Postoperative analgesia with minidose intrathecal morphine for bipolar hip prosthesis in extremely elderly patients

Purpose

It is known that an optimal dose of intrathecal morphine for analgesia after total hip arthroplasty in older patients is 0.1 mg. On the other hand, minidose intrathecal morphine (0.05 mg) is useful for analgesia after the transurethral resection of the prostate in elderly patients. We evaluated the postoperative analgesic effect of minidose intrathecal morphine after bipolar hip prosthesis in seniors (age 85 years or more) undergoing spinal anesthesia.

Methods

Twenty seniors undergoing bipolar hip prosthesis under spinal anesthesia were randomly allocated to one of two groups. Group A (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, and group B (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, plus morphine, 0.05 mg. Pain, nausea, and itching were evaluated using a numerical rating scale, ranging from 0 to 10, at 0, 4, 8, 12, and 24 h after the operation.

Results

The values on the numerical rating scale for pain in group B were significantly lower than those in group A at 4, 8, and 12 h after the operation. There were no significant differences between the groups in the values on the numerical rating scale for nausea or itching throughout the time course of the study. No patient in either group showed hypoxemia or respiratory depression throughout the time course.

Conclusion

The results show that minidose intrathecal morphine provides a good analgesic effect without side effects, and it would be an effective and safe procedure for bipolar hip prosthesis in seniors.     

Efficacy of intrathecal morphine with epidural ropivacaine infusion for postcesarean analgesia

Study ObjectiveTo evaluate the analgesia following cesarean delivery and the frequency of side effects of intrathecal morphine when combined with a continuous epidural infusion.DesignRandomized, double-blinded study.SettingUniversity hospital.Patients76 ASA physical status I and II term parturients undergoing cesarean delivery with combined spinal-epidural anesthesia.InterventionsPatients were randomized to one of three groups to receive 0, 50, or 100 μg (Group 0, Group 50, and Group 100, respectively) intrathecal morphine in addition to 8 mg of hyperbaric bupivacaine. Each patient received a continuous epidural infusion of 0.2% ropivacaine at the rate of 6 mL/hr.Measurements24-hour visual analog pain scores (VAPS), number of patients who requested rescue analgesics, frequency of requests for rescue analgesics per patient, and time interval before the first request for rescue analgesics were recorded. Frequency of pruritus and postoperative nausea and vomiting (PONV) were also recorded.Main ResultsGroup 50 and Group 100 patients exhibited lower VAPS and longer time intervals before the first request for rescue analgesics, and they requested rescue analgesics less frequently than Group 0 patients. The frequency of pruritus was significantly higher in Group 100 than Group 0. The groups did not differ with regard to PONV.Conclusions50 μg and 100 μg of intrathecal morphine improve analgesia when combined with a continuous epidural infusion of 0.2% ropivacaine (6 mL/hr) after cesarean delivery. 50 μg of intrathecal morphine is associated with a low frequency of side effects such as pruritus and PONV.     

Long-term intrathecal infusion of morphine in the home care of patients with advanced cancer

Background: Fear of infections and other complications has made many clinicians avoid intrathecal application of morphine in chronic cancer pain. However, recent comparative studies show that, in long-term treatment, intrathecal morphine administration may give a more satisfactory pain relief with lower doses of morphine and fewer side-effects than epidural administration. In Montpellier Cancer Institute, first cancer pain patients received long-term intrathecal morphine as early as in 1979, and since then more than 400 patients have been treated.
Methods: In 1991–1994, 50 patients having refractory cancer pain were treated with a continuous intrathecal infusion of morphine using an external pump with patient-controlled boluses. In this retrospective study, the outcome of these 5602 days of morphine therapy will be analysed. The treatment consisted of a lateral puncture technique, strictly aseptic conditions during catheter insertion and changes of pump reservoirs, and effective prevention of side-effects.
Results: The average duration of intrathecal infusion was 142 (7–584) days. The mean starting dose, 2.5 (0.4–8.3) mg/day, increased to a mean final dose of 9.2 (1–94) mg/day, the average dose being 5.4 (1–23) mg/day. During the treatment period, no clinically detectable infections and no respiratory depression occurred. Leakage of cerebrospinal fluid followed by post-spinal headache occurred in only 6 patients who received a temporary external catheter: the lateral lumbar puncture technique seemed to protect from this complication in long-term treatment. The patients stayed at home, coming to agreed control visits only at 4–6-week intervals, using a telephone-telefax service for emergencies.
Conclusions: Long-term intrathecal morphine infusion seems to provide satisfactory analgesia, few side-effects and a high degree of patient autonomy.     

Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain

Purpose

Ketamine has been administered epidurally and intrathecally for operative and post-operative pain control. Animal studies showed potentiation of analgesia induced by ketamine and morphine. We hypothesized that intrathecal ketamine would potentiate the effects of intrathecal morphine in the treatment of cancer pain.

Methods

A double blind, cross over study was designed to evaluate the effect of ketamine on spinal morphine analgesia in terminal cancer pain patients. A two-phase protocol was used; phase M, intrathecal morphine alone twice daily; phase M+K, co-administration of ketamine (1.0 mg) with morphine intrathecally twice daily. The dose of morphine was titrated upwards until acceptable pain relief was achieved, defined by numeric rating scales (0–10) ≤ 3, and the rescue dose of morphine was less than 5 mg after each intrathecal administration for two days. The dose of intrathecal morphine was defined as the effective dose.

Results

The effective dose of intrathecal morphine in phase M of 0.38 ± 0.04 mg · day^?1 was higher than that in phase M+K (0.17 ± 0.02 mg · day^?1) (P < 0.05). The average pain scales were 7.95 ± 0.25 before intrathecal drug administration. Pain scales were decreased to 2.2 ± 0.17 (P < 0.05) in phase M and 1.95 ± 0.20 (P < 0.05) in phase M+K after the effective dose of morphine had been reached. No serious side effects were observed in this study.

Conclusion

The present study demonstrates that ketamine enhances the analgesic effect of morphine, thus reducing the dose of intrathecal morphine.     

An audit of intrathecal morphine analgesia for non-obstetric postsurgical patients in an adult tertiary hospital

We conducted a retrospective audit of adult non-obstetric patients who had received a single dose of intrathecal morphine for postoperative analgesia. These patients were predominantly admitted to a regular postsurgical ward with strict hourly nursing observations, treatment protocols in place and supervision by an Acute Pain Service for the first 24 hours after intrathecal morphine administration. A total of 409 cases were examined for sedation score, incidence of respiratory depression and other side-effects, admission to the high dependency or intensive care unit and opioid-tolerance. Respiratory depression was defined as requiring treatment with naloxone (implying a sedation score of 3 irrespective of respiratory rate), or a sedation score of 2 with a respiratory rate less than six breaths per minute. The patients were predominantly elderly (57.2% were over the age of 70 years) and 84.8% had undergone vascular surgery. Of the total of 409 cases, only one case of respiratory depression was observed. A total of 77 patients were admitted to high dependency or intensive care unit for various reasons including management of postsurgical complications and patient co-morbidities. Our findings suggest that elderly patients who receive intrathecal morphine analgesia can be safely managed in a regular postsurgical ward.     

The use of ondansetron to treat pruritus associated with intrathecal morphine in two paediatric patients

Intrathecal morphine is an effective technique for providing postoperative analgesia after major surgical procedures in children. Pruritus is a common side effect associated with intrathecal morphine. We report two patients who experienced significant pruritus associated with intrathecal morphine administration and were successfully treated with ondansetron. Ondansetron appears to be a beneficial and safe method of relieving pruritus associated with intrathecal morphine.     

A comparison of intrathecal morphine/fentanyl and patient-controlled analgesia with patient-controlled analgesia alone for analgesia after liver resection

Continuous epidural anesthesia and analgesia may be considered in liver resection, but is often avoided because of the potential development of coagulopathies and the risk of epidural hematoma. In this prospective, randomized, double-blind study we compared postoperative morphine consumption via patient-controlled analgesia after liver surgery between two groups of patients: patients receiving a preoperative dose of intrathecal morphine (0.5 mg) and fentanyl (15 microg) (treatment group) and patients receiving a sham intrathecal injection (placebo group). Forty patients scheduled for major liver resection (> or = two segments) were enrolled. The primary outcome measure was patient-controlled analgesia morphine consumption. Secondary outcomes were evaluation of pain at rest and with movement, scored on a visual analog scale with assessment of sedation, nausea, pruritus, and respiratory frequency. Outcome measures were recorded at 6, 12, 18, 24, and 48 h postspinal anesthesia or simulation. Patients in the placebo group consumed approximately three times more morphine during each time interval than patients in the treatment group (at 48 h: 124 +/- 30 vs 47 +/- 21 mg, P < 0.0001). Pain evaluation on the visual analog scale was lower for the first 18 h in the treatment group. There was no difference in the incidence of side effects in both groups. Intrathecal morphine (0.5 mg) and fentanyl (15 microg) given before liver surgery significantly decreased postoperative morphine consumption compared to placebo without any increase in side effects.     

Naloxone lowers cerebrospinal fluid levels of excitatory amino acids after thoracoabdominal aortic surgery

OBJECTIVE: Although naloxone has been used to prevent ischemic spinal cord injury (SCI), its effect on excitatory amino acids (EAAs) has not been understood. We investigated the clinical significance of naloxone by measuring EAAs in the cerebrospinal fluid (CSF) in patients undergoing thoracoabdominal aortic surgery. METHODS AND SUBJECTS: Twenty-seven patients (15 men and 12 women; mean age, 66 +/- 12 years) undergoing prosthetic replacement of the thoracoabdominal aorta (n = 19) or the descending thoracic aorta (n = 8) from April 1997 to June 2003 under distal perfusion and mild hypothermia were enrolled in this cohort study with historical controls. Their etiology was 7 dissections and 20 nondissections. In 16 patients (naloxone group), intravenous infusion of naloxone (1 microg/kg/h) was continued until the patients became alert. In the remaining 11 patients (control group) naloxone was not given. CSF drainage was used in all patients. CSF levels of EAAs, glutamate, aspartate, and glycine were measured at 6 points in time until 72 hours postoperatively, using a high-performance liquid chromatography method. RESULTS: In 5 patients with SCI (2 patients in control group, 3 in naloxone group), CSF levels of glutamate and glycine continued to increase even at 72 hours postoperatively, and were significantly more elevated than those in patients without SCI ( P < .0001, glutamate; P = .0006, glycine). Postoperative maximum levels of CSF glutamate and glycine were also significantly higher in patients with postoperative SCI than in patients without SCI (glutamate: 215.3% +/- 158.6% vs 32.9% +/- 37.3% increase from baseline, P < .0001; glycine: 309.1% +/- 218.2% vs 89.2% +/- 103.1% increase from baseline, P = .0036). CSF levels of glutamate and aspartate in naloxone group were significantly lower than those in control group ( P = .0161, glutamate; P < .0001, aspartate). Postoperative maximum level of CSF aspartate was also significantly lower in the naloxone group than in the control group (8.3% +/- 75.5% vs 119.7% +/- 120.6% increase from baseline, P = .0077). In multivariate logistic regression analysis, postoperative maximum CSF glutamate >100% from baseline ( P < .001) and postoperative maximum level of CSF glycine ( P = .005)were identified as the independent risk factors for SCI. Both SCI ( P < .001) and postoperative maximum level of CSF glycine ( P = .005) were the independent predictors for postoperative maximum level of CSF glutamate >100% from baseline. CONCLUSIONS: CSF levels of EAAs are elevated in patients with SCI. CSF glutamate is the strongest independent predictor of SCI. Naloxone is effective in lowering CSF levels of EAAs.     

The effects of naloxone associated with the intrathecal use of morphine in labor

The efficacy of naloxone in reducing the incidence of side effects after intrathecal injection of morphine and the effects of maternal naloxone administration on the condition of the newborn were evaluated in 40 patients. Patients in labor were given a 1-mg intrathecal injection of morphine and, 1 hr later, either a 0.4-mg bolus of naloxone, followed by a 0.4-0.6 mg/hr intravenous infusion of naloxone, or an intravenous bolus of saline, followed by an intravenous infusion of saline. Intrathecal morphine provided at least 50% pain relief in 78% of patients given naloxone, and in 82% given saline. Intravenous naloxone significantly decreased the incidence of pruritus during labor and delivery. There was no significant decrease in the incidence of nausea, vomiting, somnolence, dizziness, or urinary retention in patients given naloxone. Despite placental transfer of naloxone, neonatal outcome was not adversely affected. For both groups, maternal beta-endorphin levels decreased significantly with the onset of analgesia and returned to control levels at delivery. We conclude that intravenous infusion of naloxone reduced pruritus after intrathecal injection of 1 mg of morphine for labor pain without lessening analgesia or adversely affecting maternal or neonatal status.     

Ultrasound-guided bilateral transversus abdominis plane blocks in conjunction with intrathecal morphine for postcesarean analgesia

Study ObjectiveTo determine whether transversus abdominis plane (TAP) blocks administered in conjunction with intrathecal morphine provided superior analgesia to intrathecal morphine alone.DesignRandomized, double-blind, placebo-controlled study.SettingOperating room of a university hospital.Patients51 women undergoing elective Cesarean delivery with a combined spinal-epidural technique that included intrathecal morphine.InterventionsSubjects were randomized to receive a bilateral TAP block with 0.5% ropivacaine or 0.9% saline. Postoperative analgesics were administered on request and selected based on pain severity.MeasurementsPatients were evaluated at 2, 24, and 48 hours after the TAP blocks were performed. Verbal rating scale (VRS) pain scores at rest, with movement, and for colicky pain were recorded, as was analgesic consumption. Patients rated the severity of opioid side effects and their satisfaction with the procedure and analgesia.Main Results51 subjects received TAP blocks with ropivacaine (n = 26) or saline (n = 25). At two hours, the ropivacaine group reported less pain at rest and with movement (0.5 and 1.9 vs 2.8 and 4.9 in the saline group [VRS scale 0 – 10]; P < 0.001) and had no requests for analgesics; there were several requests for analgesia in the saline group. At 24 hours, there was no difference in pain scores or analgesic consumption. At 48 hours, the ropivacaine group received more analgesics for moderate pain (P = 0.04) and the saline group received more analgesics for severe pain (P = 0.01).ConclusionsTransversus abdominis plane blocks in conjunction with intrathecal morphine provided superior early postcesarean analgesia to intrathecal morphine alone. By 24 hours there was no difference in pain scores or analgesic consumption.     

Temporary motor and sensory paralysis associated with intrathecal administration of morphine

We are reporting a temporary, totally reversed motor and sensory paralysis subsequent to the intrathecal administration of 1.6 mg of morphine sulfate. This may represent an event which is not based on medication-induced myelopathy but on cardiovascular changes occurring as a result of pain relief.     

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.     

Intestinal metaplasia in patients with columnar lined esophagus is associated with high levels of duodenogastroesophageal reflux

OBJECTIVE: To evaluate the rate of duodenogastroesophageal reflux in patients with columnar lined esophagus compared with patients with gastroesophageal reflux disease without columnar lined esophagus, and to analyze whether it is related to the presence of specialized columnar epithelium in the metaplastic segment. SUMMARY BACKGROUND DATA: The carcinomatous degeneration of columnar lined esophagus originates from a specialized columnar epithelium. The appearance of this metaplastic phenomenon is clearly related to severe prolonged gastroesophageal reflux, but only some of these patients finally develop columnar lined esophagus. For this reason other factors have been suggested, particularly the role played by the reflux of duodenal contents into the esophagus. METHODS: The authors studied 15 healthy volunteers (control group), 10 patients with reflux symptoms but without endoscopic lesions, 20 patients with reflux esophagitis without columnar lined esophagus, and 35 patients with columnar lined esophagus (complicated with ulcers or stenosis in 8 cases), of whom 22 had intestinal metaplasia. To assess the reflux of duodenal contents into the esophagus, all the patients underwent Bilitec 2000 and 24-hour esophageal pH monitoring. RESULTS: The presence of bilirubin in the material refluxed into the esophagus was greater in the patients with columnar lined esophagus than in the rest of the groups. Likewise, duodenogastroesophageal reflux was greater in the columnar lined esophagus patients who had intestinal metaplasia. CONCLUSIONS: Duodenogastroesophageal reflux may play a major role in the development of columnar lined esophagus, especially in patients with intestinal metaplasia.     

Neurohistopathological findings after continuous intrathecal administration of morphine or a morphine/ bupivacaine mixture in cancer pain patients

Background: As the number of terminal cancer patients receiving continuous intrathecalinfusion of opioids and local anesthetics for relief of pain increases, we decided to investigate the post-mortem findings of the spinal cord, meninges and nerve roots of patients after continuous intrathecal administration of morphine and combined with bupivacaine.
Methods: Neurohistopathological findings were obtained from 10 cancer patients [2 men and 8 women, 29–69 (median 52) yrs old] and 4 controls [4 men, 46–75 (median 64) yrs old]. The cancer patients had been treated for a mean of 98 (range 8–452) d with morphine/NaCl 0.9% or morphine/bupivacaine, administered through a polyamide lumbar catheter. Concomitant radiation therapy and chemotherapeutic drug had been given to 5 and 6 patients, respectively. Cumulative doses of morphine ranged from 22 to 3895 mg, those of bupivacaine from 0 to 3250 mg and of sodium metabisulfite (antioxidant) from 0.6 to 97.4 mg.
Results: No macroscopic abnormalities of the catheter tract, dura, leptomeninges, nerve roots or spinal cord were found. Microscopically, focal foreign body giant cells were seenin 2 cases in the area of the catheter pathway both without any sign of inflammation. In one case treated for 103 d, an intrathecal reaction was found. This consisted of small aggregates of lymphocytes predominantly in the leptomeninges and focally in the cord parenchyma. No abnormalities were found in the other cases when using hematoxylin-eosin and Kluver or Bodian stained specimens, indicating neither myelin nor axonal damage. Microglial reactions were similar in both cancer patients and controls.
Conclusion: The discrete and limited neurohistopathological findings in both catheter patients and controls suggest that intrathecal infusion of morphine and bupivacaine via a polyamide catheter is devoid of significant neurotoxic effects in cancer patients.