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Pathonsamit C, Onklin I, Hongku N, Chaiyakit P. Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty. Arthroplast Today 2020; 7:253-259. [PMID: 33786350 PMCID: PMC7987934 DOI: 10.1016/j.artd.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). Methods This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M0), ITM 0.1 mg (M1), and ITM 0.2 mg (M2). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. Results The trial enrolled 102 patients: M0 (n = 32), M1 (n = 35), and M2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M1 and M2 did not differ significantly within the first 24 hours and were significantly lower than those in group M0. Nausea and vomiting were observed more frequently 4 hours postoperatively in M2 than in groups M1 and M0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). Conclusion Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.
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Affiliation(s)
- Chompunoot Pathonsamit
- Department of Anesthesiology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittiwat Onklin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruk Chaiyakit
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Koning MV, van der Sijp M, Stolker RJ, Niggebrugge A. Intrathecal Morphine Is Associated with Less Delirium Following Hip Fracture Surgery: A Register Study. Anesth Pain Med 2020; 10:e106076. [PMID: 33134152 PMCID: PMC7539054 DOI: 10.5812/aapm.106076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/20/2020] [Accepted: 08/05/2020] [Indexed: 01/01/2023] Open
Abstract
Background Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium. Objectives This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium. Methods A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving spinal anesthesia (SA group) were compared with patients receiving spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defined by the DSM-V classification. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed. Results The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19.7% in the SA group versus 5.9% in the SIM group (P = 0.046). This association remained significant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1.062 - 21.006, P = 0.041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium. Conclusions This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study.
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Affiliation(s)
- Mark Vincent Koning
- Department of Anesthesiology and Intensive Care, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Anesthesiology, Erasmus Univerity Medical Center, Rotterdam, The Netherlands
- Corresponding Author: Department of Anesthesiology, Erasmus Univerity Medical Center, Rotterdam, The Netherlands
| | - Max van der Sijp
- Department of Public Health and Primary Care, Leiden University Medical Center, LUMC-Campus the Hague, Leiden, The Netherlands
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Robert Jan Stolker
- Department of Anesthesiology, Erasmus Univerity Medical Center, Rotterdam, The Netherlands
| | - Arthur Niggebrugge
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
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Intrathecal morphine and sleep apnoea severity in patients undergoing hip arthroplasty: a randomised, controlled, triple-blinded trial. Br J Anaesth 2020; 125:811-817. [DOI: 10.1016/j.bja.2020.07.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/19/2020] [Accepted: 07/03/2020] [Indexed: 11/24/2022] Open
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Wagemans MF, Scholten WK, Hollmann MW, Kuipers AH. Epidural anesthesia is no longer the standard of care in abdominal surgery with ERAS. What are the alternatives? Minerva Anestesiol 2020; 86:1079-1088. [DOI: 10.23736/s0375-9393.20.14324-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Teunissen AJW, Koning MV, Ruijgrok EJ, Liefers WJ, de Bruijn B, Koopman SA. Measurement of drug concentration and bacterial contamination after diluting morphine for intrathecal administration: an experimental study. BMC Anesthesiol 2020; 20:244. [PMID: 32977744 PMCID: PMC7517689 DOI: 10.1186/s12871-020-01151-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022] Open
Abstract
Background Low concentrations of morphine are required for safe dosing for intrathecal injections. Sometimes, manual dilution of morphine is performed to achieve these low concentrations, but risks dilution errors and bacterial contamination. The primary goal was to compare the concentrations of morphine and bupivacaine between four groups of syringes. The secondary goal was to investigate the difference in contamination rate between these groups. Methods Twenty-five experienced anesthesia providers were asked to prepare a mixture of bupivacaine 2.0 mg/ml and morphine 60 μg/ml using 3 different methods as clean and precise as possible. The fourth method used was the aspiration of ampoules prepared by the pharmacy. The concentrations of morphine and bupivacaine were measured by High-Pressure Liquid Chromatography (HPLC). The medication was cultured for bacterial contamination. Results Group 1 (median 60 μg/ml; 95% CI: 59–110 μg/ml) yielded 3 outliers above 180 μg/ml morphine concentration. Group 2 (76 μg/ml; 95% CI: 72–80 μg/ml) and 3 (69 μg/ml; 95% CI: 66–71 μg/ml) were consistently higher than the target concentration of 60 μg. The group “pharmacy” was precise and accurate (59 μg/ml; 95% CI: 59–59 μg/ml). Group 2 and “pharmacy” had one contaminated sample with a spore-forming aerobic gram-positive rod. Conclusion Manually diluted morphine is at risk for deviating concentrations, which could lead to increased side-effects. Medication produced by the hospital pharmacy was highly accurate. Furthermore, even when precautions are undertaken, contamination of the medication is a serious risk and appeared to be unrelated to the dilution process.
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Affiliation(s)
- Aart Jan W Teunissen
- Anesthesiology, Maasstadziekenhuis, Maasstadweg 21, 3079DZ, Rotterdam, The Netherlands.
| | - Mark V Koning
- Anesthesiology, Rijnstate hospital, Arnhem, The Netherlands
| | - Elisabeth J Ruijgrok
- Pharmacy, Erasmus Medical Center, University of Rotterdam, Rotterdam, The Netherlands
| | | | - Bart de Bruijn
- Anesthesiology, Maasstadziekenhuis, Maasstadweg 21, 3079DZ, Rotterdam, The Netherlands
| | - Seppe A Koopman
- Anesthesiology, Maasstadziekenhuis, Maasstadweg 21, 3079DZ, Rotterdam, The Netherlands
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Intrathecal Morphine versus Intrathecal Hydromorphone for Analgesia after Cesarean Delivery: A Randomized Clinical Trial. Anesthesiology 2020; 132:1382-1391. [PMID: 32251031 DOI: 10.1097/aln.0000000000003283] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. METHODS In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. RESULTS There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). CONCLUSIONS Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.
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Tang J, Churilov L, Tan CO, Hu R, Pearce B, Cosic L, Christophi C, Weinberg L. Intrathecal morphine is associated with reduction in postoperative opioid requirements and improvement in postoperative analgesia in patients undergoing open liver resection. BMC Anesthesiol 2020; 20:207. [PMID: 32814546 PMCID: PMC7436971 DOI: 10.1186/s12871-020-01113-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background Our study aimed to test the hypothesis that the addition of intrathecal morphine (ITM) results in reduced postoperative opioid use and enhanced postoperative analgesia in patients undergoing open liver resection using a standardized enhanced recovery after surgery (ERAS) protocol with multimodal analgesia. Methods A retrospective analysis of 216 adult patients undergoing open liver resection between June 2010 and July 2017 at a university teaching hospital was conducted. The primary outcome was the cumulative oral morphine equivalent daily dose (oMEDD) on postoperative day (POD) 1. Secondary outcomes included postoperative pain scores, opioid related complications, and length of hospital stay. We also performed a cost analysis evaluating the economic benefits of ITM. Results One hundred twenty-five patients received ITM (ITM group) and 91 patients received usual care (UC group). Patient characteristics were similar between the groups. The primary outcome - cumulative oMEDD on POD1 - was significantly reduced in the ITM group. Postoperative pain scores up to 24 h post-surgery were significantly reduced in the ITM group. There was no statistically significant difference in complications or hospital stay between the two study groups. Total hospital costs were significantly higher in the ITM group. Conclusion In patients undergoing open liver resection, ITM in addition to conventional multimodal analgesic strategies reduced postoperative opioid requirements and improved analgesia for 24 h after surgery, without any statistically significant differences in opioid-related complications, and length of hospital stay. Hospital costs were significantly higher in patients receiving ITM, reflective of a longer mandatory stay in intensive care. Trial registration Registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) under ACTRN12620000001998.
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Affiliation(s)
- Jefferson Tang
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Luka Cosic
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia. .,Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.
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Koning MV, Klimek M, Rijs K, Stolker RJ, Heesen MA. Intrathecal hydrophilic opioids for abdominal surgery: a meta-analysis, meta-regression, and trial sequential analysis. Br J Anaesth 2020; 125:358-372. [PMID: 32660719 PMCID: PMC7497029 DOI: 10.1016/j.bja.2020.05.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/27/2020] [Accepted: 05/19/2020] [Indexed: 02/01/2023] Open
Abstract
Background Intrathecal hydrophilic opioids decrease systemic opioid consumption after abdominal surgery and potentially facilitate enhanced recovery. A meta-analysis is needed to quantify associated risks and benefits. Methods A systematic search was performed to find RCTs investigating intrathecal hydrophilic opioids in abdominal surgery. Caesarean section and continuous regional or neuraxial techniques were excluded. Several subgroup analyses were prespecified. A conventional meta-analysis, meta-regression, trial sequential analysis, and provision of GRADE scores were planned. Results The search yielded 40 trials consisting of 2500 patients. A difference was detected in ‘i.v. morphine consumption’ at Day 1 {mean difference [MD] −18.4 mg, (95% confidence interval [CI]: −22.3 to −14.4)} and Day 2 (MD −25.5 mg [95% CI: −30.2 to −20.8]), pain scores at Day 1 in rest (MD −0.9 [95% CI: −1.1 to −0.7]) and during movement (MD −1.2 [95% CI: −1.6 to −0.8]), length of stay (MD −0.2 days [95% CI: −0.4 to −0.1]) and pruritus (relative risk 4.3 [95% CI: 2.5–7.5]) but not in nausea or sedation. A difference was detected for respiratory depression (odds ratio 5.5 [95% CI: 2.1–14.2]) but not when two small outlying studies were excluded (odds ratio 1.4 [95% CI: 0.4–5.2]). The level of evidence was graded as high for morphine consumption, in part because the required information size was reached. Conclusions This study showed important opioid-sparing effects of intrathecal hydrophilic opioids. Our data suggest a dose-dependent relationship between the risk of respiratory depression and the dose of intrathecal opioids. Excluding two high-dose studies, intrathecal opioids have a comparable incidence of respiratory depression as the control group. Clinical trial registration PROSPERO-registry: CRD42018090682.
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Affiliation(s)
- Mark V Koning
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands; Department of Anaesthesiology and Critical Care, Rijnstate Hospital, Arnhem, the Netherlands.
| | - Markus Klimek
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Koen Rijs
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Robert J Stolker
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Michael A Heesen
- Department of Anaesthesiology, Kantonsspital Baden, Baden, Switzerland
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Finneran JJ, Urman RD, Gabriel RA. Is there a benefit in adding local anesthetics to intrathecal opioids for patients undergoing general anesthesia for laparoscopic surgery? J Clin Anesth 2020; 66:109933. [PMID: 32593913 DOI: 10.1016/j.jclinane.2020.109933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Affiliation(s)
- John J Finneran
- University of California, San Diego, Department of Anesthesiology, San Diego, CA, United States of America
| | - Richard D Urman
- Harvard Medical School/Brigham and Women's Hospital, Department of Anesthesiology and Perioperative Pain Medicine, Boston, MA, United States of America
| | - Rodney A Gabriel
- University of California, San Diego, Department of Anesthesiology, San Diego, CA, United States of America.
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Wang Y, Guo X, Guo Z, Xu M. Preemptive analgesia with a single low dose of intrathecal morphine in multilevel posterior lumbar interbody fusion surgery: a double-blind, randomized, controlled trial. Spine J 2020; 20:989-997. [PMID: 32179153 DOI: 10.1016/j.spinee.2020.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients undergoing lumbar spinal surgery may experience considerable pain in the early postoperative period, and poor pain control after multilevel lumbar spinal fusion surgery is frequently associated with multiple complications and delayed discharge from hospital. PURPOSE The current study evaluated the efficacy and safety of preemptive analgesia with intrathecal morphine (ITM) in patients undergoing multilevel posterior lumbar spinal fusion surgery. STUDY DESIGN Double-blinded, randomized, controlled trial. PATIENT SAMPLE Ninety-two patients aged between 18 and 80 years who were scheduled to undergo elective lumbar laminectomy (L3-S1) and dual-level fusions. OUTCOME MEASURES The primary endpoint was the degree of postoperative pain at rest and during movement evaluated using a 10-point visual analogue scale. The secondary outcomes included the consumption of analgesics, the patient-assessed postoperative and satisfaction scores, adverse effects, time to first ambulation, and length of hospital stay. METHODS Patients were randomly allocated to either the ITM group that received 0.2 mg of ITM or the control (CON) group that received 2 ml of 0.9% saline as a skin infiltration 30 minutes prior to anesthesia induction. RESULTS The ITM group had a significantly lower visual analogue scale score than the CON group during the first 3 days postoperatively (at rest, P=0.000, during movement, P=0.000). The ITM group used significantly less sufentanil than the CON group in the first 3 days postoperatively (p=.000) in patient-controlled intravenous analgesia, as well as in supplemental analgesic demands. The ITM group reported a greater degree of satisfaction with the whole hospitalization experience than the CON group (2.4±0.6 vs. 1.9±0.6, p=.000). The two groups did not significantly differ regarding adverse effects, length of hospital stay, and time taken to regain the ability to walk without support. CONCLUSIONS Preemptive analgesia with ITM results in significantly improved early postoperative pain control and decreased postoperative patient-controlled intravenous analgesia consumption, with no increase in adverse effects.
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Affiliation(s)
- Yujie Wang
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Zhaoqing Guo
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China.
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China.
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The Quality of Recovery after Dexamethasone, Ondansetron, or Placebo Administration in Patients Undergoing Lower Limbs Orthopedic Surgery under Spinal Anesthesia Using Intrathecal Morphine. A Randomized Controlled Trial. Anesthesiol Res Pract 2020; 2020:9265698. [PMID: 32518560 PMCID: PMC7256731 DOI: 10.1155/2020/9265698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/02/2023] Open
Abstract
Intrathecal morphine is widely and successfully used to prevent postoperative pain after orthopedic surgery, but it is frequently associated with side effects. The aim of this study was to evaluate the effect of dexamethasone or ondansetron when compared to placebo to reduce the occurrence of these undesirable effects and, consequently, to improve the quality of recovery based on patient's perspective. Methods. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline. On the morning following surgery, a quality of recovery questionnaire (QoR-40) was completed. Results. No differences were detected in the global and dimensional QoR-40 scores following surgery; however, following postanesthesia care unit (PACU) discharge, pain scores were higher in patients receiving ondansetron compared with patients who received dexamethasone. Conclusion. Neither ondansetron nor dexamethasone improves the quality of recovery after lower limbs orthopedic surgery under spinal anesthesia using intrathecal morphine.
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Gomez NAG, Warren N, Labko Y, Sinclair DR. Intrathecal Opioid Dosing During Spinal Anesthesia for Cesarean Section: An Integrative Review. J Dr Nurs Pract 2020; 13:108-119. [DOI: 10.1891/jdnp-d-19-00025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately one in three women in the United States deliver via Cesarean section (CS), making it one of the most common surgical procedures in the country. Neuraxial (spinal or epidural) anesthesia is the most effective and common anesthetic approach for pain relief during a CS in the United States and often associated with adverse effects such as nausea, vomiting, and pruritus. While recommended dose ranges exist to protect patient safety, there are a lack of guidelines for opioid doses that both optimize postoperative pain management and minimize side effects. This integrative review synthesizes the evidence regarding best practice of opioid dosing in neuraxial anesthesia for planned CS. Evidence supports the use of lower doses of intrathecal (IT) opioids, specifically 0.1 morphine, to achieve optimal pain management with minimal nausea, vomiting, and pruritus. Lower IT doses have potential to achieve pain management and to alleviate preventable side effects in women delivering via CS.
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Intrathecal Morphine and Pulmonary Complications after Arthroplasty in Patients with Obstructive Sleep Apnea. Anesthesiology 2020; 132:702-712. [DOI: 10.1097/aln.0000000000003110] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Intrathecal morphine is commonly and effectively used for analgesia after joint arthroplasty, but has been associated with delayed respiratory depression. Patients with obstructive sleep apnea may be at higher risk of postoperative pulmonary complications. However, data is limited regarding the safety of intrathecal morphine in this population undergoing arthroplasty.
Methods
This retrospective cohort study aimed to determine the safety of intrathecal morphine in 1,326 patients with documented or suspected obstructive sleep apnea undergoing hip or knee arthroplasty. Chart review was performed to determine clinical characteristics, perioperative events, and postoperative outcomes. All patients received neuraxial anesthesia with low-dose (100 μg) intrathecal morphine (exposure) or without opioids (control). The primary outcome was any postoperative pulmonary complication including: (1) respiratory depression requiring naloxone; (2) pneumonia; (3) acute respiratory event requiring consultation with the critical care response team; (4) respiratory failure requiring intubation/mechanical ventilation; (5) unplanned admission to the intensive care unit for respiratory support; and (6) death from a respiratory cause. The authors hypothesized that intrathecal morphine would be associated with increased postoperative complications.
Results
In 1,326 patients, 1,042 (78.6%) received intrathecal morphine. The mean age of patients was 65 ± 9 yr and body mass index was 34.7 ± 7.0 kg/m2. Of 1,326 patients, 622 (46.9%) had suspected obstructive sleep apnea (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender [STOP-Bang] score greater than 3), while 704 of 1,326 (53.1%) had documented polysomnographic diagnosis. Postoperatively, 20 of 1,322 (1.5%) patients experienced pulmonary complications, including 14 of 1,039 (1.3%) in the exposed and 6 of 283 (2.1%) in the control group (P = 0.345). Overall, there were 6 of 1 322 (0.5%) cases of respiratory depression, 18 of 1,322 (1.4%) respiratory events requiring critical care team consultation, and 4 of 1,322 (0.3%) unplanned intensive care unit admissions; these rates were similar between both groups. After adjustment for confounding, intrathecal morphine was not significantly associated with postoperative pulmonary complication (adjusted odds ratio, 0.60 [95% CI, 0.24 to 1.67]; P = 0.308).
Conclusions
Low-dose intrathecal morphine, in conjunction with multimodal analgesia, was not reliably associated with postoperative pulmonary complications in patients with obstructive sleep apnea undergoing joint arthroplasty.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS ®) Society recommendations. Acta Orthop 2020; 91:3-19. [PMID: 31663402 PMCID: PMC7006728 DOI: 10.1080/17453674.2019.1683790] [Citation(s) in RCA: 312] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.
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Affiliation(s)
- Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Mike Gill
- Golden Jubilee National Hospital, Glasgow, Scotland
| | - David A McDonald
- Scottish Government, Glasgow, Scotland
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, Scotland
| | - Robert G Middleton
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
- Poole Hospital NHS Foundation Trust, Poole, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundational Trust, Northumbria, UK
- Health Sciences, University of York, York, UK
| | - Opinder Sahota
- Nottingham University Hospital, Nottingham, UK
- Nottingham University, Nottingham, UK
| | - Piers Yates
- University of Western Australia, Perth, Australia
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65
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Bodrogi A, Dervin GF, Beaulé PE. Management of patients undergoing same-day discharge primary total hip and knee arthroplasty. CMAJ 2020; 192:E34-E39. [PMID: 31932338 PMCID: PMC6957327 DOI: 10.1503/cmaj.190182] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrew Bodrogi
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ont
| | - Geoffrey F Dervin
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ont
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Ottawa, Ont.
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66
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Koning MV, de Vlieger R, Teunissen AJW, Gan M, Ruijgrok EJ, de Graaff JC, Koopman JSHA, Stolker RJ. The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial. Anaesthesia 2019; 75:599-608. [PMID: 31845316 PMCID: PMC7187216 DOI: 10.1111/anae.14922] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 11/30/2022]
Abstract
Robot‐assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty‐five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg−1 morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery‐15 (QoR‐15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR‐15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot‐assisted radical prostatectomy.
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Affiliation(s)
- M V Koning
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands.,Department of Anaesthesiology and Critical Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - R de Vlieger
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - A J W Teunissen
- Department of Anaesthesiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - M Gan
- Department of Urology, Maasstad Hospital, Rotterdam, the Netherlands
| | - E J Ruijgrok
- Department of Hospital Pharmacy, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - J C de Graaff
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
| | - J S H A Koopman
- Department of Anaesthesiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - R J Stolker
- Department of Anaesthesiology, Erasmus Medical Centre, University Medical Centre Rotterdam, the Netherlands
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67
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Tang JZJ, Weinberg L. A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery. Anesth Pain Med 2019; 9:e94441. [PMID: 32280615 PMCID: PMC7118737 DOI: 10.5812/aapm.94441] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 10/25/2019] [Accepted: 11/12/2019] [Indexed: 01/27/2023] Open
Abstract
CONTEXT The optimal analgesic method for patients undergoing major open hepato-pancreatic-biliary surgery remains controversial. Continuous epidural infusion at the thoracic level remains the standard choice, however concerns have been raised due to associated complications. Single shot intrathecal morphine has emerged as a promising alternative offering similar analgesia with an enhanced safety profile. EVIDENCE ACQUISITION This review aimed to evaluate the literature comparing intrathecal morphine analgesia to other analgesic modalities following major open hepato-pancreatic-biliary surgery. The primary outcome was pain scores at rest and on movement 24 h after surgery. Secondary outcomes were postoperative opioid consumption within 72 postoperative hours, length of stay (LOS), intra-operative fluid administration and post-operative fluid administration within 72 postoperative hours, and overall systemic complication rate within 30 postoperative days. RESULTS Eleven trials matching the inclusion criteria were analysed. Intrathecal morphine resulted in equivalent or lower pain scores when contrasted to alternative techniques, but required higher amounts of postoperative opioid. Intrathecal morphine also offered reduced LOS and reduced fluid administration requirements to epidural analgesia, and there was no difference observed in major complication rate between analgesic modalities. CONCLUSIONS In summary the evidence suggests that intrathecal morphine may be a better first-line analgesic modality than epidural analgesia in the context of major open hepato-pancreatic-biliary surgery, but high-quality evidence supporting this is limited.
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68
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Kang R, Chin KJ, Gwak MS, Kim GS, Choi SJ, Kim JM, Choi GS, Ko JS. Bilateral single-injection erector spinae plane block versus intrathecal morphine for postoperative analgesia in living donor laparoscopic hepatectomy: a randomized non-inferiority trial. Reg Anesth Pain Med 2019:rapm-2019-100902. [PMID: 31649028 DOI: 10.1136/rapm-2019-100902] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/02/2019] [Accepted: 10/09/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intrathecal morphine (ITM) provides effective postoperative analgesia in living donor hepatectomy but has significant adverse effects. Studies support the efficacy of erector spinae plane (ESP) blocks in laparoscopic abdominal surgery; we therefore hypothesized that they would provide non-inferior postoperative analgesia compared with ITM and reduce postoperative nausea/vomiting and pruritus. We conducted a randomized, controlled, non-inferiority trial to compare the analgesic efficacy of ITM and bilateral single-injection ESP blocks in laparoscopic donor hepatectomy. METHODS Fifty-four donors were randomized to receive bilateral ESP blocks with 20 mL 0.5% ropivacaine (n=27) or 400 µg ITM (n=27). Primary outcome was resting pain score 24 hours postoperatively measured on an 11-point numeric rating scale. The prespecified non-inferiority limit was 1. Incidences of postoperative nausea/vomiting and pruritus were assessed. RESULTS The mean treatment difference (ESP-ITM) in the primary outcome was 1.2 (95% CI 0.7 to 1.8). The 95% CI upper limit exceeded the non-inferiority limit. Opioid consumption and all other pain measurements were similar between groups up to 72 hours postoperatively. The ESP group had significantly lower incidences of postoperative vomiting (p=0.002) and pruritus (p<0.001). CONCLUSIONS Bilateral single-injection ESP blocks resulted in higher resting pain scores 24 hours postoperatively compared with ITM and thus did not meet the study definition of non-inferiority. However, the pain intensity with ESP blocks was mild (mean pain scores <3/10) and associated with reduced incidence of postoperative vomiting and pruritus. It warrants further investigation as an analgesic option after laparoscopic living donor hepatectomy. TRIAL REGISTRATION NUMBER KCT0003191.
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Affiliation(s)
- RyungA Kang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, South Korea
| | - Ki Jinn Chin
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Mi Sook Gwak
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, South Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, South Korea
| | - Soo Joo Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, South Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Seoul, South Korea
| | - Justin Sangwook Ko
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Seoul, South Korea
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69
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Black ND, Heggie J, Moga R, Silversides C, Chin KJ. Total Hip Replacement in a Patient With a Fontan Circulation: A Case Report. A A Pract 2019; 13:316-318. [PMID: 31343431 DOI: 10.1213/xaa.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anesthetic management of the adult patient with a Fontan circulation is complex and requires understanding of the specific physiology of the individual patient. Long-term survival in this cohort has increased to the point where patients are presenting for noncardiac surgery related to degenerative diseases of aging. We describe the perioperative management of a patient with a Fontan circulation undergoing total hip arthroplasty using combined spinal-epidural anesthesia and discuss the issues requiring special consideration for this surgical procedure in this group of patients.
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Affiliation(s)
- Nicholas D Black
- From the Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Rebecca Moga
- From the Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ki Jinn Chin
- From the Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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70
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Mawson AL, Bumrungphuet S, Manonai J. A randomized controlled trial comparing early versus late oral feeding after cesarean section under regional anesthesia. Int J Womens Health 2019; 11:519-525. [PMID: 31686920 PMCID: PMC6751764 DOI: 10.2147/ijwh.s222922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/02/2019] [Indexed: 01/15/2023] Open
Abstract
Objective To compare the return of bowel movements in regionally anesthetized women undergoing cesarean section (C-section) given Early Oral Feeding (EOF) to that of women given Late Oral Feeding (LOF). Secondary outcomes of maternal satisfaction and gastrointestinal complications were also examined. Methods In a single-blinded randomized controlled trial (TCTR20181202001), 148 singleton pregnant women undergoing elective C-sections with regional anesthesia were assigned to receive either EOF or LOF. Participants began to sip water at 6–8 hrs or more than 12 hrs post-operation, for EOF or LOF respectively. Participants were then placed onto a stepping diet as tolerated. Participants failing to tolerate the stepping diet or those having surgical complications were excluded from the study. Results After exclusion, 69 women remained in the EOF group and 67 in the LOF group. The ages of participants ranged from 19 to 42, with a mean of 32.07. There was no-loss follow up and no significant difference in patient characteristics, except the site of the surgical incision. Participants given EOF were more likely to experience bowel sound the next morning than patients given LOF (EOF 87.0%, LOF 44.8%, P-value<0.001). However, there was no difference in time to passing flatus and time to passing stool. Maternal satisfaction regarding hunger (EOF 3.78±0.91, LOF 3.24±1.01, P-value 0.002) and maternal satisfaction with postoperative consumption (EOF 4.38±0.64, LOF 4.13±0.48, P-value 0.049) were significantly higher in the EOF group. There was no difference in gastrointestinal complications between the groups (P-value 0.978). Conclusion The EOF group experienced an earlier return of bowel movement and greater maternal satisfaction than the LOF group, with no difference in gastrointestinal complications. These findings support the recommendation of EOF for women who undergo uncomplicated C-sections under regional anesthesia.
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Affiliation(s)
- Apinun Luksanachinda Mawson
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sommart Bumrungphuet
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jittima Manonai
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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71
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Ren Y, Shi W, Chen C, Li H, Zheng X, Zheng X, Niu C. Efficacy of dexmedetomidine as an adjuvant to local wound infiltration anaesthesia in abdominal surgery: A meta-analysis of randomised controlled trials. Int Wound J 2019; 16:1206-1213. [PMID: 31418529 DOI: 10.1111/iwj.13195] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023] Open
Abstract
To assess the efficacy and safety of dexmedetomidine (DEX) as an adjuvant to local wound infiltration anaesthesia in abdominal surgery, we conducted this meta-analysis. First, the systematic search strategy was performed on PubMed, Embase, and Cochrane Library and five randomised controlled trials (RCTs) involving 294 patients were included. Then, the outcome data were extracted from the studies and their effect sizes were calculated using Review Manager 5. As a result, the addition of DEX significantly reduced visual analogy scores at 6 hours after surgery (mean difference = -0.53[-0.82, -0.25], P < .001), 12 hours after surgery (mean difference = -0.39 [-0.73, -0.05]; P = .03), and 24 hours after surgery (mean difference = -0.20 [-0.29, -0.11], P < .001) and reduced total analgesic consumption within 24 hours after surgery (mean difference = -4.92 [-9.00, -0.84]; P = .02) compared with placebo groups. However, there was no difference in the incidence of postoperative nausea and vomiting (risk ratio = 0.68 [0.41, 1.14]; P = .14). In summary, DEX as a local anaesthetic adjuvant added for local wound infiltration anaesthesia in abdominal surgery could reduce visual analogy scores and postoperative analgesic consumption without changing incidence of postoperative nausea and vomiting.
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Affiliation(s)
- Yifeng Ren
- Key Laboratory of Clinical Resources Translation, Henan University, Kaifeng, China.,Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Shi
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Chengzhe Chen
- Key Laboratory of Clinical Resources Translation, Henan University, Kaifeng, China.,Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, China
| | - Huifang Li
- Key Laboratory of Clinical Resources Translation, Henan University, Kaifeng, China.,Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xiaozhen Zheng
- Department of Anesthesiology, First Affiliated Hospital of Henan University, Kaifeng, China
| | - Xuemei Zheng
- Key Laboratory of Clinical Resources Translation, Henan University, Kaifeng, China
| | - Chenguang Niu
- Key Laboratory of Clinical Resources Translation, Henan University, Kaifeng, China
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73
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Jain S, Malinowski M, Chopra P, Varshney V, Deer TR. Intrathecal drug delivery for pain management: recent advances and future developments. Expert Opin Drug Deliv 2019; 16:815-822. [PMID: 31305165 DOI: 10.1080/17425247.2019.1642870] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Chronic pain conditions of malignant and non-malignant etiology afflict a large group of the population and pose a vast economic burden on society. Intrathecal drug therapy is a viable treatment option in such patients who have failed conservative medical measures and less invasive pain management procedures. However, the clinical growth of intrathecal therapy in managing intractable chronic pain conditions continues to face many challenges and is likely underutilized secondary to its high-complexity and lack of understanding. Areas covered: This review will briefly discuss the history of intrathecal drug delivery systems (IDDS), cerebrospinal fluid (CSF) flow dynamics, types of IDDS, indications and patient profile suitable for this therapy, and risks and complications related to IDDS. We will also discuss challenges faced by physicians utilizing this therapy and the future changes that are needed for making this treatment modality more efficacious. Expert opinion: IDDS offer an effective therapy for pain control in patients suffering from chronic intractable pain conditions. These devices provide a safer alternative to oral opioid medications with reduced systemic side effects. Adherence to best practices and continued clinical and basic science research is important to ensure continuing success of this therapy.
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Affiliation(s)
- Sameer Jain
- a Pain Treatment Centers of America , Little Rock , AR , USA
| | - Mark Malinowski
- b Ohio University - HCOM , OH , USA.,c Adena Spine Center , Chillicothe , OH , USA
| | - Pooja Chopra
- d Department of Physical Medicine and Rehabilitation, University of Kentucky , Lexington , KY , USA
| | - Vishal Varshney
- e Division of Pain Medicine, Department of Anesthesiology, University of Calgary , Calgary , AB , Canada
| | - Timothy R Deer
- f Spine and Nerve Center of the Virginias , Charleston , WV , USA
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74
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Abdalla E, Kamel EZ, Farrag WS. Intravenous dexamethasone combined with intrathecal atropine to prevent morphine-related nausea and vomiting after cesarean delivery: A randomized double-blinded study. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1080/11101849.2019.1636497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Esam Abdalla
- Anesthesia, ICU, and Pain, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Emad Zarief Kamel
- Anesthesia, ICU, and Pain, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Waleed Saleh Farrag
- Anesthesia, ICU, and Pain, Faculty of Medicine, Assiut University, Assiut, Egypt
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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76
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Nalbuphine added to intrathecal morphine in total knee arthroplasty; effect on postoperative analgesic requirements and morphine related side effects. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Holder-Murray J, Esper SA, Boisen ML, Gealey J, Meister K, Medich DS, Subramaniam K. Postoperative nausea and vomiting in patients undergoing colorectal surgery within an institutional enhanced recovery after surgery protocol: comparison of two prophylactic antiemetic regimens. Korean J Anesthesiol 2019; 72:344-350. [PMID: 31096730 PMCID: PMC6676025 DOI: 10.4097/kja.d.18.00355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 05/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Enhanced recovery protocols (ERP) provide optimal perioperative care for surgical patients. Postoperative nausea and vomiting (PONV) is common after colorectal surgery (CRS). We aim to compare the efficacy of aprepitant to a cost-effective alternative, perphenazine, as components of triple antiemetic prophylaxis in ERP patients. METHODS Patients who underwent ERP CRS at a single institution from July 2015 to July 2017 were evaluated retrospectively. Only subjects who received aprepitant (Group 1) or perphenazine (Group 2) preoperatively for PONV prophylaxis were included. Patient characteristics, simplified Apfel PONV scores, perioperative medications, and PONV incidence were compared between the groups. PONV was defined as the need for rescue antiemetics on postoperative days (POD) 0-5. RESULTS Five hundred ninety-seven patients underwent CRS of which 498 met the inclusion criteria. Two hundred thirty-one (46.4%) received aprepitant and 267 (53.6%) received perphenazine. The incidence of early PONV (POD 0-1) was comparable between the two groups: 44.2% in Group 1 and 44.6% in Group 2 (P = 0.926). Late PONV (POD 2-5) occurred less often in Group 1 than Group 2, respectively (35.9% vs. 45.7%, P = 0.027). After matching the groups for preoperative, procedural, and anesthesia characteristics (164 pairs), no difference in early or late PONV could be demonstrated between the groups. CONCLUSIONS The incidence of PONV remains high despite most patients receiving three prophylactic antiemetic medications. Perphenazine can be considered a cost-effective alternative to oral aprepitant for prophylaxis of PONV in patients undergoing CRS within an ERP.
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Affiliation(s)
| | - Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie Gealey
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Meister
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David S Medich
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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78
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Kresnoadi E. The Difference Duration between Analgesia Bupivacaine Hyperbaric Morphine and Bupivacaine Hyperbaric Epinephrine Intrathecal toward Post Surgery of Sectio Caesaria Patient in Bhayangkara Mataram Hospital. PAIN MEDICINE 2019. [DOI: 10.31636/pmjua.v4i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background and Objectives: The most used of regional anesthesia technic is spinal anesthesia. Spinal anesthesia is an easier technic to get the depth and speed of nerve blockade. Some medicine can be used as an adjuvant of local anesthesia to increase the effect of analgesia bupivacaine. This research is aimed to compare the effectiveness of administration of 0.1 mg intrathecal morphine and 0.1 mg intrathecal epinephrine to prolong 0.5% 12.5 mg hyperbaric analgesia bupivacaine toward caesarean section postoperative period. Method: This research is an experimental clinical trial randomized double-blind phase II. Subject of this study is the elective surgery patients (ASA I and II) with spinal anesthesia who are 18–40 years old and having weight around 50–70 kgs. There are 48 patients that is divided into 2 groups; 24 patients of group M (morphine 0.1 mg) and 24 patients of group E (epinephrine 0.1 mg). Result: The result of this study revealed the duration of analgesia is longer in group M (morphine 0.1 mg) than group T (tramadol 25 mg) (309.08±5.55 vs 221.66±6.43). Conclusion: adjuvant of 0.1 mg morphine and 0.5% 12.5 mg intrathecal hyperbaric bupivacaine can make the work period of analgesia longer while post caesaria section surgery rather than 0.5% 12.5 mg bupivacaine and 0.1 intrathecal epinephrine.
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Colibaseanu DT, Osagiede O, Merchea A, Ball CT, Bojaxhi E, Panchamia JK, Jacob AK, Kelley SR, Naessens JM, Larson DW. Randomized clinical trial of liposomal bupivacaine transverse abdominis plane block versus intrathecal analgesia in colorectal surgery. Br J Surg 2019; 106:692-699. [DOI: 10.1002/bjs.11141] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/20/2018] [Accepted: 01/06/2019] [Indexed: 01/07/2023]
Abstract
Abstract
Background
Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT.
Methods
Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia.
Results
In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes.
Conclusion
IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- D T Colibaseanu
- Department of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - O Osagiede
- Department of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - A Merchea
- Department of Colon and Rectal Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - C T Ball
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - E Bojaxhi
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - J K Panchamia
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - A K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - S R Kelley
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - J M Naessens
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota, USA
| | - D W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Rutström E, Söndergaard S, Lundborg C, Ene K. Postoperative pain experience, pain treatment and recovery after lumbar fusion and fixation surgery. Int J Orthop Trauma Nurs 2019; 34:3-8. [PMID: 30846358 DOI: 10.1016/j.ijotn.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Eva Rutström
- The Sahlgrenska Academy at Gothenburg University, Institute of Health and Care Sciences, SE 413 46, Gothenburg, Sweden.
| | - Sören Söndergaard
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Lundborg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Ene
- The Sahlgrenska Academy at Gothenburg University, Institute of Health and Care Sciences, SE 413 46, Gothenburg, Sweden
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81
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Kjølhede P, Bergdahl O, Borendal Wodlin N, Nilsson L. Effect of intrathecal morphine and epidural analgesia on postoperative recovery after abdominal surgery for gynecologic malignancy: an open-label randomised trial. BMJ Open 2019; 9:e024484. [PMID: 30837253 PMCID: PMC6430030 DOI: 10.1136/bmjopen-2018-024484] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 01/06/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to determine whether regional analgesia with intrathecal morphine (ITM) in an enhanced recovery programme (enhanced recovery after surgery [ERAS]) gives a shorter hospital stay with good pain relief and equal health-related quality of life (QoL) to epidural analgesia (EDA) in women after midline laparotomy for proven or assumed gynaecological malignancies. DESIGN An open-label, randomised, single-centre study. SETTING A tertiary referral Swedish university hospital. PARTICIPANTS Eighty women, 18-70 years of age, American Society of Anesthesiologists I and II, admitted consecutively to the department of Obstetrics and Gynaecology. INTERVENTIONS The women were allocated (1:1) to either the standard analgesic method at the clinic (EDA) or the experimental treatment (ITM). An ERAS protocol with standardised perioperative routines and standardised general anaesthesia were applied. The EDA or ITM started immediately preoperatively. The ITM group received morphine, clonidine and bupivacaine intrathecally; the EDA group had an epidural infusion of bupivacaine, adrenalin and fentanyl. PRIMARY AND SECONDARY OUTCOME MEASURES Primary endpoint was length of hospital stay (LOS). Secondary endpoints were QoL and pain assessments. RESULTS LOS was statistically significantly shorter for the ITM group compared with the EDA group (median [IQR]3.3 [1.5-56.3] vs 4.3 [2.2-43.2] days; p=0.01). No differences were observed in pain assessment or QoL. The ITM group used postoperatively the first week significantly less opioids than the EDA group (median (IQR) 20 mg (14-35 mg) vs 81 mg (67-101 mg); p<0.0001). No serious adverse events were attributed to ITM or EDA. CONCLUSIONS Compared with EDA, ITM is simpler to administer and manage, is associated with shorter hospital stay and reduces opioid consumption postoperatively with an equally good QoL. ITM is effective as postoperative analgesia in gynaecological cancer surgery. TRIAL REGISTRATION NUMBER NCT02026687; Results.
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Affiliation(s)
- Preben Kjølhede
- Children and Women’s Health, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Olga Bergdahl
- Department of Obstetrics and Gynecology, Vrinnevisjukhuset i Norrkoping, Norrkoping, Sweden
| | - Ninnie Borendal Wodlin
- Children and Women’s Health, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Lena Nilsson
- Department of Anesthesiology and Intensive Care, and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Postoperative Analgesic Effects of Different Doses of Epidural Hydromorphone Coadministered with Ropivacaine after Cesarean Section: A Randomized Controlled Trial. Pain Res Manag 2019; 2019:9054538. [PMID: 30944686 PMCID: PMC6421812 DOI: 10.1155/2019/9054538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 01/22/2019] [Indexed: 11/18/2022]
Abstract
Purpose Single dose of epidural hydromorphone has been introduced to serve as an alternative method for postcesarean section analgesia. However, optimal dose of epidural hydromorphone remains unknown. Hence, we evaluated and compared the analgesic and adverse effects of postoperative different doses of epidural hydromorphone coadministered with ropivacaine after cesarean section. Methods Eighty term parturients with elective cesarean section under epidural anesthesia were allocated into four groups. Epidural analgesia was administered with an epidural bolus of either 0 mg (group H0), or 0.2 mg (group H1), or 0.4 mg (group H2), or 0.6 mg (group H3) hydromorphone coadministered with ropivacaine. The primary outcome was the visual analogue pain scores (VAPSs) and rescue opioid consumption (PCIA with sulfentanil) in 24 hours. Adverse effects such as respiratory depression, pruritus, nausea, and vomiting were recorded. Results The VAPSs of group H1 at 2, 4, 6, 12 h and 24 h after surgery was similar to group H0. The VAPSs of group H2 at 4 and 6 h postoperatively were significantly decreased when compared to group H0. But, the VAPSs of group H2 at 2, 12, and 24 h postoperatively were similar to those of group H0. The VAPSs of group H3 at 4, 6, 12 h, and 24 h after surgery were significantly decreased when compared to those of group H0. The total sulfentanil consumption in 24 hours was 90 ± 26 μg in group H0, 75 ± 29 μg in group H1, 54 ± 32 μg in group H2, and 15 ± 16 μg in group H0. Adverse effects were comparable in the four groups. Conclusions Epidural administration of 0.6 mg hydromorphone coadministered with ropivacaine after cesarean section provided satisfactory pain relief with less sulfentanil consumption. This trial is registered with ChiCTR-IPR-16010026.
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:454-465. [DOI: 10.1213/ane.0000000000003663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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84
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick E, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:441-453. [DOI: 10.1213/ane.0000000000003564] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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85
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Grant MC, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery. Reg Anesth Pain Med 2019; 44:rapm-2018-100071. [PMID: 30737316 DOI: 10.1136/rapm-2018-100071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 12/27/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.
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Affiliation(s)
- Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Melinda M Gibbons
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Clifford Y Ko
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Anesthesiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher L Wu
- Anesthesiology, Hospital for Special Surgery, New York City, New York, USA
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Kumar P, Khandelwal M, Rao H, Bafna U, Beniwal S. Comparative study of morphine or dexmedetomidine as intrathecal adjuvants to 0.5% hyperbaric bupivacaine in infraumbilical surgeries. INDIAN JOURNAL OF PAIN 2019. [DOI: 10.4103/ijpn.ijpn_31_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Ghaffari S, Dehghanpisheh L, Tavakkoli F, Mahmoudi H. The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request. Cureus 2018; 10:e3715. [PMID: 30788204 PMCID: PMC6373886 DOI: 10.7759/cureus.3715] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction The proportion of women electing for cesarean delivery has increased in both developed and developing countries. Cesarean delivery on maternal request (CDMR) refers to a primary cesarean delivery performed because the mother requests this method of delivery in the absence of standard medical/obstetrical indications. Several studies compared anesthesia modalities in cesarean section regarding clinical outcomes such as maternal mortality, post-operative pain and bleeding, but only a few compared health-related quality of life (HRQoL) of women undergoing general anesthesia versus spinal anesthesia. The aim of this study was to determine whether pregnant women who undergo general anesthesia (GA) for cesarean delivery compared with spinal anesthesia (SA) differ regarding their perceived HRQoL. Methodology We enrolled 160 pregnant women with American Society of Anesthesiologists (ASA) class II, scheduled for CDMR with GA or SA. Anesthesia modality was based on patient’s preference. Participants assessed their state of health with the EuroQoL-5 Dimensions-3 Levels (EQ-5D-3L) self-administered questionnaire at four time points: six hours before cesarean delivery, 24 hours after cesarean delivery, one week and one month after cesarean delivery. Patients also rated their health on the EQ visual analog scale (EQ-VAS) from 100 mm “best imaginable health state” to 0 mm “worst imaginable health state”. Results More women who underwent spinal anesthesia reported “no problem” with regards to “mobility’ (64% vs. 30%, p = 0.00), “usual activities” (90% vs. 38%, p = 0.00), and “pain/discomfort” (20% vs. 5%, p = 0.007). Repeated measurement analysis showed that the two groups started off with the same EQ-VAS score, however, both decreased over time with different slope resulting in different scores at 24 hours after CS. Then the scores increased in both groups over time and ended up being rather close at one month after CS. Discussion Unless there is a contraindication, neuraxial anesthesia is the anesthetic technique of choice for cesarean delivery in all parturient in general. This concept is based on more mortality and morbidity that have been seen with general anesthesia in this particular population. Our study demonstrated significant advantages of spinal anesthesia compared to general anesthesia in cesarean section regarding postoperatively perceived HRQoL. We showed that more pregnant women who chose spinal anesthesia as their anesthesia modality reported “no problem” with respect to “mobility” and “Self-care” 24 hours after cesarean section. On the top of that, more women in this group had “no problem” in their “usual activities” at one week and one month after cesarean delivery time points. Moreover, EQ-5D general health score was higher 24 hours after cesarean delivery with regional anesthesia comparing to general anesthesia. Conclusion We determined that compared to general anesthesia, spinal anesthesia is the technique of choice for cesarean section because not only it avoids a general anesthetic and the risk of failed intubation, but also because it provides effective pain control, mobility and fast return back to daily activities for new mothers and increase their quality of life.
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Affiliation(s)
| | | | | | - Hilda Mahmoudi
- Epidemiology and Public Health, Nova Southeastern University School of Osteopathic Medicine, Miami, USA
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88
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Sivevski AG, Karadjova D, Ivanov E, Kartalov A. Neuraxial Anesthesia in the Geriatric Patient. Front Med (Lausanne) 2018; 5:254. [PMID: 30320111 PMCID: PMC6165911 DOI: 10.3389/fmed.2018.00254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/23/2018] [Indexed: 12/16/2022] Open
Abstract
Neuraxial anesthesia is recommended as a well-accepted option to minimize the perioperative side effects in the geriatric patients. The available data from the current researches have shifted the focus from the conventional approach to spinal anesthesia to the concept of low dose local anesthetic combined with opioids. What remains clear from all these studies is that hemodynamic stability is much better in patients who received low-doses of intrathecal bupivacaine in combination with opioids, which is possibly result of a potent synergistic nociceptive analgesic effect and their minimal potential effects on sympathetic pathways thus minimizing spinal hypotension. Spinal anesthesia with 5–10 mg of 0.5% heavy bupivacaine, fentanyl 20 mcg and 100 mcg of long-acting morphine added to the perioperative plan decreased the incidence of spinal hypotension and improved perioperative outcomes in the geriatric patients undergoing (low segment) surgical procedures. These findings may be of interest in the gynecologic geriatric surgery also in which area there are very few studies concerning the use of low-dose concept.
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Affiliation(s)
- Atanas G Sivevski
- Department of Anaesthesia, Clinical Center Mother Teresa, University Clinic for Gynecology and Obstetrics, Skopje, Macedonia
| | - Dafina Karadjova
- Department of Anaesthesia, Clinical Center Mother Teresa, University Clinic for Gynecology and Obstetrics, Skopje, Macedonia
| | - Emilija Ivanov
- Department of Anaesthesia, Clinical Center Mother Teresa, University Clinic for Gynecology and Obstetrics, Skopje, Macedonia
| | - Andrijan Kartalov
- Clinical Center Mother Teresa, University Clinic for TOARILUC, Skopje, Macedonia
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Intrathecal Morphine for Laparoscopic Segmental Colonic Resection as Part of an Enhanced Recovery Protocol: A Randomized Controlled Trial. Reg Anesth Pain Med 2018; 43:166-173. [PMID: 29219935 PMCID: PMC5794252 DOI: 10.1097/aap.0000000000000703] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background and Objectives Management of postoperative pain after laparoscopic segmental colonic resections remains controversial. We compared 2 methods of analgesia within an Enhanced Recovery After Surgery (ERAS) program. The goal of the study was to investigate whether administration of intrathecal bupivacaine/morphine would lead to an enhanced recovery. Methods A single-center, randomized, double-blind controlled trial was performed (NL43488.101.13). Patients scheduled for laparoscopic segmental intestinal resections were considered. Exclusion criteria were patients in whom contraindications to spinal anesthesia were present, conversion to open surgery, and gastric and rectal surgery. The intervention group received single-shot intrathecal bupivacaine/morphine (12.5 mg/300 μg), with an altered dose for older patients. The control group received a sham procedure and a bolus of piritramide (0.1 mg/kg). Both groups received standardized general anesthesia and a patient-controlled intravenous analgesia pump as postoperative analgesia. All patients were treated according to an ERAS protocol. A decrease in days to “fit for discharge” was the primary outcome. Results Fifty-six patients were enrolled. Intervention group patients were fit for discharge earlier (median of 3 vs 4 days, P = 0.044). Furthermore, there was a significant decrease in opioid use and lower pain scores on the first postoperative day in the intervention group. There were no differences in adverse events (except for more pruritus), time to mobilization, fluid administration, or patient satisfaction. Conclusions This randomized controlled trial shows that intrathecal morphine is a more effective method of postoperative analgesia in laparoscopic surgery than intravenous opioids within an ERAS program. Recovery is faster and less painful with intrathecal morphine. Other studies have confirmed these results, although data on faster recovery are new and require confirmation in future trials. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02284282.
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90
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Safety and side-effect profile of intrathecal morphine in a diverse patient population undergoing total knee and hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:125-129. [DOI: 10.1007/s00590-018-2293-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/03/2018] [Indexed: 01/25/2023]
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91
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Aly M, Ibrahim A, Farrag W, Abdelsalam K, Mohamed H, Tawfik A. Pruritus after intrathecal morphine for cesarean delivery: incidence, severity and its relation to serum serotonin level. Int J Obstet Anesth 2018; 35:52-56. [DOI: 10.1016/j.ijoa.2018.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/03/2018] [Accepted: 02/12/2018] [Indexed: 11/26/2022]
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Cheah JW, Sing DC, Hansen EN, Aleshi P, Vail TP. Does Intrathecal Morphine in Spinal Anesthesia Have a Role in Modern Multimodal Analgesia for Primary Total Joint Arthroplasty? J Arthroplasty 2018; 33:1693-1698. [PMID: 29433962 DOI: 10.1016/j.arth.2018.01.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/08/2018] [Accepted: 01/08/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Intrathecal morphine (ITM) combined with bupivacaine spinal anesthesia can improve postoperative pain, but has potential side effects of postoperative nausea/vomiting (PONV) and pruritus. With the use of multimodal analgesia and regional anesthetic techniques, postoperative pain control has improved significantly to a point where ITM may be avoided in total joint arthroplasty (TJA). METHODS We performed a retrospective study of primary TJA patients who underwent a standardized multimodal recovery pathway and received bupivacaine neuraxial anesthesia with ITM vs bupivacaine neuraxial anesthesia alone (control). RESULTS In total, 598 patients were identified (131 controls, 467 ITMs) with similar demographics. On postoperative day 0 (POD 0), ITM patients had significantly lower mean visual analog scale scores (1.5 ± 1.6 vs 2.5 ± 1.9, P < .001) and consumed less oral morphine equivalents (10.5 ± 25.4 vs 16.8 ± 27.2, P = .013). ITM patients walked further compared to controls by POD 1 (133.6 ± 159.6 vs 97.3 ± 141 m, P = .028) and were less likely to develop PONV during their entire hospital stay (38.5% vs 48.6%, P = .043). No significant differences were seen for total morphine equivalents consumption, rate of discharge to care facility, length of stay, and 90-day readmission rates. CONCLUSION ITM was associated with improved POD 0 pain scores and less initial oral/intravenous opioid consumption, which likely contributes to the subsequent improved mobilization and lower rates of PONV. In the setting of a modern regional anesthesia and multimodal analgesia recovery plan for TJA, ITM can still be considered for its benefits.
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Affiliation(s)
- Jonathan W Cheah
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - David C Sing
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Erik N Hansen
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Pedram Aleshi
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco Medical Center, San Francisco, California
| | - Thomas P Vail
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
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94
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Ibrahim AS, Aly MG, Thabet ME, Abdelaziz MR. Effect of adding nalbuphine to intrathecal bupivacaine with morphine on postoperative nausea and vomiting and pruritus after elective cesarean delivery: a randomized double blinded study. Minerva Anestesiol 2018; 85:255-262. [PMID: 29856176 DOI: 10.23736/s0375-9393.18.12751-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of intrathecal morphine may result in serious side effects in parturients undergoing cesarean delivery. Nalbuphine, is a mu receptor antagonist and a ĸappa receptor agonist. Combinations of opioid agonist and agonist antagonist can decrease the incidence of opioid related side effects. We aimed to investigate the effect of adding nalbuphine, to intrathecal morphine on postoperative nausea and vomiting and pruritus after a cesarean delivery. METHODS Eighty parturient undergoing elective cesarean delivery under spinal anesthesia were randomized into two similar groups. Group 1: received 10 mg of 0.5% hyperbaric bupivacaine with 0.2 mg morphine. Group 2: received as a group 1 plus 0.5 mg nalbuphine, with total volume 2.5 mL in both groups. Measurements: Data on the severity of nausea and vomiting were collected using a numerical rating scale and visual analogue scale was used to quantify pruritus. Onset and duration of sensory blockade, Visual Analog Scale for pain, the first time to ask for rescue analgesia and total rescue analgesic consumption were recorded. RESULTS Nausea and vomiting and pruritus severity scores and number of patients developed nausea and vomiting and pruritus were significantly lower (P<0.001) in group 2. Onset and duration of sensory block, time to first request for rescue analgesia, Visual Analog Scale for pain and paracetamol consumption showed no statistically differences between both groups (P>0.05). CONCLUSIONS We concluded that the addition of nalbuphine to intrathecal bupivacaine plus morphine significantly reduced the incidence and severity of postoperative nausea and vomiting and pruritus without affecting analgesic potency.
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Affiliation(s)
- Abdelrady S Ibrahim
- Department of Anesthesia and ICU, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt -
| | - Mohamed G Aly
- Department of Anesthesia and ICU, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
| | - Mostafa E Thabet
- Department of Anesthesia and ICU, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
| | - Mohamed R Abdelaziz
- Department of Anesthesia and ICU, Faculty of Medicine, Assiut University Hospital, Assiut, Egypt
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Plasma Ropivacaine Concentrations Following Local Infiltration Analgesia in Total Knee Arthroplasty. Reg Anesth Pain Med 2018; 43:347-351. [DOI: 10.1097/aap.0000000000000727] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Selvam V, Subramaniam R, Baidya DK, Chhabra A, Gupta N, Dadhwal V, Malhotra N. Safety and Efficacy of Low-Dose Intrathecal Morphine for Laparoscopic Hysterectomy: A Randomized, Controlled Pilot Study. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Velmurugan Selvam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anjolie Chhabra
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Nandita Gupta
- Department of Endocrinology, Metabolism and Diabetes, All India Institute of Medical Sciences, New Delhi, India
| | - Vatsla Dadhwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Neena Malhotra
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
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Thay YJ, Goh QY, Han RN, Sultana R, Sng BL. Pruritus and postoperative nausea and vomiting after intrathecal morphine in spinal anaesthesia for caesarean section: Prospective cohort study. PROCEEDINGS OF SINGAPORE HEALTHCARE 2018. [DOI: 10.1177/2010105818760340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Spinal anaesthesia is a common anaesthetic technique for caesarean sections. Neuraxial opioids such as intrathecal morphine may cause common adverse effects (pruritus, post-operative nausea and vomiting). Objectives: We investigated the incidence, severity and need for treatment of pruritus and post-operative nausea and vomiting following administration of intrathecal morphine in spinal anaesthesia for caesarean section at KK Women’s and Children’s Hospital, Singapore. Methods: We conducted a prospective study involving 124 parturients who received intrathecal morphine in spinal anaesthesia for caesarean section from October 2012 to October 2014. Results: Seventy patients (56.5%) had moderate or severe pruritus (score 4–10), while 54 patients (43.5%) had no or mild pruritus (score 0–3). Mean (SD) value of the worst pruritus score reported on a scale of 0–10 was 4 (2.59). Only seven out of the 124 patients (5.6%) required treatment for pruritus. With respect to distress and bother from itching in the past 24 hours on a score of 0–4, the mean score reported was 1.7 (1.23). Fourteen (11.2%) patients reported vomiting, dry-retching and nausea. Six (4.8%) patients had nausea that interfered with activities of daily living. Four (3.2%) patients had clinically significant post-operative nausea and vomiting. Seven (5.6%) patients received anti-emetics. The average Overall Benefit of Analgesia Score was 3.8 (SD 2.6, min–max: 0–15). The average (SD) maternal satisfaction with pain relief and side effects was 84.9% (9.9%). Conclusion: There is a high incidence of pruritus, with most women reporting moderate to severe pruritus. The incidence of post-operative nausea and vomiting is low, and women reported good maternal satisfaction.
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Affiliation(s)
- Yu Jia Thay
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Qing Yuan Goh
- Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| | - Reena Nianlin Han
- Clinical Support Services, KK Women’s and Children’s Hospital, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Ban Leong Sng
- Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore
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98
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Woods JM, Lim AG. Prevalence and management of intrathecal morphine-induced pruritus in New Zealand Māori healthcare recipients. Br J Pain 2018; 12:20-25. [PMID: 29416861 DOI: 10.1177/2049463717719773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Aims and objectives The aim of this article was to determine whether the incidence of intrathecal morphine-induced pruritus (ITMI) was influenced by ethnicity, age or gender in relation to orthopaedic versus caesarean surgeries. Background The use of intrathecal morphine for patients undergoing total hip and knee joint replacements and for lower segment caesarean sections (LSCS) has gained popularity worldwide since its introduction over 30 years ago. Several international studies show that morphine delivered via the intrathecal route is an effective and safe method of pain relief. However, while the beneficial effects of intrathecal morphine have been clearly documented in many studies, so also have the adverse effects, predominantly being nausea and vomiting, pruritus and respiratory depression. Pruritus is described as one of the most common adverse effects, with a reported incidence of 30-100%. Design A retrospective study was conducted using data collected over a 21-month period on post-operative patients who had received intrathecal morphine as their post-operative pain management. Methods A two-phased approach was undertaken. The study was conducted to determine the incidence of ITMI pruritus among two patient groups, New Zealand Māori and New Zealand European, 96 subjects in total, and if treatment was received. Results The findings revealed significant ethnic disparities whereas New Zealand Māori had a significantly higher rate of ITMI pruritus than New Zealand European, New Zealand Māori experienced the pruritus with more intensity and are less likely to be treated for it. Conclusion Increased international knowledge and awareness for health professionals around the diversities of ethnicity and associated pharmacogenetics playing a significant role in patient response to opioid therapy can lead to improved overall care and patient satisfaction.
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Affiliation(s)
- Jennifer M Woods
- Department of Nursing, Toi Ohomai, Private Bag 12001, Tauranga 3143, New Zealand
| | - Anecita Gigi Lim
- Department of Nursing, Building 503, 85 Park Rd, Auckland 1142, New Zealand
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Cosgrave D, Galligan M, Soukhin E, McMullan V, McGuinness S, Puttappa A, Conlon N, Boylan J, Hussain R, Doran P, Nichol A. The NAPRESSIM trial: the use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine in elective hepatobiliary surgery: a study protocol and statistical analysis plan for a randomised controlled trial. Trials 2017; 18:633. [PMID: 29284510 PMCID: PMC5747267 DOI: 10.1186/s13063-017-2370-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 11/21/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Intrathecally administered morphine is effective as part of a postoperative analgesia regimen following major hepatopancreaticobiliary surgery. However, the potential for postoperative respiratory depression at the doses required for effective analgesia currently limits its clinical use. The use of a low-dose, prophylactic naloxone infusion following intrathecally administered morphine may significantly reduce postoperative respiratory depression. The NAPRESSIM trial aims to answer this question. METHODS/DESIGN 'The use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine' trial is an investigator-led, single-centre, randomised, double-blind, placebo-controlled, double-arm comparator study. The trial will recruit 96 patients aged > 18 years, undergoing major open hepatopancreaticobiliary resections, who are receiving intrathecally administered morphine as part of a standard anaesthetic regimen. It aims to investigate whether the prophylactic administration of naloxone via intravenous infusion compared to placebo will reduce the proportion of episodes of respiratory depression in this cohort of patients. Trial patients will receive an infusion of naloxone or placebo, commenced within 1 h of postoperative extubation continued until the first postoperative morning. The primary outcome is the rate of respiratory depression in the intervention group as compared to the placebo group. Secondary outcomes include pain scores, rates of nausea and vomiting, pruritus, sedation scores and adverse outcomes. We will also employ a novel, non-invasive, respiratory minute volume monitor (ExSpiron 1Xi, Respiratory Motion, Inc., 411 Waverley Oaks Road, Building 1, Suite 150, Waltham, MA, USA) to assess the monitor's accuracy for detecting respiratory depression. DISCUSSION The trial aims to provide a clear management plan to prevent respiratory depression after the intrathecal administration of morphine, and thereby improve patient safety. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02885948 . Registered retrospectively on 4 July 2016. Protocol Version 2.0, 3 April 2017. Protocol identification (code or reference number): UCDCRC/15/006 EudraCT registration number: 2015-003504-22. Registered on 5 August 2015.
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Affiliation(s)
| | - Marie Galligan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Era Soukhin
- St Vincent's University Hospital, Dublin, Ireland
| | | | | | | | - Niamh Conlon
- St Vincent's University Hospital, Dublin, Ireland
| | - John Boylan
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Rabia Hussain
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Alistair Nichol
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Monash University, Melbourne, VIC, Australia.,The Alfred Hospital, Melbourne, VIC, Australia
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100
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Hein A, Jakobsson JG. Portable respiratory polygraphy monitoring of obese mothers the first night after caesarean section with bupivacaine/morphine/fentanyl spinal anaesthesia. F1000Res 2017; 6:2062. [PMID: 29527293 PMCID: PMC5820605 DOI: 10.12688/f1000research.13206.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Obesity, abdominal surgery, and intrathecal opioids are all factors associated with a risk for respiratory compromise. The aim of this explorative trial was to study the apnoea/hypopnea index 1st postoperative night in obese mothers having had caesarean section (CS) in spinal anaesthesia with a combination of bupivacaine/morphine and fentanyl. Methods: Consecutive obese (BMI >30 kg/m 2) mothers, ≥18 years, scheduled for CS with bupivacaine/morphine/fentanyl spinal anaesthesia were monitored with a portable polygraphy device Embletta /NOX on 1 st postoperative night. The apnoea/hypopnea index (AHI) was identified by clinical algorithm and assessed in accordance to general guidelines; number of apnoea/hypopnea episodes per hour: <5 "normal", ≥5 and <15 mild sleep apnoea, ≥15 and <30 moderate sleep apnoea, ≥ 30 severe sleep apnoea. Oxygen desaturation events were in similar manner calculated per hour as oxygen desaturation index (ODI). Results: Forty mothers were invited to participate: 27 consented, 23 were included, but polysomnography registration failed in 3. Among the 20 mothers studied: 11 had an AHI <5 ( normal), 7 mothers had AHI ≥5 but <15 ( mild OSAS) and 2 mothers had AHI ≥15 ( moderate OSA), none had an AHI ≥ 30. The ODI was on average 4.4, and eight patients had an ODI >5. Mothers with a high AHI (15.3 and 18.2) did not show high ODI. Mean saturation was 94% (91-96%), and four mothers had mean SpO 2 90-94%, none had a mean SpO2 <90%. Conclusion: Respiratory polygraphy 1 st night after caesarean section in spinal anaesthesia with morphine in moderately obese mothers showed AHIs that in sleep medicine terms are considered normal, mild and moderate. Obstructive events and episodes of desaturation were commonly not synchronised. Further studies looking at preoperative screening for sleep apnoea in obese mothers are warranted but early postop respiratory polygraphy recording is cumbersome and provided sparse important information.
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Affiliation(s)
- Anette Hein
- Anaesthesia & Intensive Care, Institution for Clinical Sciences, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
| | - Jan G. Jakobsson
- Anaesthesia & Intensive Care, Institution for Clinical Sciences, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
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