Intrathecal Morphine: The Forgotten Child

Analgesic Efficacy and Safety of Intrathecal Morphine or Intercostal Levobupivacaine in Lung Cancer Patients after Major Lung Resection Surgery by Videothoracoscopy: A Prospective Randomized Controlled Trial

Background: Lung resection using video-assisted thoracoscopic surgery (VATS) improves surgical accuracy and postoperative recovery. Unfortunately, moderate-to-severe acute postoperative pain is still inherent to the procedure, and a technique of choice has not been established for the appropriate control of pain. In this study, we aimed to compare the efficacy and safety of intrathecal morphine (ITM) with that of intercostal levobupivacaine (ICL). Methods: We conducted a single-center, prospective, randomized, observer-blinded, controlled trial among 181 adult patients undergoing VATS (ISRCTN12771155). Participants were randomized to receive ITM or ICL. Primary outcomes were the intensity of pain, assessed by a numeric rating scale (NRS) over the first 48 h after surgery, and the amount of intravenous morphine used. Secondary outcomes included the incidence of adverse effects, length of hospital stay, mortality, and chronic post-surgical pain at 6 and 12 months after surgery. Results: There are no statistically significant differences between ITM and ICL groups in pain intensity and evolution at rest. In cough-related pain, differences in pain trajectories over time are observed. Upon admission to the PACU, cough-related pain was higher in the ITM group, but the trend reversed after 6 h. There are no significant differences in adverse effects. The rate of chronic pain was low and did not differ significantly between groups. Conclusions: ITM can be considered an adequate and satisfactory regional technique for the control of acute postoperative pain in VATS, compatible with the multimodal rehabilitation and early discharge protocols used in these types of surgeries.

Toraks cerrahisinde postoperatif analjezide intratekal morfin: Tek merkez deneyimi

Amaç: Bu çalışmada kliniğimizde toraks cerrahisi uygulanan hastalarda postoperatif analjezi amaçlı intratekal morfin kullanımı ile ilgili deneyimlerimizi sunmayı amaçladık. Gereç ve Yöntem: Bu çalışmada Ocak 2020-Haziran 2020 tarihleri arasında toraks cerrahisi geçiren ve postoperatif analjezi amaçlı intratekal morfin uygulanan toplam 18 erişkin hastanın dosyası ve anestezi formları retrospektif olarak incelendi. Grup 1;10 mcg/kg intratekal morfin, Grup 2; 7 mcg/kg intratekal morfin uygulanan grup olarak ikiye ayrıldı. Hastaların demografik verileri, uygulanan morfin dozları, anestezi ve cerrahi süreleri, intraoperatif anestezik ajan tüketimleri, postoperatif hemodinamik verileri, ağrı düzeyleri, ek analjezik ihtiyaçları ve yan etkiler incelendi. Bulgular: Hastaların 12’sine (% 66,7) ideal vücut ağırlığına göre 10 mcg/kg, 6’sına (%33,3) 7 mcg/kg intratekal morfin uygulandığı tespit edildi. İntraoperatif anestezik ajan tüketimi Grup 1’de Grup 2’ye kıyasla daha düşük bulundu, ancak aradaki fark istatistiksel olarak anlamlı değildi. Postoperatif 12, 24 ve 48. saatlerde dinlenme sırasında bakılan ağrı düzeyleri Grup 1’de istatistiksel olarak daha düşük. Postoperatif 12, 18, 24 ve 48. saatlerde efor sırasında bakılan ağrı düzeyleri de Grup 1’de istatistiksel olarak daha düşük bulundu. Sonuç: Toraks cerrahisi hastalarında uygulanan intratekal morfin güvenli bir postoperatif analjezi seçeneğidir. Bu amaçla 10 mcg/kg dozunda uygulanan intratekal morfinin 7 mcg/kg’e göre daha etkin analjezi sağladığı kanaatindeyiz.

The effect of ultrasound-guided serratus anterior plane block in addition to intrathecal morphine on early postoperative period after video-assisted thoracoscopic surgery

Background

The aim of this study was to evaluate the effect of serratus anterior plane block in addition to intrathecal morphine for early postoperative period after video-assisted thoracoscopic surgery on the amount of morphine consumption and the Visual Analog Scale scores.

Methods

This single-blind, randomized-controlled study included a total of 64 patients (39 males, 25 females; mean age: 53.6±17.0 years; range, 20 to 89 years) who were scheduled for video-assisted thoracoscopic surgery in a tertiary hospital between September 2019 and March 2020. Postoperative pain control was achieved with intrathecal morphine 0.6 mg addition to serratus anterior plane block (Group ITM+SAPB) or with only intrathecal morphine (Group ITM) after an induction of anesthesia. The serratus anterior plane block was performed with a single injection of 0.4 mL/kg of 0.25% bupivacaine at the level of fifth rib with ultrasound guidance. Morphine consumption, pain scores, and side effects were recorded in the postoperative period.

Results

The mean morphine consumption was significantly lower in the ITM+SAPB group at all time points. Compared to the control group, the Visual Analog Scale-resting and coughing scores were significantly lower in the first 12 h after surgery. Pain scores were significantly higher in the ITM+SAPB group in patients where the trocar was inserted at upper level of the fifth rib than the lower level (3-5 vs. 5-8) during the first 6 h after surgery.

Conclusion

The use of serratus anterior plane block in addition to intrathecal morphine is a safe and effective way to improve pain control for early postoperative period after video-assisted thoracoscopic surgery. The serratus anterior plane block ensures better analgesia until the peak effect of spinal morphine occurs.

Comparative evaluation of intrathecal morphine and intrathecal dexmedetomidine in patients undergoing gynaecological surgeries under spinal anaesthesia: A prospective randomised double blind study

BACKGROUND AND AIMS

Inrathecal opioids like morphine added to local anaesthetic agents have been found to be effective in achieving prolonged post-operative analgesia. Intrathecal dexmedetomidine may be devoid of undesirable side effects related to morphine and hence, this study was designed to evaluate analgesic efficacy, haemodynamic stability and adverse effects of both these adjuvants in patients undergoing gynaecological surgeries.

METHODS

This was a prospective, randomised, double blind study involving 25 patients in each group. Group M received 15 mg of 0.5% hyperbaric bupivacaine with 250 μg of morphine while Group D received 15 mg of 0.5% hyperbaric bupivacaine with 2.5 μg of dexmedetomidine. Characteristics of spinal block, time for first rescue analgesic and total dose of rescue analgesics were noted. Vital parameters and adverse effects were noted perioperatively. Data analysis was done with independent two sample t-test and Mann-Whitney U test.

RESULTS

Time for first rescue analgesic (P = 0.056) and total analgesic demand were similar in both groups. Duration of sensory (P = 0.001) and motor (P = 000) block was significantly higher in dexmedetomidine group. Itching was noticed in 36% and nausea in 52% of patients in the morphine group, either of which was not seen in dexmedetomidine group.

CONCLUSION

Intrathecal dexmedetomidine produces prolonged motor and sensory blockade without undesirable side effects but intraoperative hypotension was more frequent in dexmedetomidine group.