The Safety And Efficacy of Intrathecal Opioid Analgesia for Acute Postoperative Pain: Seven Years' Experience with 5969 Surgical Patients at Indiana University Hospital

Nalbuphine versus morphine: an adjuvant to spinal anesthesia for controlling pain after total knee arthroplasty: a propensity score-matched analysis

BACKGROUND

Nalbuphine, a synthetic k-agonist and µ-antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain.

METHODS

A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS).

RESULTS

The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h (P < 0.01). Group M had lower CMU than group N at 24 h (P < 0.01) and 48 h (P < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively (p = 0.04), and group N had significantly shorter LHS compared to group M (P < 0.001).

CONCLUSION

Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS.

The effect of transversus abdominis plane block application on postoperative analgesia quality and patient satisfaction after varicocele surgery: a randomized clinical trial

Background

Postoperative pain management is an important aspect of anesthesia care and multimodal analgesic techniques are generally recommended.

Objective

To compare the effect of spinal anesthesia + transversus abdominis plane (TAP) block application on postoperative analgesia quality and patient satisfaction with spinal anesthesia + intrathecal morphine (ITM) application.

Methods

A total of 70 patients were randomly separated into 2 groups as spinal anesthesia + TAP block (TAP block group, n = 34) and spinal anesthesia + ITM group (ITM group, n = 36). The groups were compared in respect of age, body mass index values, and visual analog scale (VAS) values at 0 h, 2 h, 6 h, 12 h, and 18 h, and patient satisfaction was scored by Quality Improvement in Postoperative Pain Management at 24 h.

Results

The mean age of the patients was 32.52 ± 6.50 years in the TAP block group and 30.11 ± 5.62 years in the ITM group, with no statistically significant difference determined. There was no statistically significant difference in terms of VAS values at 0 h, 2 h, 6 h, 12 h, and 18 h. When the factors affecting postoperative patient satisfaction were evaluated, feeling fatigue after the surgery (r = -0.811, P = 0.001) and postoperative complications such as nausea, vomiting, and itching (r = -0.831, P = 0.001) were found to have a negative effect on patient satisfaction.

Conclusion

Due to low complication rates, TAP block is an effective application for postoperative analgesia management in varicocele operations that increases patient satisfaction postoperatively.

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.

Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review

Background

The dose of intrathecal morphine is important because of its narrow therapeutic range. Due to a compounding error, pharmacy-compounded, ready-to-use syringes contained 1 mg ml⁻¹ morphine instead of the intended 50 mcg ml⁻¹. Six patients consequently received this twenty-fold dose. This study aims to describe the serious adverse events in these six patients and a systematic review is added to describe the characteristics of serious adverse events after intrathecal morphine.

Methods

A retrospective case series described all six patients that received the erroneous morphine intrathecally for analgesia after laparoscopic segmental colonic resections. The patients' charts were reviewed for the occurrence, timing, duration and management of adverse events, the vital signs at the night after surgery, and length of hospital stay. A systematic review investigated characteristics of serious adverse events after intrathecal morphine in a perioperative setting.

Results

Four patients had a serious adverse event, which was respiratory depression combined with somnolence (n = 3) and hypotension (n = 1). The review yielded 63 cases with serious adverse events, predominantly somnolence and/or respiratory depression. The onset occurred between 2 and 24 hours after injection. The severity of symptoms varied and life-threatening respiratory depression only occurred after a dose >900 mcg or when potentiating medication was used. Naloxone did not affect analgesia. No prolonged sequalae occurred.

Conclusion

This study reveals that respiratory depression and somnolence are the predominant serious adverse events after intrathecal morphine in a perioperative setting and demonstrated a large variation in the presentation of symptoms.

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.

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine

STUDY OBJECTIVE

To describe the frequency and timing of intravenous patient-controlled analgesia (IV-PCA) or neuraxial morphine-induced postoperative respiratory depression.

DESIGN

Audit of data captured by routine quality assurance of the acute pain protocols that were implemented by nurses performing routine postoperative care.

SETTING

The surgical wards of a university-affiliated, 700-bed, tertiary hospital.

PATIENTS AND INTERVENTIONS

In real time, the data of all patients enrolled into our Acute Pain Service (APS) were entered and stored in the APS database. Thereafter, patients who had received IV morphine via a PCA device or neuraxial morphine between January 1999 and December 2002 were isolated. From this subset, all patients in whom a respiratory rate (RR) less than 10 breaths per minute was recorded were retrieved.

MEASUREMENTS AND MAIN RESULTS

From a total of 4500 patients, IV or neuraxial morphine was administered to 1524 patients. Eighteen (1.2%) cases of an RR less than 10 breaths per minute were recorded (13 patients, 4 patients, and 1 patient in the IV-PCA, daily epidural morphine, and single-dose intrathecal morphine groups, respectively). A direct correlation between intraoperative fentanyl administration and postoperative respiratory depression was demonstrated between the IV-PCA (P = 0.03) and epidural groups (P = 0.05). The time from IV-PCA initiation or last neuraxial morphine administration until the diagnosis of respiratory depression ranged between 2 hours and 31.26 hours and 2 hours and 12.15 hours, respectively. Ten (55.6%) patients received naloxone.

CONCLUSION

Morphine-induced respiratory depression may occur at any time during the APS admission. However, the optimal frequency of intermittent RR monitoring is unknown. Furthermore, because multiple variables (age, sex, prior opioid administration, site of operation) may affect morphine-induced respiratory depression, further investigation must be performed to determine the ideal monitoring protocol.

A comparison of 0.2 and 0.5 mg intrathecal morphine for postoperative analgesia after total knee replacement

The optimal dose of intrathecal morphine for postoperative analgesia after major surgery is a matter of debate, with some uncertainty concerning the therapeutic potential and safety of intrathecal morphine in the dose range 0.3-1.0 mg. This randomised double-blind study compared the efficacy and side-effect profile of 0.2 mg and 0.5 mg intrathecal morphine in 70 patients undergoing knee replacement surgery. The primary endpoint was the number of patients requiring rescue analgesia (tramadol) during the first 24 h postoperatively. Secondary endpoints included consumption of tramadol and the incidence of adverse effects. Fewer patients in the 0.5-mg group required rescue analgesia in the first 24 h than in the 0.2-mg group (16 (48%) vs 28 (85%), respectively; p = 0.003). Median (IQR [range]) tramadol consumption was lower in the 0.5-mg group than in the 0.2-mg group (0 (0-100 [0-350]) mg vs 100 (50-100 [0-350]) mg, respectively; p = 0.02). The incidence of adverse effects was similar in both groups. This study has demonstrated that 0.5 mg intrathecal morphine produces better analgesia than 0.2 mg after knee replacement without any increase in side-effects.

Enquête sur les pratiques d'analgésie après thoracotomie

OBJECTIVE

To estimate qualitatively and quantitatively analgesic methods used after thoracotomy.

METHODS

Postal questionnaire addressed to all French public (34 academic institutions, 37 public hospitals) and private hospitals (60), which routinely perform pulmonary surgery.

RESULTS

Analysis of the questionnaires related only to those coming from academic institutions (rate of response of 85%) and from private hospitals (60%). Intravenous patient-controlled analgesia, thoracic epidural analgesia and intrathecal analgesia are the most frequently suggested techniques of analgesia. Thoracic epidural analgesia is more frequently suggested in private hospitals than in academic institutions (77% vs. 55%, NS). There is no significant difference between academic institutions and private hospitals regarding the practised analgesic technique. Analysis of the practices of thoracic epidural analgesia and of intrathecal analgesia in particular showed limited impact of guidelines concerning preoperative administration of anticoagulants in 15-20% of the centres. Only six (in the academic institutions) to 18% (in the private hospitals) of the patients receiving thoracic epidural analgesia were hospitalised in a surgical ward. Thoracic epidural analgesia is continued generally for more than 48 h; there is however a significant difference between centres since epidural analgesia is continued longer in academic institutions than in private hospitals.

CONCLUSION

Intravenous patient-controlled analgesia and thoracic epidural analgesia are the most commonly analgesic techniques used after thoracotomy for pulmonary surgery. In the latter case, most centres choose to maintain these patients in high dependency units.

Complications of peripheral blockade

The wide variety of peripheral blocks makes for a difficult endeavor in trying to grasp their many potential complications. However, the common features of these complications makes it possible to use the construct presented here, in combination with one's knowledge of anatomy, to be able anticipate many, if not most, of the complications of any particular peripheral regional anesthetic.