Continuous Epidural Infusion Of Morphine Research Articles

Postoperative Pain Management in a Sheep Using Continuous Epidural Morphine

Background: Although ruminants experience pain like other species, diagnosis and treatment may be imprecise and challenging, especially because of lack of recognition and restraint of therapeutic resources. In addition to the restrictions inherent in the species, organic dysfunctions may further restrict the analgesic arsenal, making it necessary to find viable and effective alternative for pain control. The continuous administration of opioids in the epidural space has been highlightedas an analgesic resource in several species. However, until this moment, there are few information on this practice in ruminants. Therefore, the aim of this study was to describe the use of continuous epidural infusion of morphine in a sheep undergoing to urethrostomy with a history of chronic pain and urolithiasis.Case: A 3-year-old Santa Ines sheep, weighting 110 kg, was presented to the Veterinary Hospital of Federal University of Bahia with history of recurrent urolithiasis, lameness, severe pain and continuous use of nonsteroidal anti-inflammatory drug (NSAID). The findings of the physical examination, imaging and laboratory tests revealed possible abomasum inflammation, chronic laminitis, left humerus-radioulnar osteoarthritis and urethral urolithiasis with uremia. A clinical stabilization of the animal was performed, including an interruption of the use of the NSAID and the administration of fluid, urinary acidifier (ammonium chloride), histamine H2 receptor antagonist (ranitidine), cytoprotectant (sucralfate), antibiotic (norfloxacin) and dipyrone. After 3 days, urethrostomy was performed followed by the implantation of an epidural catheter (19G) in the lumbosacral space (L7 - S1) by means of a Tuohy needle (18G), after the surgical procedure. Administration of morphine (0.1 mg kg-1) through the catheter at 24-h intervals, associated with dipyrone (25 mg kg-1) intravenously (IV), every 8 h, over a 5-day period, was the postoperative analgesic protocol chosen. The data of heart rate (HR), respiratory rate (f),rectal temperature (T °C), ruminal movements (RM) and possible behavior related to pain were registered at intervals of four-hours until the fifth day after surgery. After 24 h postoperative, stability of the variables (HR, f, T °C) with increased RM concomitant to the interest for food was verified. On the fifth postoperative day, the animal was hydrated, visibly comfortable and with normal levels of serum creatinine.Discussion: Considering the initial clinical status involving renal insufficiency and significant gastric abnormalities, the use of NSAIDs was immediately disregarded. However, the need to relieved musculoskeletal and postoperative pain, has raised interest in the use of morphine, whose literature refers duration of up to 24 h in other species, with reduced adverse effects compared to systemic administration, due to the considerably lower dose. Dipyrone was incorporated into the protocol forproviding visceral analgesia and minimal effects on the organic functions. During the 5-days of evaluation, the signs of well-being presented by the animal associated to the stability of vital parameters, feeding and satisfactory ruminal activity attested to the viability of the protocol tested. It was concluded that the use of morphine, through the continuous epiduralroute, contributed to the relief of postoperative pain, reestablishment of the organic functions and patient welfare, being suitable as an analgesic alternative to NSAID use in sheep.Keywords: ovine, analgesia, opioid, epidural.

Does Epidural Morphine Loading in Addition to Thoracic Epidural Analgesia Benefit the Postoperative Management of Morbidly Obese Patients Undergoing Open Bariatric Surgery? A Pilot Study

Insufficient data exist regarding postoperative thoracic epidural analgesia for morbidly obese patients undergoing open bariatric surgery. This study evaluated the effectiveness of morphine loading in a postoperative thoracic epidural analgesic regimen of patient-controlled epidural analgesia (PCEA) with levobupivacaine combined with continuously administered epidural morphine in this patient group. In this prospective randomized controlled trial, 48 superobese patients (body mass index of ≥ 50 kg/m(2)) undergoing open bariatric surgery were randomly allocated to three groups of 16 patients each. Postoperatively, all groups received a continuous epidural morphine infusion of 0.2 mg/h with 0.1 % levobupivacaine via PCEA. Group A did not receive intraoperative epidural morphine loading, while groups B and C received an intraoperative 1- and 2-mg morphine bolus, respectively. Levobupivacaine consumption via PCEA (primary outcome), pain scores at rest and on cough, the time to return of bowel function and ambulation, and arterial blood gas levels (secondary outcomes) were recorded. The increase in perioperative morphine administration (groups B and C) led to a significantly prolonged return to normal bowel function and delayed ambulation (P<0.05 to 0.01, respectively), without an improvement in postoperative analgesia or a reduction in local anesthetic consumption. Although the prevalence of obstructive sleep apnea (OSA) was high in all groups, no respiratory depression was observed. Thoracic PCEA with 0.1 % levobupivacaine combined with continuous epidural morphine administration of 0.2 mg/h without morphine loading is an effective postoperative analgesic regimen that provides adequate pain control, early ambulation, and early return of bowel function in superobese patients, particularly those with OSA.

Respiratory Failure Following Delayed Intrathecal Morphine Pump Refill: A Valuable, but Costly Lesson

Background: Spinal analgesia, mediated by opioid receptors, requires only a fraction of the opioid dose that is needed systemically. By infusing a small amount of opioid into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, profound analgesia may be achieved while sparing some of the side effects due to systemic opioids. Intraspinal drug delivery (IDD) has been increasingly used in patients with intractable chronic pain, when these patients have developed untoward side effects with systemic opioid usage. The introduction of intrathecal opioids has been considered one of the most important breakthroughs in pain management in the past three decades. A variety of side effects associated with the long-term usage of IDD have been recognized. Among them, respiratory depression is the most feared. Objective: To describe a severe adverse event, i.e., respiratory failure, following delayed intrathecal morphine pump refill. Case Report: A 65-year-old woman with intractable chronic low back pain, due to degenerative disc disease, and was referred to our clinic for an intraspinal drug delivery evaluation, after failing to respond to multidisciplinary pain treatment. Following a psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine infusion trial. The infusion trial lasted 12 days and was beneficial in controlling her pain. The patient reported more than 90% pain reduction with improved distance for ambulation. She subsequently consented and was scheduled for permanent intrathecal morphine pump implantation. The intrathecal catheter was inserted at right paramedian L3-L4, with catheter tip advanced to L1, confirmed under fluoroscopy. Intrathecal catheter placement was confirmed by positive CSF flow and by myelogram. A non-programmable Codman 3000 constant-flow rate infusion pump was placed in the right mid quandrant between right rib cage and right iliac crest. The intrathecal infusion consisted of preservative free morphine, delivering 1.0 mg / day. Over the following 6 months, the dosage was gradually titrated up to 4 mg/day with satisfactory pain control without significant side effects. However, the patient was not able to return to the clinic for pump refill until 12 days later than the previously scheduled pump-refill date. Her pump was accessed and was noted to be empty. Her intrathecal pump was refilled with preservative free morphine, delivering 4 mg/day (the same daily dose as her previous refill). However, on the night of pump refill, 10 hours after the pump refill, the patient was found to be unresponsive by her family members. 911 was called. Upon arriving, paramedics found her in respiratory failure, with shallow breathing at a rate of 5/min, pulse oxymetry showing oxygen saturation about 55-58%. She was emergently intubated on site and rushed to local hospital ER. The on call physician for our clinic was immediately contacted, and advised the administration of intravenous Naloxone. Her respiratory effort improved dramatically after receiving a total of 0.6 mg IV Naloxone IV over 25 minutes. Her intrathecal pump was immediately accessed by clinic on call physician and the remainder of the medication in the catheter space was aspirated. The pump infusate was immediately diluted with preservative free normal saline, to deliver preservative free morphine at 1mg/day. She was transferred to the intensive care unit and extubated the next morning. She recovered fully without any sequelae. Conclusion: Loss of opioid tolerance due to delayed pump refill may subject patients to the development of severe respiratory depression. Meticulous approach should be employed when refilling pumps in these patients when their pumps are completely empty. To our knowledge, this is the first reported case of this type. Key words: intraspinal drug delivery pump, intrathecal morphine, respiratory depression, opioid tolerance

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

This study retrospectively compared the continuous epidural infusion of morphine with a single epidural injection of extended-release morphine for postoperative pain control after arthroplasty. Medical records were reviewed for subjects who had total knee or hip arthroplasty (THA) under spinal anesthesia and received either a continuous epidural infusion of morphine (Group EPID; n = 101) or an extended-release epidural morphine (Group EREM; n = 109) for postoperative pain. Data were collected for three postoperative days (POD) on: pain scores; supplemental opioids; medications for respiratory depression, nausea, and pruritus, and distance ambulated during physical therapy. Pain scores were similar until subjects were transitioned to another analgesic approach on POD 2; after that time, pain scores increased in Group EPID, although they decreased in Group EREM. Supplemental opioids were used more on POD1 in Group EREM than in Group EPID, although time to first opioid and total daily morphine equivalents were similar. Naloxone and antiemetics, not antipruritics, were used more in Group EREM. Distance ambulated after THA was greater in Group EREM than in Group EPID. These results suggest that EREM is associated with better postoperative ambulation and analgesia during the transition to oral or intravenous analgesics, although a higher incidence of side-effects was evident.

Comparison of efficacy of continuous epidural infusion of morphine, fentanyl and combination of morphine and fentanyl with bupivacaine for postoperative analgesia in children

Forty-five children of ASA I & II aged 2-10 years scheduled for elective abdominal, urological and major orthopedic procedures were included in the study. They were divided into three groups of 15 each Group I children received continuous epidural infusion of morphine 6ug/kg/hr with 0.0625% bupivacaine group II patients received an epidural infusion of fentanyl 0.4 ug/kg/hr with 0.0625% bupivacaine, whereas patients in group III received continuous epidural infusion of fentanyl 0.2 ug/kg/hr and morphine 3 ug/kg/hr with 0.0625% bupivacaine.

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

An acute pain service improves postoperative pain management for children undergoing selective dorsal rhizotomy

A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children. We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children's Hospital in April 2001. Ninety-two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid-induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay. Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre-APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3-3 25-75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre-APS group [median of 5 (5-5 25-75%ile) vs 6 (5-6 25-75%ile) days, P < 0.001]. Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day.

Severe Peripheral Edema During an Outpatient Continuous Epidural Morphine Infusion Trial in a Patient with Failed Back Surgery Syndrome

Intraspinal drug delivery therapy has been increasingly used in patients with intractable, nonmalignant pain who fail to respond to conventional treatment or cannot tolerate systemic opioid therapy due to side effects. By infusing small amount of analgesics directly into the cerebrospinal fluid in close proximity to the receptor sites in the spinal cord, one is able to achieve the spinally mediated analgesia, sparing side effects due to systemic opioids. Prior to permanent intraspinal pump implantation, an intraspinal opioid screening trial is required to document the efficacy of intraspinal opioid for analgesia. Although there are a few approaches in conducting such screening trials, a patient controlled continuous epidural morphine infusion trial, performed in an outpatient setting, is widely accepted by many interventional pain specialists. The major advantage of conducting an outpatient trial is that it mimics what patients do in their daily living, therefore minimizing the false positive rate. To report a case of severe peripheral edema observed during an outpatient continuous epidural morphine infusion trial. A 64-year-old female, with a 7-year history of severe low back pain and bilateral leg pain due to failed back surgery syndrome, was referred to our clinic for intraspinal drug delivery therapy after failing to respond to conservative treatment, including a previous history of 3 lumbosacral surgeries. Following a pre-implantation psychological evaluation confirming her candidacy, she underwent an outpatient patient-controlled continuous epidural morphine trial. A tunneled lumbar epidural catheter was placed at L2-L3 with catheter tip advanced to T12 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The proximal tip of the catheter was then tunneled, subcutaneously and connected to a Microject PCEA pump (Codman, Raynham, MA, USA) and reservoir bag containing preservative-free morphine 0.5 mg/mL. The pump was programmed to deliver a basal rate of 0.5 mL/hr. The bolus dose was 0.2 mL with 60 minute lock-out interval. The patient was instructed how to operate the infusion pump before discharging home. During the following 2 weeks, she reported more than 90% reduction of her low back and leg pain. She only had to use the on-demand bolus doses averaging 2 - 3 times a day. She was able to wean off her oral opioids completely. However, she developed bilateral leg edema and gained over 12 pounds during the 2-week infusion trial, despite wearing elastic stockings and keeping her legs elevated whenever possible. She did not experience any other significant side effects. Her edema finally resolved 2 days after termination of the epidural infusion. Peripheral edema may occur and persist during epidural morphine infusion. This report represents the first case report, to the best of our knowledge, describing severe peripheral edema in an otherwise healthy patient while on epidural morphine administration during an outpatient epidural morphine infusion trial. This case report shows that continuous epidural morphine infusion, even in small dose, may cause peripheral edema in some patients.

Priapism — A Rare Complication Following Continuous Epidural Morphine and Bupivacaine Infusion

Background: Intraspinal drug delivery (IDD) therapy has been increasingly used in patients with intractable, nonmalignant pain who fail to respond to conventional treatment or can not tolerate systemic opioid therapy due to side effects. By infusing a small amount of analgesics directly into the cerebrospinal fluid (CSF) in close proximity to the receptor sites in the spinal cord, one is able to achieve the spinally mediated analgesia, sparing side effects ffrom systemic opioids. Prior to permanent intraspinal pump implantation, an intraspinal opioid screening trial is required to document the efficacy of intraspinal opioid for analgesia. Although there are a few approaches in conducting such screening trials, a patient-controlled continuous epidural morphine infusion trial, performed in an outpatient setting, is widely accepted by many interventional pain specialists. The major advantage of conducting an outpatient functional opioid infusion trial versus an inpatient trial is that it more closely mimics what the patient does in his or her usual activities of daily living, therefore minimizing the false positive rate of the inpatient screening trial. Objective: To describe a rare complication, priapism, observed during an outpatient continuous epidural morphine and bupivacaine infusion trial. Case Report: A 49-year-old male with intractable, chronic low back pain due to diffuse lumbar degenerative disc disease, lumbar spondylosis referred to our clinic for consideration of IDD therapy, after failing to respond to multi-modality pain management including medications, physical therapy with modality, transcutaneous nerve stimulation (TENS), and various interventional procedures. Following a pre-implant psychological evaluation, he was scheduled for the outpatient epidural morphine and bupivacaine infusion trial. A tunneled lumbar epidural a catheter was placed at L3-L4 with the catheter tip advanced to L1 under fluoroscopic guidance. The proximal tip of the catheter was then tunneled, subcutaneously, and connected to a MicrojectTM PCEA pump (Codman, Raynham, MA, USA) and reservoir bag containing preservative-free morphine 0.4 mg/mL and bupivacaine 0.016%. The pump was programmed to deliver a basal rate of 0.5 mL/h. The bolus dose was 0.2 mL with a 60-minute lock out interval. The patient was instructed how to use the pump properly before discharging home. Two hours following the initiation of infusion trial, the patient started to experience penile erection. It was initially painless, but became progressively painful and intensified. The unremitting priapism lasted 8 hours, finally resolving 2 to 3 hours after discontinuing the infusion. The patient recovered fully without any sequelae. Conclusion: Priapism may occur as a rare complication following epidural morphine administration. This report represents the third case report thus far in the literature revealing priapism induced by epidural morphine administration, yet, it is the only report, to our knowledge, describing priapism occurring in a patient undergoing an outpatient epidural morphine and bupivacaine infusion trial. We believe that epidural morphine, rather than bupivacaine, is responsible for causing priapism in this patient, through a yet to be defined spinal mechanism. Key words: Epidural morphine and bupivacaine infusion trial, intraspinal drug delivery pump, priapism

Cancer Pain Management by Continuous Epidural Morphine Infusion via Subcutaneous Tunneling

Background: Most terminal cancer patients suffered from intractable pain. For the treatment of these patients, opioids, via various routes, are usually administered. Continuous epidural opioid, especially morphine, administration is a good method for the management of intractable cancer pain. Methods: We retrospectively analyzed 347 terminal cancer patients, who had been treated with continuous epidural morphine infusion, between 1999 and 2004. For the epidural infusion, an epidural catheter was inserted, tunneled subcutaneously and exited from the anterior chest or abdomen. Multiday (Baxter, 0.5 ml/h) was used for the continuous infusion. Results: Of the 347 patients studied, there were 211 males and 136 females. The mean treatment time was 54.7 days, ranging from 5 to 481 days. The mean starting and termination doses of morphine were 32.4 (for 5 days) and 100.0 mg, respectively. The doubling time of the morphine dose was 26.3 days, corresponded to a 3.8 percent increase per day. Incidental catheter removal was the most common side effect, which occurred 130 times in 61 cases. Conclusions: The procedure of epidural catheterization, with subcutaneous tunneling, was simple and inexpensive. Despite the disadvantages, such as incidental catheter removal, it is a useful method for the control of terminal cancer pain.

The Optimal Dose Range of Epidural Naloxone to Minimize Nausea during Continuous Epidural Infusion of Morphine

The Optimal Dose Range of Epidural Naloxone to Minimize Nausea during Continuous Epidural Infusion of Morphine

Continuous epidural morphine infusion against postoperative pain

Continuous epidural morphine infusion against postoperative pain

Characteristics of Tolerance to Somatic and Visceral Antinociception After Continuous Epidural Infusion of Morphine in Rats

A continuous epidural infusion of morphine may cause a complicated tolerance to develop, depending on the spinal and supraspinal sites. We designed this study to clarify the characteristics of the tolerance to somatic and visceral antinociception after epidural morphine infusion. Rats received epidural infusion of morphine at the rates of 50 or 100 microg kg(-1) h(-1), or isotonic sodium chloride solution for 7 days. The tail-flick (TF) test and colorectal distension (CD) test were used to measure the somatic and visceral antinociceptive effects, respectively. Nociceptive tests were performed on Days 1, 2, 3, 4, and 7. After 7 days, time-response curves after epidural morphine (10 microg) or intraperitoneal morphine (3 mg) challenge tests were conducted to assess the magnitude of tolerance. Epidurally infused morphine significantly increased percent maximal possible effects (%MPEs) (P < 0.05) in both the TF and CD tests, depending on the concentration of morphine. In the epidural morphine challenge test, increases in %MPEs were significantly attenuated (P < 0.05) in the morphine-infused group compared with the isotonic sodium chloride solution-infused group. The increases in %MPEs in the intraperitoneal challenge test were also attenuated in the morphine-infused group. We conclude that morphine tolerance to both somatic and visceral antinociception develops rapidly during epidural infusion and is based on the development of tolerance at the systemic, as well as the epidural, level. A continuous epidural infusion of morphine rapidly induces tolerance to visceral and somatic antinociception in rats. This development is based on the development of tolerance at the systemic, as well as the epidural, level.

Characteristics of Tolerance to Somatic and Visceral Antinociception After Continuous Epidural Infusion of Morphine in Rats

Characteristics of Tolerance to Somatic and Visceral Antinociception After Continuous Epidural Infusion of Morphine in Rats

Prolonged Urinary Retention following Continuous Epidural Infusion of Morphine and Fentanyl Using Continuous Drug Infusor: A case report

Prolonged Urinary Retention following Continuous Epidural Infusion of Morphine and Fentanyl Using Continuous Drug Infusor: A case report

リドカイン・モルヒネを併用した持続硬膜外鎮痛法による術後とう痛管理の検討

リドカイン・モルヒネを併用した持続硬膜外鎮痛法による術後とう痛管理の検討

Analgesic Effects according to the Dose of Continuous Epidural Infusion of Morphine and Clonidine after Epidural Anesthesia for Cesarean Section

Analgesic Effects according to the Dose of Continuous Epidural Infusion of Morphine and Clonidine after Epidural Anesthesia for Cesarean Section

Comparison of Postoperative Analgesia and Side Effects of Continuous Epidural Morphine Infusion and Continuous Intravenous Morphine Infusion following Cesarean Section

Comparison of Postoperative Analgesia and Side Effects of Continuous Epidural Morphine Infusion and Continuous Intravenous Morphine Infusion following Cesarean Section

Analgesic effects of continuous epidural infusion of morphine and bupivacaine after cesarean section

Analgesic effects of continuous epidural infusion of morphine and bupivacaine after cesarean section