Skip to main content

Rebound Pain after Dialysis...Searching for NON Dialyzable Opioid



Today I was covering the acute pain service...i had a case of 81 y/o female patient with ESRD and Lymphoma...she was maintained on Duragesic patch 25mcg..we are consulted because she is suffering of severe chest and back pain during dialysis.."yes it is Rebound pain"..a well known phenomenon that occurs when opioids get dialyzed ...SO i thought How to manage..and what opioid that will stay in during dialysis...



Here is what I found:


The factors that determine whether or not a drug is filtered during dialysis are

the molecular weight (MW) of the compound and

its degree of protein binding,

volume of distribution (VD),

and solubility (WS)



Molecules less likely to be removed by dialysis have low MW and WS, are highly protein bound, and have a high VD.

 Using these criteria, one would anticipate that morphine, a drug of relatively low protein binding and moderate WS, would be removed by dialysis

 Whereas methadone with its high protein binding, high VD, and low MW would not be removed.

 Fentanyl and sufentanil are highly protein bound, with low WS and a high VD. Therefore, these drugs should not be removed during dialysis.

 This what is written in literature..but as you see in our case although she was maintained on Duragesic patch or Fentanyl patch..the above rule didn’t apply and withdrawal happened..
a very similar case scenario reported Fentanyl withdrawal during and after dialysis !! Click Here

What i want to suggest is, contrary to the published literature, lipophilic opioids may be removed by dialysis and hence may not provide effective pain relief. This may have been the result of the particular dialyzer membrane used, as fentanyl has been shown to be dialyzable with some membranes but not others.

As it takes a finite period of time for serum and central nervous system opioid levels to reach
an efficacious level following dialysis, the only appropriate drug to use in chronic pain is one that is not removed by dialysis. Methadone may have been a more appropriate opioid to use earlier in this case. There is some evidence to suggest that it is poorly removed by dialysis.


Bastani B, Jamal JA. Removal of morphine but not fentanyl during haemodialysis [letter].
Nephrol Dial Transplant 1997;12:2804

Joh J, Sila MK, Bastani B. Nondialyzability of fentanyl with high-efficiency and high-flux membranes. [letter]. Anesth Analg 1998;86:447.

Furlan V, Hafi A, Dessalles MC, et al. Methadone is poorly removed by haemodialysis.
 Nephrol Dial Transplant 1999;14(1):254e255

Labels:

Comments

Post a Comment

Popular posts from this blog

power injectable peripherally inserted central catheters

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients     Introduction In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters . Method We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications ...
1 comment
Read more

Things to Avoid in Anesthesia for Pregnant with Pulmonary hypertension

Anesthesia for Pregnant woman with Pulmonary Hypertension is a real challenge for anesthesiologist. It is very crucial to remember the pathophysiology of pulmonary hypertension in pregnant women and to avoid some practices that will worsen the cardiac status. 1-Avoid single shot spinal anesthesia. Some authorities consider pulmonary hypertension as absolute contraindication for single shot spinal anesthesia specially in patients with NYHA III ,IV. Spinal anesthesia causes major hemodynamic instability(decrease SVR, decrease VR, decrease in CO) The preferred neuroaxial techniques are (epidural anesthesia and CSE with minimal spinal dose) 2-Avoid PAC. Pulmonary Artery catheters insertion may lead to pulmonary artery rupture or thrombosis. TEE is better cardiac monitor/Arteial line is mandatory. 3-Avoid Nitrous oxide in gas mixture.N2O increase the PVR 4-If MV to be started, avoid High TV and PEEP 5-Avoid Oxytocin Boluses, or rapid administration of Pitocin. Oxytocin causes ...
Post a Comment
Read more

Steroids In Perioperative period...The Multi-purpose Drugs

1-Steroids are not Bronchodilator ,but have well established usefulness in hyper-reactive airway. They are also said to have a permissive role for bronchodilator medication. They can be administered orally, parenterally or in aerosol form 2- Steroids have been commonly used in chemotherapy for prevention of nausea along with other anti-emetic agents . Dexamethasone was found to be highly effective when given immediately before induction rather than at the end of anesthesia . 3- Steroids do exert analgesic effects. Various routes of administration of steroids include parentral, local infiltration at operated site , as an adjuvant in nerve blocks and central-neuraxial blockade. 4 - Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine. 5- Steroids (Dexamethsone) are of value in reduction or prevention of cerebral edema associated with parasitic infections and neopla...
1 comment
Read more