A comparative study of patient-controlled epidural fentanyl and single dose epidural morphine for post-caesarean analgesia

In a prospective, randomized, double-blinded study, 23 patients who had undergone Caesarean delivery under epidural anaesthesia were assessed to evaluate the effectiveness of patientcontrolled epidural analgesia (PCEA) with fentanyl compared with a single dose of epidural morphine for postoperative analgesia. Group A (n = 11) received epidural fentanyl 100 μg intraoperatively, then self-administered a maximum of two epidural fentanyl boluses 50 μg (10 μg · ml^?1) with a lockout period of five minutes for a maximum of two doses per hour. Group B (n = 11) received a single bolus of epidural morphine 3 mg (0.5 mg · ml^?1) intraoperatively and received the same instructions as Group A but had their PCA devices filled with 0.9% NaCl. Patients were assessed up to 24 hr for pain, satisfaction with pain relief, nausea and pruritus using visual analogue scales (VAS). The treatments for inadequate analgesia, nausea and pruritus as well as time to first independent ambulation were recorded. The ventilatory response to carbon dioxide challenge was measured at four and eight hours. Pain relief, satisfaction with pain relief, and the use of supplemental analgesics were similar in both groups. The mean 24 hr dose of epidural fentanyl used by group A patients was 680 μg. Pruritus was less common in Group A patients at the 8 and 24 hr observation periods (P < 0.0125). Both groups experienced the same degree of nausea and clinically unimportant respiratory depression. We conclude that PCEA with fentanyl provides analgesia equal to a single dose of epidural morphine and may be suitable for patients who have experienced considerable pruritus after epidural morphine adminstration.     

Intrathecal + PCA morphine improves analgesia during the first 24 hr after major abdominal surgery compared to PCA alone

PURPOSE: To compare, over a 48-hr follow-up period, the analgesia and side-effects of patient controlled iv analgesia (PCA) with morphine alone vs combined intrathecal and PCA morphine (IT+PCA) in patients undergoing major abdominal surgery. METHODS: Sixty adult patients undergoing abdominal surgery for cancer were randomly allocated to receive preoperative IT (0.3 or 0.4 mg) plus postoperative PCA morphine or postoperative PCA morphine alone. Postoperative analgesia was tested at rest and while coughing on a visual analogue pain scale and morphine consumption was recorded. Patients' satisfaction, arterial oxygen saturation, respiratory rate, episodes of nausea, vomiting and pruritus were also noted. RESULTS: Analgesia at rest and while coughing was significantly better in the IT+PCA morphine group (rest: P = 0.01; coughing: P = 0.005) on the first postoperative day only. IT+PCA morphine constantly provided adequate analgesia during this period. Morphine consumption was lower in the IT+PCA morphine group during this period also (IT+PCA: 9 (17) vs PCA: 40 (26); mg of morphine, mean (SD), P = 0.0001). No difference was found in pain relief and morphine consumption between the groups on the second postoperative day. Nausea and vomiting were more frequent with IT+PCA morphine on the first postoperative day. No respiratory depression occurred in either group. Satisfaction was high in both groups. CONCLUSIONS: IT+PCA morphine improves patient comfort constantly during the first postoperative day after major abdominal surgery. However, after the first postoperative day, IT+PCA morphine provides no additional benefit.     

Epidural morphine after anterior cruciate ligament repair: a comparison with patient-controlled intravenous morphine

To compare the management of postoperative pain using morphine administered by epidural catheter with intravenous patient-controlled analgesia (PCA), we prospectively studied 47 consecutive cases involving repair of the anterior cruciate ligament of the knee. Both the quality of analgesia and the incidence of side effects were documented. Compared with patients receiving PCA morphine, patients given epidural morphine reported significantly lower pain scores both at rest (0.7 +/- 1.1 versus 3.4 +/- 2.1, P less than 0.01) and with mobilization (3.2 +/- 2.1 versus 6.1 +/- 2.1, P less than 0.01). Although patients receiving epidural morphine had a greater incidence of urinary retention, there were no significant differences in the incidence of nausea or pruritus. There was no respiratory depression in either group. We conclude that epidural morphine provides superior analgesia with a clinically inconsequential increase in side effects. Further, epidural morphine may have special advantages when early mobilization is indicated.     

Epidural morphine analgesia compared with intravenous morphine for oral cancer surgery with pectoralis major myocutaneous flap reconstruction

BACKGROUND: Oral cancer surgery with reconstruction is a complex operative procedure with morbidities such as respiratory complications and post-operative pain. These morbidities may be reduced with appropriate operative and post-operative pain management. Epidural analgesia provides better pain control than intravenous opioids after major thoraco-abdominal surgical procedures. We planned to undertake a prospective study to compare the efficacy and side-effects of epidural morphine analgesia vs. intravenous morphine in patients undergoing oral cancer surgery with pectoralis major myocutaneous flap reconstruction. METHODS: Sixty patients undergoing a major surgical procedure for oral cancer with pectoralis major myocutaneous flap reconstruction were prospectively randomized to receive either epidural morphine or intravenous morphine in the post-operative period. The intensity of pain was assessed daily using a 100-mm visual analogue scale. The post-operative side-effects, time to ambulation, time to tolerate first nasogastric feed, total length of hospital stay and global satisfaction score were recorded. RESULTS: The epidural morphine group had statistically significant lower pain scores at the three evaluation times through the post-operative 48 h (P < 0.05). However, the mean visual analogue scores were always below 35 in the intravenous morphine group. Patients in the epidural morphine group ambulated and accepted nasogastric feed significantly earlier than those in the intravenous morphine group. The incidence of nausea/vomiting or pruritus, the length of hospital stay and the global satisfaction score were not statistically different between the groups. CONCLUSION: This study illustrates that epidural morphine offers better pain control than intravenous morphine after oral cancer surgery with pectoralis major myocutaneous flap reconstruction. Nevertheless, both methods appear to provide very good pain relief, and perhaps the extra risks inherent to epidural catheter insertion are not outweighed by the benefits in this type of surgery.     

Central neuraxial opioid analgesia after caesarean section: comparison of epidural diamorphine and intrathecal morphine

In a prospective, randomized, double-blind study in 55 women undergoing elective caesarean section under spinal anaesthesia, we compared epidural diamorphine 3 mg (2 distinct boluses, group ED) with single-dose intrathecal morphine 0.2 mg (group SM), in terms of analgesic efficacy, patient satisfaction and side-effects at 2, 3, 4, 8, 12, 16, 24 and 28 h postoperatively. There were no significant differences between groups in pain (assessed by 100 mm visual analogue scale), incidence of pruritus, sedation or respiratory depression measured by continuous pulse oximetry. However, time to first request for supplementary oral analgesia was longer in SM than in ED (mean +/- SD: 22.3+/-12.0 h vs. 13.8+/-6.5 h, P=0.04). The incidence of nausea or vomiting was significantly higher in SM than ED (73% vs. 41%, P=0.01). In ED, the mean +/- SD time to requirement of the second bolus was 6.7+/-3.2 h. There was a high level of satisfaction in both groups. We conclude that two boluses of epidural diamorphine 3 mg and single-dose intrathecal morphine 0.2 mg provide satisfactory analgesia after caesarean section, but spinal morphine was associated with both delayed requirement for supplementary analgesia and a higher incidence of nausea and vomiting.     

Postcesarean epidural morphine: a dose-response study

The purpose of this study was to describe the dose-response relationship of epidural morphine for postcesarean analgesia for quality of analgesia and relation to the side effects of pruritus, nausea, and vomiting. Sixty term parturients undergoing nonurgent cesarean delivery were enrolled and randomized to receive a single dose of epidural morphine after delivery (0,1.25, 2.5, 3.75, or 5 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. PCA morphine use and the incidence and severity of side effects were recorded for 24 h. Data were analyzed with analysis of variance, Student's t-tests, and chi(2) analysis. Nonlinear regression was used to describe a dose-response curve. PCA use differed significantly among groups (P < 0.001); PCA use was significantly greater in Group 0 mg than Groups 2.5, 3.75, and 5 mg (P < 0.05). PCA use was also significantly greater in Group 1.25 mg than Groups 3.75 and 5 mg (P < 0.05). Pruritus scores were significantly higher in all groups given epidural morphine than the control group (0 mg) (P < 0.05), but did not differ among the treatment groups (1.25-5 mg), although pruritus scores were significantly higher in treatment groups than in the control (P < 0. 05). No relation was found between epidural morphine dose and incidence or severity of nausea and vomiting. We concluded that, for optimal analgesia, augmentation of epidural morphine with systemic analgesics or other epidural medications may be necessary. IMPLICATIONS: Quality of analgesia increases as the dose of epidural morphine increases to at least 3.75 mg; increasing the dose further to 5 mg did not improve analgesia. Side effects were not dose related. For optimal analgesia, augmentation of epidural morphine with systemic analgesics or other epidural medications may be necessary.     

A comparison of morphine, meperidine, and oxymorphone as utilized in patient-controlled analgesia following cesarean delivery

Seventy-five patients (n = 75) undergoing elective cesarean delivery during epidural anesthesia were randomly assigned to receive one of three opioid analgesics via patient-controlled analgesia (PCA) when they first complained of pain in the recovery room. Following administration of an analgesic loading dose, patients were allowed to self-administer morphine 1.8 mg, meperidine 18 mg, or oxymorphone 0.3 mg iv every 8 min as required. Data collected during the 24-h observation period included visual analog scale (VAS) pain scores at rest and during movement, VAS patient satisfaction scores, total drug administered, the ratio of attempts/injections, and the incidence of nausea/vomiting, sedation, and pruritus. After adjusting for narcotic potency, no differences in 24-h dose requirements were noted between treatment groups (NS). All patients achieved an excellent level of analgesia at rest (NS); however, onset was most rapid with oxymorphone (P less than 0.05). The percentage of patients reporting severe pain during movement was highest in the meperidine group (P less than 0.05). Oxymorphone was associated with the highest incidence of nausea and vomiting (P less than 0.05), whereas increased sedation and pruritus were noted with morphine. Patient satisfaction with drug effect demonstrated significant negative correlations with resting pain scores and degree of sedation. Whereas morphine is a more commonly utilized PCA analgesic, the excellent analgesia, low incidence of sedation, and high patient satisfaction provided by meperidine and oxymorphone suggested useful alternatives.     

Premedication with low dose oral clonidine does not enhance postoperative analgesia of intrathecal morphine

PURPOSE: A number of studies have demonstrated that perioperative intravenous, intrathecal, and epidural clonidine enhance postoperative analgesia. The results of previous studies on the usefulness of oral clonidine on enhancing postoperative analgesia have been mixed. The effect of a single preoperative dose of oral clonidine on postoperative analgesia was assessed in this study. METHODS: Forty-three male patients undergoing radical prostectomy were randomized to receive either 3 microg x kg(-1) clonidine or placebo po 90 min prior to surgery. All patients received isobaric 15 mg bupivacaine and intrathecal 5 microg x kg morphine, followed by a standardized general anesthetic, consisting of thiopental, sufentanil, rocuronium, isoflurane, oxygen and air. Postoperatively, PCA morphine use and visual analogue pain scores were recorded for the first 48 hr. The incidence and severity of side effects such as sedation, nausea, and pruritus were assessed, as well as patient satisfaction. Usage of PCA morphine was compared. RESULTS: There was no difference in total morphine requirements between the placebo and oral clonidine groups, nor in six hourly morphine usage (P = 0.96). Second, there was no difference in visual analogue pain scores, or the incidence of side effects. Patient satisfaction was high in both groups and again, no differences between groups was noted. CONCLUSIONS: Oral clonidine 3 microg x kg(-1) as a premedication does not prolong the effect of intrathecal morphine: there was no difference in PCA morphine requirements (P = 0.96). Clonidine did not effect the incidence or severity of nausea or pruritus.     

Epidural analgesia compared with intravenous morphine patient-controlled analgesia: postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction

BACKGROUND AND OBJECTIVES: Epidural analgesia has been shown to provide superior pain control compared with intravenous (IV) opioids after major surgical procedures. In this study, we compared the effect of epidural analgesia and IV morphine patient-controlled analgesia (PCA) on pain relief, duration of hospitalization, oral nutrition, ambulation, and side effects in patients undergoing a major surgical procedure (i.e., unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction). METHODS: Eighteen patients were prospectively randomized to receive either epidural analgesia or PCA during the postoperative period. The intensity of pain was assessed daily by a 100-mm visual analog scale. The total length of hospital stay, time to ambulation, and time to oral nutrition were recorded. RESULTS: The epidural group had significantly lower pain scores at 3 evaluation times through postoperative day number 4 (P < .05). The total length of hospitalization for the epidural group (median, 101 hours) was significantly less than the PCA group (median, 126 hours; P = .0498). The time to first ambulation, time to first bowel sounds, time to tolerating oral nutrition, incidence of nausea/vomiting or pruritus, and time to first flatus were not statistically different between the groups. CONCLUSIONS: These results show that epidural analgesia compared with PCA offered improved pain control after breast reconstruction with immediate transverse rectus abdominis musculocutaneous flap reconstruction. It also resulted in a 25-hour reduction in time of hospitalization.     

Double epidural catheter with ropivacaine versus intravenous morphine: a comparison for postoperative analgesia after scoliosis correction surgery

BACKGROUND: Major spine surgery with a dorsal or ventrodorsal approach causes severe postoperative pain. The use of continuous epidural analgesia through one or two epidural catheters placed intraoperatively by the surgeon has been shown to provide efficient postoperative pain control. In this prospective unblinded study, the authors compared the efficacy of continuous intravenous morphine with a continuous double epidural catheter technique with ropivacaine after scoliosis correction. METHODS: Thirty patients with American Society of Anesthesiology physical status I-III were prospectively randomized to either the morphine group or the epidural group. At the end of surgery, patients in the epidural group received two epidural catheters placed by the surgeon, one directed cephalad and one caudally. Correct placement was checked radiographically. Postoperative analgesia until the first postoperative morning was performed with remifentanil target-control infusion for all patients. From that time remifentanil was stopped and continuous intravenous analgesia with morphine or double epidural analgesia with ropivacaine 0.3% was initiated (T0 = beginning of study). Pain at rest and pain in motion (using a visual analog scale from 0-100), the amount of rescue analgesics, sensory level, motor blockade, postoperative nausea and vomiting, and pruritus were assessed every 6 h and bowel function was assessed every 12 h until T72 (end of study). Two days later, patient satisfaction was assessed. RESULTS: Pain scores at rest were significantly decreased in the epidural group at all time points except at T12, T60, and T72. Pain scores in motion were significantly decreased in the epidural group at T24, T48, and T72. Bowel activity was significantly better in the epidural group at T24, T36, T48, and T60. Postoperative nausea and vomiting and pruritus occurred significantly less frequently in the epidural group. No complications related to the epidural catheter occurred. CONCLUSIONS: Both methods provide efficient postoperative analgesia. However, double epidural catheter technique provides better postoperative analgesia, earlier recovery of bowel function, fewer side effects, and a higher patient satisfaction.     

Comparison of epidural and patient-controlled intravenous morphine following joint replacement surgery

The authors conducted a randomized, prospective study comparing epidural morphine with patient-controlled intravenous (iv) morphine in 30 patients recovering from total hip or total knee arthroplasty. Six, 18, and 24 hr postoperatively, patients used a 10 cm visual-analogue scale to indicate both their current degree of discomfort and the maximum discomfort they had experienced since the previous evaluation. Pain at the time of evaluation did not differ between patients receiving epidural (2.6 +/- 0.4 cm, mean +/- SEM) and patient-controlled iv morphine (3.4 +/- 0.3 cm). However, patients who received epidural morphine recalled less pain during the period preceding evaluation (4.2 +/- 0.5 cm) than did those receiving patient-controlled analgesia (5.5 +/- 0.4 cm, P less than 0.05). Patients receiving epidural morphine were more likely to require treatment for pruritus (4 of 15) than patients who received patient-controlled iv morphine (none of 15, P less than 0.05). Minimum respiratory rates were lower in patients receiving epidural morphine (15.0 +/- 0.3) than in those receiving patient-controlled analgesia (16.5 +/- 0.4, P less than 0.05), but no patients required treatment for respiratory depression. The authors conclude that epidural morphine may provide more consistent analgesia following joint replacement surgery than patient-controlled morphine; however, there is a higher incidence of side-effects with the epidural technique.     

Decreased postpartum use of oral pain medication after a single dose of epidural morphine

BACKGROUND: Pain after vaginal delivery may result from episiotomy, perineal laceration, or uterine involution. Many women have indwelling epidural catheters in place at delivery. We hypothesized that a small dose of epidural morphine would be an effective strategy for postpartum analgesia. METHODS: Eighty-one healthy parturients receiving epidural analgesia for labor were enrolled. Patients were randomized in double-blind fashion to 1 of 3 groups: all groups received a 4-mL volume of epidural solution consisting of saline (group 1, control), 1 mg (group 2), or 2 mg morphine (group 3) after vaginal delivery. During the first 24 hours postpartum, patients were evaluated for the amount of oral pain medication requested; visual analog scale scores for pain at rest and with movement; satisfaction with postpartum pain treatment; and opioid side effects including nausea, pruritus, urinary retention, and respiratory depression. RESULTS: Patients who received 2 mg of epidural morphine used an average of 0.7 (0-1, interquartile range) opioid-containing pain pills (acetaminophen with codeine or oxycodone) compared with 1.2 (0-2) in the 1-mg group and 1.9 (0-3) in the control group ( P = .07). There was a statistically significant difference in oral drug usage between those who received epidural morphine and those who did not ( P < .03). There were no differences in side effects except that at 12 hours postpartum there was an increase in Foley catheterization in the 1-mg morphine group ( P = .007). CONCLUSIONS: These results suggest that epidural morphine decreases the need for oral pain medication in the first 24 hours postpartum. No significant dose-dependent side effects were found.     

Thoracic epidural clonidine and morphine for postoperative pain relief

This study was undertaken to evaluate the potentiation of the postoperative analgesic effect of thoracic epidural morphine by coadministration of thoracic epidural clonidine in a randomized double-blinded design. Twenty patients underwent radical gastrectomy under combined general anaesthesia (enflurane and nitrous oxide/oxygen) and epidural anaesthesia with local anaesthetics. They received a thoracic epidural bolus injection of either 0.05 mg · kg^?1 morphine plus 3 μg · kg^?1 clonidine (M+C group; n =10) or 0.05 mg · kg^?1 morphine alone, (M group; n = 10) immediately before completion of surgery. All patients received iv morphine via patient-controlled analgesia (PCA) equipment for 24 hr postoperative period, and the PCA iv consumption of morphine was the primary variable of efficacy of the analgesic regimen. In addition, data analyses included mean arterial blood pressure, heart rate, respiratory rate, arterial blood gas measurement, sedation score, and visual analogue pain scale score (VAS). The cumulative number of iv morphine injections via PCA was less in the M+C group than in the M group at each hour for 24 hr postoperative period (P < 0.05), while the numbers of PCA morphine injections per hour beyond nine hours after surgery were higher in the M group than in the M+C group (P < 0.05). Sedation score was higher, and VAS and mean blood pressure were lower in the M+C group only at one hour after surgery compared with the M group. We conclude that the combined single thoracic epidural administration of morphine plus clonidine produces a more potent and longer lasting analgesia than does morphine alone.     

Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine

STUDY OBJECTIVE: To evaluate the quality of analgesia and the severity of side effects of intrathecal morphine administered for a dose range of 0.0 to 0.4 mg for postcesarean analgesia with low-dose bupivacaine. DESIGN: Double-blind, randomized study. SETTING: University hospital. PATIENTS: 100 ASA physical status I and II term parturients undergoing cesarean delivery with spinal anesthesia in the operating room. INTERVENTIONS: Patients were randomized to one of 5 groups to receive 0.0, 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine in addition to low-dose (7.5 mg) heavy bupivacaine. Each patient received intravenous (IV) patient-controlled analgesia (PCA) with morphine after the operation. MEASUREMENTS: 24-hour IV PCA morphine use and visual analog scores for pain were recorded. The severity score (4-point scale) of nausea, vomiting, and pruritus were assessed intraoperatively and at 4-hour intervals during the first 24 hours postoperatively. MAIN RESULTS: PCA morphine use was higher in the control group (0.0 mg) than in groups receiving 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine. There was no difference in IV PCA morphine use between the 0.1 and 0.4-mg groups, despite a 4-fold increase in intrathecal morphine dose. There was no difference between groups in nausea and vomiting, but pruritus increased in direct proportion to the dose of intrathecal morphine (linear regression, P = 0.0001). CONCLUSIONS: The dose of 0.1 mg intrathecal morphine produces analgesia comparable with doses as high as 0.4 mg, with significantly less pruritus when combined with low-dose bupivacaine.     

Patient-controlled epidural analgesia with morphine or morphine plus ketamine for post-operative pain relief

Sixty patients were randomly assigned to two equal groups. Group I received epidural morphine 1 mg after surgery and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg h-1, 0.2 mg per bolus. Group II received an epidural loading dose of morphine 1 mg plus ketamine 5 mg and used a patient-controlled analgesia device programmed to deliver morphine 0. 2 mg+ketamine 0.5 mg h-1, morphine 0.2 mg+ketamine 0.5 mg per bolus with a lockout time of 10 min. The mean morphine consumption was 8. 6+/-0.7 mg for group I and 6.2+/-0.2 mg for group II. Although group II utilized significantly less morphine (P < 0.05), pain relief was significantly better in group II than in group I (P < 0.05) in the first 3 h. Vomiting occurred more frequently in group I (26%) than in group II (13%). The frequency and severity of pruritus and level of sedation were similar in the two groups. These findings suggest that patient-controlled epidural analgesia with morphine plus ketamine may provide effective analgesia with a lesser dose of morphine and fewer subsequent side effects, compared with patient-controlled epidural analgesia with morphine alone after lower abdominal surgery.     

Continuous epidural infusion of morphine for treatment of pain after thoracic surgery: a new technique

We evaluated postoperative pain relief and the incidence of side effects of three methods of thoracic epidural analgesia. Ninety patients, divided into three equal groups, received postoperative analgesia after thoracic surgery either as intermittent epidural injections of bupivacaine (25 mg/5 ml, 0.5% solution) as needed, or, intermittent epidural injections of morphine (5 mg/5 ml of normal saline, 0.1% solution) as needed, or continuous epidural infusion of morphine (0.1 mg, in 1 ml of normal saline) per hour supplemented with intravenous morphine (2 mg) upon request. Pain relief was evaluated by each patient on a pain scale visual analogue and by pain relief questionnaire for a period of 72 hr. Postoperative pain relief was achieved equally with these three methods of epidural analgesia in all patients with no significant difference between groups. Intermittent epidural injection of bupivacaine relieved pain for 4.9 +/- 1.9 (SD) hr/injection and was associated with urinary retention in all patients, with numbness and weakness of the hands in 12 patients, and with severe hypotension in 7 patients. Intermittent epidural injection of morphine relieved pain for 5.8 +/- 2.3 hr/injection and was associated with urinary retention in all patients, with pruritus in 12 patients, and with central narcosis and respiratory depression in 8 patients. Continuous epidural infusion of morphine with occasional intravenous morphine (2 mg) supplementation also effectively relieved postoperative pain and was associated with minimal systemic side effects. One patient complained of pruritus, and two patients developed urinary retention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Morphine and hydromorphone epidural analgesia. A prospective, randomized comparison.

Because evidence from uncontrolled, unblinded studies suggested fewer side effects from epidural hydromorphone than from epidural morphine, we employed a randomized, blinded study design to compare the side effects of lumbar epidural morphine and hydromorphone in 55 adult, non-obstetric patients undergoing major surgical procedures. A bolus dose of epidural study drug was given at least 1 h prior to the conclusion of surgery, followed by a continuous infusion of the same drug for two postoperative days. Infusions were titrated to patient comfort. Visual analog scale (VAS) pain scores, VAS sedation scores, and subjective ratings of nausea and pruritus were assessed twice daily. The two treatments provided equivalent analgesia. Sedation scores and prevalence of nausea did not differ significantly between groups. Prevalence of pruritus, however, differed significantly on postoperative day 1, with moderate to severe pruritus reported by 44.4% of patients in the morphine group versus 11.5% in the hydromorphone group (P < .01). On post-operative day 2, reports of pruritus by patients receiving morphine remained higher than those among the hydromorphone-treated subjects, although this difference was no longer statistically significant (32% vs. 16.7%, P = .18). We conclude that lumbar epidural morphine and hydromorphone afford comparable analgesia, but the occurrence of moderate to severe pruritus on the first postoperative day is reduced by the use of hydromorphone.     

Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia

Postoperative analgesia provided by epidurally administered sufentanil and/or morphine was evaluated in 45 patients recovering from major gynecologic surgery. At the first complaint of pain in the Postanesthesia Care Unit, patients received a single epidural bolus of 30 micrograms sufentanil (group A), 5 mg morphine (group B), or 30 micrograms sufentanil plus 3 mg morphine (group C) in a randomized blinded fashion. Analgesic efficacy was assessed throughout the 24-h study period with 10-cm visual analog scales. The need for additional postoperative analgesia (patient-controlled analgesia, 1 mg of morphine every 6 min as necessary) and the incidence of adverse effects were also assessed. Patients receiving sufentanil (groups A and C) had significantly faster onset of analgesia than did patients given morphine alone (group B, P less than 0.05). Group B subjects experienced the longest duration of analgesia (B vs A and C, P less than 0.05) and required significantly less patient-controlled analgesia (morphine) than patients in group A (P less than 0.05). No patient developed clinically significant respiratory depression or excessive sedation, and there were no intergroup differences in incidence of pruritus or nausea (P value not significant). The data indicate that a mixture of sufentanil and morphine provides either a more rapid onset of epidural analgesia or reduced patient-controlled analgesia narcotic requirement than respective doses of each agent administered alone.     

Epidural buprenorphine for postoperative analgesia. A controlled comparison with epidural morphine.

In a double-blind controlled study, epidural buprenorphine 0.3 mg was compared with 4 mg of epidural morphine for postoperative pain relief the first 24 hours after major orthopaedic surgery. The degree of analgesia was equal and satisfactory in both groups. Duration of action was 620 minutes with buprenorphine and 580 minutes with morphine, which was not significantly different. The only serious side effects were recorded in the morphine group, with two patients complaining of pruritus and five of urinary retention. In conclusion, epidural buprenorphine did not offer any advantages in preference to morphine for postoperative pain relief following orthopaedic surgery.     

Continuous epidural infusion of ropivacaine for postoperative analgesia after major abdominal surgery: comparative study with i.v. PCA morphine

We have compared the quality of three regimens of postoperative analgesia (continuous epidural administration of ropivacaine (Ropi. group), epidural ropivacaine and patient-controlled analgesia (PCA) with i.v. morphine (Ropi. + PCA group) and PCA morphine alone (PCA group)) during the first postoperative 24 h in a multicentre, randomized, prospective study. Postoperative analgesia was studied in 130 patients after major abdominal surgery performed under general anaesthesia. The ropivacaine groups received 20 ml of epidural bolus ropivacaine 2 mg ml-1 via the epidural route at the end of surgery, followed by continuous infusion of 10 ml h-1 for 24 h. The Ropi. + PCA group also had access to i.v. PCA morphine 1 mg, with a 5-min lockout. The PCA group received morphine as the sole postoperative pain treatment. The two ropivacaine groups had lower pain scores (P < 0.01) than the PCA group. Morphine consumption was higher in the PCA group (P < 0.05) than in the two ropivacaine groups. The quality of pain relief was rated as good or excellent in 79-85% of patients in the three groups. The percentage of patients without motor block increased between 4 and 24 h from 61% to 89% in the Ropi. group, and from 51% to 71% in the Ropi. + PCA group.