The Impact of Intrathecal Hydrophilic Opioids on Postoperative Pain, Opioid Consumption and Adverse Events for Abdominal Surgery: A Systematic Review and Meta-analysis

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Abstract Purpose of Review Intrathecal morphine (ITM) is a promising analgesic option for major abdominal surgery, but its clinical efficacy, potential adverse events and optimal dosing require further investigation. Methods We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) for data from 1990 until July 2024 to identify studies comparing a preoperative intrathecal dose of hydrophilic opioid to alternative analgesia in adult patients undergoing abdominal surgery under general anaesthesia. The Cochrane Risk of Bias 2 (RoB 2) tool was used to assess risk of bias in individual studies. Meta-analyses were conducted using a random-effects model. The primary outcomes were opioid consumption and pain intensity. Additional outcomes included incidence of opioid related adverse effects and hospital length of stay. Results A total of 59 studies were included, with 2005 patients that received ITM (dose range 0.04 − 3.75 mg). Four comparator groups were identified based on analgesic strategy. Substantial heterogeneity was present across all reported data (I 2 > 75%). Patients receiving ITM required significantly lower intravenous morphine-equivalent dosages within the first 72 h postoperatively compared with patients in the comparator groups, pooled weighted mean difference (MD) -17.9 mg (95% CI: -23.1 to -12.8 mg). Pain scores were statistically lower at rest in the ITM group. The effect on opioid consumption and pain scores was greatest when comparing ITM to sham/IV morphine in minimally invasive surgery. Conclusion In patients undergoing abdominal surgery, our meta-analysis found that ITM reduced opioid consumption, pain intensity and hospital LOS at the expense of increased pruritus. No significant increase in respiratory depression was observed and sedation was reduced. The clinical significance of these differences is likely small. PROSPERO ID: CRD42018115996.