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Meineke MN, Losli MV, Sztain JF, Swisher MW, Abramson WB, Martin EI, Furnish TJ, Salmasi A, Derweesh IH, Gabriel RA, Said ET. Robot-assisted laparoscopic nephrectomy: early outcome measures with the implementation of multimodal analgesia and intrathecal morphine via the acute pain service. World J Urol 2024; 42:117. [PMID: 38436828 PMCID: PMC10912429 DOI: 10.1007/s00345-024-04801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/16/2024] [Indexed: 03/05/2024] Open
Abstract
PURPOSE The objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use. METHODS This was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24-48 h and 48-72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series. RESULTS There were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005). CONCLUSIONS The implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.
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Affiliation(s)
- Minhthy N Meineke
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
| | - Matthew V Losli
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Jacklynn F Sztain
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
| | - Matthew W Swisher
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
| | - Wendy B Abramson
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
- Division of Obstetric Anesthesia, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Erin I Martin
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
- Division of Obstetric Anesthesia, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Timothy J Furnish
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
- Division of Pain, Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Amirali Salmasi
- Department of Urology, University of California, San Diego, La Jolla, CA, USA
| | - Ithaar H Derweesh
- Department of Urology, University of California, San Diego, La Jolla, CA, USA
| | - Rodney A Gabriel
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA.
| | - Engy T Said
- Division of Acute Pain, Department of Anesthesiology, University of California, 9400 Campus Point Dr, San Diego, La Jolla, CA, 92037, USA
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Chau A, Smiley R. Intrathecal morphine and delayed micturition after cesarean delivery: the rose and the thorn. Anaesth Crit Care Pain Med 2023; 42:101272. [PMID: 37419322 DOI: 10.1016/j.accpm.2023.101272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Affiliation(s)
- A Chau
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada.
| | - R Smiley
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, USA. https://twitter.com/RichSmileyMD
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Guo M, Tang S, Wang Y, Liu F, Wang L, Yang D, Zhang J. Comparison of intrathecal low-dose bupivacaine and morphine with intravenous patient control analgesia for postoperative analgesia for video-assisted thoracoscopic surgery. BMC Anesthesiol 2023; 23:395. [PMID: 38041014 PMCID: PMC10691143 DOI: 10.1186/s12871-023-02350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/20/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Thoracoscopic surgical techniques continue to advance, yet the intensity of postoperative pain remains significant, impeding swift patient recovery. This study aimed to evaluate the differences in postoperative pain and recuperation between patients receiving intrathecal morphine paired with low-dose bupivacaine and those administered general anesthesia exclusively. METHODS This randomized controlled trial enrolled 100 patients, who were allocated into three groups: Group M (5 μg/kg morphine intrathecal injection), Group B (5 μg/kg morphine combined with bupivacaine 3 mg intrathecal injection) and Group C (intrathecal sham injection). The primary outcome was the assessment of pain relief using the Numeric Rating Scale (NRS). Additionally, intraoperative remifentanil consumption was quantified at the end of the surgery, and postoperative opioid use was determined by the number of patient-controlled analgesia (PCIA) compressions at 48 h post-surgery. Both the efficacy of the treatments and any complications were meticulously recorded. RESULTS Postoperative NRS scores for both rest and exercise at 6, 12, 24, and 48 h were significantly lower in groups M and B than in group C (P<0.05). The intraoperative remifentanil dosage was significantly greater in groups M and C than in group B (P<0.05), while there was no significant difference between groups M and C (P>0.05). There was no significant difference in intraoperative propofol dosage across all three groups (P>0.05). Postoperative dosages of both sufentanil and Nonsteroidal anti-inflammatory drugs (NSAIDs) were significantly less in groups M and B compared to group C (P<0.05). The time of first analgesic request was later in both groups M and B than in group C (P<0.05). Specific and total scores were elevated at 2 days postoperative when compared to scores at 1 day for all groups (P<0.05). Furthermore, at 1 day and 2 days postoperatively, both specific scores and total scores were higher in groups M and B compared to group C (P<0.05). CONCLUSION Intrathecal administration of morphine combined with bupivacaine has been shown to effectively ameliorate acute pain in patients undergoing thoracoscopic surgery. TRIAL REGISTRATION The trial was registered on ClinicalTrials.gov: ChiCTR2200058544, registered 10/04/2022.
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Affiliation(s)
- Miao Guo
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou, 225000, China
| | - Suhong Tang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou, 225000, China
| | - Yixin Wang
- Graduate School of Dalian Medical University, Dalian, 116000, China
| | - Fengxia Liu
- Graduate School of Dalian Medical University, Dalian, 116000, China
| | - Lin Wang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou, 225000, China
| | - Dawei Yang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou, 225000, China
| | - Jianyou Zhang
- Department of Anesthesiology, Affiliated Hospital of Yangzhou University, Yangzhou, 225000, China.
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Onay M, Şanal Baş S, Işıker A, Akkemik Ü, Bilir A. Effect of Intrathecal Morphine on Postdural Puncture Headache in Obstetric Anaesthesia. Turk J Anaesthesiol Reanim 2023; 51:297-303. [PMID: 37587656 PMCID: PMC10440479 DOI: 10.4274/tjar.2023.221140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 06/13/2023] [Indexed: 08/18/2023] Open
Abstract
Objective Intrathecal morphine is used as an effective component of multimodal analgesia in postoperative analgesia in cesarean section patients. We aimed to analyze the relationship between intrathecal morphine administration and postdural puncture headache (PDPH), pain score and analgesia consumption in the postoperative period, and maternal fetal effects. Methods One hundred four pregnant women aged ≥18 years (American Society of Anesthesiology physical status I or II, >36 weeks gestation) who were scheduled for elective cesarean section under spinal anaesthesia were included in this study. Spinal anesthesia consisted of bupivacaine with or without morphine (Group M: 10 mg heavy marcaine + 25 mcg fentanyl + 100 mcg morphine; Group F: 10 mg heavy marcaine + 25 mcg fentanyl). The effect of intrathecal morphine on PDPH, postoperative pain score, analgesia consumption, and maternal and fetal effects were recorded for 5 days. Results PDPH developed in a total of 33 patients (Group M: 18 and Group F: 15, P=0.274). When we evaluated PDPH with the VAS, there was no significant difference between the groups. The postoperative visual analogue scale (VAS) was lower in the morphine group, and no statistically significant difference was found in the VAS 1st hr and VAS 2nd hr, whereas the VAS 6th hr and VAS 24th hr were found to be statistically significant. There was no difference in terms of PDPH, the first analgesic requirement and postoperative nausea-vomiting, but meperidine consumption was lower in the morphine group. Conclusion Low-dose intrathecal morphine did not affect the incidence of PDPH. It is an effective method that can be used in cesarean section patients without increasing the maternal and fetal side effects from postoperative analgesia.
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Affiliation(s)
- Meryem Onay
- Department of Anaesthesiology and Reanimation, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Sema Şanal Baş
- Department of Anaesthesiology and Reanimation, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
| | - Arda Işıker
- Clinic of Anaesthesiology and Reanimation, Kırklareli Training and Research Hospital, Kırklareli, Turkey
| | - Ümit Akkemik
- Clinic of Algology, Eskişehir City Hospital, Eskişehir, Turkey
| | - Ayten Bilir
- Department of Anaesthesiology and Reanimation, Eskişehir Osmangazi University Faculty of Medicine, Eskişehir, Turkey
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Pirie KP, Wang A, Yu J, Teng B, Doane MA, Myles PS, Riedel B. Postoperative analgesia for upper gastrointestinal surgery: a retrospective cohort analysis. Perioper Med (Lond) 2023; 12:40. [PMID: 37464387 DOI: 10.1186/s13741-023-00324-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/03/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Thoracic epidural analgesia is commonly used for upper gastrointestinal surgery. Intrathecal morphine is an appealing opioid-sparing non-epidural analgesic option, especially for laparoscopic gastrointestinal surgery. METHODS Following ethics committee approval, we extracted data from the electronic medical records of patients at Royal North Shore Hospital (Sydney, Australia) that had upper gastrointestinal surgery between November 2015 and October 2020. Postoperative morphine consumption and pain scores were modelled with a Bayesian mixed effect model. RESULTS A total of 427 patients were identified who underwent open (n = 300), laparoscopic (n = 120) or laparoscopic converted to open (n = 7) upper gastrointestinal surgery. The majority of patients undergoing open surgery received a neuraxial technique (thoracic epidural [58%, n = 174]; intrathecal morphine [21%, n = 63]) compared to a minority in laparoscopic approaches (thoracic epidural [3%, n = 4]; intrathecal morphine [12%, n = 14]). Intrathecal morphine was superior over non-neuraxial analgesia in terms of lower median oral morphine equivalent consumption and higher probability of adequate pain control; however, this effect was not sustained beyond postoperative day 2. Thoracic epidural analgesia was superior to both intrathecal and non-neuraxial analgesia options for both primary outcomes, but at the expense of higher rates of postoperative hypotension (60%, n = 113) and substantial technique failure rates (32%). CONCLUSIONS We found that thoracic epidural analgesia was superior to intrathecal morphine, and intrathecal morphine was superior to non-neuraxial analgesia, in terms of reduced postoperative morphine requirements and the probability of adequate pain control in patients who underwent upper gastrointestinal surgery. However, the benefits of thoracic epidural analgesia and intrathecal morphine were not sustained across all time periods regarding control of pain. The study is limited by its retrospective design, heterogenous group of upper gastrointestinal surgeries and confounding by indication.
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Affiliation(s)
- Katrina P Pirie
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia.
- Central Clinical School, Monash University, Melbourne, Australia.
| | - Andy Wang
- Sydney Medical School (Northern), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
- Chris O'Brien Lifehouse, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Joanna Yu
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Bao Teng
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Matthew A Doane
- Sydney Medical School (Northern), Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Anaesthesia and Perioperative Medicine, Royal North Shore Hospital, Sydney, Australia
- Kolling Research Institute, Sydney, Australia
- Northern Sydney Anaesthesia Research Institute, Sydney, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum, University of Melbourne, Melbourne, Australia
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Dana E, Ben-Zur O, Dichtwald S, Feigin G, Brin N, Markushevich M, Fredman B, Brin YS. Postoperative urinary retention following hip or knee arthroplasty under spinal anaesthesia with intrathecal morphine: a retrospective cohort study. Singapore Med J 2023; 0:378363. [PMID: 37338499 DOI: 10.4103/singaporemedj.smj-2022-108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Introduction Postoperative urinary retention (POUR) frequently complicates the course of patients following hip and knee arthroplasty. Intrathecal morphine (ITM) was identified as a significant risk factor for POUR. The objective of this study was to investigate the incidence and risk factors for POUR in fast-track total joint arthroplasty (TJA) under spinal anaesthesia (SA) with ITM. Methods We conducted a retrospective study of our institutional joint registry of patients who underwent primary TJA under SA with ITM between October 2017 and May 2021. Preoperative (baseline demographics) and perioperative data were collected. The primary outcome was the incidence of POUR after 8 h or earlier, either due to lack of voiding or according to patient's complaints of bladder distension. Univariate and adjusted analyses were performed to identify predictors of POUR. Results Sixty-nine patients who underwent total knee arthroplasty (TKA) and 36 patients who underwent total hip arthroplasty (THA) under SA with ITM were included in the study. POUR requiring bladder catheterisation was diagnosed in 21% of patients. Independent predictors of POUR were age over 65 years and male gender. Conclusions SA with ITM for TJA is associated with high rates of POUR in males older than 65 years of age. Other previously identified risk factors such as intraoperative fluid administration or comorbidities may not be as influential.
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Affiliation(s)
- Elad Dana
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University,, Israel
| | - Oz Ben-Zur
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University,, Israel
| | - Sara Dichtwald
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University,, Israel
| | - Guy Feigin
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University,, Israel
| | - Noa Brin
- Department of Orthopedic surgery, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Michael Markushevich
- Department of Orthopedic surgery, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Brian Fredman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University,, Israel
| | - Yaron Shraga Brin
- Department of Orthopedic surgery, Meir Medical Center, Affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
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de Bock S, Wijburg CJ, Koning MV. Postoperative effects and complications of intrathecal morphine compared to epidural analgesia in patients undergoing intracorporeal robot-assisted radical cystectomy: a retrospective study. BMC Anesthesiol 2023; 23:174. [PMID: 37217847 DOI: 10.1186/s12871-023-02141-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Analgesia after robot assisted radical cystectomy aims to reduce postoperative pain and opioid consumption, while facilitating early mobilization and enteral nutrition and minimizing complications. Epidural analgesia is currently recommended for an open radical cystectomy, but it is unclear if intrathecal morphine is a suiting, less-invasive alternative for a robot-assisted radical cystectomy. METHODS The analgesic method of choice changed from epidural anesthesia to intrathecal anesthesia for patients undergoing a robot-assisted radical cystectomy. This single-center retrospective study aims to investigate if there is a difference between epidural and intrathecal analgesia in postoperative pain scores, opioid consumption, length of hospital stays and postoperative complications. An Propensity Matched Analysis was added to conventional analysis to consolidate the findings. RESULTS The study population consisted of 153 patients of whom 114 received an epidural catheter with bupivacaine/sufentanil and 39 received a single shot of intrathecal bupivacaine/morphine. Mean pain scores on the first two postoperative days (POD) were slightly higher in the intrathecal analgesia group (epidural versus intrathecal analgesia, NRS POD0: 0(0-2)[0-8] versus 1(0-3)[0-5], p = 0.050; POD1: 2(1-3)[0-8] versus 3(1-4)[0-7], p = 0.058; POD2: 2(0-3)[0-8] versus 3(2-4)[0-7], p = 0.010). Total postoperative morphine consumption was similar over the first seven days: 15 mg (5-35)[0-148] in the epidural group versus 11 mg (0-35)[0-148] in the intrathecal morphine group, p = 0.167. Length of hospital stay and time until fit for discharge where slightly higher in the epidural group (respectively 7 days (5-9)[4-42] versus 6 days (5-7)[4-38], p = 0.006, and 5 days (4-8)[3-30]) versus 5 days (4-6)[3-34], p = 0.018). There was no further difference in postoperative course. CONCLUSIONS This study showed that the effects of epidural analgesia and intrathecal morphine are comparable and that intrathecal morphine may be a suiting alternative for epidural analgesia.
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Affiliation(s)
- Sanne de Bock
- Resident Intensive Care Unit, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Mark V Koning
- Anesthesiologist-Intensivist, Rijnstate Hospital, Arnhem, The Netherlands.
- Department of Anesthesia and Critical Care, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands.
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Villavicencio A, Taha HB, Burneikiene S. Does the combination of intrathecal fentanyl and morphine improve clinical outcomes in patients undergoing lumbar fusions? Neurosurg Rev 2023; 46:97. [PMID: 37106209 DOI: 10.1007/s10143-023-02011-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/01/2023] [Accepted: 04/23/2023] [Indexed: 04/29/2023]
Abstract
Intrathecal morphine (ITM) has been widely effective in improving postoperative outcomes in patients undergoing a multitude of surgeries, including lumbar spine fusion. A major limitation of ITM administration is the increase in the incidence of respiratory depression in a dose-dependent manner. One way to bypass this is to use a more potent opioid with a shorter half-life, such as fentanyl. This is a retrospective analysis of patients who underwent one- or two-level transforaminal lumbar interbody fusions. The patients received one of two interventions: 0.2mg intrathecal duramorph/morphine (ITM group; n=70), 0.2mg duramorph + 50 mcg fentanyl (ITM + fentanyl group; n=68) and the control group (n=102). Primary outcomes included postoperative pain (Visual Analog Scale) and opioid intake (MED - morphine equivalent dosage, mg) for postoperative days (POD) 1- 4. Secondary outcomes included opioid-related side effects. One-way analyses of variance and follow-up post-hoc Tukey's honest significant difference statistical tests were used to measure treatment effects. Significantly lower POD1 pain scores for both the ITM and ITM + fentanyl groups vs. control were detected, with no difference between the ITM vs. ITM + fentanyl groups. Similar results were found for POD1 MED intake. A multivariate regression analysis controlling for confounding variables did not attenuate the differences seen in POD1 pain scores while revealing that only the ITM + fentanyl predicted a decrease in POD1 MED intake. No differences were seen for postoperative opioid-related side effects. Our study provides support for supplementing a low dose of both intrathecal morphine and fentanyl to improve postoperative outcomes.
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Affiliation(s)
- Alan Villavicencio
- Boulder Neurosurgical and Spine Associates, Boulder, CO, USA
- Justin Parker Neurological Institute, 4743 Arapahoe Avenue, Suite 202, Boulder, CO, 80303, USA
| | - Hash Brown Taha
- Department of Integrative Physiology, University of Colorado-Boulder, Boulder, CO, USA
- Department of Integrative Biology & Physiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sigita Burneikiene
- Justin Parker Neurological Institute, 4743 Arapahoe Avenue, Suite 202, Boulder, CO, 80303, USA.
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Kamimura Y, Kamijo K, Banno M, Tsuji T, Aoki Y, Ito H, Tanaka M, Sobue K. Efficacy of intravenous dexamethasone on postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid: a systematic review and meta-analysis. J Anesth 2023; 37:416-425. [PMID: 36964795 DOI: 10.1007/s00540-023-03183-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 03/13/2023] [Indexed: 03/26/2023]
Abstract
PURPOSE Intravenous dexamethasone is recommended in elective caesarean delivery to decrease postoperative pain. However, the efficacy of spinal anaesthesia with an intrathecal long-acting opioid such as morphine or diamorphine for caesarean delivery has not been systematically investigated. METHODS We searched all randomized controlled trials (RCTs) of pregnant women undergoing caesarean delivery under spinal anaesthesia with an intrathecal morphine or diamorphine via MEDLINE, CENTRAL, EMBASE, ICTRP, and ClinicalTrials.gov on May 18, 2022. Primary outcomes were time to first rescue analgesia, consumption of oral morphine equivalents, and incidence of drug-related adverse reactions. We evaluated the risk of bias for each outcome using the Risk of Bias 2. We conducted a meta-analysis using a random effects model. We evaluated the certainty of evidence with the GRADE approach. RESULTS Five RCTs (455 patients) were included. The results of intravenous dexamethasone were as follows: time to first rescue analgesia (mean difference [MD] 0.99 h, 95% confidence interval [CI] - 0.86 to 2.84; very low certainty) and consumption of oral morphine equivalents (MD - 6.55 mg, 95% CI - 17.13 to 4.02; moderate certainty). No incidence of drug-related adverse reactions was reported (very low certainty). CONCLUSION The evidence was very uncertain about the efficacy of intravenous dexamethasone on time to first rescue analgesia and the incidence of drug-related adverse reactions. Intravenous dexamethasone probably reduces the consumption of oral morphine equivalents. Anaesthesiologists might want to consider intravenous dexamethasone for postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid.
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Affiliation(s)
- Yuji Kamimura
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan.
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Kyosuke Kamijo
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Gynecology, Nagano Municipal Hospital, Nagano, Japan
| | - Masahiro Banno
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Psychiatry, Seichiryo Hospital, Nagoya, Japan
- Department of Psychiatry, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tatsuya Tsuji
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Yusuke Aoki
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Hidekazu Ito
- Department of Anesthesiology, Toyokawa City Hospital, Toyokawa, Japan
| | - Motoshi Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
| | - Kazuya Sobue
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-Cho, Mizuho-Ku, Nagoya, 467-8601, Japan
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Mahmoud AM, Ragab SG, Shawky MA, Masry DH, Botros JM. The Efficacy of Erector Spinae Plane Block Compared With Intrathecal Morphine in Postoperative Analgesia in Patients Undergoing Lumbar Spine Surgery: A Double-blind Prospective Comparative Study. Pain Physician 2023; 26:149-159. [PMID: 36988361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Severe postoperative pain is experienced by most patients who undergo spine surgery. Erector spinae plane block (ESPB) is a successful method for postoperative analgesia and has only minor complications. Intrathecal morphine (ITM) demonstrates high efficacy for analgesia up to 24 hours postsurgery. ESPBs and ITM for postoperative analgesia in lumbar spine surgeries have never been compared in prior studies. OBJECTIVES This study aimed to compare the efficacy of ESPB and ITM in postoperative analgesia after lumbar spine surgeries. STUDY DESIGN A double-blind prospective comparative study. SETTING This study was performed at Al Fayoum University Hospital after being confirmed by the local institutional ethical committee (#80) with approval number M520 and retrospectively registered at clinicaltrials.gov number (NCT05123092). METHODS A prospective randomized double-blinded interventional trial was conducted with 82 patients, 41 in each group. In the ESPB group, a 0.25% bupivacaine injection was used to conduct a bilateral ultrasound-guided ESPB. In the ITM group, an injection of 0.3 mg morphine intrathecally was done. The Visual Analog Scale (VAS) was recorded as the primary outcome. The time to the first analgesic request, intra- and postoperative opioid consumption, hemodynamics, sedation score, and complications were also recorded as secondary outcomes. RESULTS Postoperative VAS scores were significantly lower in the intrathecal group throughout the postoperative period at all recorded study time points until 48 hours (P < 0.001). Time to the first rescue analgesia and doses of postoperative analgesic required were significant, with a P value of 0.000. Significant differences were found in postoperative oxygen saturation up to 24 hours (P < 0.001) and the sedation score up to 6 hours (P < 0.01). A higher incidence of complications was recorded in the ITM group (P = 0.000). LIMITATIONS We did not measure patient preoperative VAS scores to ensure that the 2 groups were matched in pain severity. Also, we did not compare patient satisfaction. Another limitation was the inability to determine the degree of pain relief of ESPB since there was no control group in our study. CONCLUSION We concluded that ITM 0.3 mg provides more potent analgesia up to 48 hours postoperatively than an ESPB, based upon VAS score, analgesic durations, and postoperative analgesic requirements.
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Affiliation(s)
| | | | | | - Doha Hamad Masry
- Pain and Intensive Care Medicine, Fayoum University, Fayoum, Egypt
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Apisutimaitri K, Thepsoparn M, Chairat S, Ruanma O, Taesombat W. Comparison of intrathecal morphine and low-dose bupivacaine with intravenous morphine for postoperative analgesia in laparoscopic liver resection: a randomized controlled trial. Surg Endosc 2023; 37:2035-2042. [PMID: 36284013 DOI: 10.1007/s00464-022-09700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/29/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Laparoscopic liver surgery has undergone substantial advancements over the past few decades, and the key to this improvement has been an improved understanding of liver anatomy, radiologic imaging, and advancements in anesthesia and postoperative care. This study aimed to compare postoperative opioid consumption in patients receiving intrathecal morphine plus low-dose bupivacaine versus those receiving intravenous morphine. METHODS In this randomized controlled trial, 40 patients were enrolled and randomly assigned to two groups, of which one received 0.2 mg intrathecal morphine plus 0.25% Marcaine in a total volume of 4 mL and the other received intravenous morphine intraoperatively. Pain relief and patient satisfaction were evaluated using the visual analog scale. Intraoperative blood loss was measured at the end of the surgery while morphine consumption was measured by monitoring intravenous patient-controlled morphine at 12, 24, 36, and 48 h postoperatively. Treatment efficacy and complications were documented. RESULTS Morphine consumption was significantly different in both groups at all time points, although the pain score did not show any difference. Shoulder pain, a common adverse effect of laparoscopic surgery, was significantly lower in the intrathecal group (25% vs. 75%). Blood loss and patient satisfaction were not different between the groups. However, the intrathecal group showed a significantly higher incidence of intraoperative hypotension. CONCLUSION Intrathecal morphine with bupivacaine can be used effectively for managing acute post-LLR pain. THAI CLINICAL TRIAL REGISTRY TCTR20211015004.
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Affiliation(s)
- Kirada Apisutimaitri
- Department of Anesthesia, King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok, Bangkok, Thailand
| | - Marvin Thepsoparn
- Department of Anesthesia, King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok, Bangkok, Thailand.
- Pain Management Research Unit, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.
| | - Supichaya Chairat
- Department of Anesthesia, King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok, Bangkok, Thailand
| | - Ontira Ruanma
- Department of Anesthesia, King Chulalongkorn Memorial Hospital, Thai Red Cross Society Bangkok, Bangkok, Thailand
| | - Wipusit Taesombat
- Hepatobiliary-Pancreas Surgery and Transplantation Unit, Department of Surgery, Kingchulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
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Villavicencio A, Taha HB, Nelson EL, Rajpal S, Beasley K, Burneikiene S. The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion. Acta Neurochir (Wien) 2022; 164:3061-9. [PMID: 36114913 DOI: 10.1007/s00701-022-05359-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 08/25/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects. METHODS The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose). RESULTS In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (β = - 0.83, p < 0.001; β = - 0.63, p = 0.022) and MED intake for the first two PODs (β = - 20.8, p = 0.047; β = - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10). CONCLUSIONS In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.
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Toolyodpun S, Laoruengthana A, Kositanurit I, Podjanasupawun S, Saenghirunvattana C, Pongpirul K. Effect of multiple analgesic pathways including local infiltration analgesia, peripheral nerve blocks, and intrathecal morphine for controlling pain after total knee arthroplasty. Eur J Orthop Surg Traumatol 2022:10.1007/s00590-022-03405-w. [PMID: 36260155 DOI: 10.1007/s00590-022-03405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We questioned whether the triple analgesic pathways procedure via local infiltration analgesia (LIA), peripheral nerve blocks, and intrathecal morphine (ITM) is superior to LIA only for controlling pain after Total Knee Arthroplasty (TKA). METHODS This retrospective study included 192 primary TKA patients. Group A (76 patients) received LIA only, Group B (61 patients) had ITM, adductor canal block and LIA, while Group C (55 patients) received ITM, femoral nerve block and LIA. A propensity score-matched analysis was used to compare visual analog scales (VAS) for pain intensity, total amount of morphine consumption (TMC), angle of knee flexion, and length of hospital stay (LHS). RESULTS Group A showed significantly higher VAS than Group B at 12 h (4.27 ± 2.70 vs 2.42 ± 2.35) and 18 h (4.24 ± 2.35 vs 2.18 ± 2.02), and significantly higher than Group C at 6 h (3.46 ± 3.07 vs 0.60 ± 1.50), 12 h (4.27 ± 2.70 vs 0.89 ± 1.48), and 18 h postoperative (4.24 ± 2.35 vs 1.82 ± 2.18). However, the VAS of Group C and B converged to equalize with Group A after 12 and 18 h, respectively. The TMC at 48 h postoperative of Group A was higher than that of Group B (p < 0.01). Nevertheless, there was no difference between groups in terms of knee flexion and LHS, except the LHS of Group B was longer than Group A (p = 0.04). CONCLUSION Triple analgesic pathways could provide a better initial analgesic profile. However, the pain seems to be rebound after resolution of nerve block and ITM, with potentially longer LHS.
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Affiliation(s)
- Siriluk Toolyodpun
- Department of Anesthesiology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Inthiporn Kositanurit
- Department of Anesthesiology, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand.
| | | | | | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Sibanyoni M, Biyase N, Motshabi Chakane P. The use of intrathecal morphine for acute postoperative pain in lower limb arthroplasty surgery: a survey of practice at an academic hospital. J Orthop Surg Res 2022; 17:323. [PMID: 35729586 PMCID: PMC9210664 DOI: 10.1186/s13018-022-03215-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE OF THE STUDY Intrathecal morphine (ITM) provides optimal postoperative analgesia in patients who are scheduled for total knee and hip operation with spinal anaesthesia. However, the ideal dose at which maximal analgesic effect occurs with minimal side effects is not known. This study aimed to describe the use of two doses of ITM and side effect profile in patients undergoing elective hip and knee arthroplasty. METHODS This was a prospective, descriptive, and contextual study conducted on patients who had total hip and knee replacement at Chris Hani Baragwanath Academic Hospital from 1 September to 30 November 2020. The sample size consisted of 66 patients who were 18 years and older, American Society of Anaesthesiology (ASA) classification 1-3, patients who had received either 100 mcg or 150 mcg ITM dose under spinal anaesthesia and sent to the ward postoperatively. Visual Analogue Scale (VAS) score was used to assess pain in the first 24 h, consumption of rescue analgesia and reported side effects were documented. RESULTS There was no relationship between age, weight, ASA classification or type of surgery and VAS score classification groups. Patients who received 100 mcg ITM had a higher median VAS pain score 2 (1-5) compared to those who received 150 mcg ITM 1 (0-2), p = 0.01. The need for rescue analgesia between the two groups was marginally less in the 150 mcg ITM group (p = 0.098). There was no difference in the rate of side effects between the 100 mcg ITM group [12 (41%)] and the 150 mcg ITM group [17 (59%)], p = 0.92. Rescue analgesia was marginally different between groups, p = 0.09. There were no real differences in the VAS pain scores between the total knee and total hip surgeries. None of the patients experienced clinically significant respiratory depression. CONCLUSION The 150 mcg ITM dose provided good analgesic effects with longer duration of action and comparable side effect profile to the 100 mcg ITM dose. This dose was not associated with development of respiratory depression and can therefore be administered safely to patients who are discharged to the ward postoperatively in a resource constraint environment.
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Affiliation(s)
- Mpumelelo Sibanyoni
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa.
| | - Ntombiyethu Biyase
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa
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Xu Z, Tang Z, Yao J, Liang D, Jin F, Liu Y, Guo K, Yang X. Comparison of low-dose morphine intrathecal analgesia and sufentanil PCIA in elderly patients with hip fracture undergoing single spinal anesthesia - a randomized clinical trial. BMC Anesthesiol 2022; 22:124. [PMID: 35477377 PMCID: PMC9044775 DOI: 10.1186/s12871-022-01677-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 04/22/2022] [Indexed: 11/12/2022] Open
Abstract
Background The complications of postoperative pain, such as hypertension, hypermetabolism, irritability, and postoperative cognitive dysfunction, significantly affect the postoperative rehabilitation of elderly patients. Intrathecal morphine prolongs analgesia after surgery, but has been implicated in nausea and vomiting, pruritus, postoperative respiratory depression, or apneic episodes. The present study explored the effect and safety of low-dose morphine used adjunctively with bupivacaine during single spinal anesthesia or sufentanil patient-controlled intravenous analgesia (PCIA) in elderly patients with hip fracture surgery. Since elderly patients often need anticoagulant therapy in the early postoperative period, single spinal anesthesia was involved in completing the operation in this study. Methods Eighty elderly patients aged 70–85 years who underwent elective hip fracture surgery with single spinal anesthesia were divided into two groups, 12.5 mg of 0.5% hyperbaric bupivacaine with 100 µg of morphine (morphine group, group M) and 12.5 mg of 0.5% hyperbaric bupivacaine with 100 µg of sufentanil PCIA (sufentanil group, group S). The analgesia scores using the visual analogue scale (VAS), the Brinell comfort scale (BCS) were evaluated at 6, 12, 24, and 48 h after operation, and adverse reactions were recorded such as nausea and vomiting, pruritus, sedation, respiratory depression, and POD (postoperative delirium) with Delirium Rating Scale-r 98. Results Within 24 h after operation, the analgesic and BCS scores of group M were better than those of group S (P < 0.05). Group M had higher frequency of skin pruritus than group S within 24 h, and the difference was statistically significant. The incidence of POD in group M (2 cases) was lower than that in group S (6 cases) (5.71% vs 18.18%) (P < 0.05) with the DRS-r 98 scores. No significant difference was observed in nausea and vomiting between the two groups, and the difference of severe respiratory depression was not found in both groups. Conclusion Compared with sufentanil PCIA, low-dose intrathecal morphine has a satisfactory analgesic effect, and little effect on the patient's cognitive function with low medical cost. Under effective respiratory monitoring, it can be used safely and effectively in elderly patients with hip fracture. Trial registration Registered with the Chinese Clinical Trial Registry under ChiCTR2100042706. 26/01/2021.
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Affiliation(s)
- Zhifei Xu
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China.
| | - Zairong Tang
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Juan Yao
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Dongliang Liang
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Feng Jin
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Ying Liu
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Kai Guo
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
| | - Xiulu Yang
- Department of Anesthesiology, Gaoyou T.C.M. Hospital, 225600, Jiang Su, P. R. China
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Trivedi R, John J, Ghodke A, Trivedi J, Munigangaiah S, Dheerendra S, Balain B, Ockendon M, Kuiper J. Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study. J Orthop Surg Res 2022; 17:241. [PMID: 35436917 PMCID: PMC9017052 DOI: 10.1186/s13018-022-03124-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. Methods Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1–4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. Results For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. Conclusion ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).
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Affiliation(s)
- R Trivedi
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK.
| | - J John
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - A Ghodke
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - J Trivedi
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - S Munigangaiah
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - S Dheerendra
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - B Balain
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - M Ockendon
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - J Kuiper
- The Robert Jones and Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
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Lardone E, Giaiot V, Franci P. A case of priapism following intrathecal morphine injection in a dog. Open Vet J 2022; 12:693-696. [PMID: 36589402 PMCID: PMC9789757 DOI: 10.5455/ovj.2022.v12.i5.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/17/2022] [Indexed: 11/07/2022] Open
Abstract
Background Priapism refers to prolonged erection unrelated to sexual stimulation, with severe sequelae unless treated. In humans, it is a rare complication associated with epidural or spinal opioid administration. Its pathophysiology is unclear. This is the first report of priapism following neuraxial anesthesia in dog. Case Description An intrathecal morphine injection (30 mcg/kg) at L5-L6 for postoperative analgesia was given at the end of surgery for removal of cutaneous mastocytomas of the abdomen and left axillary lymphadenectomy. Painless penile erection occurred 2 hours later and lasted 6 hours, before spontaneously resolving 7-8 hours after the injection. No pain or other adverse events (e.g., nausea, urinary retention, and itching) were recorded. Recovery was complete without treatment. Conclusion Painless, self-resolving priapism is a rare complication associated with intrathecal morphine injection in dogs.
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Affiliation(s)
- Elena Lardone
- Corresponding Author: Elena Lardone. Department of Veterinary Science, University of Turin, Turin, Italy.
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Keskin G, Akın M, Şenaylı Y, Öztorun Cİ, Bahçecitapar M. Effects of 5 µg/kg intrathecal morphine for postoperative analgesia in pediatric patients undergoing major surgery. Anaesthesist 2021; 71:212-218. [PMID: 34549311 DOI: 10.1007/s00101-021-01040-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 07/12/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effects and analgesic adequacy of intrathecal morphine (ITM) administration have been studied less frequently than other regional analgesia techniques in pediatric surgical procedures. OBJECTIVE To evaluate the efficacy and adverse event rate of 5 µg/kg ITM administration for postoperative analgesia according to age group. METHODS We retrospectively evaluated the medical records of patients who underwent major pediatric surgery and were administered ITM for postoperative analgesia. Patients were divided into three age groups: ≤ 5 years (group I), 5.1-13 years (group II) and > 13 years (group III). All patients received ITM 5 µg/kg (max 300 μg) through the L4-5 or L5-S1 interspace. Postoperative pain (modified pediatric objective pain score > 4), need for rescue analgesics, sleep interruption due to pain, sedation (Ramsay sedation scale score > 3), opioid-related postoperative adverse events (at 0, 4, 8, 12, and 24 h after intervention), hemodynamic data and nurse satisfaction with the analgesic method were compared between groups. RESULTS The analysis included 100 children (47 girls, 9 ± 5.4 years). Groups were similar regarding postoperative rescue analgesia consumption and sleep interruption (p = 0.238, p = 0.958), 96% of the children did not require rescue analgesia, and sleep interruption was not observed in 97%. Postoperative adverse events were pruritus in 14 and nausea/vomiting in 9 patients (p = 0.052). Overall, nurses were satisfied or very satisfied in 99% of the cases. CONCLUSION Administration of 5 µg/kg ITM can be used for postoperative analgesia in pediatric surgery in all age groups, with no severe adverse events and high nurse satisfaction with analgesic management.
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Affiliation(s)
- Gülsen Keskin
- Clinic of Anesthesiology and Reanimation, Health Sciences University Dışkapı Yıldırım Beyazıt Training and Research Hospital, Üniversiteler mah. 1598 sok. Kümeevleri 17/22, 06800, Ankara, Turkey.
| | - Mine Akın
- Clinic of Anesthesiology and Reanimation, Ankara City Hospital, Ankara, Turkey
| | - Yeşim Şenaylı
- Clinic of Anesthesiology and Reanimation, University of Health Sciences, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Can İhsan Öztorun
- Department of Pediatric Surgery, Yıldırım Beyazıt University, School of Medicine, Ankara, Turkey
| | - Melike Bahçecitapar
- Department of Statistics, Faculty of Sciences, Hacettepe University, Ankara, Turkey
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Poe-Kochert C, Ina JG, Thompson GH, Hardesty CK, Son-Hing JP, Rubin K, Tripi PA. The safety and efficacy of intrathecal morphine in pediatric spinal deformity surgery: a 25-year single-center experience. Spine Deform 2021; 9:1303-13. [PMID: 33704687 DOI: 10.1007/s43390-021-00320-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Pre-incision intrathecal morphine (IM) is a popular adjunct in adolescent idiopathic spinal deformity surgery. This study represents our 25-year experience with IM in all diagnostic groups undergoing posterior spinal fusion (PSF) and segmental instrumentation (SI). METHODS Our prospective Pediatric Orthopaedic Spine Database (1992-2018) identified all patients undergoing PSF and SI. We included patients 21 years of age or less, had a PSF with SSI, and received the recommended IM dose of 9-19 mcg/kg (up to 1 mg) or no IM. We assessed demographics, pain scores, duration of surgery, time to first dose of narcotics, pediatric intensive care unit (PICU) admission, length of hospital stay, and IM complications (respiratory depression, pruritus, nausea/vomiting). RESULTS There were 984 patients who met inclusion criteria: 760 patients received IM, 224 did not (non-IM). They were divided into 5 diagnostic groups: idiopathic, neuromuscular, syndromic, and congenital scoliosis and kyphosis. The mean first post-operative opioid following IM administration was at 16.1 h in the IM group compared to 8.7 h in the non-IM group (p = < 0.001). The post-operative pain scores in the IM groups were significantly lower (p = < 0.001). Sixteen patients (2%) in the IM group were admitted to the PICU for observation secondary to respiratory depression, none requiring re-intubation. There were no other complications related to IM. CONCLUSION Pre-incision IM is a safe adjunct for pain management in select children in all diagnostic groups undergoing spinal deformity surgery. There were no serious complications. LEVEL OF EVIDENCE III.
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Yang TR, He XM, Li XH, Wang RR. Intrathecal morphine versus transversus abdominis plane block for caesarean delivery: a systematic review and meta-analysis. BMC Anesthesiol 2021; 21:174. [PMID: 34157985 PMCID: PMC8218454 DOI: 10.1186/s12871-021-01392-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/02/2021] [Indexed: 02/08/2023] Open
Abstract
Background The number of caesarean deliveries has been increasing. Although intrathecal morphine (ITM) can relieve pain and is widely applied in caesarean deliveries, it is associated with many side effects. Transversus abdominis plane block (TAPB), a new analgesic technology, has also began playing a certain role after caesarean delivery, with fewer adverse effects. This study mainly compares the analgesic and adverse effects of ITM and TAPB in caesarean delivery. Methods We systematically searched PubMed, Cochrane Library, EMBASE, and Web of Science, for randomised controlled trials (RCTs) published before 9 October, 2020 to compare the effects of ITM and TAPB. Primary outcome of the study was the pain score at rest 24 h after caesarean delivery, whereas the secondary outcomes were the pain score at movement 24 h after operation, postoperative nausea and vomiting (PONV), itching, and morphine consumption. For the outcome assessment, we conducted a sensitivity analysis. Result Six RCTs involving 563 patients and meeting the study inclusion criteria were included in this study. Results indicated no significant difference in the pain score between ITM and TAPB at 24 h of rest or movement. The sensitivity analysis results indicated that the resting pain score (95% CI = − 1.27 to − 0.28; P = 0.002) and 24-h moving pain score (95% CI = − 1.8 to − 0.07; P = 0.03) of the ITM group were lower than those of the TAPB group. The consumption of morphine in the ITM group was lower than in the TAPB group (95% CI = 1.92 to 4.87; P < 0.00001); however, in terms of adverse reactions, the incidence of pruritus (95% CI = 1.17 to 8.26; P = 0.02) and PONV (95% CI = 1.92 to 4.87, P < 0.00001) in the ITM group was higher than in the TAPB group. Conclusion Parturients in the ITM and TAPB groups exhibited similar analgesic effects. However, in the sensitivity analysis performed by eliminating the studies causing heterogeneity, the ITM group was found to have superior analgesic effects compared with the TAPB group, with less morphine consumption. Differently, the TAPB group displayed less side effects such as PONV. Therefore, TAPB is still a valuable analgesia option for patients who cannot use ITM for analgesia after caesarean delivery or those having a high risk of PONV. Trial registration Registration number: Registered on Prospero with the registration number of CRD42020210135. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01392-9.
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Affiliation(s)
- Tao-Ran Yang
- Department of Anesthesiology, The Research Units of West China (2018RU12), Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37, Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Xue-Mei He
- Department of Anesthesiology, The Research Units of West China (2018RU12), Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37, Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Xue-Han Li
- Department of Anesthesiology, The Research Units of West China (2018RU12), Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37, Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Ru-Rong Wang
- Department of Anesthesiology, The Research Units of West China (2018RU12), Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37, Guoxue Xiang, Chengdu, 610041, Sichuan, China.
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Pathonsamit C, Onklin I, Hongku N, Chaiyakit P. Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty. Arthroplast Today 2020; 7:253-259. [PMID: 33786350 PMCID: PMC7987934 DOI: 10.1016/j.artd.2020.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 10/27/2020] [Accepted: 11/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). Methods This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M0), ITM 0.1 mg (M1), and ITM 0.2 mg (M2). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. Results The trial enrolled 102 patients: M0 (n = 32), M1 (n = 35), and M2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M1 and M2 did not differ significantly within the first 24 hours and were significantly lower than those in group M0. Nausea and vomiting were observed more frequently 4 hours postoperatively in M2 than in groups M1 and M0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). Conclusion Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.
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Affiliation(s)
- Chompunoot Pathonsamit
- Department of Anesthesiology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Ittiwat Onklin
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Natthapong Hongku
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Pruk Chaiyakit
- Department of Orthopedics, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Subramani Y, Nagappa M, Kumar K, Mortuza R, Fochesato LA, Chohan MBY, Martin J, Armstrong K, Singh SI. Medications for the prevention of pruritus in women undergoing cesarean delivery with Intrathecal morphine: A systematic review and bayesian network meta-analysis of randomized controlled trials. J Clin Anesth 2021; 68:110102. [PMID: 33129065 DOI: 10.1016/j.jclinane.2020.110102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Intrathecal morphine-induced pruritus can cause significant discomfort in parturients and is refractory to conventional antipruritic treatment. This systematic review and network meta-analysis evaluates the effectiveness of the medications used for prevention of intrathecal (IT) morphine-induced pruritus after cesarean delivery under spinal anesthesia. METHODS A literature search was conducted from 1946 up to October 2019. We included all randomized controlled trials (RCTs) that compared medications used for prevention of pruritus with a control group in women undergoing cesarean delivery under spinal anesthesia with IT morphine. The primary outcome examined was the incidence of pruritus up to 24 h after cesarean delivery. Dichotomous data were extracted and summarized using odds ratios (OR) and 95% credible intervals (CrI) with Bayesian random effects network meta-analysis model. The GRADE approach was used to evaluate quality of the studies and effect evidence. RESULTS Of the 26 studies included in the systematic review, 21 studies with a total of 2594 patients were included in the network meta-analysis [prophylaxis, n = 1603 (62%) vs. control, n = 991 (38%)]. These studies investigated seven classes of drugs including serotonin-receptor antagonists, dopamine-receptor antagonists, opioid agonist-antagonists, opioid-receptor antagonists, histamine-receptor antagonists, propofol and celecoxib. The network meta-analysis showed that serotonin-receptor antagonists' prophylaxis [control vs. prophylaxis: 60% vs. 47%; OR (95% CrI): 2.69 (1.43-5.36)] and opioid agonist-antagonists prophylaxis [control vs. prophylaxis: 72% vs. 47%; OR (95% CrI): 4.57 (1.67-12.91)] decreased the incidence of pruritus compared to the control group. Although all included studies were at low risk of bias, the quality of the overall network meta-analysis pooled estimates was low. CONCLUSION This bayesian network meta-analysis of RCTs demonstrates serotonin-receptor antagonists and opioid agonist-antagonists may prevent pruritus in women undergoing cesarean delivery with intrathecal morphine compared to control group. However, further RCTs of adequate power and clearly defined end points are warranted.
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De Bie A, Siboni R, Smati MF, Ohl X, Bredin S. Intrathecal morphine injections in lumbar fusion surgery: Case-control study. Orthop Traumatol Surg Res 2020; 106:1187-1190. [PMID: 32800600 DOI: 10.1016/j.otsr.2020.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/13/2020] [Accepted: 02/24/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Intrathecal morphine (ITM) is a well-known and extensively used method for analgesia in various surgical fields; however, its relevance in spine surgery is debated given the conflicting results in the literature. The aim of this study was to investigate the opioid-sparing effect of ITM after lumbar fusion. METHODS This retrospective study involves two consecutive series of patients undergoing posterior lumbar fusion. The first cohort (control group, n=30) received the standard analgesia protocol while the second cohort (ITM Group, n=30) had the standard protocol supplemented with ITM (100μg of morphine hydrochloride). Morphine consumption, pain assessment (VAS), specific complications and postoperative recovery data were collected. RESULTS Consumption of morphine at 24hours and 48hours postoperatively was lower in the ITM group than the control group (p<0.001 and p=0.004). The pattern was similar for pain on VAS at H6, H24 and H36 (p=0.001; p=0.003 and p=0.01). The patients in the ITM group were able to get out of bed faster than the controls (1.13 days vs 1.83 days, p=0.002) and the discharge was earlier in the ITM group (5.1 days vs. 6.2 days, p=0.002). There was no difference in morphine-specific complications between the two groups. CONCLUSION Adding ITM to the analgesia protocol for lumbar fusion provides better management of postoperative pain, without increasing early complications, and it accelerates the recovery process after surgery. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anaïs De Bie
- Orthopedic and trauma surgery department,hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Anesthesia and critical care unit, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - Renaud Siboni
- Orthopedic and trauma surgery department,hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Anesthesia and critical care unit, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - Mohamed F Smati
- Orthopedic and trauma surgery department,hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Anesthesia and critical care unit, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - Xavier Ohl
- Orthopedic and trauma surgery department,hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Anesthesia and critical care unit, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - Simon Bredin
- Orthopedic and trauma surgery department,hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Anesthesia and critical care unit, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
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Tang J, Churilov L, Tan CO, Hu R, Pearce B, Cosic L, Christophi C, Weinberg L. Intrathecal morphine is associated with reduction in postoperative opioid requirements and improvement in postoperative analgesia in patients undergoing open liver resection. BMC Anesthesiol 2020; 20:207. [PMID: 32814546 PMCID: PMC7436971 DOI: 10.1186/s12871-020-01113-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 07/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background Our study aimed to test the hypothesis that the addition of intrathecal morphine (ITM) results in reduced postoperative opioid use and enhanced postoperative analgesia in patients undergoing open liver resection using a standardized enhanced recovery after surgery (ERAS) protocol with multimodal analgesia. Methods A retrospective analysis of 216 adult patients undergoing open liver resection between June 2010 and July 2017 at a university teaching hospital was conducted. The primary outcome was the cumulative oral morphine equivalent daily dose (oMEDD) on postoperative day (POD) 1. Secondary outcomes included postoperative pain scores, opioid related complications, and length of hospital stay. We also performed a cost analysis evaluating the economic benefits of ITM. Results One hundred twenty-five patients received ITM (ITM group) and 91 patients received usual care (UC group). Patient characteristics were similar between the groups. The primary outcome - cumulative oMEDD on POD1 - was significantly reduced in the ITM group. Postoperative pain scores up to 24 h post-surgery were significantly reduced in the ITM group. There was no statistically significant difference in complications or hospital stay between the two study groups. Total hospital costs were significantly higher in the ITM group. Conclusion In patients undergoing open liver resection, ITM in addition to conventional multimodal analgesic strategies reduced postoperative opioid requirements and improved analgesia for 24 h after surgery, without any statistically significant differences in opioid-related complications, and length of hospital stay. Hospital costs were significantly higher in patients receiving ITM, reflective of a longer mandatory stay in intensive care. Trial registration Registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) under ACTRN12620000001998.
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Affiliation(s)
- Jefferson Tang
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Luka Cosic
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Christopher Christophi
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia. .,Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.
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Wang Y, Guo X, Guo Z, Xu M. Preemptive analgesia with a single low dose of intrathecal morphine in multilevel posterior lumbar interbody fusion surgery: a double-blind, randomized, controlled trial. Spine J 2020; 20:989-997. [PMID: 32179153 DOI: 10.1016/j.spinee.2020.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Patients undergoing lumbar spinal surgery may experience considerable pain in the early postoperative period, and poor pain control after multilevel lumbar spinal fusion surgery is frequently associated with multiple complications and delayed discharge from hospital. PURPOSE The current study evaluated the efficacy and safety of preemptive analgesia with intrathecal morphine (ITM) in patients undergoing multilevel posterior lumbar spinal fusion surgery. STUDY DESIGN Double-blinded, randomized, controlled trial. PATIENT SAMPLE Ninety-two patients aged between 18 and 80 years who were scheduled to undergo elective lumbar laminectomy (L3-S1) and dual-level fusions. OUTCOME MEASURES The primary endpoint was the degree of postoperative pain at rest and during movement evaluated using a 10-point visual analogue scale. The secondary outcomes included the consumption of analgesics, the patient-assessed postoperative and satisfaction scores, adverse effects, time to first ambulation, and length of hospital stay. METHODS Patients were randomly allocated to either the ITM group that received 0.2 mg of ITM or the control (CON) group that received 2 ml of 0.9% saline as a skin infiltration 30 minutes prior to anesthesia induction. RESULTS The ITM group had a significantly lower visual analogue scale score than the CON group during the first 3 days postoperatively (at rest, P=0.000, during movement, P=0.000). The ITM group used significantly less sufentanil than the CON group in the first 3 days postoperatively (p=.000) in patient-controlled intravenous analgesia, as well as in supplemental analgesic demands. The ITM group reported a greater degree of satisfaction with the whole hospitalization experience than the CON group (2.4±0.6 vs. 1.9±0.6, p=.000). The two groups did not significantly differ regarding adverse effects, length of hospital stay, and time taken to regain the ability to walk without support. CONCLUSIONS Preemptive analgesia with ITM results in significantly improved early postoperative pain control and decreased postoperative patient-controlled intravenous analgesia consumption, with no increase in adverse effects.
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Affiliation(s)
- Yujie Wang
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China
| | - Zhaoqing Guo
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China.
| | - Mao Xu
- Department of Anesthesiology, Peking University Third Hospital, 49 North Garden Rd., Haidian District, Beijing, China.
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Sato I, Iwasaki H, Luthe SK, Iida T, Kanda H. Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine alone for post-cesarean section analgesia: a randomized controlled trial. BMC Anesthesiol 2020; 20:138. [PMID: 32493372 PMCID: PMC7268233 DOI: 10.1186/s12871-020-01050-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/24/2020] [Indexed: 12/02/2022] Open
Abstract
Background Several neuraxial techniques have demonstrated effective post-cesarean section analgesia. According to previous reports, it is likely that patient-controlled epidural analgesia (PCEA) without opioids is inferior to intrathecal morphine (IM) alone for post-cesarean section analgesia. However, little is known whether adding PCEA to IM is effective or not. The aim of this study was to compare post-cesarean section analgesia between IM with PCEA and IM alone. Methods Fifty patients undergoing elective cesarean section were enrolled in this prospective randomized study. Patients were randomized to one of two groups: IM group and IM + PCEA group. All patients received spinal anesthesia with 12 mg of 0.5% hyperbaric bupivacaine, 10 μg of fentanyl, and 150 μg of morphine. Patients in IM + PCEA group received epidural catheterization through Th11–12 or Th12-L1 before spinal anesthesia and PCEA (basal 0.167% levobupivacaine infusion rate of 6 mL/h, bolus dose of 3 mL in lockout interval of 30 min) was commenced at the end of surgery. A numerical rating scale (NRS) at rest and on movement at 4,8,12,24,48 h after the intrathecal administration of morphine were recorded. In addition, we recorded the incidence of delayed ambulation and the number of patients who requested rescue analgesics. We examined NRS using Bonferroni’s multiple comparison test following repeated measures analysis of variance; p < 0.05 was considered as statistically significant. Results Twenty-three patients in each group were finally analyzed. Mean NRS at rest was significantly higher in IM group than in IM + PCEA group at 4 (2.7 vs 0.6), 8 (2.2 vs 0.6), and 12 h (2.5 vs 0.7), and NRS during mobilization was significantly higher in IM group than in IM + PCEA group at 4 (4.9 vs 1.5), 8 (4.8 vs 1.9), 12 (4.9 vs 2), and 24 h (5.7 vs 3.5). The number of patients who required rescue analgesics during the first 24 h was significantly higher in IM group compared to IM + PCEA group. No significant difference was observed between the groups in incidence of delayed ambulation. Conclusions The combined use of PCEA with IM provided better post-cesarean section analgesia compared to IM alone. Trial registration UMIN-CTR (Registration No. UMIN000032475). Registered 6 May 2018 – Retrospectively registered.
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Affiliation(s)
- Izumi Sato
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Hajime Iwasaki
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Sarah Kyuragi Luthe
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.,Department of Anesthesiology, Indiana University School of Medicine, 1130 W. Michigan Street, Fesler Hall 204, Indianapolis, IN, 46202, USA
| | - Takafumi Iida
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
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Shen L, Wang W, Li S, Qin J, Huang Y. NMDA receptor antagonists attenuate intrathecal morphine-induced pruritus through ERK phosphorylation. Mol Brain 2018; 11:35. [PMID: 29954440 PMCID: PMC6022508 DOI: 10.1186/s13041-018-0379-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/19/2018] [Indexed: 01/30/2023] Open
Abstract
Pruritus is the most common complication of intrathecal morphine; however, its exact molecular mechanism is unclear, and treatment is challenging. The analgesic effect of N-methyl-D-aspartate (NMDA) receptor antagonists and the morphine-associated increase in NMDA receptor activation suggest potential role of NMDA receptor in the spinal itch sensation. Male C57BL/6 mice were given intrathecal morphine to induce scratching behavior. The effects of NMDA, ketamine, ifenprodil and U0126 on morphine-induced pruritus and analgesia were evaluated also. The number of scratching responses was counted for 30 min post-injection to evaluate pruritus. A warm-water tail immersion assay was conducted before and until 120 min post-injection at 30-min intervals. Percent of maximal possible effect (%MPE) and area under curve (AUC) were calculated based on tail-flick latency to evaluate analgesic efficacy. Compared with control treatment, intrathecal morphine elicited an obvious scratching response and analgesic effect in a dose dependent manner. Ketamine (1 μg), ifenprodil (0.1 μg) and U0126 (0.1 μg and 1.0 μg) all significantly attenuated morphine induced scratches. Ifenprodil (0.1 μg) injection significantly prolonged the analgesic effect of intrathecal morphine. The ERK1/2 phosphorylation induced by intrathecal morphine was inhibited by ketamine, ifenprodil and U0126 as well. U0126 inhibited morphine-induced pruritus with no effect on its analgesia. Therefore, intrathecal coadministration of morphine with NMDA receptor antagonists ketamine and ifenprodil alleviated morphine-induced scratching. Intrathecal morphine increased ERK phosphorylation in the lumbar spinal dorsal horn, which may be related with morphine-induced pruritus, and was counteracted by NMDA receptor antagonists.
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Affiliation(s)
- Le Shen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730 China
| | - Weijia Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730 China
| | - Siyu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730 China
| | - Jing Qin
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730 China
- Department of Anesthesiology, The first hospital of Jilin University, Changchun, Jilin, 130021 China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730 China
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Cosgrave D, Galligan M, Soukhin E, McMullan V, McGuinness S, Puttappa A, Conlon N, Boylan J, Hussain R, Doran P, Nichol A. The NAPRESSIM trial: the use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine in elective hepatobiliary surgery: a study protocol and statistical analysis plan for a randomised controlled trial. Trials 2017; 18:633. [PMID: 29284510 PMCID: PMC5747267 DOI: 10.1186/s13063-017-2370-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 11/21/2017] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Intrathecally administered morphine is effective as part of a postoperative analgesia regimen following major hepatopancreaticobiliary surgery. However, the potential for postoperative respiratory depression at the doses required for effective analgesia currently limits its clinical use. The use of a low-dose, prophylactic naloxone infusion following intrathecally administered morphine may significantly reduce postoperative respiratory depression. The NAPRESSIM trial aims to answer this question. METHODS/DESIGN 'The use of low-dose, prophylactic naloxone infusion to prevent respiratory depression with intrathecally administered morphine' trial is an investigator-led, single-centre, randomised, double-blind, placebo-controlled, double-arm comparator study. The trial will recruit 96 patients aged > 18 years, undergoing major open hepatopancreaticobiliary resections, who are receiving intrathecally administered morphine as part of a standard anaesthetic regimen. It aims to investigate whether the prophylactic administration of naloxone via intravenous infusion compared to placebo will reduce the proportion of episodes of respiratory depression in this cohort of patients. Trial patients will receive an infusion of naloxone or placebo, commenced within 1 h of postoperative extubation continued until the first postoperative morning. The primary outcome is the rate of respiratory depression in the intervention group as compared to the placebo group. Secondary outcomes include pain scores, rates of nausea and vomiting, pruritus, sedation scores and adverse outcomes. We will also employ a novel, non-invasive, respiratory minute volume monitor (ExSpiron 1Xi, Respiratory Motion, Inc., 411 Waverley Oaks Road, Building 1, Suite 150, Waltham, MA, USA) to assess the monitor's accuracy for detecting respiratory depression. DISCUSSION The trial aims to provide a clear management plan to prevent respiratory depression after the intrathecal administration of morphine, and thereby improve patient safety. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02885948 . Registered retrospectively on 4 July 2016. Protocol Version 2.0, 3 April 2017. Protocol identification (code or reference number): UCDCRC/15/006 EudraCT registration number: 2015-003504-22. Registered on 5 August 2015.
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Affiliation(s)
| | - Marie Galligan
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Era Soukhin
- St Vincent's University Hospital, Dublin, Ireland
| | | | | | | | - Niamh Conlon
- St Vincent's University Hospital, Dublin, Ireland
| | - John Boylan
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Rabia Hussain
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Peter Doran
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Alistair Nichol
- St Vincent's University Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Monash University, Melbourne, VIC, Australia.,The Alfred Hospital, Melbourne, VIC, Australia
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Tang Y, Tang X, Wei Q, Zhang H. Intrathecal morphine versus femoral nerve block for pain control after total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2017; 12:125. [PMID: 28814320 PMCID: PMC5559845 DOI: 10.1186/s13018-017-0621-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 07/18/2017] [Indexed: 01/23/2023] Open
Abstract
Background This meta-analysis aims to illustrate the efficacy and safety of intrathecal morphine (ITM) versus femoral nerve block (FNB) for pain control after total knee arthroplasty (TKA). Methods In April 2017, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, Cami Info. Inc., Casalini databases, EBSCO databases, Verlag database and Google database. Data on patients prepared for TKA surgery in studies that compared ITM versus FNB for pain control after TKA were collected. The main outcomes were the visual analogue scale (VAS) at 6, 12, 24, 48 and 72 and total morphine consumption at 12, 24 and 48 h. The secondary outcomes were complications that included postoperative nausea and vomiting (PONV) and itching. Stata 12.0 was used for pooling the data. Results Five clinical studies with a total of 225 patients (ITM group = 114, FNB group = 111) were ultimately included in the meta-analysis. The results revealed that the ITM group was associated with a reduction of VAS at 6, 12, 24, 48 and 72 h and total morphine consumption at 12, 24 and 48 h. There was no significant difference between the occurrences of PONV. However, the ITM group was associated with an increased occurrence of itching after TKA. Conclusions Some immediate analgesic efficacy and opioid-sparing effects were obtained with the administration of ITM when compared with FNB. The complications of itching in the ITM group were greater than in the FNB group. The sample size and the quality of the included studies were limited. A multi-centre RCT is needed to identify the optimal method for reaching maximum pain control after TKA. Electronic supplementary material The online version of this article (doi:10.1186/s13018-017-0621-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yi Tang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Xu Tang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Qinghua Wei
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopedics, People's Hospital of JianYang, No. 180, Yiyuan Road, Jiancheng zhen, Jianyang, Sichuan Province, China.
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Jia XF, Ji Y, Huang GP, Zhou Y, Long M. Comparison of intrathecal and local infiltration analgesia by morphine for pain management in total knee and hip arthroplasty: A meta-analysis of randomized controlled trial. Int J Surg. 2017;40:97-108. [PMID: 28254422 DOI: 10.1016/j.ijsu.2017.02.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We performed a meta-analysis from randomized controlled trials to evaluate the efficiency and safety between local infiltration analgesia and intrathecal morphine for pain control in total knee and hip arthroplasty. METHODS We systemically searched electronic databases including Embase (1980-2016.7), Medline (1966-2016.7), PubMed (1966-2016.7), ScienceDirect (1985-2016.7), web of science (1950-2016.7) and Cochrane Library for relevant articles. All calculation was carried out by Stata 11.0. RESULTS Four randomized controlled trials (RCTs) involving 242 patients met the inclusion criteria. The meta-analysis showed that there were significant differences in terms of postoperative pain scores at 24 h during rest (P = 0.008) and mobilization (P = 0.049) following total knee and hip arthroplasty. Significant difference was found regarding the incidence of nausea (P = 0.030), vomiting (P = 0.005), and pruritus (P = 0.000) between two groups. There was no significant difference between groups in terms of morphine equivalent consumption at postoperative 24 or 48 h. CONCLUSIONS Local infiltration analgesia (LIA) provided superior analgesic effects within the first 24 h compared to intrathecal morphine (ITM) following total knee and hip arthroplasty. There were fewer adverse effects in LIA. Doses of morphine consumption were similar in the two groups.
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DeSousa K, Chandran R. Intrathecal morphine vs femoral nerve block for postoperative-analgesia after total knee arthroplasty: A two-year retrospective analysis. World J Anesthesiol 2016; 5:67-72. [DOI: 10.5313/wja.v5.i3.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 07/17/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy of intrathecal morphine and single shot femoral nerve block for patients undergoing primary total knee arthroplasty.
METHODS Data was extracted from electronic medical records and case-paper record files of patients who underwent unilateral primary total knee arthroplasty under spinal anesthesia using bupivacaine 12.5 mg with intrathecal morphine (ITM) 0.2 mg and under general anesthesia (GA) with single shot femoral nerve block (FNB) using 20 mL 0.5% bupivacaine at our hospital in 2013 and 2014. All patients had received peri-articular infiltration as per the hospital protocol. Data for gender, age, weight, American Society of Anesthesiologists status, total surgical time, postoperative pain score using visual analogue scale (VAS) from 1 to 10 at 6 h, 12 h and 24 h postoperatively, 24 h opioid consumption, use of oral multimodal analgesia, postoperative high dependency unit (HDU) admission and the time to discharge from the hospital was collected. The data was analyzed using Mann-Whitney U test for continuous variables and Fischer’s exact-t-test for categorical variables.
RESULTS Twenty-two patients in ITM group and 32 patients in FNB group were analyzed. Median pain scores using VAS in ITM group were significantly lower at 6 h (0.0 vs 2.0, P < 0.001), 12 h (0.0 vs 2.0, P < 0.001) and 24 h (0.0 vs 2.0, P < 0.001) postoperatively. Also, postoperative morphine consumption in ITM group was significantly lower (P < 0.001). However, median of non-steroid anti-inflammatory drug unit requirement in 24 h postoperatively was statistically significant higher in ITM compared to FNB group (2.0 vs 1.0, P = 0.025). The difference in postoperative paracetamol consumption in 24 h was not statistically significant (P = 0.147). There was no significant difference in the postoperative HDU admission or time to discharge from the hospital. No respiratory depression in either group was noticed.
CONCLUSION The ITM group patients had much lower pain scores and morphine requirement in the first 24 hour postoperatively compared to FNB group.
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El Sherif FA, Othman AH, Abd El-Rahman AM, Taha O. Effect of adding intrathecal morphine to a multimodal analgesic regimen for postoperative pain management after laparoscopic bariatric surgery: a prospective, double-blind, randomized controlled trial. Br J Pain 2016; 10:209-216. [PMID: 27867510 DOI: 10.1177/2049463716668904] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Pain control after bariatric surgery is a major challenge. Our objective was to study the efficacy and safety of intrathecal (IT) morphine 0.3 mg added to bupivacaine 0.5% for postoperative pain after laparoscopic bariatric surgery. METHODS After local ethics committee approval, 100 morbidly obese patients scheduled for laparoscopic bariatric surgery were enrolled in this study. Patients were randomly assigned into two groups: Group I received IT 0.3 mg morphine (0.3 mL) added to 1.2 mL of bupivacaine 0.5%; Group II received IT 0.3 mL saline added to 1.2 mL of bupivacaine 0.5%, immediately before induction of general anaesthesia. For both groups, 60 mg ketorolac and 1000 mg paracetamol were infused 30 minutes before the end of surgery. After wound closure, 20 mL bupivacaine 0.25% was infiltrated at wound edges. RESULTS Visual Analogue Scale (VAS) score was significantly lower in group I immediately, 30 minutes and 1 hour postoperatively. Time to first ambulation, return of intestinal sounds and hospital stay were shorter in group I than group II (p < 0.05); total morphine consumption was significantly lower in group I than group II (p < 0.05). Sedation score was significantly higher in group I immediately postoperatively, while at 30 minutes, 1, 2 and 6 hours postoperatively sedation scores were significantly higher in group II. Itching was significantly higher in group I. CONCLUSION The addition of IT morphine to a multimodal analgesic regimen after laparoscopic bariatric surgery was an effective and safe method that markedly reduced postoperative pain, systemic opioid consumption and length of hospital stay.
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Affiliation(s)
- Fatma Adel El Sherif
- Department of Anesthesia, ICU and Pain Relief, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | - Ahmed Hassan Othman
- Department of Anesthesia, ICU and Pain Relief, South Egypt Cancer Institute, Assiut University, Assiut, Egypt
| | | | - Osama Taha
- Department of Plastic Surgery, Faculty of Medicine, Assiut University, Assiut, Egypt
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Li XM, Huang CM, Zhong CF. Intrathecal morphine verse femoral nerve block for pain control in total knee arthroplasty: A meta-analysis from randomized control trials. Int J Surg 2016; 32:89-98. [PMID: 27370542 DOI: 10.1016/j.ijsu.2016.06.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/22/2016] [Accepted: 06/25/2016] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Total knee arthroplasty (TKA) is usually associated with postoperative pain. The objective of this systematic review and meta-analysis was to evaluate the effectiveness and safety of femoral nerve block compared with intrathecal morphine for pain management after TKA. METHODS Potentially relevant literature was identified from electronic databases including Medline, PubMed, Embase, ScienceDirect and the Cochrane Library. Gray academic studies were also identified from the reference of included literature. There was no language restriction. Pooling of data was carried out using Stata 11.0. RESULTS Four randomized controlled trials (RCTs) involving 185 patients met the inclusion criteria. The meta-analysis indicated that there were no significant differences in terms of Visual Analog Scale (VAS) score at 6 h (standard mean difference (SMD) = -0.09, 95% CI: -1.62 to 1.43, P = 0.903), 12 h (weighted mean difference (WMD) = 1.84, 95% CI: -8.01 to 11.69, P = 0.714) or 24 h (WMD = 1.56, 95% CI: -14.31 to 17.42, P = 0.8474). No significant difference were found regarding morphine consumption at 6 h (WMD = -0.84, 95% CI: -2.52 to 0.85, P = 0.332), 12 h (WMD = 0.031, 95% CI: -3.304 to 0.3366, P = 0.985), 24 h (WMD = 0.21, 95% CI: -7.32 to 7.75, P = 0.956) or incidence of postoperative vomit and nausea (risk difference (RD) = -0.01, 95% CI: -0.15 to 0.12, P = 0.847). There was a significant difference between the groups in terms of the risk of itching postoperatively (RD = 0.41, 95% CI: 0.29 to 0.54, P < 0.001). CONCLUSIONS Femoral nerve block provides equal postoperative pain control compared with intrathecal morphine following total knee arthroplasty, although there were fewer side effects in the FNB groups. In contrast, FNB was performed with an additional procedure and required a special apparatus. Both methods are effective at pain control following TKA.
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Affiliation(s)
- Xian-Min Li
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China.
| | - Chun-Ming Huang
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China
| | - Cheng-Fan Zhong
- Orthopedics Department, Gaozhou People's Hospital, No 89, Xi-Guan Road, Guangdong, 525200, PR China
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DeSousa KA, Chandran R. Intrathecal morphine for postoperative analgesia: Current trends. World J Anesthesiol 2014; 3:191-202. [DOI: 10.5313/wja.v3.i3.191] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 03/31/2014] [Accepted: 07/14/2014] [Indexed: 02/07/2023] Open
Abstract
The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal (IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, cost-effective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.
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Licker M, Christoph E, Cartier V, Mugnai D, Murith N, Kalangos A, Aldenkortt M, Cassina T, Diaper J. Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study. J Clin Anesth 2013; 25:296-308. [PMID: 23685100 DOI: 10.1016/j.jclinane.2013.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 01/06/2013] [Accepted: 01/17/2013] [Indexed: 01/27/2023]
Abstract
STUDY OBJECTIVE To determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery. DESIGN Retrospective analysis of a prospective cohort. SETTINGS Operating room, intensive care unit, and Postanesthesia Care Unit of a university hospital. MEASUREMENTS Data from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded. MAIN RESULTS Patients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99). CONCLUSIONS This single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital, CH-1211 Geneva, Switzerland.
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Park CK, Cho CK, Lee JH, Shin HH. Optimizing the dose of intrathecal morphine when combined with continuous 3-in-1 nerve block after total knee replacement. Korean J Anesthesiol 2009; 57:69-77. [PMID: 30625833 DOI: 10.4097/kjae.2009.57.1.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Continuous femoral 3-in-1 block alone is insufficient for the treatment of severe pain after total knee replacement (TKR). Intrathecal (IT) morphine provides effective postoperative analgesia but may result in many side effects. The optimal dose of spinal morphine when combined with continuous 3-in-1 block after TKR is not known. METHODS Patients were randomized to receive IT morphine in five groups (n = 20 per group): 1) 0.0 mg, 2) 0.05 mg, 3) 0.1 mg, 4) 0.15 mg, and 5) 0.2 mg. All patients received continuous 3-in-1 block performed with 20 ml of 0.25% bupivacaine, followed by a continuous infusion of 0.125% bupivacaine at the rate of 2 ml/h plus PCA boluses of 1 ml with a lockout of 10 minutes. The intensity of pain at rest and on movement of the knee was assessed by using a visual analog scale for the first two postoperative days. RESULTS All treatment groups produced effective pain relief and decreased cumulative femoral PCA bolus use of 0.125% bupivacaine compared with control, respectively (P < 0.05); however, there were no significant differences among the treatment groups. The incidence of vomiting was significantly more frequent with 0.1-0.2 mg IT morphine groups compared with control, respectively (P < 0.05). The rate of administration of antipruritic medication was increased as IT morphine dose increased (P < 0.05). CONCLUSIONS Use of 0.05 mg IT morphine would appear to provide the optimal balance between pain relief and adverse effects following TKR.
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Affiliation(s)
- Chang Kil Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Eulji University, Daejeon, Korea.
| | - Choon Kyu Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Eulji University, Daejeon, Korea.
| | - Jong Hyuk Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Eulji University, Daejeon, Korea.
| | - Hyun Ho Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Eulji University, Daejeon, Korea.
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