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REGIONAL ANESTHESIA

More Epidural than Intravenous Sufentanil is Required to Provide Comparable Postoperative Pain Relief

Christophe Menigaux, MD^*, Bruno Guignard, MD^*, Dominique Fletcher, MD^*, Daniel I. Sessler, MD, Jean-Claude Levron, PhD, and Marcel Chauvin, MD^*

*Department of Anesthesiology, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Outcomes Research^TM Institute and Department of Anesthesiology, University of Louisville, Louisville, Kentucky, and Ludwig Boltzmann Anesthesia Institute, University of Vienna, Vienna, Austria; and Janssen Research Foundation, Val de Reuil, France

Address correspondence and reprint requests to Marcel Chauvin, MD, Department of Anesthesiology, Hôpital Ambroise Paré, 9 Avenue Charles de Gaulle, Boulogne-Billancourt, 92100, France. Address e-mail to marcel.chauvin{at}apr.ap-hop-paris.fr

The extent to which epidurally administered sufentanil acts directly on spinal opioid receptors remains controversial. We tested the hypothesis that small-dose boluses of sufentanil, given epidurally or IV, provide comparable analgesia at similar plasma sufentanil concentrations. The lipophilicity of sufentanil makes it likely to be absorbed into fat surrounding the epidural space. We therefore also tested the hypothesis that more epidural than IV sufentanil is required to produce comparable analgesia. Analgesia and plasma sufentanil concentrations were evaluated in 20 postoperative patients randomly assigned to patient-controlled epidural or IV sufentanil. Pain was evaluated with visual analog scales by blinded observers. Sufentanil doses and plasma concentrations were measured. Analgesia was similar with epidural and IV sufentanil administration. Plasma sufentanil concentrations were virtually identical in the two groups. However, significantly larger sufentanil doses were required with epidural administration: 238 ± 50 µg vs 160 ± 32 µg (P < 0.01). The primary mechanism by which small-dose boluses of epidurally-administered sufentanil produce analgesia seems to be systemic absorption of the drug with subsequent recirculation to the supraspinal opioid receptors. This study demonstrates that the cumulative dose of sufentanil, when administered as a small epidural bolus, is approximately 50% more than that administered IV to provide comparable analgesia. This indicates that the bioavailability of epidurally-administered sufentanil is reduced and suggests that a large proportion of the drug may be absorbed into the epidural fat.

IMPLICATIONS: More epidural than IV sufentanil was required to provide comparable postoperative pain relief and similar plasma sufentanil concentrations. These data suggest that when sufentanil is administered in small-dose boluses, much of the drug is absorbed into the epidural fat and that the primary mechanism by which epidurally administered sufentanil produces analgesia is via systemic absorption.

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