The improved quality of postoperative analgesia after intrathecal morphine does not result in improved recovery and quality of life in the first 6 months after orthopedic surgery: a randomized controlled pilot study

Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis

Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side‐effects. We undertook a systematic review, meta‐analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty‐nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high‐quality evidence), without sub‐group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high‐quality evidence). However, a sub‐group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub‐group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high‐quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.

The Role of Intrathecal Morphine for Postoperative Analgesia in Primary Total Joint Arthroplasty under Spinal Anesthesia: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the efficacy and safety of intrathecal morphine (ITM) for postoperative analgesia in primary total joint arthroplasty (TJA) under spinal anesthesia and to explore the dose-response relationship for analgesic efficacy or risk of side effects.

METHODS

We searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for any studies meeting the inclusion criteria. All the data were summarized using the random effects model. Subgroup analyses were performed based on the surgical procedure and dose of ITM. Meta-regression was used to explore the dose-response relationship.

RESULTS

Eighteen randomized controlled trials were included. Compared with the placebo or blank control, ITM reduced the postoperative 24-h morphine consumption by 10.07 mg and prolonged the duration of analgesia. However, ITM significantly increased the risk of pruritus by 2.79 fold, with a tendency to increase the risk of postoperative nausea and/or vomiting (P = 0.08). No difference was observed regarding the length of stay (LOS) and incidence of respiratory depression or urinary retention. Furthermore, meta-regression showed a linear dose-response relationship for the postoperative 24-h morphine consumption but no linear dose-response relationship for the risk of side effects.

CONCLUSIONS

Adding morphine to intrathecal anesthetics provides a prolonged and robust analgesic effect without significantly increasing the risk of side effects other than pruritus. Although we found a linear dose-response relationship for the postoperative 24-h morphine consumption, the optimal dose of ITM remains to be further explored in high-quality RCTs with a large sample size.

Associations between early postoperative pain outcome measures and late functional outcomes in patients after knee arthroplasty

INTRODUCTION/AIM

Early rehabilitation, return to daily life activities and function are the ultimate goals of perioperative care. It is unclear which pain-related patient-reported outcome measures (PROM) mirror treatment effects or are related with early and late functional outcomes.

METHODS

We examined associations between two approaches of pain management (scheduled vs 'on demand') and PROMs on post-operative days one and five (POD1, 5) with function on POD5 and 3 months after surgery in patients undergoing Total Knee Arthroplasty (TKA) in a single centre. The scheduled pain management consisted of pain assessment and routine administration of non-opioid drugs, and a weak opioid based on severity of pain reported by patients. The 'on demand' group received non-opioids and/or a weak opioid only when asking 'on demand' for analgesics.

RESULTS

On POD1, patients in the scheduled treatment group reported reduced severity of worst pain, less interference of pain with activities in-bed and sleep, and a higher proportion got out of bed. On POD5, these patients reported as well significantly less worst pain, spent significantly less time in severe pain, experienced less interference of pain with activities in bed, and felt less helpless. Furthermore, tests of function, extension and flexion ranges, Barthel index and 6 minutes walking test on POD5, and the Knee Injury and Osteoarthritis Outcome Score (KOOS) 3 months later were significantly better in the scheduled treatment group compared to the 'on demand' treatment group. Pain related PROMs assessed at POD1 and especially at POD5 are associated with better knee range of motion, better performance in activities of daily living, and faster gait speed, as well as less pain, better performance in activities of daily living, as well as higher knee-related quality of life 3 months postoperatively.

CONCLUSIONS

Our study demonstrates that severe postoperative pain after TKA might have long lasting consequences, and even small improvements in treatment, although being far from optimal, are accompanied by improved outcomes.

Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia

BACKGROUND

Intrathecal opioids have been used to reduce pain after total joint arthroplasty; however, the utility of these drugs is disputed. We examined the impact of eliminating intrathecal fentanyl on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA).

METHODS

Retrospective review of 376 THA patients from a single institution was conducted. Univariate analysis was used to compare intraoperative medication usage and postoperative outcomes for THA patients receiving intrathecal fentanyl compared with those who did not receive intrathecal fentanyl.

RESULTS

Recovery room pain scores were significantly lower for patients who received intrathecal fentanyl (intrathecal fentanyl 1.4 vs no 2.2, P = .001), but no difference in opioid consumption was observed (intrathecal fentanyl 9.3 milligram morphine equivalent vs no 10.5 milligram morphine equivalent, P = .200). Intraoperative use and dose of intravenous morphine, hydromorphone, and dexamethasone did not differ significantly between groups. There were no significant differences in length of stay between the groups (intrathecal fentanyl 1.1 days vs 1.1 days, P = .973), 90-day readmission, or recatherization rates between groups (readmission, intrathecal fentanyl 4.8% vs no 5.8%, P = .709; recatherization, intrathecal fentanyl 0% vs no 0.7%, P = 1.00).

CONCLUSION

The administration of intrathecal fentanyl does not have a significant effect on early postoperative narcotic consumption, length of stay, 90-day readmissions, or recatheterization after THA with neuraxial anesthesia. Intrathecal fentanyl does not appear to improve outcomes and should not be included as a standard element of THA rapid recovery protocols.

A Comprehensive Review of Analgesia and Pain Modalities in Hip Fracture Pathogenesis

PURPOSE OF REVIEW

Hip fracture is common in the elderly population, painful and costly. The present investigation was undertaken to review epidemiology, socio-economic and medical implications, relevant anatomy, and anesthetic and pain modalities of hip fracture.

RECENT FINDINGS

A literature search of PubMed, Ovid Medline, and Cochrane databases was conducted in December 2018 to identify relevant published clinical trials, review articles, and meta-analyses studies related to anesthetic and pain modalities of hip fracture. The acute pain management in these situations is often challenging. Common issues associated with morbidity and mortality include patients' physiological decrease in function, medical comorbidities, and cognitive impairment, which all can confound and complicate pain assessment and treatment. Perioperative multidisciplinary and multimodal approaches require medical, surgical, and anesthesiology teams employing adequate preoperative optimization. Reduction in pain and disability utilizing opioid and non-opioid therapies, regional anesthesia, patient-tailored anesthetic approach, and delirium prevention strategies seems to ensure best outcomes.