Efficacy of a low-dose spinal morphine with bupivacaine for postoperative analgesia in children undergoing hypospadias repair

Background:  Children undergoing hypospadias repair need to be protected from highly unpleasant sensory and emotional experiences during and after surgery. We designed a double-blinded, randomized, and placebo-controlled study to compare the efficacy of a low-dose (2 μg·kg⁻¹) of intrathecal morphine with placebo for postoperative pain control of children undergoing repair of hypospadias surgery with spinal anesthesia.
Methods:  Fifty-four children were randomly assigned to one of two spinal anesthesia groups. Group M ( n  = 27) received hyperbaric bupivacaine plus 2 μg·kg⁻¹ of preservative-free morphine and group P ( n  = 27) received hyperbaric bupivacaine plus 0.9% NaCl (placebo) under inhalation anesthesia. General anesthetics were discontinued subsequent to the block. The primary outcome was the presence of pain-requiring analgesics during the first 12 h after the spinal block. Side effects were also recorded. The analgesic effects were evaluated by using the Children's Hospital of Eastern Ontario Pain Scale.
Results:  Forty-nine patients completed the trial. Fifteen patients (60%) in group P received supplementary analgesics within the first 12 h compared to only four patients (16.7%) in group M ( P  = 0.005). Mean duration of analgesia was 480 ± 209 and 720 ± 190 min in group P and group M respectively ( P  = 0.009). The groups were similar in postoperative side effects.
Conclusion:  Spinal anesthesia provided by hyperbaric bupivacaine is adequate for distal hypospadias repair in children, but adding 2 μg·kg⁻¹ intrathecal morphine provides better postoperative pain control when compared to placebo in these children.     

Intravenous regional analgesia using morphine. The effect on postoperative pain following total knee arthroplasty

Background: We hypothesised that any peripheral action of morphine may contibute to improved postoperative analgesia. The aim of this study was to evaluate the analgesic efficacy of morphine administered preoperatively into an exsanguinated limb prior to total knee arthroplasty.
Methods: A randomised, double-blind, controlled study was performed in 50 patients having total knee arthroplasty surgery. Patients were divided into two groups. In the study group, 0.125 mg/kg morphine in 60 ml of saline was administered intravenously (iv) into the exsanguinated operative limb via a can-nula in the foot. A saline intramuscular (im) injection was administered into the opposite leg. The control group received 60 ml saline iv into the operative leg and 0.12 5mg/kg morphine im into the opposite leg. Pain was assessed postoperatively using a 10-point visual analogue scale and by comparing morphine requirements and demand: delivery ratios from a patient-controlled analgesic pump.
Results: We found no statistically significant difference between the groups in relation to any of the analgesic measures employed.
Conclusions: Intravenous regional analgesia using morphine provides no analgesic advantage over the intramuscular route from 6–24 h postoperatively.     

肌肉注射帕瑞昔布钠用于全膝关节置换术病人术后镇痛的效果

目的 评价肌肉注射帕瑞昔布钠用于全膝关节置换术病人术后镇痛的效果.方法 拟行单侧全膝关节置换术的的骨关节炎病人54例,性别不限,年龄65 ～ 75岁,ASA分级Ⅰ～Ⅲ级,采用随机数字表法,将病人随机分成2组(n=27)∶曲马多组(T组)和帕瑞昔布钠组(P组).2组均采用全凭静脉麻醉.P组分别于术前12 h及术后12、24、36、48、60、72 h时肌肉注射帕瑞昔布钠40 mg,T组在相应时间点给予曲马多100 mg.当术后镇痛无效(VAS评分＞3分)时肌肉注射哌替啶50 mg进行补救镇痛,分别记录静态和动态时镇痛无效情况.记录术后膝关节活动度达到90°的时间和心血管事件发生情况;术后7、14 d行双下肢静脉多普勒超声检查,记录下肢静脉血栓形成的发生情况.结果 与T组比较,P组静态和动态时镇痛无效率降低,术后膝关节活动度达到90°时间缩短,深静脉血栓形成发生率降低(P＜ 0.05或0.01),心血管事件发生率和肌间静脉血栓形成发生率差异无统计学意义(P＞0.05).结论 术前12 h及术后间断肌肉注射帕瑞昔布钠40 mg可明显缓解全膝关节置换术病人术后疼痛,有助于术后关节功能的康复,且可降低深静脉血栓形成的发生.     

Intrathecal infusion of bupivacaine with or without morphine for postoperative analgesia after hip and knee arthroplasty

Postoperative pain after major orthopaedic operations can be controlled by continuous intrathecal administration of opioids or local anaesthetics. Effective intrathecal analgesia can be achieved through synergism of low doses of the two analgesic drugs and, possibly, less drug-related adverse effects. Therefore, we have evaluated the usefulness of a combined low-dose bupivacaine and morphine infusion in patients undergoing hip and knee arthroplasty. Spinal anaesthesia was induced in 55 ASA I-III patients with 0.5% bupivacaine 2 ml via a 28- gauge spinal catheter (L3-4 interspace) and 0.5-ml increments were given if needed. Intrathecal 24-h infusions consisted of bupivacaine 2 mg h-1 alone (n = 18), bupivacaine 1 mg h-1 alone (n = 18) or bupivacaine 1 mg h-1 combined with morphine 8 micrograms h-1 (n = 19). The interview after 3, 6, 12 and 24 h included assessment of pain at rest and on movement (VAS scale), occurrence of sensory and motor block and nausea/vomiting. Bupivacaine 1 mg h-1 combined with an infusion of morphine provided as good postoperative analgesia as bupivacaine 2 mg h- 1, but motor block disappeared earlier (P = 0.01). Patients in the bupivacaine 1-mg h-1 group required more supplementary doses of oxycodone i.m. than the other groups (P = 0.04). Time to first oxycodone dose from the start of intrathecal infusion did not differ between groups. The frequency of nausea and vomiting was similar in all groups. In spite of this, antiemetic medication was required more often in the bupivacaine 1-mg h-1 group (possible because of opioid rescue medication). On the ward, one patient in the bupivacaine 2-mg h-1 group experienced a new increase in sensory block with concomitant hypotension. One patient in the same group had minor decubitus on the heel of the operated leg, probably because of prolonged motor block. We conclude that intrathecal infusion of a combination of bupivacaine 1 mg h-1 and morphine 8 micrograms h-1 produced adequate postoperative analgesia. Unfortunately, postoperative nausea and vomiting was a frequent disturbing adverse effect.      

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence-based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non-steroidal anti-inflammatory drugs or COX-2-selective inhibitors, plus intravenous strong opioids (high-intensity pain) or weak opioids (moderate- to low-intensity pain).     

Intrathecal baclofen for postoperative analgesia after total knee arthroplasty

Study ObjectiveTo determine whether intrathecal baclofen is an effective adjunctive agent to decrease acute and chronic postoperative pain after total knee arthroplasty.DesignProspective, randomized, double-blind controlled trial.SettingOperating room and inpatient units of a university hospital.Patients60 adult, ASA physical status I, II, and III patients presenting for total knee arthroplasty.InterventionsAnesthesia was provided by spinal injection of 15 mg of 0.75% hyperbaric bupivacaine combined with either 100 mcg baclofen or saline. Sedation was provided with intravenous midazolam and propofol.MeasurementsData were collected on adverse effects, opioid usage, and verbal pain scale (VPS) from 0 to 10. The study period was divided into six discrete time intervals that included the 1^st 72-hour postoperative period and a three-month post-discharge follow-up telephone call.Main ResultsThe baclofen group used less morphine in the PACU than the control group (5 mg vs. 9.3 mg; P = 0.04). VPS were lower in the baclofen group than the treatment group, but significant differences could be demonstrated only in the time periods 48-72 hours and three months postoperatively. At three months, fewer patients in the baclofen group reported pain than the control group (8/27 vs. 19/29; P = 0.009). Regression analysis showed that the baclofen group was 4.5 times less likely to report pain at three months (95% CI: 1.5–16.6).ConclusionsIT baclofen used as an adjuvant to spinal anesthesia for total knee arthroplasty allows for less postoperative opioid usage and less chronic pain at three months.     

Perioperative adjuvant corticosteroids for postoperative analgesia in knee arthroplasty

Background and purpose — Immediate postoperative pain management offered in knee arthroplasty is suboptimal in up to one-third of patients resulting in high opiate consumption and delayed discharge. In this meta-analysis we investigate the analgesic effect and safety of perioperative adjuvant corticosteroids in knee arthroplasty.

Methods — Databases Medline, Embase, and Central were searched for randomized studies comparing the analgesic effect of adjuvant perioperative corticosteroids in knee arthroplasty. Our primary outcome was pain score at 24?hours postoperatively. Secondary outcomes included pain at 12, 48, and 72?hours, opiate consumption, postoperative nausea and vomiting, infection, and discharge time. Systemic (intravenous) and local (intra-articular) corticosteroids were analyzed separately.

Results — 14 randomized controlled trials (1,396 knees) were included. Mean corticosteroid dosages were predominantly 50–75mg oral prednisolone equivalents for both systemic and local routes. Systemic corticosteroids demonstrated statistically significant and clinically modest reductions in pain at 12?hours by –1.1 points (95%CI –2.2 to 0.02), 24?hours by –1.3 points (CI –2.3 to –0.26) and 48?hours by –0.4 points (CI –0.67 to –0.04). Local corticosteroids did not reduce pain. Opiate consumption, postoperative nausea and vomiting, infection, or time till discharge were similar between groups.

Interpretation — Corticosteroids modestly reduce pain postoperatively at 12 and 24?hours when used systemically without any increase in associated risks for dosages between 50 and 75?mg oral prednisolone equivalents.     

Efficacy of low-dose intrathecal morphine for postoperative analgesia after abdominal aortic surgery: a double-blind randomized study

BACKGROUND AND OBJECTIVES: Several studies suggest that intrathecal morphine (ITM) improves analgesia after aortic surgery. We tested the hypothesis that in combination with multimodal postoperative pain management, low-dose ITM associated with general anesthesia would decrease postoperative analgesic requirements in patients undergoing abdominal aortic surgery. METHODS: Thirty patients were randomized to receive either general anesthesia alone or preceded by low-dose ITM (0.2 mg) administration. Patients and providers were blinded to treatment. Postsurgical multimodal pain management was similar in both groups, including parenteral paracetamol, followed by intravenous nefopam and then morphine if not sufficient. Intravenous analgesic requirements, visual analog scale (VAS) scores, and the incidence and severity of side effects were recorded for 48 hours after surgery. RESULTS: Intraoperative data were comparable between the 2 groups, except sufentanil consumption, which was significantly lower in the ITM group when compared with the control group (P = .023). ITM decreased postoperative total-morphine requirements with respect to both the number of patients who received morphine (4 v 12 patients, P = .003) and the cumulative dose of morphine administered (0 [0-12.4] v 23 [13.9-45.6] mg, P = .006). VAS scores at rest were higher in the control group than in the ITM group at awakening (P < .01), at 4 hours (P < .01) after surgery, and at 8 hours (P < .05) after surgery but did not differ between groups after this period. Whereas VAS scores on coughing were higher in the control group at awakening (P < .01) and 4 hours after surgery (P < .05), no differences were found between groups from 8 hours after surgery. CONCLUSION: In patients undergoing abdominal aortic surgery, intrathecal morphine (0.2 mg) improves postoperative analgesia and decreases the need in intraoperative and postoperative analgesics. Further studies are indicated to evaluate the role of ITM in postoperative recovery.     

Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty

Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I-III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 microg), 3) morphine (250 microg) with clonidine (25 microg), and 4) morphine (250 microg) with clonidine (75 microg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone. IMPLICATIONS: In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 microg) combined with clonidine (25 or 75 microg) provided superior analgesia compared with intrathecal morphine alone.     

Intrathecal morphine for postoperative analgesia: a randomized, controlled, dose-ranging study after hip and knee arthroplasty

In this series, we examined analgesia and side effects of intrathecal morphine sulfate (ITMS) after hip and knee arthroplasty over a dose range of 0.0-0.3 mg. Eighty patients undergoing hip (n = 40) or knee (n = 40) arthroplasty were randomized to receive ITMS (0.0, 0.1, 0.2, or 0.3 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. Morphine use, pain relief, and side effects were recorded for 24 h. Data were analyzed with analysis of variance and linear regression. After hip arthroplasty, morphine use was less in patients receiving 0.1, 0.2, or 0.3 mg of ITMS than in control patients (P < 0.05). After knee arthroplasty, ITMS did not reduce postoperative morphine requirements. Nausea and vomiting and the incidence of oxygen saturation <93% were similar in all groups. Pruritus was more common after ITMS. Patients receiving 0.2 or 0.3 mg of ITMS were more satisfied with their pain control than those receiving 0.0 or 0.1 mg after both hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than after hip arthroplasty. We conclude that combining small-dose (0.2 mg) ITMS with PCA morphine provides good to excellent pain control in most patients after total hip or knee arthroplasty. However, PCA morphine use was reduced by the addition of ITMS only after hip arthroplasty. IMPLICATIONS: This series examined the need for supplemental analgesics, the quality of analgesia, and the incidence of side effects with intrathecal morphine sulfate (ITMS) for analgesia after hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than hip arthroplasty. Combining small-dose (0.2 mg) ITMS with standard doses of PCA morphine provided good to excellent pain control in most patients and reduced patient-controlled analgesia morphine use after hip, but not knee, arthroplasty.     

Respiratory depression following postoperative analgesia with epidural morphine

Eighteen healthy patients subjected to operation for duodenal ulcer were allocated randomly to one of two regimes of analgesic treatment with epidural morphine. The analgesic regime was started either per- or postoperatively. Epidural morphine in doses of 4 mg was given until satisfactory pain relief was achieved. PaCO2 and respiratory rate were measured hourly for 10 h and a nearly identical respiratory depression was found in the two groups. Peak PaCO2-values were seen in the 5th and 6th postoperative hour. The respiratory rate was initially high and declined during the first postoperative hours. Only one patient in each group had a pathologically low respiratory rate (8 min-1), but this was transient and seen in the 10th postoperative hour. The needs for epidural morphine on the first postoperative day were highest in the peroperative group. It is concluded that a peroperative start of pain treatment with epidural morphine does not affect the degree of respiratory depression or reduce the postoperative analgesic requirements.     

Peridural morphine for postoperative analgesia in patients following Milligan-Morgan surgery

Postoperative analgesia and side effects of epidural morphine (3 mg in 5 ml saline) were studied in 30 patients scheduled for Milligan-Morgan surgery. The patients were pain-free for a mean duration of 10-12 hr. Urinary retention was the most prominent side effect observed.     

普瑞巴林在全膝关节置换术后镇痛的有效性及安全性

加速康复外科(enhanced recovery after surgery,ERAS)理念越来越受关节外科医师重视,通过各种围术期措施减少手术应激,降低疼痛与并发症的发生率,加快功能康复,提高患者满意度。其中优化疼痛管理是全膝关节置换术(TKA)加速康复的基石。近年来,研究发现普瑞巴林通过降低中枢和外周痛觉敏化,可以有效缓解TKA术后疼痛,减少阿片类药物的使用量,加速患者康复。因此,应用普瑞巴林可能是加速康复TKA围手术期多模式镇痛中的一种有效措施。