Measurement of drug concentration and bacterial contamination after diluting morphine for intrathecal administration: an experimental study

A double-blind, randomised, placebo-controlled trial comparing intrathecal bupivacaine with bupivacaine plus morphine to reduce delirium in patients with hip fractures-Salmon-Mind trial study protocol

Background

Surgical treatment of proximal femur fractures is complicated by postoperative delirium in about one-third of patients. Pain and opioid consumption are modifiable factors that may influence the incidence of delirium.1 An intrathecal injection of morphine may lead to a reduction in postoperative pain and reduced systemic opioid consumption. In current practice, the addition of morphine to intrathecal anaesthesia is commonly used but depends on the anaesthesiologist's preference. Recently, a retrospective study found that intrathecal morphine was independently associated with a lower incidence of delirium. However, this has to be confirmed in a prospective, randomised study. We hypothesise that using intrathecal morphine reduces postoperative pain and opioid consumption during the first 48 h after surgery and reduces the incidence of delirium during hospital admission. We also seek additional evidence of the association between neuronal injury (delirium) and neurofilament light in serum of patients with proximal femur fractures.

Objective

The primary objective is to compare the incidence of delirium. The secondary objectives are to compare pain scores, systemic opioid consumption, and (opioid-related) side-effects. The tertiary objective is to test the association between intrathecal morphine and neurofilament light as a marker of neuronal injury.

Study design

A double-blind, randomised, placebo-controlled intervention study is proposed.

Study population

All patients with a proximal femur fracture who are scheduled for surgery under spinal anaesthesia.

Intervention

The intervention is the addition of morphine 100 μg to the intrathecal injection for spinal anaesthesia. The intervention group will receive a mixture of bupivacaine 10 mg and morphine 100 μg. The control group will receive bupivacaine 10 mg.

Clinical trial registration

EU Clinical Trials Register: EudraCT number 2020-002143-27.

Comparison between intrathecal morphine and intravenous patient control analgesia for pain control after video-assisted thoracoscopic surgery: A pilot randomized controlled study

Background

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure, but patients may still experience intense pain, especially during the early postoperative period. Intrathecal morphine (ITM) is an effective pain control method that involves a simple maneuver and has a low risk of complications. This study aimed to study the effectiveness of ITM for pain control in patients who undergo VATS.

Materials and methods

A randomized controlled study was conducted who were in ASA classes 1–3, aged over 18 years, and scheduled for elective VATS. Patients were randomized into two groups: the ITM group (n = 19) received a single shot of 0.2 mg ITM before general anesthesia; and the control group (n = 19) received general anesthesia only. For 48 hours after surgery, other than intravenous patient-controlled analgesia (IVPCA) morphine, patients received no sedatives or opioid medications except for 500 mg acetaminophen four times daily orally. Postoperative pain scores and IVPCA morphine used, side effects, sedation at specific time-points, i.e., 1, 6, 12, 24, and 48-hours and overall treatment satisfaction scores were assessed.

Results

Postoperative pain scores (median [IQR]) in ITM group were significantly lower than control group (repeated-measure ANOVA, p = 0.006) and differed at the first (7 [2, 7] vs 8 [6, 9], p = 0.007) and sixth hours (3 [2, 5] vs 5 [5, 7], p = 0.002). The cumulative dose of post-operative morphine (median [IQR]) in ITM group was also lower (6 [3, 20] vs 19 [14, 28], p = 0.006). The incidence of pruritus was significantly higher in ITM group (68.42% vs. 26.32%, p = 0.009). No significant differences in nausea and vomiting, sedation scores, and satisfaction scores were observed between the two groups.

Conclusion

ITM could reduce pain scores and opioid consumption after VATS compared to IVPCA-opioids. However, pain scores and opioid consumption still remained high. No difference in patient satisfaction was detected.