Nebenwirkungsraten von Opioiden unter äquianalgetischen Dosen im Rahmen intravenöser patientenkontrollierter Analgesie - eine systematische Übersicht und Netzwerkmetaanalyse

Side effects during an opioid therapy are common in clinical practice and influence not only the quality of pain management, but also the recovery of patients. An individual choice of opioid, geared to the side effect profile and patient’s needs, could optimize pain management and healing process. According to that, the goal of this review was to examine the influence of the choice of an opioid on common side effects under equianalgetic conditions in an intravenous patient controlled analgesia setting. The electronic databases Medline, Embase, The Cochrane Library and Web of Science were searched for randomized controlled trials. After developing a structured literature search strategy, 168 studies were read and evaluated by two independent reviewers. By creating a systematic review and network-metaanalysis, data of 17 different opioids and their side effect profiles were compared and summarized. From 63 studies matching the inclusion criteria, data of 5063 patients from 18 to 90 years could be extracted. Primary endpoints were all opioid-induced side effects under equianalgetic doses. The side effects nausea and vomiting, pruritus, sedation and respiratory depression were the most reported ones. Secondary endpoints were the patients satisfaction, pca pump-settings and opioid consumption in total. With a relative risk ratio of 1,37 [1,05; 1,80] buprenorphine shows a significant higher rate in causing nausea and vomiting, whereas fentanyl seems to cause less with a risk of 0,82 [0,67; 1,00]. At the risks of pruritus first of all nalbuphine with 0,07 [0,01; 0,60] and pethidine/meperidine with 0,47 [0,25; 0,87] seems to have a little benefit. From the analysis of sedation scores, it was seen that oxymorphone with -1,40[-2,41; -0,39], fentanyl with -1,57 [-2,91; -0,23] and pethidine/meperidine with -1,70[-2,77; -0,62] caused significantly lower sedation. The extracted data in this study cannot detect a benefit of any substance for the incidence of respiratory depression. Regarding satisfaction by visual analogue scales pethidine/meperidine with 0,59 [0,18; 1,00], fentanyl with 0,96 [0,39; 1,52], remifentanil with 1,80 [1,12; 2,48], alfentanil with 1,95 [1,06; 2,85] and oxycodone with 2,00 [1,18; 2,82] mean differences reached the statistical significant highest values. The analgesic potency ratios from included studies mostly deviated more than ten percent from current literature values. In summary of all results fentanyl and pethidine/meperidine seems to have most good-natured side effect profiles under equianalgetic doses. Both substances can be recommended for postoperative intravenous patient-controlled analgesia after excluding individual contraindications. Tendencies in side effect profiles shown in this network metaanalysis should be considered in choosing the best substance for individual pain therapy.