Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial

Intravenous Methadone versus Intrathecal Morphine as Part of an Enhanced Recovery After Cardiac Surgery Protocol on Postoperative Pain and Outcomes: A Retrospective Cohort Study

OBJECTIVES

Evaluate the effect of intravenous (IV) methadone versus intrathecal morphine (ITM) within an Enhanced Recovery After Cardiac Surgery (ERACS) pathway on postoperative pain and outcomes (length of hospital stay and postoperative complications) after cardiac surgery.

DESIGN

Retrospective cohort study.

SETTING

Two tertiary academic medical institutions within the same health system.

PARTICIPANTS

Eligible 289 adult patients undergoing elective cardiac surgery with an enhanced recovery pathway from January 2020 through July 2021.

INTERVENTIONS

Patients were administered ITM (0.25 mg) or IV methadone (0.1 mg/kg) if ITM was contraindicated. All patients were enrolled in an ERACS pathway using current Enhanced Recovery After Surgery society guidelines.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measures included postoperative pain scores and opioid consumption measured as oral morphine equivalents. We analyzed patient demographics, procedural factors, intraoperative medications, and outcomes. Adjusted linear mixed models were fit to analyze associations between intervention and pain outcomes. ITM was associated with decrease in pain scores on postoperative day 0 after adjusting for clinical variables (average marginal effect, 0.49; 95% confidence interval, 0.002-0.977; p = 0.049). No difference in opioid consumption could be demonstrated between groups after adjusting for postoperative day and other variables of interest.

CONCLUSIONS

ITM when compared with IV methadone was associated with a decrease in pain scores without any difference in opioid consumption after elective cardiac surgery. Methadone can be considered as a safe and effective alternative to ITM for ERACS protocols. Future large prospective studies are needed to validate this finding and further improve analgesia and safety.

Perioperative Pain Management for Thoracic Surgery: A Multi-Layered Approach

Cardiothoracic surgeries frequently pose unique challenges in the management of perioperative acute pain that require a multifaceted and personalized approach in order to optimize patient outcomes. This article discusses various analgesic strategies including regional anesthesia techniques such as thoracic epidurals, erector spinae plane blocks, and serratus anterior plane blocks and underscores the significance of perioperative multimodal medications, while providing nuanced recommendations for their use. This article further attempts to provide evidence for the efficacy of the different modalities and compares the effectiveness of the choice of analgesia. The roles of Acute Pain Services (APS) and Transitional Pain Services (TPS) in mitigating opioid dependence and chronic postsurgical pain are also discussed. Precision medicine is also presented as a potential way to offer a patient tailored analgesic strategy. Supported by various randomized controlled trials and meta-analyses, the article concludes that an integrated, patient-specific approach encompassing regional anesthesia and multimodal medications, while also utilizing the services of the Acute Pain Service can help to enhance pain management outcomes in cardiothoracic surgery.

Intrathecal Morphine for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

ABSTRACT

Cardiac surgeries often result in significant postoperative pain, leading to considerable use of opioids for pain management. However, excessive opioid use can lead to undesirable side effects and chronic opioid use. This systematic review and meta-analysis aimed to evaluate whether preoperative intrathecal morphine could reduce postoperative opioid consumption in patients undergoing cardiac surgery requiring sternotomy. We conducted a systematic search of Cochrane, EMBASE, and MEDLINE databases from inception to May 2022 for randomized controlled trials that evaluated the use of intrathecal morphine in patients undergoing cardiac surgery. Studies that evaluated intrathecal administration of other opioids or combinations of medications were excluded. The primary outcome was postoperative morphine consumption at 24 h. Secondary outcomes included time to extubation and hospital length of stay. The final analysis included ten randomized controlled trials, with a total of 402 patients. The results showed that postoperative morphine consumption at 24 h was significantly lower in the intervention group (standardized mean difference -1.43 [-2.12, -0.74], 95% CI, P < 0.0001). There were no significant differences in time to extubation and hospital length of stay. Our meta-analysis concluded that preoperative intrathecal morphine is associated with lower postoperative morphine consumption at 24 h following cardiac surgeries, without prolonging the time to extubation. The use of preoperative intrathecal morphine can be considered part of a multimodal analgesic and opioid-sparing strategy in patients undergoing cardiac surgery.

Intrathecal Morphine and Post-Operative Pain Relief in Robotic Surgeries: A Systematic Review and Meta-Analysis

Despite the potential benefits of intrathecal morphine (ITM), the precise role and dosing of ITM in robotic assisted surgery (RAS) remains unclear. This systematic review explores real-world evidence to evaluate the efficacy and outcomes of ITM in patients undergoing RAS. In accordance with PRISMA guidelines, a comprehensive search was conducted on four databases: MEDLINE, Embase, Cochrane Library and APA PsycInfo. Primary outcomes included pain scores at rest and on exertion at 24- and 48-h time intervals, and secondary outcomes aimed to explore the side effects of ITM. A meta-analysis was conducted to determine mean differences. A risk of bias assessment was conducted via the Cochrane Risk of Bias 2 tool. A total of 9 RCTs involving 619 patients were included in this review, of which 298 patients were administered ITM. Significant pain score reductions were observed both at rest (MD = -27.15; 95% CI [-43.97, -10.33]; I2 = 95%; p = 0.002) and on exertion (MD = -25.88; 95% CI [-37.03, -14.72]; I2 = 79%; p = 0.0003) 24 h postoperatively in the ITM groups, accompanied by a notable decrease in postoperative IV morphine equivalent consumption at 24 h (MD = -20.13; 95% CI [-30.74, -9.52]; I2 = 77%; p = 0.0002). ITM improved pain scores both at rest and on exertion at 24 and 48 h intervals, concurrently reducing the need for postoperative opioid consumption, but at the cost of an increased incidence of adverse events.

Pain management and opioid stewardship in adult cardiac surgery: Joint consensus report of the PeriOperative Quality Initiative and the Enhanced Recovery After Surgery Cardiac Society

BACKGROUND

Opioid-based anesthesia and analgesia is a traditional component of perioperative care for the cardiac surgery patient. Growing enthusiasm for Enhanced Recovery Programs (ERPs) coupled with evidence of potential harm associated with high-dose opioids suggests that we reconsider the role of opioids in cardiac surgery.

METHODS

An interdisciplinary North American panel of experts, using a structured appraisal of the literature and a modified Delphi method, derived consensus recommendations for optimal pain management and opioid stewardship for cardiac surgery patients. Individual recommendations are graded based on the strength and level of evidence.

RESULTS

The panel addressed 4 main topics: the harms associated with historical opioid use, the benefits of more targeted opioid administration, the use of nonopioid medications and techniques, and patient and provider education. A key principle that emerged is that opioid stewardship should apply to all cardiac surgery patients, entailing judicious and targeted use of opioids to achieve optimal analgesia with the fewest potential side effects. The process resulted in the promulgation of 6 recommendations regarding pain management and opioid stewardship in cardiac surgery, focused on avoiding the use of high-dose opioids, as well as encouraging more widespread application of foundational aspects of ERPs, such as the use of multimodal nonopioid medications and regional anesthesia techniques, formal patient and provider education, and structured system-level opioid prescription practices.

CONCLUSIONS

Based on the available literature and expert consensus, there is an opportunity to optimize anesthesia and analgesia for cardiac surgery patients. Although additional research is needed to establish specific strategies, core principles of pain management and opioid stewardship apply to the cardiac surgery population.

Comparison of intrathecal low-dose bupivacaine and morphine with intravenous patient control analgesia for postoperative analgesia for video-assisted thoracoscopic surgery

BACKGROUND

Thoracoscopic surgical techniques continue to advance, yet the intensity of postoperative pain remains significant, impeding swift patient recovery. This study aimed to evaluate the differences in postoperative pain and recuperation between patients receiving intrathecal morphine paired with low-dose bupivacaine and those administered general anesthesia exclusively.

METHODS

This randomized controlled trial enrolled 100 patients, who were allocated into three groups: Group M (5 μg/kg morphine intrathecal injection), Group B (5 μg/kg morphine combined with bupivacaine 3 mg intrathecal injection) and Group C (intrathecal sham injection). The primary outcome was the assessment of pain relief using the Numeric Rating Scale (NRS). Additionally, intraoperative remifentanil consumption was quantified at the end of the surgery, and postoperative opioid use was determined by the number of patient-controlled analgesia (PCIA) compressions at 48 h post-surgery. Both the efficacy of the treatments and any complications were meticulously recorded.

RESULTS

Postoperative NRS scores for both rest and exercise at 6, 12, 24, and 48 h were significantly lower in groups M and B than in group C (P<0.05). The intraoperative remifentanil dosage was significantly greater in groups M and C than in group B (P<0.05), while there was no significant difference between groups M and C (P>0.05). There was no significant difference in intraoperative propofol dosage across all three groups (P>0.05). Postoperative dosages of both sufentanil and Nonsteroidal anti-inflammatory drugs (NSAIDs) were significantly less in groups M and B compared to group C (P<0.05). The time of first analgesic request was later in both groups M and B than in group C (P<0.05). Specific and total scores were elevated at 2 days postoperative when compared to scores at 1 day for all groups (P<0.05). Furthermore, at 1 day and 2 days postoperatively, both specific scores and total scores were higher in groups M and B compared to group C (P<0.05).

CONCLUSION

Intrathecal administration of morphine combined with bupivacaine has been shown to effectively ameliorate acute pain in patients undergoing thoracoscopic surgery.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov: ChiCTR2200058544, registered 10/04/2022.

Efficacy of Continuous Intrathecal Infusion Trialing with a Mixture of Fentanyl and Bupivacaine in Chronic Low Back Pain Patients

Intrathecal trialing is used as a screening prognostic measure prior to intrathecal drug delivery system implant. The purpose of this study was to determine the efficacy of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. Patients with refractory chronic low back pain in the setting of previous lumbar spine surgery and/or chronic vertebral compression fracture(s) were enrolled in a randomized double blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The primary outcome measure was the change in pain intensity at the end of the screening trial. Patients who experienced significant pain reduction from either infusion relative to baseline pain were offered a permanent implant. In total, 36 patients were enrolled, with 31 patients trialed and 25 implanted. At the end of the screening trial, pain scores, at rest or with activity, decreased appreciably in both groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group compared to saline both with activity and at rest (P = .016 and .006, respectively). Treatment order appeared to affect outcome with saline demonstrating a placebo response. At 12 months following implant, primary and secondary outcome measures continued to be significantly reduced from baseline. Continuous intrathecal delivery of a combination of zlow-dose fentanyl with bupivacaine is superior to saline in screening intrathecal trialing for back pain reduction. With longer term delivery, a sustained reduction of chronic low back pain was also observed.

Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2

Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.

Role of spinal anesthesia in robot-assisted radical prostatectomy: Gamble or opportunity?

To the Editor, Although postoperative pain associated with robot-assisted radical prostatectomy (RARP) is less than pain following the open technique, it remains a fundamental issue as it can be a significant source of discomfort for the patient and lengthen recovery times after surgery. The optimal management of pain after RARP is far from being fully elucidated and many factors have to be evaluated to choose the best analgesic approach. [...].

Current indications for spinal anesthesia-a narrative review

Spinal anesthesia is a commonly performed regional anesthesia technique by most anesthesiologists worldwide. This technique is learned early during training and is relatively easy to master. Despite being an old technique, spinal anesthesia has evolved and developed in various aspects. This review attempts to highlight the current indications of this technique. Understanding the finer aspects and knowledge gaps will help postgraduates and practicing anesthesiologists in designing patient-specific techniques and interventions.

Intrathecal Morphine Injection for Postoperative Analgesia Following Gender-Affirming Pelvic Surgery: A Retrospective Case-Control Study

Background Gender-affirming pelvic surgery (GAPS) can be associated with significant postoperative pelvic pain. Given the lack of available peripheral nerve blocks to the perineum, intrathecal morphine (ITM) injection could offer a potent analgesic modality for this patient population. No prior studies to date have been performed examining the analgesic effects of intrathecal morphine for these patients. Methods This retrospective case-control study aims to understand the postoperative analgesic effects of intrathecal morphine for these patients with a historical comparison group of patients who did not receive intrathecal morphine. Results Fourteen patients presented for gender-affirming pelvic surgery over an eight-month period at a single institution and were offered intrathecal morphine for postoperative analgesia. Their analgesic results were compared to a similar historical group of 13 patients who were not offered or declined intrathecal morphine. Conclusions Intrathecal morphine injection is a potent analgesic modality for patients presenting for gender-affirming pelvic surgery.

Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis

Background

To evaluate the analgesic efficacy and risk of low-to-medium dose intrathecal morphine (ITM) (i.e., ≤0.5 mg) following cardiac surgery.

Methods

Medline, Cochrane Library, Google scholar and EMBASE databases were searched from inception to February 2022. The primary outcome was pain intensity at postoperative 24 h, while the secondary outcomes included intravenous morphine consumption (IMC), extubation time, hospital/intensive care unit (ICU) length of stay (LOS), and ITM-associated side effects (e.g., respiratory depression). Subgroup analysis was performed on ITM dosage (low: <0.3 mg vs. medium: 0.3–0.5 mg).

Results

Fifteen RCTs involving 683 patients published from 1988 to 2021 were included. Pooled results showed significantly lower postoperative 24-h pain scores [mean difference (MD) = −1.61, 95% confidence interval: −1.98 to −1.24, p < 0.00001; trial sequential analysis: sufficient evidence; certainty of evidence: moderate] in the ITM group compared to the controls. Similar positive findings were noted at 12 (MD = −2.1) and 48 h (MD = −1.88). Use of ITM was also associated with lower IMC at 24 and 48 h (MD: −13.69 and −14.57 mg, respectively; all p < 0.05) and early tracheal extubation (i.e., 48.08 min). No difference was noted in hospital/ICU LOS, and nausea/vomiting in both groups, but patients receiving ITM had higher risk of pruritus (relative risk = 2.88, p = 0.008). There was no subgroup difference in IMC except a lower pain score with 0.3–0.5 mg than <0.3 mg at postoperative 24 h. Respiratory depression events were not noted in the ITM group.

Conclusion

Our results validated the analgesic efficacy of low-to-medium dose ITM for patients receiving cardiac surgery without increasing the risk of respiratory depression.

Regional analgesia for cardiac surgery

PURPOSE OF REVIEW

Regional anesthesia is gaining attention as a valuable component of multimodal, opioid-sparing analgesia in cardiac surgery, where improving the patient's quality of recovery while minimizing the harms of opioid administration are key points of emphasis in perioperative care. This review serves as an outline of recent advancements in a variety of applications of regional analgesia for cardiac surgery.

RECENT FINDINGS

Growing interest in regional analgesia, particularly the use of newer "chest wall blocks", has led to accumulating evidence for the efficacy of multiple regional techniques in cardiac surgery. These include a variety of technical approaches, with results consistently demonstrating optimized pain control and reduced opioid requirements. Regional and pain management experts have worked to derive consensus around nerve block nomenclature, which will be foundational to establish best practice, design and report future research consistently, improve medical education, and generally advance our knowledge in this vital area of perioperative patient care.

SUMMARY

The field of regional analgesia for cardiac surgery has matured over the last several years. A variety of regional techniques have been described and shown to be efficacious as part of the multimodal, opioid-sparing approach to pain management in the cardiac surgical setting.

Intrathecal Morphine and Effect on Opioid Consumption and Functional Recovery after Pancreaticoduodenectomy

BACKGROUND

Single-shot intrathecal morphine (ITM) is an effective strategy for postoperative analgesia, but there are limited data on its safety, efficacy, and relationship with functional recovery among patients undergoing pancreaticoduodenectomy.

STUDY DESIGN

This was a retrospective review of patients undergoing pancreaticoduodenectomy from 2014 to 2020 as identified by the institutional NSQIP Hepato-pancreato-biliary database. Patients were categorized by having received no spinal analgesia, ITM, or ITM with transversus abdominus plane block (ITM+TAP). The primary outcomes were average daily pain scores from postoperative days (POD) 0 to 3, total morphine equivalents (MEQ) consumed over POD 0 to 3, and average daily inpatient MEQ from POD 4 to discharge. Secondary outcomes included the incidence of opioid related complications, length of stay, and functional recovery.

RESULTS

A total of 233 patients with a median age of 67 years were included. Of these, 36.5% received no spinal analgesia, 49.3% received ITM, and 14.2% received ITM+TAP. Average pain scores in POD 0 to 3 were similar by mode of spinal analgesia (none [2.8], ITM [2.6], ITM+TAP [2.3]). Total MEQ consumed from POD 0 to 3 were lower for patients who received ITM (121 mg) and ITM+TAP (132 mg), compared with no spinal analgesia (232 mg) (p < 0.0001). Average daily MEQ consumption from POD 4 to discharge was lower for ITM (18 mg) and ITM+TAP (13.1 mg) cohorts compared with no spinal analgesia (32.9 mg) (p = 0.0016). Days to functional recovery and length of stay were significantly reduced for ITM and ITM+TAP compared with no spinal analgesia. These findings remained consistent through multivariate analysis, and there were no differences in opioid-related complications among cohorts.

CONCLUSIONS

ITM was associated with reduced early postoperative and total inpatient opioid utilization, days to functional recovery, and length of stay among patients undergoing pancreaticoduodenectomy. ITM is a safe and effective form of perioperative analgesia that may benefit patients undergoing pancreaticoduodenectomy.

Year in Review 2021: Noteworthy Literature in Cardiothoracic Anesthesia

In 2021, progress in clinical science related to Cardiac Anesthesiology continued, but at a slower rate due to the ongoing pandemic and disruptions to clinical research. Most progress was incremental and addressed persistent questions related to our field. To identify articles for this review, we completed a structured review using our previously reported methods (1). Specifically, we used the search terms: "cardiac anesthesiology and outcomes" (n = 177), "cardiothoracic anesthesiology" (n = 34), "cardiac anesthesia," and "clinical outcomes" (n = 42) filtered on clinical trials and the year 2021 in PubMed. We also reviewed clinical trials from the most prominent clinical journals to identify additional studies for a narrative review. We then selected the most noteworthy publications for inclusion in this review and identified key themes.