Continuous intravenous morphine infusion for postoperative analgesia following posterior spinal fusion for idiopathic scoliosis

Rapid recovery pathway without epidural catheter analgesia for surgical treatment of adolescent idiopathic scoliosis: a comparative study

PURPOSE

To assess effectiveness of a rapid recovery pathway (RRP) without epidural catheter analgesia (ECA) or intravenous patient controlled analgesia (PCA) in accelerating recovery and decreasing opioid consumption in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion (PSF).

METHODS

A retrospective cohort study included collection of demographics, ECA use, IV PCA, postoperative opioid consumption, postoperative pain scores, and reoperation rate. Opioid consumption was calculated using morphine milligram equivalents (MME). Hospital length of stay (HLOS) and first reported ambulation with physical therapy (PT) were also recorded.

RESULTS

53 patients were included, with 18 in the RRP group. Patient characteristics were comparable between the groups, except in ECA use and BMI. The RRP group consumed less total MME from postoperative day (POD) 0 to 2 (mean difference 61.6 MME; 95% CI 37.1-86.1 MME; p < 0.001). In addition, the RRP group had significantly shorter HLOS (2.5 vs 4.0 days; p < 0.001). There were no differences in VAS scores between the two groups. A subset analysis comparing patients who did and did not receive ECA showed that ECA resulted in overall higher inpatient MME and HLOS. A prediction model was developed using multiple regression based on the different medications used for multimodal analgesia (MMA) in the RRP.

CONCLUSIONS

An RRP without the use of ECA or IV PCA can provide adequate analgesia in patients with AIS undergoing PSF while lowering inpatient narcotic consumption and accelerating immediate postoperative recovery.

Efficacy of surgeon-directed postoperative local injection with an analgesic mixture in posterior fusion surgery for adolescent idiopathic scoliosis

Background

Severe postsurgical pain in posterior spinal fusion is common. Multimodality analgesia, including opioid-based patient-controlled analgesia (PCA), is commonly used, but opioid-related adverse events such as nausea and vomiting are sometimes a problem. We used a ropivacaine-epinephrine-dexamethasone mixture given as one-time local bilateral submyofascial injections at the operated levels added to conventional multimodality analgesia including PCA for postoperative pain control in one group of patients to confirm whether administration of this mixture reduced postoperative pain and opioid use status post posterior spinal fusion.

Methods

We retrospectively reviewed 67 consecutive patients who had undergone posterior fusion surgery for adolescent idiopathic scoliosis (AIS), 35 of whom were treated with conventional analgesia that consisted mainly of PCA (control group) and 32 of whom were treated with one-time submyofascial injections of a ropivacaine-epinephrine-dexamethasone mixture (submyofascial injection group) added to conventional multimodality analgesia. We compared postsurgical pain levels and the amount of opioid use over the first 48 h after surgery, as well as physical activity levels and adverse events 2 weeks after surgery.

Results

Postsurgical pain quantified by a numeric rating scale (1–10) in the submyofascial injection group was significantly lower than that in the control group. The amount of fentanyl use was significantly less in the submyofascial injection group at 24 h, 48 h, and all subsequent periods after surgery. In addition, Walking Recovery Time (WRT) defined as the number of days until the first event of ambulation was significantly less in the submyofascial injection group (3.3 d vs 4.1 d, P = 0.0007)). Laxative use was significantly less in the submyofascial injection group (0.3 times vs 1.3 times, P = 0.02).

Conclusions

One-time submyofascial injections at the operated levels with a ropivacaine-epinephrine-dexamethasone mixture after spinal fusion surgery reduced pain, opioid consumption, and opioid-related adverse events. This technique can contribute significantly to postoperative analgesia.

Comparison of low dose intravenous fentanyl and morphine infusion for postoperative analgesia in spine fusion surgeries - a randomized control trial

BACKGROUND AND AIMS

Post-operative analgesia for Spine surgeries is difficult without patient control analgesia (PCA) and inadequate monitoring facilities. The objective was to study the effectiveness of analgesia of intravenous administration of low dose fentanyl and morphine for postoperative analgesia following spine fusion surgeries.

METHODS

One hundred adult patients undergoing spine instrumentation surgeries were randomly allotted into two groups: Group M (morphine) or Group F (fentanyl). The patients received either 0.02 mg.kg^-1.h^-1 of morphine or 0.3 mcg.kg^-1.h^-1 of fentanyl infusion postoperatively. If the patient had pain, additional bolus dose of 0.04 mg.kg^-1 and 0.6 mcg. kg^-1 bolus for morphine and fentanyl respectively were given and noted. The additional analgesic consumption was recorded. The Ramsay sedation score (RSS), visual analogue score (VAS), vital parameters and complications were observed.

RESULTS

The demographic characteristics did not reveal significant difference among the two groups. In morphine group, 32 patients did not require any additional bolus dose, 15 patients needed one bolus dose and one patient each required two and three boluses. In fentanyl group, two, 24, 20 and four patients required 0, 1, 2 and 3 bolus doses respectively. There were no statistically significant variations in hemodynamic features like heart rate, blood pressure and oxygen saturation, RSS and VAS. The complication rate was not significant among the groups.

CONCLUSION

Low dose continuous infusion of morphine is more effective than fentanyl with fewer requirements of rescue analgesics for postoperative analgesia. Both drugs are safe without any serious complications.

Removal of a urinary catheter before discontinuation of epidural analgesia is associated with an increased risk of postoperative urinary retention and hospital episode costs in patients undergoing surgical correction for adolescent idiopathic scoliosis

OBJECTIVES

In adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal instrumented fusion (PSIF), we aimed to answer these questions: (1) is there a difference in postoperative urinary retention (UR) rates among patients who had removal of their Foley catheters before vs. after discontinuation of epidural analgesia (EA)? (2) Can the timing of Foley catheter removal be an independent risk factor for postoperative UR requiring recatheterization? (3) Is there an incurred cost related to treating UR?

STUDY DESIGN

Retrospective cohort.

BACKGROUND

EA has been widely used for postoperative pain control after PSIF for AIS. In these patients, removing the Foley catheter, inserted for intraoperative monitoring of urine output, is indicated in the early postoperative period. However, a controversy exists as to whether it should be removed before or after the EA has been discontinued.

METHODS

A single-institution, longitudinally maintained database was queried to identify 297 patients who met specific inclusion and exclusion criteria. Patient characteristics and the order and timing of removing the urinary and epidural catheters were collected. Rates of UR were statistically compared in patients who had early vs. late urinary catheter removal. A univariate and multivariate regression analysis was conducted to identify independent risk factors. Hospital episode costs were analyzed.

RESULTS

Patients who had early (n = 66, 22%) vs. late (n = 231, 78%) urinary catheter removal had a significantly higher incidence of UR requiring recatheterization (15 vs. 4.7%, p = 0.007). Patient with early removal were almost 4 times more likely to develop UR requiring recatheterization [odds ratio (OR) 3.8, 95% confidence interval (CI) 1.5-9.7, p = 0.005]. UR incurred additional costs averaging $15,000/patient (p = 0.204).

CONCLUSION

In patients who had PSIF for AIS, removal of a urinary catheter before discontinuation of EA is an independent risk factor for UR, requiring recatheterization and associated with increased cost.

LEVEL OF EVIDENCE

III.

[Progress in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery]

OBJECTIVE

To review the advances in perioperative pain management of pediatric and adolescent spinal deformity corrective surgery.

METHODS

Regular analgesics, drug administrations, and analgesic regimens were reviewed and summarized by consulting domestic and overseas related literatures about perioperative pain management of pediatric and adolescent spinal deformity corrective surgery in recent years.

RESULTS

As for perioperative analgesis regimens of pediatric and adolescent spinal deformity corrective surgery, regular analgesics include non-steroidal anti-inflammatory drugs, opioids, antiepileptic drugs, adrenergic agonists, and local anesthetic, etc. Besides drug administration by mouth, intravenous injection, and intramuscular injection, the administration also includes patient controlled analgesia, epidural injection, and intrathecal injection. Multimodal analgesia is the most important regimen currently.

CONCLUSION

Heretofore, a number of perioperative pain managements of pediatric and adolescent spinal deformity corrective surgery have been applied clinically, but the ideal regimen has not been developed. To design a safe and effective analgesic regimen needs further investigations.

Addition of Intrathecal Morphine for Postoperative Pain Management in Pediatric Spine Surgery: A Meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery.

SUMMARY OF BACKGROUND DATA

Previous studies that have tested supplemental ITM to manage pain after pediatric spine surgery have been limited by small sample sizes.

METHODS

A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was performed for clinical trials and observational studies. Time to first analgesic demand, postoperative analgesic use, pain scores, and complication data were abstracted from each study. Mean difference (MD) and 95% confidence interval (CI) were used to compare continuous outcomes and odds ratios (OR) and 95% CI were used for dichotomous outcomes.

RESULTS

A total of 5 studies, including 3 randomized controlled trials and 2 retrospective chart reviews, containing 636 subjects, were incorporated into meta-analysis. Subjects that were administered ITM in addition to postoperative analgesics (ITM group) were compared with those receiving postoperative analgesics only (control group). In the ITM group, time to first analgesic demand was longer (MD, 8.79; 95% CI, 4.20-13.37; P<0.001), cumulative analgesic consumption was reduced at 24 hours (MD, -0.40; 95% CI, -0.56 to -0.24; P<0.001), and cumulative analgesic consumption was reduced at 48 hours (MD, -0.43; 95% CI, -0.59 to -0.27; P<0.001). Neither postoperative pain scores at 24 hours (P=0.16) nor 48 hours (P=0.18) were significantly different between ITM and control groups. Rates of respiratory depression, nausea, vomiting, and pruritus were not different between groups (all Ps>0.05).

CONCLUSIONS

Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.

Analgesia, sedation, and delirium in pediatric surgical critical care

The alleviation of discomfort and distress is an essential component of the management of critically ill surgical patients. Pain and anxiety have multifocal etiologies that may be related to an underlying disease or surgical procedure, ongoing medical therapy, invasive monitors, an unfamiliar, complex and chaotic environment, as well as fear. Pharmacologic and non-pharmacologic therapies have complex risk benefit profiles. A fundamental understanding of analgesia, sedation, and delirium is essential for optimizing important outcomes in critically ill pediatric surgical patients. There has been a recent emphasis on goal directed, evidence based, and patient-centered management of the physical and psychological needs of these children. The purpose of this article is to review and summarize recent advances and describe current practice of these important subjects in the pediatric surgical intensive care environment.

Postoperative pain management in patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis: a narrative review

Posterior spinal fusion for adolescent idiopathic scoliosis is one of the most invasive surgical procedures performed in children and adolescents. Because of the extensive surgical incision and massive tissue trauma, posterior spinal fusion causes severe postoperative pain. Intravenous patient-controlled analgesia with opioids has been the mainstay of postoperative pain management in these patients. However, the use of systemic opioids is sometimes limited by opioid-related side effects, resulting in poor analgesia. To improve pain management while reducing opioid consumption and opioid-related complications, concurrent use of analgesics and analgesic modalities with different mechanisms of action seems to be rational. The efficacy of intrathecal opioids and nonsteroidal anti-inflammatory drugs as components of multimodal analgesia in scoliosis surgery has been well established. However, there is either controversy or insufficient evidence regarding the use of other analgesic methods, such as continuous ketamine infusion, perioperative oral gabapentin, acetaminophen, continuous wound infiltration of local anesthetics, a single dose of systemic dexamethasone, and lidocaine infusion in this patient population. Moreover, appropriate combinations of analgesics have not been established. The aim of this literature review is to provide detailed information of each analgesic technique so that clinicians can make appropriate choices regarding pain management in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

Intrathecal Morphine and Oral Analgesics Provide Safe and Effective Pain Control After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

STUDY DESIGN

Retrospective comparative study.

OBJECTIVE

The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor.

SUMMARY OF BACKGROUND DATA

Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics.

METHODS

We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded.

RESULTS

A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups.

CONCLUSION

ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary.

LEVEL OF EVIDENCE

3.

Is a single low dose of intrathecal morphine a useful adjunct to patient-controlled analgesia for postoperative pain control following lumbar spine surgery? A preliminary report

BACKGROUND

Several studies addressing intrathecal morphine (ITM) use following spine surgery have been published either involving the pediatric population, using mid- to high-dose ITM, or not in conjunction with morphine patient-controlled analgesia (PCA).

OBJECTIVES

To determine whether low-dose ITM is a useful adjunct to PCA for postoperative pain control following elective lumbar spine surgery in adults.

METHODS

Thirty-two patients were enrolled in a double-blinded randomized controlled trial, and received either ITM or intrathecal placebo. Postoperatively, all patients were given a PCA pump and observed for the first 24 h in a step-down unit. Measurements of: total PCA morphine consumed in the first 24 h; intensity of pain; pruritus; nausea at 4 h, 8 h and 24&nbsp;h; time to first ambulation; length of hospital stay; and occurrences of respiratory depression were recorded.

RESULTS

The total PCA use was significantly lower in the ITM group. There were lower average pain scores in the ITM group, which increased to that of the intrathecal placebo group over 24 h; however, this failed to attain statistical significance. There were no differences in nausea, pruritus, time to first ambulation or hospital length stay. There were no cases of respiratory depression in either group.

CONCLUSIONS

ITM may be a useful adjunct to PCA, but did not decrease time to ambulation or length of stay.

Intrathecal morphine attenuates acute opioid tolerance secondary to remifentanil infusions during spinal surgery in adolescents

Introduction

The unique pharmacokinetic properties of remifentanil with a context-sensitive half-life unaffected by length of infusion contribute to its frequent use during anesthetic management during posterior spinal fusion in children and adolescents. However, its intraoperative administration can lead to increased postoperative analgesic requirements, which is postulated to be the result of acute opioid tolerance with enhancement of spinal N-methyl-D-aspartate receptor function. Although strategies to prevent or reduce tolerance have included the coadministration of longer acting opioids or ketamine, the majority of these studies have demonstrated little to no benefit. The current study retrospectively evaluates the efficacy of intrathecal morphine (ITM) in preventing hyperalgesia following a remifentanil infusion.

Methods

We retrospectively analyzed 54 patients undergoing posterior spinal fusion with segmental spinal instrumentation, to evaluate the effects of ITM on hyperalgesia from remifentanil. Patients were divided into two groups based on whether they did or did not receive remifentanil during the surgery: no remifentanil (control group) (n=27) and remifentanil (study group) (n=27). Data included demographics, remifentanil dose and duration, Wong–Baker visual analog scale postoperative pain scores, and postoperative intravenous morphine consumption in the first 48 postoperative hours.

Results

The demographics of the two study groups were similar. There were no differences in the Wong–Baker visual analog scale pain scores in the postanesthesia care unit and on postoperative days 1 and 3. Pain scores were higher in the remifentanil group on postoperative day 2 (2.9 vs 3.8). Postoperative morphine requirements were similar between the two groups (0.029 vs 0.017 mg/kg/48 h for the control group and the study group, respectively).

Conclusion

In patients receiving preincisional ITM during spinal surgery, intraoperative remifentanil does not increase postoperative analgesic requirements.

Continuous infusion versus intermittent bolus dosing of morphine: a comparison of analgesia, tolerance, and subsequent voluntary morphine intake

Improved utilization of continuous or intermittent opioid administration in pain treatment necessitates a comparison of the antinociceptive effect and tolerance of these two treatment methods. More importantly, the effect of treatment method on subsequent opioid consumption has not been directly compared, although it is widely assumed that continuous opioid treatment may produce lower addictive liability relative to intermittent opioid treatment. In this study, we compared the antinociceptive effect and tolerance of morphine in rats that received repeated injection (10 mg/kg twice daily for 7 days) or continuous infusion (20 mg/kg daily for 7 days) subcutaneously and the self-administration of intravenous morphine in these rats after 7 days of withdrawal. Both intermittent and continuous morphine treatment produced antinociceptive tolerance, but the exhibition of tolerance differed. Moreover, intermittent morphine pretreatment facilitated subsequent morphine self-administration, whereas continuous morphine pretreatment produced minimal effects, as shown by comparable levels of active responses and morphine consumption between continuous morphine and saline-treated rats. These results suggest that the administration method of opioid should be selected according to the specific pain situation and that continuous opioid administration or long-acting therapy may be advantageous, producing less influence on drug-taking behavior than intermittent administration of short-acting drugs.

A randomized prospective evaluation of 3 techniques of postoperative pain management after posterior spinal instrumentation and fusion

STUDY DESIGN

Randomized prospective trial.

OBJECTIVE

To compare the efficacy of intravenous analgesia with single and dual continuous epidural analgesia (CEA) in patients with adolescent idiopathic scoliosis (AIS) undergoing posterior spinal fusion and instrumentation (PSIF).

SUMMARY OF BACKGROUND DATA

Pain management after posterior spinal fusion (PSF) for patients with AIS is challenging. Although intravenous patient-controlled analgesia (PCA) is used most commonly, CEA has been found to be safe and effective. Recently, the use of 2 epidural catheters has been thought to be more effective than a single catheter, although the efficacy of using 2 catheters has not been directly compared with a single catheter.

METHODS

Sixty-six patients with AIS were randomized into 3 groups prior to PSF; PCA, single CEA, and double CEA. Postoperative pain scores as well as side effects, complications, and use of breakthrough medication were collected. Recovery times were also recorded, including hospitalization, times to first bowel movement, and days to walk and climb stairs. Four patients were withdrawn due to the inability to maintain the pain management protocol.

RESULTS

Pain intensity was most effectively controlled with a double CEA when compared with PCA (P < 0.05) and a single CEA (P < 0.05). Pain control was equivalent in both the PCA and single CEA groups (P = 0.21). The pain control method with the fewest side effects trended toward the single CEA, with an average of 2.55 side effects per patient. The majority of the side effects included pruritis, constipation, and nausea. Late onset neurological events were absent in all patients.

CONCLUSION

These data document that the double CEA most effectively controls postoperative pain after surgery for AIS. The single CEA trended toward having the fewest side effects when compared with the other techniques. On the basis these findings, we now routinely use the double CEA technique for all patients having surgery for AIS.

Compatibility and stability of morphine sulphate and naloxone hydrochloride in 0.9% sodium chloride for injection

BACKGROUND

Naloxone may be administered in conjunction with morphine to reduce the risk of opioid-induced pruritis. Combining these drugs for coadministration may be beneficial, but little is known about their physical compatibility and stability in combined solutions.

OBJECTIVE

To describe the physical compatibility and stability of morphine sulphate and naloxone hydrochloride (at various concentrations) in IV admixtures.

METHODS

The physical compatibility and stability of admixtures of morphine 1000 μg/mL and naloxone 4 μg/mL, 12.5 μg/mL, and 25 μg/mL in 0.9% sodium chloride were studied. For each concentration of naloxone, one bag was stored at room temperature (22°C) for 72 h and one bag was stored under refrigeration (4°C) for 30 days. For all preparations, physical characteristics, including pH, colour, and formation of precipitate, were evaluated. The samples were also analyzed by a stability-indicating high-performance liquid chromatographic method. Stability was defined as the retention of at least 90% of the initial concentration.

RESULTS

No notable changes in pH or colour and no macroprecipitation were observed in any of the preparations after storage at 22°C for up to 72 h or at 4°C for up to 30 days. All preparations maintained more than 90% of the initial concentrations of morphine and naloxone at the end of the respective study periods. The calculated lower limit of the 95% confidence interval also indicated that 90% or more of the initial concentration remained at the end of each study period.

CONCLUSION

Admixtures of morphine sulphate and naloxone hydrochloride were stable for 72 h at room temperature and for 30 days with refrigeration.

Postoperative pain management after spinal fusion surgery: an analysis of the efficacy of continuous infusion of local anesthetics

Spinal fusion surgery is a major surgery that results in severe postoperative pain, therefore pain reduction is a primary concern. New strategies for pain management are currently under investigation and include multimodal treatment. A 3-year retrospective analysis of patients with idiopathic scoliosis undergoing spinal fusion surgery was performed at our hospital, assessing patient pain scores, opioid use, and recovery. We evaluated the effect of adding continuous infusion of local anesthetics (CILA) to a postoperative pain management protocol that includes intraoperative intrathecal morphine, as well as postoperative patient-controlled analgesia and oral opioid/acetaminophen combination. The study compared 25 patients treated according to the standard protocol, with 62 patients treated with CILA in addition to the pain management protocol. Patients in the CILA group used nearly 0.5 mg/kg less opioid analgesics during the first 24 hours after surgery.

Morphine at "sub-analgesic" background infusion rate plus low-dose PCA bolus control pain better and is as safe as twice a bolus-only PCA regimen: a randomized, double blind study

Morphine for postoperative pain control is commonly titrated via intravenous patient-controlled analgesia (IV-PCA). An IV morphine background infusion is rarely used. We investigated whether analgesia is effectively attained and morphine consumption is reduced if PCA titration is coadjuvated by a continuous infusion protocol. Following colorectal cancer surgery, consenting patients were randomized to receive a minimal ("sub-analgesic") dose of morphine 0.01 mg/kg/h background infusion plus a 0.01 mg/kg bolus (BI), or a 1.5mg bolus-only morphine (B0) (bolus ratio ∼1:2). Bolus lockout time was 7 min in either case. All patients received 0.1mg/kg morphine before protocol initiation, and diclofenac 75 mg intramuscularly b.i.d. during the study period, lasting 48 h. Eighty-six patients (51 males, age 26-95 years) participated in the study. The total mean morphine consumption during the 48 h was 25% lower in the BI than in the B0 group (P<0.05). Although the former applied the PCA device for boluses 19% less than the latter (P<0.05), their pain score was lower (P<0.05) most of the time, and they reported greater satisfaction (P<0.05) on a 10-scale numerical rating score. Pre- and postoperative vital signs were similar for both groups. No patient depicted hypoxemia or lapsed into deep sedation. Four BI and three B0 patients required treatment for postoperative nausea and vomiting. One BI patient had transient pruritus and one B0 69-year individual became disoriented 24h into treatment; either event subsided soon after stopping their respective regimen without the need for treatment. The main conclusions of the results are that very-low-dose background morphine infusion combined with small-dose PCA boluses may provide better pain relief, lower morphine consumption, and minimal complication rate as a 1.5mg PCA bolus-only protocol.