Comparison of low-dose morphine intrathecal analgesia and sufentanil PCIA in elderly patients with hip fracture undergoing single spinal anesthesia - a randomized clinical trial

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.

Effect of different analgesic treatments on the pulmonary function in elderly hip fracture patients: A prospective study

BACKGROUND

To investigate the effect of different analgesic methods on lungs in elderly patients with hip fractures.

METHODS

A prospective study was conducted on 78 elderly hip fracture patients undergoing spinal anesthesia for surgery, where 3 analgesic methods were used: postoperative Patient-controlled intravenous analgesia pump (PCIA) (group I), pre and postoperative PCIA (group II), and preoperative fascia iliaca compartment block (FICB) + postoperative PCIA (group III). The following indicators were monitored at admission (T1), on the day of surgery before anesthesia (T2), and 7 days after surgery (T3): heart rate (HR), respiratory rate (RR), forced expiratory volume during the first second, arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), C-reactive protein (CRP), and interleukin 6 (IL-6). Pulmonary complications such as pulmonary atelectasis and respiratory insufficiency were analyzed.

RESULTS

The HR, RR, forced expiratory volume during the first second, PaO2, PaCO2, IL-6, and CRP levels at T1 after fracture did not significantly differ among the 3 groups (P > .05). After different analgesic treatments post-admission, all indicators at T2 were significantly higher in group I than in groups II and III (P < .05), while there was no significant difference between groups II and III (P > .05). At T3, there were no significant differences in RR, HR, PaO2, PaCO2, and CRP levels among the groups (P > .05), but IL-6 levels at T3 were significantly higher in group I than in groups II and III (P < .05).

CONCLUSION

The use of effective pain relief during surgery can help protect the lung function of elderly patients with hip fractures. When using PCIA with FICB before surgery, respiratory performance may be better protected compared to using unsustained analgesia. This could be due to a decrease in the levels of inflammatory markers such as CRP and interleukin-6.

Application of dexmedetomidine combined with ultrasound-guided transverse abdominal fascia block during radical colorectal cancer surgery under general anesthesia

BACKGROUND

Radical surgery is the main treatment for colorectal cancer, and effective anaesthesia is required in the perioperative period to ensure a smooth operation. Dexmedetomidine is a commonly used anaesthetic drug, but the optimal dose for general anaesthesia in radical colorectal cancer surgery is still unknown.

AIM

To investigate the application of different doses of dexmede-tomidine combined with ultrasound-guided transverse abdominal fascial block in radical colorectal cancer surgery under general anesthesia.

METHODS

Two hundred patients proposed for radical colorectal cancer surgery under general anesthesia at our hospital from October 2017 to September 2022 were selected and divided into three groups (A, B, and C) using the random number table method. Sixty-seven patients in group A were given 0.5 μg/kg dexmedetomidine, 67 patients in group B were given 0.25 μg/kg dexmedetomidine, and 66 patients in group C were given an equal dose of saline. The vital signs [heart rate (HR), oxygen saturation (SaO₂), and mean arterial pressure (MAP)] before induction of anesthesia (T0), after dexmedetomidine injection (T1), 1 h after the start of surgery (T2), and immediately after the end of surgery (T3), the visual analog scale (VAS) scores at 6 h, 12 h, and 24 h after surgery, the number of analgesic pump compressions at 24 h after surgery, the number of times of remedial analgesia, the levels of immune cytokines [tumor necrosis factor-α (TNF-α), interleukin-2 (IL-2), and interleukin-10 (IL-10)], serum neurotransmitter [serum S100B protein (S100B), serum neuron-specific enolase (NSE), and serum brain-derived neurotrophic factor (BDNF)] before surgery and 12 h and 24 h after surgery, and adverse effects were recorded.

RESULTS

There was no statistically significant difference in SaO₂ among the three groups from T0 to T3 (P > 0.05), and HR and MAP at T1 and T2 were lower in group A than in groups B and C, and in group B than in group C (P < 0.05). VAS scores in group A were lower than those in groups B and C at 6 h, 12 h, and 24 h postoperatively, and the number of analgesic pump compressions and times of remedial analgesia at 24 h postoperatively were less in group A than in groups B and C (P < 0.05), and in group B than in group C (P < 0.05). Serum TNF-α and IL-10 at 12 h and 24 h postoperatively were lower in group A than in groups B and C, and IL-2 was higher than in groups B and C; these indexes in group B were superior to those in group C (P < 0.05). Serum S100B and NSE at 12 h postoperatively were lower in group A than in groups B and C, and BDNF was higher than in groups B and C; these indexes in group B were superior to those in group C (P < 0.05). The differences in the incidence of adverse reactions were not statistically significant among the three groups (P > 0.05).

CONCLUSION

Compared with 0.25 μg/kg dexmedetomidine, 0.5 μg/kg dexmedetomidine combined with ultrasound-guided transverse abdominal fascial block for radical colorectal cancer surgery under general anesthesia can more effectively maintain the stability of patients' vital signs, with less impact on patients' immune function and neurological function, and better postoperative analgesia without increasing the risk of adverse effects.

Postoperative delirium in geriatric patients with hip fractures

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

Effect of different low doses of intrathecal morphine (0.1 and 0.2 mg) on pain and vital functions in patients undergoing total hip arthroplasty: a randomised controlled study

BACKGROUND

Orthopaedic surgeries are among the most painful procedures. By adding low-dose morphine to intrathecal bupivacaine for spinal anaesthesia, the analgesic effect can be improved. The objeсtive of the study was tо compare the efficacy and safety of lоw-dоse (0.1 mg аnd 0.2 mg) intrаtheсаl mоrphine (ITM).

METHODS

А prоspeсtive rаndоmised study was соnduсted at the Hоspitаl оf Trаumаtоlоgy аnd Оrthоpaediсs, Riga, Latvia (February 2020 tо May 2021) and enrolled 90 patients undergoing primary hip arthroplasty. All subjects were randomised intо three study grоups, using the online tool оn www.randomiser.org . Treatment groups were allocated to intrathecal morphine (0.1 mg and 0.2 mg) in addition to bupivacaine (15 to 18 mg). The primary outcome was postoperative pain intensity among the three study groups within 24 hours by NRS. The secondary outcomes: pain at rest 4 h, 7 h, 12 h, 24 h postoperatively, respiratory rate, SpО2, morphine соnsumptiоn, оxygen supply, opioid-related аdverse reасtiоns within 24 hours postoperatively. Dаtа were аnаlysed using R version 4.2.0, applying the Mann-Whitney test, Pearson's chi-squared test, Fisher's exact test, Friedman test, Wilcoxon test.

RESULTS

The primary outcome in the control, ITM 0.1 mg, ITM 0.2 mg groups, respectively: 2.56, 0.87, 0.28 (p < 0.001). The secondary outcomes in the control, ITM 0.1 mg, ITM 0.2 mg group, respectively: pain scores 4h - 1.21, 0.48, 0.17 (p = 0.068); 7 h - 2.62, 1.00, 0.17 (p < 0.001); 12 h - 3.08, 0.65, 0.37 (p < 0.001); 24 h - 2.50, 1.20, 0.41 (p < 0.001); rescue medication requests (incidence, %): 77%, 16.7%, 13.3% (p < 0.001); mean respiratory rate (breath/min) - 15.2; 15.2 (p > 0.05); mean SpO2 (%): 96.7%; 95.7%; 96.07%. Significant adverse effects: pruritus in ITM 0.2 mg group (23% of subjects, p < 0.001).

CONCLUSIONS

Adult patients undergoing THA under spinal anaesthesia with bupivacaine and 0.2 mg morphine had superior analgesia to patients who received spinal analgesia with bupivacaine or bupivacaine and 0.1 mg morphine.

TRIAL REGISTRATION

Study ID ISRCTN37212222; 20/04/2022 (registered retrospectively).