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Intrathecal opioids have been used for several decades in different clinical settings. They are easy to administer and provide many benefits in clinical practice, such as better quality of spinal anaesthesia, prolonged postoperative analgesia, decreased postoperative analgesic requirements and early mobilisation. Several lipophilic and hydrophilic opioids are available for intrathecal administration, either in combination with general anaesthesia or as adjuncts to local anaesthetics. Adverse effects after intrathecal lipophilic opioids administration are predominantly short-lived and benign. In contrast, intrathecal hydrophilic opioids may have potentially serious adverse effects, the most feared of which is respiratory depression. In this review, we will focus on the contemporary evidence regarding intrathecal hydrophilic opioids and present their adverse effects and how to manage them., Competing Interests: Declaration of competing interest EA has received grants from the Swiss Academy for Anaesthesia Research (SACAR), Lausanne, Switzerland (no grant numbers attributed), from B. Braun Medical AG, Sempach, Switzerland (no grant numbers attributed), and from the Swiss National Science Foundation to support his clinical research. EA has also received an honorarium from B. Braun Medical AG Switzerland, from Sintetica Ltd UK and MSD AG Switzerland. SG has received a research grant and speakers honoraria from MSD AG Switzerland. KE or his institution has received educational, honorarial or research funding from Fisher and Paykel Healthcare, GE Health, Edwards Lifesciences., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Preemptive analgesia means that an analgesic intervention is started before the noxious stimulus arises in order to block peripheral and central nociception. This afferent blockade of nociceptive impulses is maintained throughout the intra-operative and post-operative period. The goals of preemptive analgesia are, first, to decrease acute pain after tissue injury, second, to prevent pain-related pathologic modulation of the central nervous system, and third, to inhibit the persistence of postoperative pain and the development of chronic pain. So far, the promising results from animal models have not been translated into clinical practice. Therefore, clinicians should rely on conventional anaesthetic and analgesic methods with proven efficacy, i.e. a multimodal approach including the combination of strong opioids, non-opioid analgesics, and peripheral or neuraxial local anaesthetics that act at different sites of the pain pathways.