Opioids and nonopioids for postoperative pain control in patients with chronic kidney disease

Michele Binhas, MD; Julia Egbeola-Martial, MD; Michael D. Kluger MD, MPH; Francoise Roudot-Thoraval, MD; Philippe Grimbert MD, PhD

doi:10.5055/jom.2017.0364

Authors

Michele Binhas, MD
Julia Egbeola-Martial, MD
Michael D. Kluger MD, MPH
Francoise Roudot-Thoraval, MD
Philippe Grimbert MD, PhD

DOI:

https://doi.org/10.5055/jom.2017.0364

Keywords:

renal failure, pain, opioids

Abstract

Objectives: To evaluate postoperative pain management (POPM) practices by anesthesiologists caring for patients with chronic kidney disease (CKD).

Design: Prospective one-time survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR).

Setting: A self-administered online questionnaire was distributed to members of SFAR nationally.

Participants: Three hundred seven SFAR members participated in the study.

Intervention: Close-ended questions concerned: standard test used to assess renal function, analgesic agent selection and dose adjustment based on the CKD functional stage, and the availability of standard operating procedures.

Main outcomes measures: The primary end-point was to identify the most frequently prescribed analgesics in case of CKD, variations in practice based on different stages of CKD, and drug dosing adjustments. The secondary end-point was to identify the most commonly used tests to evaluate kidney function.

Results: The most commonly used postoperative analgesics were paracetamol (acetaminophen) and morphine. The most commonly used opioid was morphine, relative to oxycodone and sufentanil. Modification of diet in renal disease (MDRD) and Cockcroft equations were used by 39 and 40 percent of anesthesiologists, respectively, to measure kidney function. Six percent of anesthesiologists declared following standard operating procedures for POPM in patients with CKD.

Conclusions: There is considerable variability in POPM practices for patients with all stages of CKD. Morphine is favored even in end-stage renal disease. Departments of anesthesiology are insufficiently involved in drafting standard operating procedures.

Author Biographies

Michele Binhas, MD

Department of Anaesthesia and Intensive care, Henri Mondor Hospital, AP-HP, Paris Est University, Creteil, France

Julia Egbeola-Martial, MD

Department of Anaesthesia and Intensive care, Henri Mondor Hospital, AP-HP, Paris Est University, Creteil, France

Michael D. Kluger MD, MPH

College of Physicians and Surgeons, New York-Presbyterian Hospital/CUMC, New York

Francoise Roudot-Thoraval, MD

Department of Public Health, Henri Mondor Hospital, AP-HP, Paris Est University, Creteil, France

Philippe Grimbert MD, PhD

Department of Nephrology and Transplantation, Henri Mondor Hospital, AP-HP, Paris Est University, Creteil, France

References

Stevens PE, Levin A, Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members: Evaluation and management of chronic kidney disease: Synopsis of the kidney disease: Improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013; 158(11): 825-830.

Park EJ, Wu K, Mi Z, et al.: A systematic comparison of Cockcroft-Gault and modification of diet in renal disease equations for classification of kidney dysfunction and dosage adjustment. Ann Pharmacother. 2012; 46(9): 1174-1187.

Dreisbach AW, Lertora JJ: The effect of chronic renal failure on drug metabolism and transport. Expert Opin Drug Metab Toxicol. 2008; 4(8): 1065-1074.

Kincaid-Smith P: Effects of non-narcotic analgesics on the kidney. Drugs. 1986; 32(suppl 4): 109-128.

Tiseo PJ, Thaler HT, Lapin J, et al.: Morphine-6-glucuronide concentrations and opioid-related side effects: A survey in cancer patients. Pain. 1995; 61(1): 47-55.

Osborne RJ, Joel SP, Slevin ML: Morphine intoxication in renal failure: The role of morphine-6-glucuronide. Br Med J. 1986; 292(6535): 1548-1549.

Lagas JS, Wagenaar JF, Huitema AD, et al.: Lethal morphine intoxication in a patient with a sickle cell crisis and renal impairment: Case report and a review of the literature. Hum Exp Toxicol. 2011; 30(9): 1399-1403.

Foral PA, Ineck JR, Nystrom KK: Oxycodone accumulation in a hemodialysis patient. South Med J. 2007; 100(2): 212-214.

Lee MA, Leng ME, Cooper RM: Measurements of plasma oxycodone, noroxycodone and oxymorphone levels in a patient with bilateral nephrectomy who is undergoing haemodialysis. Palliat Med. 2005; 19(3): 259-260.

Stamer UM, Stüber F, Muders T, et al.: Respiratory depression with tramadol in a patient with renal impairment and CYP2D6 gene duplication. Anesth Analg. 2008; 107(3): 926-929.

Dahan A, Aarts L, Smith TW: Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology. 2010; 112(1): 226-238.

King S, Forbes K, Hanks GW, et al.: A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment: A European Palliative Care Research Collaborative opioid guidelines project. Palliat Med. 2011; 25(5): 525-552.

Craig RG, Hunter JM: Recent developments in the perioperative management of adult patients with chronic kidney disease. Br J Anaesth. 2008; 101(3): 296-310.

Pergolizzi J, Böger RH, Budd K, et al.: Opioids and the management of chronic severe pain in the elderly: Consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008; 8(4): 287-313.

Trainor D, Borthwick E, Ferguson A: Perioperative management of the hemodialysis patient. Semin Dial. 2011; 24(3): 314-326.

Parmar MS, Parmar KS: Management of acute and post-operative pain in chronic kidney disease Version 3. F1000Res. 2013; 2: 28.

Fuzier R, Belbachir A, Gall O, et al.: Comité douleur et anesthésie locorégionale de Société française d'anesthésie et de réanimation. Postoperative analgesia in “particular situations”. Practical recommendations. Ann Fr Anesth Reanim. 2008; 27(11): 966-968.

Gelot S, Nakhla E: Opioid in renal and hepatic impairment. US Pharm. 2014; 39(8): 34-38.

Dean M: Opioids in renal failure and dialysis patients. J Pain Symptom Manage. 2004; 28(5): 497-504.

Tawfic QA, Bellingham G: Postoperative pain management in patients with chronic kidney disease. J Anaesthesiol Clin Pharmacol. 2015; 31(1): 6-13.

Davison SN, Koncicki H, Brennan F: Pain in chronic kidney disease: A scoping review. Semin Dial. 2014; 27(2): 188-204.

Burden R, Tomson C, Guideline Development Committee, Joint Specialty Committee on Renal Disease of the Royal College of Physicians of London and the Renal Association: Identification, management and referral of adults with chronic kidney disease: Concise guidelines. Clin Med. 2005; 5(6): 635-642.

Mimoz O, Chauvet S, Grégoire N, et al.: Nefopam pharmacokinetics in patients with end-stage renal disease. Anesth Analg. 2010; 111(5): 1146-1153.

Djerada Z, Fournet-Fayard A, Gozalo C, et al.: Population pharmacokinetics of nefopam in elderly, with or without renal impairment, and its link to treatment response. Br J Clin Pharmacol. 2014; 77(7): 1027-1038.

Ciszkowski C, Madadi P, Phillips MS, et al.: Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009; 361(8): 827-828.

Talbott GA, Lynn AM, Levy FH, et al.: Respiratory arrest precipitated by codeine in a child with chronic renal failure. Clin Pediatr (Phila). 1997; 36(3): 171-173.

Barnung SK, Treschow M, Borgbjerg FM: Respiratory depression following oral tramadol in a patient with impaired renal function. Pain. 1997; 71(1): 111-112.

Khanal A, Castelino RL, Peterson GM, et al.: Dose adjustment guidelines for medications in patients with renal impairment: How consistent are drug information sources? Intern Med J. 2014; 44(1): 77-85.

Davis PJ, Stiller RL, Cook DR, et al.: Pharmacokinetics of sufentanil in adolescent patients with chronic renal failure. Anesth Analg. 1988; 67(3): 268-271.

Fyman PN, Reynolds JR, Moser F, et al.: Pharmacokinetics of sufentanil in patients undergoing renal transplantation. Can J Anaesth. 1988; 35(3): 312-315.

Tran BW, Kohan LR, Vorenkamp KE: Postoperative oxycodone toxicity in a patient with chronic pain and end-stage renal disease. AA Case Rep. 2015; 4(4): 44-46.

Foral PA, Ineck JR, Nystrom KK: Oxycodone accumulation in a hemodialysis patient. South Med J. 2007; 100(2): 212-214.

Kirvela M, Lindgren L, Seppala T, et al.: The pharmacokinetics of oxycodone in uremic patients undergoing renal transplantation. J Clin Anesth. 1996; 8(1): 13-18.

Mion G, Villevieille T: Ketamine pharmacology: An update (pharmacodynamics and molecular aspects, recent findings). CNS Neurosci Ther. 2013; 19(6): 370-380.

Capel MM, Jenkins R, Jefferson M, et al.: Use of ketamine for ischemic pain in end-stage renal failure. J Pain Symptom Manage. 2008; 35(3): 232-234.

Grass JA: Patient-controlled analgesia. Anesth Analg. 2005; 101(5 suppl): S44-S61.

Macintyre PE: Safety and efficacy of patient-controlled analgesia. Br J Anaesth. 2001; 87(1): 36-46.

Ecoffey C, Bonnet F: [Management of postoperative pain in 2007: The summary of a European survey and a French national audit]. Ann Fr Anesth Reanim. 2008; 27(9): 661-663.

Green CR, Wheeler JR: Physician variability in the management of acute postoperative and cancer pain: A quantitative analysis of the Michigan experience. Pain Med. 2003; 4(1): 8-20.

Droney J, Levy J, Quigley C: Prescribing opioids in renal failure. J Opioid Manag. 2007; 3(6): 309-316.