Post operative analgesia with intrathecal morphine

INTRODUCTION: Sixty eight ASA I and II patients between 18 and 84 years who underwent minor to medium surgery were studied retrospectively. They were divided into 2 groups, on basis on intrathecal morphine administration. MATERIALS AND METHODS: Group I received spinal anesthesia with bupivacaine 12.5-15 mg. Group II received in addition 0.1 mg morphine (preservative free) [MO PF]. Pain assessment, up to 24 hours, was evaluated by the need of salvage medication namely pethidine i.m. (intramuscular). RESULTS: The groups matched for demographic distribution. Twenty one out of 30 patients in Group I needed salvage medication, compared to 6 out of 38 patients in Group II (p < 0.005). Minor complications of intrathecal morphine were noted. These were higher in Group II compared to Group I; itching and pruritis (14 vs. 1); urinary retention (2 vs. 0); nausea and vomiting (1 vs. 0) (p < 0.005). CONCLUSION: This study showed that a single low dose of intrathecal morphine with bupivacaine provides better quality post-operative analgesia than bupivacaine alone, and might offer enough analgesia for minor to medium cases up to 24 hours post-op. However, some side effects have to be taken into consideration.     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

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.     

鞘内注射吗啡用于胸腔镜肺叶切除术患者术后镇痛的半数有效剂量

目的 探讨鞘内注射吗啡（ITM）用于胸腔镜肺叶切除术患者术后镇痛的半数有效剂量（ED50）。
方法 选择拟行全麻下胸腔镜肺叶切除术患者22例,年龄35～64岁,BMI 18～30 kg/m²,ASA Ⅰ或Ⅱ级。所有患者于术前在L_2-3间隙行蛛网膜下腔穿刺。患者鞘内吗啡的初始给药剂量为5 μg/kg,相邻药物剂量比值为1∶1.1,剂量梯度依次为5.00、4.55、4.14、3.76、3.42、3.11 μg/kg。根据上一例患者术后镇痛效果,下一例患者上升或下降一个剂量梯度。术后镇痛有效标准：若术后6、12、24、48 h活动时VAS疼痛评分均≤3分,则认为术后镇痛有效;若任一时刻活动时VAS疼痛评分＞3分,则认为镇痛无效。采用Probit法计算ED50、ED95及其95%可信区间（CI）。记录呼吸抑制、恶心呕吐、皮肤瘙痒、尿潴留等不良反应的发生情况。
结果 ITM用于胸腔镜肺叶切除术的ED50为3.468 μg/kg（95%CI 2.926～3.782 μg/kg）,ED95为4.037 μg/kg（95%CI 3.746～7.127 μg/kg）。有2例（9%）出现皮肤轻微瘙痒,3例（14%）出现恶心呕吐,未观察到其他不良反应发生。
结论 鞘内注射吗啡用于胸腔镜肺叶切除术的ED50为3.468 μg/kg（95%CI 2.926～3.782 μg/kg）。     

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.     

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     

Spinal anesthesia and postoperative analgesia with intrathecal morphine for orthopedic surgery]

The aim of this study was to evaluate the analgesic efficacy and side effects of intrathecal morphine in the dose range 0.2-0.5 mg. One-hundred patients scheduled for elective lower limb orthopedic operation under spinal anesthesia using hyperbaric or isobaric bupivacaine 0.5% with morphine in dose from 0.2 to 0.5 mg. Pain score, duration of analgesia and the incidence of adverse effects like nausea, vomiting, pruritus, urinary retention and respiratory depression were assessed for 48 hr postoperatively. There were significant differences in the duration and efficacy analgesia and the incidence of pruritus the morphine dose-related. We did not observe the increased frequency of nausea and vomiting with increased dose. The respiratory depression not observed in connection with intrathecal morphine. The evidence from this current study suggests that spinal anesthesia with combination of local anesthetic and morphine can be employed to provide safe and efficacious analgesia in patients undergoing orthopedic operations. The adverse effects which developed due to intrathecal morphine were able to treat with success.     

A randomised comparison of regular oral oxycodone and intrathecal morphine for post-caesarean analgesia

BackgroundPrimary post-caesarean analgesia based on oral opioid has not been adequately studied. This approach may show a good side-effect profile and high satisfaction and avoid neuraxial complications.MethodsIn a double-blind, double-dummy, placebo-controlled clinical trial 120 women were randomised to receive either sustained-release oral oxycodone 20 mg in the recovery room followed by immediate-release oxycodone 10 mg 6-hourly for the first 24 h (group O) or intrathecal morphine 100 μg at the time of spinal anaesthesia (group I). All women received regular postoperative diclofenac, paracetamol and standardised supplemental analgesia.ResultsOne hundred and eleven women completed the study. The area under the curve for pain scores to 24 h did not differ significantly between groups for pain at rest (P=0.465) or on movement (P=0.533). Numerical pain scores were low and similar, except at rest at 12 h (group I 1 [0-2] vs. group O 2 [1-3]; P=0.030). The time to first analgesic request was similar but additional postoperative analgesics were required more often in group O (82% vs. 63%, P=0.034). Group O more frequently reported high worst pain scores (score 4-10 in 87% vs. 64%, P=0.007). Pruritus was more common and more severe in group I (87% vs. 56%, P=0.001). At 24 h maternal satisfaction with the analgesic regimen was lower in group O (P=0.010).ConclusionOral oxycodone produced comparable postoperative pain relief to intrathecal morphine with a lower incidence of pruritus, but was associated with a lower satisfaction score.     

The use of pre-operative intrathecal morphine for analgesia following coronary artery bypass surgery

With the emergence of rapid extubation protocols following cardiac surgery, providing adequate analgesia in the early postoperative period is important. This prospective randomised double-blind study investigated the benefits of pre-operative intrathecal administration of low dose morphine in patients undergoing coronary artery bypass graft surgery. Postoperative analgesia, pulmonary function, stress response and postoperative recovery profile were assessed. Thirty patients were allocated into two groups, receiving either 500 mug of morphine intrathecally prior to anaesthesia and intravenous patient-controlled analgesia with morphine postoperatively following tracheal extubation, or only postoperative intravenous patient-controlled analgesia. In the intrathecal group, the total consumption of intravenous morphine following surgery was significantly reduced by 40% and patients reported lower pain scores at rest, during the first 24 h following extubation. Peak expiratory flow rate was greater and postoperative catecholamine release was significantly lower. Patients in the control group had a higher incidence of reduced respiratory rate following extubation.     

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.     

Combined use of intrathecal morphine and diclofenac suppository for postoperative analgesia after caesarean section

BACKGROUND: Intrathecal morphine for postoperative analgesia after caesarean section has been used in Europe and North America, but its use is not common in Japan. METHODS: We randomized 40 parturients to two groups, given either intrathecal saline (control group) or intrathecal morphine 0.05 mg (morphine group) for caesarean section. To both groups, we gave a diclofenac suppository 50 mg every 8 hours after surgery. RESULTS: The area under curve for the visual analogue scale for pain during 24 hours after operation was significantly lower (P < 0.01) in the morphine group than the control group. In addition, the parturients who required pentazocine as a rescue analgesia was significantly fewer in the morphine group (5 parturients) than the control group (11 parturients). There was no significant difference between the two groups in the Apgar score of infants, pH in umbilical cord arterial and venous blood and the incidence of postoperative nausea and vomiting. The incidence of pruritus was significantly higher in the morphine group (11 parturients) than the control group (no parturient). CONCLUSIONS: Intrathecal morphine 0.05 mg and diclofenac suppository 50 mg given every 8 hours produced effective postoperative analgesia with minimum side effects after caesarean section.     

Comparison of 0.25 mg and 0.1 mg intrathecal morphine for analgesia after Cesarean section

PURPOSE: To test the hypothesis that 0.1 mg intrathecal morphine plus NSAIDs provides satisfactory analgesia post-Cesarean section with fewer side effects than 0.25 mg intrathecal morphine. METHODS: Sixty women, scheduled for elective Cesarean section under spinal anesthesia, were randomized to receive either 0.1 mg or 0.25 mg intrathecal morphine combined with hyperbaric bupivacaine 0.75% and 20 microg fentanyl. All patients received a 100 mg indomethacin suppository at the end of surgery and 500 mg naproxen p.o. b.i.d. was started the evening of surgery and continued until discharge. A blinded researcher recorded the pain, pruritus, and nausea scores, the time to first request for additional analgesics, a visual analogue scale (VAS) satisfaction score, and the use of additional opioids, antipruritics, and/or antiemetics. RESULTS: Of the 60 patients enrolled, two were not included in the data analysis because of protocol violations leaving 30 patients in the 0.1 mg group and 28 in the 0.25 mg group. There were no differences in the VAS pain scores or the number of women requesting an opioid other than codeine between the two groups. The VAS pruritus scores in the 0.1 mg group were lower throughout the 24 hr (P < 0.001). Fewer women in the 0.1 mg group (4/30 vs 12/28) requested nalbuphine to treat itching (P = 0.018). Nausea scores were lower in the 0.1 mg group (P < 0.001). CONCLUSION: The use of 0.1 mg intrathecal morphine plus NSAIDs provides analgesia of similar quality to 0.25 mg but with fewer undesirable side effects following Cesarean section.     

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.     

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.