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| CASE REPORT |
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| Year : 2020 | Volume
: 4
| Issue : 2 | Page : 72-74 |
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Oxycodone in mastectomy surgery
Putu Pramana Suarjaya, Cynthia Dewi Sinardja, Aninda Tanggono
Department of Anesthesiology and Intensive Care, Udayana University, Denpasar, Bali, Indonesia
| Date of Submission | 11-Dec-2019 |
| Date of Decision | 14-Feb-2020 |
| Date of Acceptance | 04-Mar-2020 |
| Date of Web Publication | 11-May-2020 |
Correspondence Address:
Dr. Aninda Tanggono
Department of Anesthesiology and Intensive Care, Udayana University, Denpasar, Bali
Indonesia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/BJOA.BJOA_16_19
The pharmacological effects of oxycodone and morphine are close. The analgesic potency between oxycodone and morphine is presumed to have a 1:1 ratio. Fentanyl-to-morphine ratio was 1:100. The plasma levels of oxycodone are more active than morphine. The analgesic potency of oxycodone is about 30% greater than that of morphine and slightly longer acting than morphine. Oxycodone showed a longer duration of action and a better analgesic effect than fentanyl. Oxycodone could minimize patient hemodynamic responses to sudden stimuli such as endotracheal intubation, similar to fentanyl. A 41-year-old woman admitted to the hospital with elective surgery of mastectomy surgery. There was no complaint about the lump in mammae dextra. For the surgery, induction bolus of oxycodone 0.2 mg/kg was diluted with normal saline; for endotracheal intubation and postoperative, we used oxycodone with patient-controlled analgesia. Hemodynamic curves were within the normal limits, she had no complaints of postoperative nausea and vomiting or pruritus, and she was discharged on the 3rd day.
Keywords: Fentanyl, hemodynamic, mastectomy surgery, morphine, oxycodone
How to cite this article:
Suarjaya PP, Sinardja CD, Tanggono A. Oxycodone in mastectomy surgery. Bali J Anaesthesiol 2020;4:72-4 |
| Introduction | |  |
Oxycodone is a semisynthetic derivative μ-opioid receptor agonist, which is replacing morphine as a first-choice opioid used in anesthesia for the treatment of both acute and chronic pain in several countries.[1],[2] Oxycodone has been used for the management of cancer-related pain as well as for chronic noncancer-related problems; the effects of oxycodone on postoperative pain control reported are better than morphine to treat moderate-to-severe pain where weak opioids failed to provide relief of pain relief.[3]
The pain would be a challenging issue, especially in acute patients with difficult experiences. Even though the direct correlation between activation and nociceptors and the sensory experience of pain is not always apparent, emotional state, degree of anxiety, attention and distraction, past experiences, memories, and other factors can either enhance or diminish the pain experience.[4]
Laryngoscopy and endotracheal tube insertion can stimulate sympathetic response. The response increases and reaches elevations in blood pressure (BP) and heart rate (HR) maximum level within 1 min and ends within 5–10 min after intubation.[5]
| Case Report | | |
A-41-years-old-woman admitted to the hospital with elective surgery of mastectomy surgery. She had no history of alergy, asthma, chemotherapy history, and no behavioral opioid usage and sedatives. Physical finding was marked for lump diameter 12 cm in mammae dextra. The pain was recorded using the Visual Analog Scale reached 10/100 mm.
At the ward, she had no complaint about the lump, and she could walk and sleep with one pillow and do daily activities regularly. Hemodynamic is stable without abnormalities laboratory findings and electrocardiogram. There were no abnormalities in radiology finding. Her weight was 50 kg, and body mass index was 20 kg/m[2]. The patient was transferred to the operating room. Pulse oximetry and electrocardiography were performed after placing the patients in a supine position. Noninvasive BP was measured twice for all patients after a 5 min-period of stabilization. The mean values were used as a reference to preoperative BP and HR.
The patient was administered intravenous (IV) bolus of oxycodone 0.2 mg/kg diluted with normal saline. We monitored any adverse events, such as dizziness, coughing, sedation, or oxygen desaturation in pulse oximetry, before anesthetic induction, then she was injected with lidocaine 40 mg intravenously prior to injecting propofol 2 mg/kg. Atracurium 30 mg (0.5 mg/kg) was admistered for muscle relaxation after the loss of patient consciousness. Endotracheal intubation was performed 2 min after induction of anesthesia. The anesthesiologist evaluated the Cormack–Lehane grade using McGrath video laryngoscope. Noninvasive BP and HR were measured and recorded at 1-min intervals for 5 min after endotracheal intubation. No hypotension and bradycardia were reported.
General anesthesia was maintained by 1.5 minimum alveolar concentration isoflurane and 50% air in oxygen with a constant fresh gas flow of 3 L/min. Postoperatively, isoflurane administration was terminated and a total 8 L/min of fresh gas flow with 100% oxygen was administered via an endotracheal tube.
Simultaneously for extubation, ventilation was assisted such that the patient was allowed to breathe spontaneously while keeping EtCO2 between 40 and 45 mmHg. Oral suction was gently performed. Extubation was performed when the patient nodded their heads, opened their eyes, obeyed commands, and could breathe deeply by themselves [Figure 1].
Meanwhile, the surgery went well, and for postsurgical management, we used oxycodone with patient-controlled analgesia. Hemodynamic curves were within the normal limits, she had no complaints of pain, postoperative nausea, and vomiting or pruritus, and she was discharged on the 3rd day postsurgical.
| Discussion | | |
The efficacy of oxycodone and morphine as a pharmacokinetic explanation by a major metabolite is morphine-6-glucuronide, which may play an important role in the analgesic efficacy and may be enhanced in long-term therapy. Oxycodone acts on the central nervous system via the μ receptor and on the κ-receptor (κ-2b receptor).[6] The plasma levels of oxycodone in the body were approximately is more active than morphine. The analgesic potency of oxycodone has been shown to be about 30% greater than that of morphine and it is slightly longer acting than morphine and it does not cause histamine release.[2]
Oxycodone could minimize patient hemodynamic responses to sudden stimuli such as endotracheal intubation, similar to fentanyl. Fentanyl commonly administered prior to intubation is an opioid with the short onset and action duration. Oxycodone is a strong μ-opioid receptor agonist and its potency is also similar to that of morphine. The onset time of oxycodone is rapid onset time about 5–8 min; therefore, it can be effectively utilized to minimize a patient's hemodynamic response to a sudden stimulus such as intubation, although its action duration is long.[7]
The safe dose conversion ratio of IV oxycodone to IV fentanyl is yet to be established, Previous studies administered a morphine-to-oxycodone ratio of 1:1 and a fentanyl-to-morphine ratio of 1:100. On this basis, we calculated a workable fentanyl to oxycodone ratio of 1:100 for the present study.[7]
A number of researches, Lee et al[7] for example compared oxycodone with morphine or fentanyl, reported “oxycodone as the more effective analgesic”. In a study of 40 patients who underwent surgery and received either morphine or oxycodone intravenously, oxycodone exhibited a more rapid effect in alleviating pain at a lower dose compared to morphine, and in a study of 78 patients who were given oxycodone or fentanyl immediately after surgery, oxycodone showed a longer duration of action and better analgesic effect than fentanyl.”[3]
In this case report, the advantage of oxycodone, especially for mastectomy surgery, indicates that it might be useful as an alternative to opioids for induction, maintenance, and postoperative analgesia; oxycodone could be successfully used to attenuate the sympathetic response during endotracheal intubation as can provide stable MBP during anesthetic induction.[5],[8]
| Conclusion | | |
Oxycodone has more benefits than fentanyl and morphine for using durante and postoperative. It has a rapid onset and can minimize sympathetic response during endotracheal intubation. Oxycodone also has a longer duration of action and better analgesic effect than fentanyl can attenuate the postoperative analgesia. No adverse effect was reported in this case while using oxycodone. Oxycodone would be beneficial in mastectomy surgery under general anesthesia compare with other opioids.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Saari TI, Ihmsen H, Neuvonen PJ, Olkkola KT, Schwilden H. Oxycodone clearance is markedly reduced with advancing age: A population pharmacokinetic study. Br J Anaesth 2012;108:491-8.  |
| 2. | Silvasti M, Rosenberg P, Seppälä T, Svartling N, Pitkänen M. Comparison of analgesic efficacy of oxycodone and morphine in postoperative intravenous patient-controlled analgesia. Acta Anaesthesiol Scand 1998;42:576-80. |
| 3. | Lee KH, Kang JH, Oh HS, Choi MK, Shim BY, Eum YJ, et al. Intravenous oxycodone versus intravenous morphine in cancer pain: A randomized, open-label, parallel-group, active-control study. Pain Res Manag 2017:1-11, Article ID 9741729. |
| 4. | Widyana IM, Cindryani M, Tanggono A. Combined morphine-clonidine adjuvant in epidural analgesia support role of supraspinal modulation in opioid tolerant patient. BJOA (Bali Journal of Anesthesiology) 2019;3:5-7. |
| 5. | Park KB, Ann J, Lee H. Effects of different dosages of oxycodone and fentanyl on the hemodynamic changes during intubation. Saudi Med J 2016;37:847-52. |
| 6. | Lenz H, Sandvik L, Qvigstad E, Bjerkelund CE, Raeder J. A comparison of intravenous oxycodone and intravenous morphine in patient-controlled postoperative analgesia after laparoscopic hysterectomy. Anesth Analg 2009;109:1279-83. |
| 7. | Lee YS, Baek CW, Kim DR, Kang H, Choi GJ, Park YH, et al. Comparison of hemodynamic response to tracheal intubation and postoperative pain in patients undergoing closed reduction of nasal bone fracture under general anesthesia: A randomized controlled trial comparing fentanyl and oxycodone. BMC Anesthesiol 2016;16:115. |
| 8. | Olczak B, Kowalski G, Leppert W, Zaporowska-Stachowiak I, Wieczorowska-Tobis K. Analgesic efficacy, adverse effects, and safety of oxycodone administered as continuous intravenous infusion in patients after total hip arthroplasty. J Pain Res 2017;10:1027-32. |
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