steroids

46. THANKS!

52. • Some pain can
be experienced
as a pleasant
experience i.e.
Dominatrix
52

54. Hypodermic needle 1857
54

55. 55
Merck of Darmstadt, Germany 1827
commercial Morphine sold out of a
single chemist’s shop

57. Alcohol tolerance

58. Controlled substances
act 1970
• Schedules for “potential of abuse”
• I:high potential no accepted medical use: Heroin,
Marijuana?, psychotropic mushrooms
• II: high potential for abuse but accepted for
medical use: cocaine, ritalin, oxycodone, morphine,
methadone, fentanyl, dilaudid, nucynta; no refills
• III: less potential: hydrocodone with another drug;5
refills
• IV: low potential: xanax, valium, ambien
• V: lower: lyrica, cough suppressant, lomotil
58

59. 59
3 Methyl Morphine or Codeine
Less potent than morphine and less dependency issues and withdrawal symptoms
1832 in France by Pierre Robiquet
Most widely used opiate in the world
In some countries it is available without prescription in combination preparations from
licensed pharmacists in doses up to 15 mg/tablet in Australia, New Zealand, Poland,
Romania (Codamin), and Costa Rica, 12.8 mg/tablet in the UK, 10 mg/tablet in Russia and
Israel and 8 mg/tablet in Canada and Estonia

60. 60