Comparison of high- and low-dose intrathecal morphine for spinal fusion in children

Background: The purpose of this prospective study was to assess the blood-sparingeffect, the quality of analgesia, and the incidence of side-effectsof a low-dose regime of intrathecal opioids (ITO) when comparedwith those of a high-dose regime in scoliosis surgery in children. Methods: Forty-six children were randomly included into one of the threegroups to receive morphine 5 µg kg^–1 plus sufentanil1 µg kg^–1 [low-dose intrathecal opioid (LITO)],morphine 15 µg kg^–1 plus sufentanil 1 µg kg^–1[high-dose intrathecal opioid (HITO)] intrathecally, or no intrathecalopioid. Postoperative analgesia was provided by i.v. opioids.Intraoperative blood loss, postoperative quality of analgesia,opioid requirements, and the incidence of side-effects wererecorded for 3 days. Results: Intraoperative blood loss was significantly reduced by ITOs[LITO: 41.4 (SD 18.8) ml kg^–1; HITO: 37.5 (6.9) ml kg^–1;control: 76.9 (15.3) ml kg^–1, P<0.001], with no differencebetween the two intrathecal opioid groups. Mean pain scoreson the day of surgery were lower in both intrathecal opioidgroups (LITO: 2.2 and HITO: 2.1) when compared with the controlgroup (4.1, P<0.03) and opioid consumption was significantlydecreased [LITO: 304.3 (65.0) µg kg^–1; HITO: 224.1(51.8) µg kg^–1; control: 667.7 (89.5) µg kg^–1,P<0.002]. Side-effects of intrathecally administered opioidswere similarly frequent in all groups. Conclusions: Intrathecal administration of opioids significantly reducesblood loss and postoperative opioid demand, thereby showingside-effects comparable with the control group. These effectswere already seen with the low-dose regimen and high dose didnot further improve efficacy.     

Analgesic effect of low-dose intrathecal morphine and bupivacaine in laparoscopic cholecystectomy

We assessed the peri-operative analgesic efficiency of low-dose intrathecal morphine combined with a low dose of bupivacaine after elective laparoscopic cholecystectomy since postoperative pain in such procedures, although less than after a conventional open technique, may be significant, particularly during the first 12-24 h. After informed consent, 34 ASA I or II patients were randomly allocated to one of two groups to receive either a lumbar intrathecal injection of morphine (75 or 100 microg) combined with 5 mg of isobaric bupivacaine (spinal group) or a subcutaneous injection of a saline solution (control group). Intra-operatively, opioid requirements, blood pressure response and heart rate changes after insufflation were recorded. Postoperatively, morphine requirements, pain scores and opioid-related side-effects were assessed by a physician blinded to the randomisation. Intra-operative opioid requirements did not differ significantly between groups. Mean (SD) postoperative morphine requirements were significantly lower in the spinal group [13 (10) vs. 23 (10) mg; p = 0.04] as were postoperative pain scores (p < 0.001). Side-effects were of comparable incidence and severity between groups. Low-dose intrathecal morphine combined with low-dose bupivacaine provided effective postoperative analgesia for elective laparoscopic cholecystectomy.     

小剂量吗啡和曲马多关节内注射用于膝关节镜术后镇痛的临床比较

目的　观察小剂量吗啡、曲马多关节内注射用于膝关节镜手术后的镇痛效果。方法　腰麻下行膝关节镜手术的病人 6 0例 ,双盲随机分为关节内注射吗啡组 (M组 ,n =2 0 )、曲马多组 (T组 ,n =2 0 )和生理盐水对照组 (C组 ,n =2 0 )。M组在术后关节内注射小剂量吗啡 (1mg) ,T组则在术后关节内注射小剂量曲马多 (10mg) ,C组则关节内注射等体积的生理盐水。给药后 8和 2 4小时 ,在病人双足站立膝关节伸展状态下进行视觉模拟评分。结果　M组评分平均为 1 7± 1 0和 1 5±1 1,T组评分为 2 0± 1 1和 1 7± 1 2 ,C组为 3 6± 1 5和 2 4± 1 3,M组与T组评分显著低于C组 (P <0 0 5 )。M组与T组评分有显著差异 (P <0 0 5 )。结论　小剂量的吗啡和曲马多关节内注射可以有效缓解膝关节镜手术的术后疼痛 ,尤以吗啡为佳     

Antinociceptive effect of low-dose intrathecal neostigmine combined with intrathecal morphine following gynecologic surgery

BACKGROUND: The purpose of this study was to determine whether combination of 1-5 microg intrathecal neostigmine would enhance analgesia from a fixed intrathecal dose of morphine. METHODS: A total of 60 patients undergoing gynecologic surgery were randomized to one of five groups. Patients received 15 mg bupivacaine plus 2 ml of the test drug intrathecally (saline, 100 microg morphine, or 1-5 microg neostigmine). The control group received spinal saline as the test drug. The morphine group received spinal morphine as test drug. The morphine + 1 microg neostigmine group received spinal morphine and 1 microg neostigmine. The morphine + 2.5 microg neostigmine group received spinal morphine and 2.5 microg neostigmine. Finally, the morphine + 5 microg neostigmine group received spinal morphine and 5 microg neostigmine. RESULTS: The groups were demographically similar. The time to first rescue analgesic (minutes) was longer for all patients who received intrathecal morphine combined with 1-5 microg neostigmine (median, 6 h) compared with the control group (median, 3 h) (P < 0.02). The morphine group (P < 0.05) and the groups that received the combination of 100 microg intrathecal morphine combined with neostigmine (P < 0.005) required less rescue analgesics in 24 h compared with the control group. The incidence of perioperative adverse effects was similar among groups (P > 0.05). CONCLUSIONS: The addition of 1-5 microg spinal neostigmine to 100 microg morphine doubled the duration to first rescue analgesic in the population studied and decreased the analgesic consumption in 24 h, without increasing the incidence of adverse effects. The data suggest that low-dose spinal neostigmine may improve morphine analgesia.     

Intrathecal morphine for spinal fusion in children

Intrathecal morphine (0.025 mg/kg) was administered preoperatively to 20 children undergoing major surgery of the rachis, ie, either posterior (16 cases) or anterior (4 cases) spinal fusions. During the surgical procedure, hemodynamic control was easily maintained. Blood loss was slightly less than 50% of blood volume and the mean infusion rate of blood was 6.3 +/- 4.5 ml/kg/hour for the duration of surgery. The technique did not significantly interfere with wake-up tests, and memory of awakening was only observed in one case. The postoperative course was also positively affected. The children could be extubated within the 30 minutes following completion of surgery, and they could perform effective breathing exercises early on. High degree and long duration (36 to 72 hours) of pain relief were obtained in every case. No major adverse effect was observed. Thus, the administration of intrathecal morphine prior to spinal fusion appears to be safe, easy, and reliable. We think it should be recommended for major surgery of the rachis.     

大鼠脊髓株网膜下腔吗啡耐药时可乐定的镇痛效应

目的 研究大鼠脊髓部位吗啡耐药时可乐定的镇痛效应。方法 大鼠蛛网膜下腔埋管,以甩尾法测痛,建立大鼠蛛网膜下腔吗啡耐药动物模型。大鼠耐药后蛛网膜下腔分别注射吗啡和可乐定测痛。结果 蛛网膜下腔注吗啡１５ｕｇ,镇痛效应百分比（％ＭＰＥ）由耐药前的８２．４％下降到耐药后的１８．６％（Ｐ〈０．０１）;蛛网膜下腔注可乐定４０ｕｇ,％ＭＰＥ在耐药前为４６．５％,耐药后为４８．１％（Ｐ〉０．０５）。结论 脊髓部位产生吗啡耐药后,蛛网膜下腔注吗啡的镇痛作用显著减弱,但对可乐定的镇痛作用无明显影响。     

The advantages of intrathecal opioids for spinal fusion in children

Two groups of 40 homogeneous patients (ASA physical status (1–2)) with idiopathic scoliosis undergoing spinal fusion with CD instrumentation were studied prospectively. Group A (intrathecal) received a mixture of morphine and sufentanil administered intrathecally at the level of L3–L4 after the induction of anaesthesia. Group B (control) had inhalation and intravenous narcotic anaesthesia. The use of intrathecal opioids resulted in a significant reduction of blood pressure without the use of any hypotensive agents and produced prolonged postoperative analgesia. There was no adverse effect on somatosensory evoked potentials. The dose requirement for the anaesthetic agents was significantly reduced and the blood loss was 27% of their blood volume compared with 53% in the control group. No long or short term impairment of cerebral or spinal function was observed. The use of intrathecal opioids supplemented with other anaesthetic agents is an alternative method with multiple benefits for any major surgery such as spinal fusion.     

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.     

Analgesic effect of intra-articular morphine after arthroscopic knee surgery

Objectives: To assess the analgesic effect of intra-articular morphine. To establish the optimal dose of morphine as well as the best volume of solution to obtain an adequate analgesic effect. Patients and methods: Prospective, randomized, double blind study of 120 patients undergoing elective arthroscopic meniscectomy. Patients were randomly allocated to one of the following five groups: In group A1 (n=28) and B1 (n=20) patients received 1 and 5 mg of intra-articular morphine, respectively; in both groups morphine was diluted in 20 ml of saline. Another two groups, groups A2 (n=22) and B2 (n=26) received 1 and 5 mg of intra-articular morphine, respectively, that was diluted in 40 ml of saline. Finally, the control group, group C (n=26), received 20 ml of saline without morphine. The intensity of the pain was evaluated by visual analog scale of 1 to 10 points at 30 min and at 1, 2, 3, 6, 12 and 24 h after arthroscopic surgery. Needs for complementary analgesia and side effects related to morphine were also recorded. Results: With respect to the control group there was a significant improvement in pain scores in those patients that were treated with morphine (p<0.05). The best morphine dose to improve pain was 5 mg. The amount of analgesic therapy required by the patients within the first 24 h after surgery was lower in groups B1 and B2. No important side effects or complications of therapy were seen in any of the groups. Conclusions: Intra-articular morphine is effective in the postoperative period after arthroscopic meniscectomy. This method of administration provides a safe way to control the postoperative pain after arthroscopic ambulatory surgery of knee. In our experience a morphine dose of 5 mg disolved in 20 ml of saline constitutes the best therapeutic approach to reduce postoperative pain after arthroscopic meniscectomy.     

Postoperative effects of low-dose intrathecal morphine in coronary artery bypass surgery

BACKGROUND: Intrathecal morphine has been used in hopes of providing long-lasting postoperative analgesia in patients after cardiac surgery. The aim of this study was to evaluate the effects of 7 micro/kg intrathecal morphine administration in coronary bypass surgery in the postoperative period. METHODS: We conducted a prospective, randomized, blinded, and controlled study. Twenty-three patients, who underwent primary elective coronary bypass surgery, were randomly allocated to receive morphine 7 micro/kg intrathecally, before the induction of general anesthesia (Group M, n = 12) or no intrathecal injection (Group C, n = 11). Pain scores, determined by visual analogue scale (VAS), were recorded immediately after extubation upon admission to the intensive care unit (ICU), at the 2nd, 4th, 6th, and 18th hour after extubation. Pethidine was administered if the patient's VAS > or = 4 and consumption was recorded. Extubation time and ICU length of stay were also recorded. RESULTS: VAS scores were lower in the Group M at each measured time than the control group (p = 0.016, 0.023, 0.004, 0.0001, and 0.001, respectively). According to the VAS scores, pethidine requirement was lower in the Group M than the control (p = 0.001). Extubation time (3.58 +/- 1.57 vs. 4.86 +/- 1.38 hours, p = 0.045) and ICU length of stay (16.25 +/- 2.70 vs. 19.30 +/- 2.45 hours, p = 0.014) were also significantly shorter in the Group M than the control group. No significant complications were seen in this group of patients. CONCLUSIONS: Intrathecal morphine provided effective analgesia, earlier tracheal extubation and less ICU length stay after on-pump coronary bypass surgery. The influence on ICU length of stay requires further evaluations.     

Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia

Background. Dextromethorphan is an N-methyl-D-aspartic acidantagonist which can attenuate acute pain with few side-effects.In this prospective, randomized, double-blind study of dextromethorphanand intrathecal morphine, we investigated postoperative pain,pruritus, nausea and vomiting in women undergoing Caesareansection under spinal anaesthesia. Methods. Women were allocated randomly to one of six groups,to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plusoral dextromethorphan 60 mg or placebo. Results. The addition of dextromethorphan did not reduce postoperativepain scores (P=0.83). Compared with women receiving intrathecalmorphine 0.05 mg, women receiving higher doses had a significantlyhigher incidence of nausea and vomiting [odds ratio for intrathecalmorphine 0.1 mg, 4.0 (95% confidence interval 1.2–14.1);for intrathecal morphine 0.2 mg, 7.9 (2.3–27.1)].Compared with women receiving intrathecal morphine 0.05 mg,women receiving higher doses also had a significantly higherincidence of pruritus [odds ratio for intrathecal morphine 0.1 mg,3.2 (95% confidence interval 1.3–8.2); for intrathecalmorphine 0.2 mg, 3.7 (1.4–9.5)]. Women receivingdextromethorphan had a lower incidence of nausea and vomiting[odds ratio 2.6 (1.1–6.3)]. Conclusions. Postoperative pain after Caesarean section underspinal anaesthesia was not reduced by the addition of oral dextromethorphanto a multimodal approach including intrathecal morphine. Br J Anaesth 2003; 90: 653–8     

The effect of baricity of intrathecal morphine in children receiving tetracaine spinal anaesthesia for cardiac surgery: a preliminary report

BACKGROUND: This prospective, randomized study examined the effect of baricity of intrathecal preservative-free morphine on the duration of postoperative analgesia and incidence of side-effects in infants and children receiving high spinal anaesthesia with hyperbaric tetracaine in combination with a light general anaesthetic. METHODS: Fourteen infants and children, aged 7-91 months, undergoing repair of either uncomplicated atrial or ventricular septal defects, were randomized to receive either 10 microg x kg(-1) of intrathecal morphine in combination with 0.5% tetracaine D10 (hyperbaric morphine group) or intrathecal morphine mixed with saline and injected sequentially after the administration of 0.5% tetracaine D10 (hypobaric morphine group). After spinal injection, patients were positioned in 30 degrees of Trendelenburg for a minimum of 10 min. Postoperatively, patients were monitored for a minimum of 12 h. Pain scores and the incidence and severity of side-effects were recorded every 1 h. RESULTS: All patients were extubated at the conclusion of surgery without any incidence of respiratory depression. There was a decreased incidence of vomiting in the hypobaric morphine group and no significant difference in the duration of analgesia. CONCLUSIONS: When intrathecal morphine is administered in conjunction with a hyperbaric tetracaine spinal to paediatric cardiac patients in the head down position, sequential administration of the hypobaric solution may mitigate side-effects.     

Allodynia after acute intrathecal morphine administration in a patient with neuropathic pain after spinal cord injury

IMPLICATIONS: Acute intrathecal administration of relatively small doses of opioids may precipitate neuropathic pain and allodynia in those with spinal cord injury.     

Efficacy of intermittent epidural morphine following posterior spinal fusion in children and adolescents

Postoperative pain is a distressing and disabling feature of scoliosis surgery. Epidural morphine has recently been advocated to reduce the frequency and severity of postoperative pain in adults. A retrospective study of 35 patients was conducted to determine whether epidural administration of morphine is useful in the management of postoperative pain in children and adolescents following posterior spinal fusion. The derived data included dose and frequency of narcotic administration on the day of surgery and during the subsequent three days. On the first postoperative day, the total morphine given averaged only 16.4 mg in patients receiving epidural morphine compared to 27 mg in those receiving only conventional parenteral morphine. Similar significant differences persisted through the second postoperative day. Intermittent epidural injection of small doses of morphine can give satisfactory and prolonged analgesia for early postoperative pain management.