Continuous Intravenous Morphine Infusion Research Articles

The Effect of Analgesia with Ketamine, Morphine and Paracetamol for Burn Pain in North-Eastern Iran

Background: Pain is a common and challenging problem in burn patients. The severity of pain in these patients often requires multi drug therapy. On the other hand, with increasing the number and dosage of drugs, the complications increase, so finding an instruction that provides acceptable analgesia with minimal complications is necessary.
 Methods: Based on the dose and half-life, the initial dose for paracetamol was 15 mg/kg every 6 hours, this dose was reduced to 30% after three days of initiation of the treatment to prevent liver toxicity and was discontinued after one week. Morphine started with an initial dose of 0.01 mg/kg/h and for opioid-tolerant patients, the initial dose was 0.02 mg/kg/h. Morphine infusion dose raised by 30 percent every week. The continuous intravenous infusion of ketamine (0.15 mg/kg/hr) with continuous intravenous infusion of morphine was administered by a silicone pump.
 Results: The mean NRS was significantly reduced in the first visit after the intervention (three hours later) (8.5 ± 1.04 vs.3.9 ± 1.74; p <0.001) and this decrease was observed in NRS in continuous observations (P> 0.001). Pain reduction was independent of history of opioids use.
 Conclusion: Continuous infusion of ketamine, morphine and paracetamol showed an effective pain management program for burn patients.

Adverse Drug Reactions in Japanese Patients with End-Stage Heart Failure Receiving Continuous Morphine Infusion: A Single-Center Retrospective Cohort Study.

BackgroundOpioids have been reported to be effective for refractory dyspnea in patients with advanced heart failure (HF) in the palliative care setting.ObjectiveThe aim of this study was to evaluate the incidence of adverse drug reactions (ADRs) and their relationship with morphine dose/duration or renal insufficiency in patients with end-stage HF receiving continuous morphine infusion.MethodsWe retrospectively studied 38 patients with end-stage HF receiving continuous intravenous or subcutaneous morphine infusion for the relief of breathlessness between 2014 and 2019 (mean age 78 years). The endpoints were nausea/vomiting, respiratory depression, and drowsiness, which are common morphine-related ADRs.ResultsOf 38 patients with end-stage HF receiving continuous intravenous/subcutaneous morphine infusion, 14 (37%) experienced ADRs. The median estimated glomerular filtration rate (eGFR) was lower in patients with than in those without ADRs (16 [range 9–48] vs. 41 [range 8–133], respectively; p = 0.011). The ADRs with the highest incidence were drowsiness (n = 13), nausea/vomiting (n =5), and respiratory depression (n =3). There were no differences in the maintenance dose or duration of morphine administration between patients with and without ADRs. A baseline eGFR of 32 mL/min/1.73 m2 was a good cutoff value for ADR prediction (sensitivity 86%, specificity 96%). A baseline eGFR < 32 mL/min/1.73 m2 was significantly associated with the occurrence of morphine-related ADRs (odds ratio 6.63, 95% confidence interval 1.19–37.01).ConclusionsOur results showed that 37% of patients with end-stage HF receiving continuous intravenous/subcutaneous morphine infusion experienced ADRs, especially drowsiness. Patients with eGFR < 32 mL/min/1.73 m2 were likely to experience morphine-related ADRs.

Impact of Opioid Administration in the Intensive Care Unit and Subsequent Use in Opioid-Naïve Patients.

Opioids are a mainstay of therapy for patients in the intensive care unit (ICU) as part of the analgesia-first approach to sedation. Despite knowledge of acute consequences of opioid based analgosedation, less is known about the potential long-term consequences, including the effect of opioid administration in the ICU on subsequent opioid use in opioid-naïve patients. To evaluate the relationship between ICU opioid administration to opioid-naïve patients and subsequent opioid use following discharge. A query of the electronic medical record was performed to identify opioid-naïve adult patients admitted directly to an ICU. Patients who received continuous intravenous infusion of fentanyl, hydromorphone, or morphine were screened for inclusion into the analysis. Of the 342 patients included for analysis, 164 (47.1%) received an opioid at hospital discharge. In total, 17 of the 342 patients (5.0%) became long-term users, noted to be more common in patients who received an opioid prescription at discharge (8.7% vs 1.6%; P = 0.006). Neither total ICU morphine milligram equivalent (MME) nor average daily ICU MME administration were found to correlate with daily MME prescription quantity at discharge (R2 = 0.008 and R2 = 0.03, respectively). Following control for potentially confounding variables, total ICU MME administration remained an insignificant predictor of subsequent receipt of an opioid prescription at discharge and long-term opioid use. This study failed to find a significant relationship between ICU opioid use in opioid-naïve patients and subsequent opioid use. These findings highlight the need to focus on transitions points between the ICU and discharge as potential opportunities to reduce inappropriate opioid continuation.

Analgesic efficacy of continuous intravenous infusion of morphine in patients after hip and knee joint endoprosthetics: prospective study

Objectives of the study was to evaluate the possibility of using and the frequency of side effects of continuous intravenous morphine infusion for patients after arthroplasty of the lower limbs joints. Materials and methods. In the prospective study the results of treatment of 2 groups of patients were compared: after total knee arthroplasty (n = 52) and after total hip arthroplasty (n = 52). The rate of morphine administration in the total knee arthroplasty group ranged from 0.6 to 1.6 mg/hour, in the total knee arthroplasty group it was from 0.4 to 1.4 mg/hour. Continuous infusion of morphine was continued 24 hours after surgery. Indicators of systemic hemodynamics, gas exchange, pain and sedation were recorded. Results. The use of the technique of continuous intravenous infusion of morphine has shown the adequate level of anesthesia. An optimal balance between adequate analgesia, sedation and the absence of respiratory depression can only be achieved through a low rate of morphine administration. There was no significant difference in the incidence of complications and side effects (nausea, vomiting, acute urinary retention, delirium) in the groups with knee and hip arthroplasty. Conclusion. The technique provided, on the one hand, a good analgesic effect and sedation, but on the other hand, it was quite laborious and required careful monitoring of the parameters of the respiratory and cardiovascular systems. It is especially necessary to carefully monitor the indicators of vital functions in the evening and night hours.

Anesthetic management in laparoscopic living donor hepatectomy, the first case-series in Thailand

Background: Laparoscopic living donor hepatectomy began early in 2020 at our institution. This surgery was the first case and a new experience in Thailand. Perioperative and anesthetic management should not only concern anesthetic and surgical com plications but also graft function, including ischemic time. In this paper, we review anesthetic considerations and perioperative management in laparoscopic living donor hepatectomy as a new experience in Thailand. Methods: All four living donors were selected and underwent elective laparoscopic living donor hepatectomy at the university hospital. Results: Differences in anesthetic considerations between laparoscopic liver resection in pathologic livers versus donor liver graft typically include heparin administration, intravenous indocyanine green, and prolong ischemic time after major vessels clamping. During the operation, only one case had subcutaneous emphysema and one other case had oliguria. There were no in traoperative hypothermia in all cases. All the patients were able to be extubated at the end of surgery inside the operation room. For postoperative pain control, two cases were given intravenous morphine patient-controlled analgesia, while the others were given continuous intravenous morphine infusion. However, emergent explore laparotomy was performed in one case to stop postoperative bleeding from the surgical site. Conclusions: The advantages of minimal invasive technique include a potential reduction in blood loss and transfusion require ment, lower incidence of intraoperative hypothermia, as well as decreased postoperative pain and opioid consumption. However, complications that must be taken into account include the effect of pneumoperitoneum, patient’s positioning, and emergent conversion to open surgery. As this surgery is largely dependent on the surgeon’s experience, operation time may be extended in some cases. As an anesthesiologist, practical and effective anesthetic management is essential to improve patient outcomes.

Breakthrough cancer pain tailored treatment: which factors influence the medication choice? An observational, prospective and cross-sectional study in patients with terminal cancer

BackgroundVarious options for the pharmacological treatment of breakthrough cancer pain (BTcP) are available. International guidelines on BTcP treatment are not univocal. A tailored treatment should be based on the assessment...

R5 Continuous Infusion for Pain Control after Pediatric Cardiothoracic Surgery Associated with Longer Length of Stay

Subjects were patients aged 3 months-4 years post-cardiac surgery with a midline sternotomy incision and planned early extubation at Advocate Children's Hospital-Oak Lawn. Sixty subjects were randomized to receive either a continuous infusion of morphine and midazolam or normal saline. The infusion group received a continuous intravenous morphine infusion at 0.03 mg/kg/hr along with a midazolam drip at 0.03 mg/kg/hr. Morphine bolus doses were available at 0.05 mg/kg/dose every two hours and midazolam 0.05 mg/kg/dose every one hour. Additional doses available at the discretion of the treating team. The control group received a normal saline infusion and the same bolus dosing. Providers were blinded to the infusion, but not to the bolus doses. Both groups received acetaminophen and ketorolac. FLACC scores were recorded hourly and as needed. There was no difference in number of bolus medication received between groups (p=0.39 for morphine, p=0.8 for midazolam). The mean FLACC score was 1.58 in the bolus group and 1.34 in the infusion group (p=0.35). Total morphine dose given was higher in the infusion group (0.23 mg/kg versus 0.9 mg/kg, p<0.01). Total midazolam dose given was higher in the infusion group (0.18 mg/kg versus 0.9 mg/kg, p<0.01). The length of ICU stay (LOS) was longer in the infusion group (4.5 days versus 2.7, p=0.03). The total hospital LOS was also longer in the infusion group (8.4 days versus 4.9, p=0.03). The addition of a continuous infusion did not decrease the amount of intermittent bolus doses or improve FLACC scores. Subjects in the infusion group did receive a significantly higher total dosage of these medications. We speculate that these higher doses led to longer ICU and hospital lengths of stay. Based on these findings, use of continuous infusions should be discouraged as routine practice after pediatric cardiac surgery in this age group.

Ultrasound-guided continuous thoracic paravertebral analgesia with bupivacaine versus continuous intravenous morphine infusion for unilateral multiple fracture ribs

Background Rib fractures are common, and pain from rib fractures can be difficult to control, particularly in first few days. This pain may affect the pulmonary functions, morbidity, and mortality. Objective The aim of this study was to compare and evaluate the efficacy of ultrasound-guided continuous thoracic paravertebral block (USG-TVPB) using bupivacaine versus continuous intravenous morphine infusion (IVMI) in pain relief for patients with unilateral multiple fractured ribs (UMFRs) and on pulmonary function improvement. Patients and methods The study included 70 ICU patients of both sexes, aged 18–60 years with ASA physical status class I to III who had unilateral three or more ribs fracture. According to the conducted method for relief of fracture rib pain, these patients were assigned into two equal groups with 35 patients in each. The first group patients (USG-TPVB) received ultrasound-guided thoracic paravertebral analgesia using bupivacaine. The second group patients (IVMI group) received intravenous morphine infusion. The recorded data included patients demographic variables, pain severity, pulmonary mechanics, arterial blood gases, hemodynamic changes, analgesic request/day, total rescue morphine analgesic dose, and total ketorolac dose over 4 days of ICU stay, and hospital stay durations, and adverse effects. Results After the start of analgesic regimen, the patients who received continuous thoracic paravertebral bupivacaine infusion (USG-TPVB group) were significantly better than those received continuous IV morphine infusion (IVMI group), where the forced vital capacity was significantly higher in USG-TPVB group than in IVMI group at 30 min, 24 h, and 48 h (P Conclusion Ultrasound-guided continuous thoracic paravertebral analgesia with bupivacaine provided better pain control with improved pulmonary functions than continuous systemic intravenous morphine analgesia in unilateral multiple rib fractures with less rescue analgesic requests, shorter length of ICU stay, and less adverse effects.

Continuous Intravenous Morphine Infusion for Severe Dyspnea in Terminally Ill Interstitial Pneumonia Patients.

The aims of this study were to evaluate the efficacy and safety of continuous morphine infusion for dyspnea in patients with acute exacerbation (AE) of end-stage interstitial pneumonia (IP). We conducted a retrospective study. Based on the subjective clinical effectiveness ratings of "good," "moderate," "poor," or "unknown," the efficacy of continuous morphine infusion treatment was evaluated as defined as symptom relief that was "good" or "moderate." This study included 22 consecutive opioid-naïve patients who received continuous morphine infusion in the palliative treatment of dyspnea resulting from AE-IP. Of 22 patients, nine achieved good dyspnea relief, eight had moderate relief, four had a poor response and one response was "unknown" within 24 hours of starting morphine infusion. Using an operational definition of dyspnea relief that was rated "good" or "moderate," the efficacy rate of morphine was 77% (n=17). There was a significant change in the respiratory rate (25 respirations per minute at baseline vs. 17 respirations per minute after 12 hours, p=0.02), however, none of the patients studied had fewer than eight respirations per minute. We conclude that continuous morphine infusion is an effective and safe therapy for severe dyspnea in terminal AE-IP patients without any serious adverse events.

Effects of continuous intravenous infusion of morphine and morphine-tramadol on the minimum alveolar concentration of sevoflurane and electroencephalographic entropy indices in dogs

ObjectiveTo compare the effects of continuous rate infusions (CRIs) of intravenous (IV) morphine and morphine-tramadol on the minimum alveolar concentration (MAC) of sevoflurane, and on electroencephalographic entropy indices in dogs. DesignProspective study. AnimalsEight young, healthy German shepherds, weighing 26.3 ± 3.1 kg (mean ± SD). MethodsAnaesthesia was induced and maintained with sevoflurane. A standard tail-clamp technique was used for MAC determination. Within one anaesthetic period, MAC was first determined during sevoflurane anaesthesia alone (MACB); then during morphine infusion (MACM), (loading dose 0.5 mg kg−1IM; CRI, 0.2 mg kg−1hour−1) then finally during morphine-tramadol infusion (tramadol loading dose 1.5 mg kg−1IV; CRI, 2.6 mg kg−1 hour−1) (MACMT). At each change, periods of 45 minutes were allowed for equilibration. Stated entropy (SE), response entropy (RE), and RE-SE differences were measured five minutes prior to and during tail clamping. ResultsThe MACB was 2.1 ± 0.3vol%. The morphine and morphine-tramadol infusions reduced MAC to 1.6 ± 0.3vol% and 1.3 ± 0.3vol%, respectively. MAC was decreased below baseline more during morphine-tramadol than during morphine alone (39 ± 9% versus 25 ± 6%, respectively; p = 0.003). All SE and RE and most RE-SE differences were increased significantly (p < 0.05) over pre-stimulation in all groups when the dogs responded purposefully to noxious stimulation. When no response to noxious stimulation occurred, the entropy indices did not change. Conclusion and clinical relevanceIn dogs, combined morphine-tramadol CRI decreased sevoflurane MAC more than morphine CRI alone. Entropy indices changed during nociceptive responses in anaesthetized animals, suggesting that entropy measurements may be useful in determining anaesthetic depth in dogs.

Effects of dexmedetomidine versus morphine on surgical stress response and analgesia in postoperative open cardiac surgery

Background The aim of this study was to compare between dexmedetomidine and morphine for use as sedative/analgesics and to evaluate their effects on surgical stress response during the first 24 h following open cardiac surgery in the Cardiac Intensive Care Unit (CICU). Patients and methods The present double-blind study was carried out on 30 adult patients 60 years of age or older admitted to the Cardiothoracic Surgery Department of the Alexandria Main University Hospital of ASA physical status grade II and III, scheduled for elective coronary artery bypass grafting surgery under general anesthesia. Immediately after sternal closure at the end of surgery, patients were classified randomly using the closed-envelope technique into two equal groups, started immediately on a continuous intravenous infusion (without a loading dose) of either dexmedetomidine or morphine and continued for 24 h postoperatively. Dexmedetomidine group (group D): dexmedetomidine was prepared at a concentration of 0.1 μg/kg/ml and was infused at a dose of 0.1-0.7 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Morphine group (group M): morphine was prepared at a concentration of 10 μg/kg/ml and was infused at a dose of 10-70 μg/kg/h (equivalent to an infusion rate of 1-7 ml/h). Patients were followed up in the CICU for the first 24 h following open cardiac surgery on the basis of hemodynamic changes, plasma interleukin (IL)-6 and cortisol levels, time to successful tracheal extubation, postoperative pain, incidence of delirium, and postoperative nausea and vomiting. Results The mean heart rate values were significantly lower in group D compared with group M during most of the postoperative period. The mean values of systolic blood pressure, diastolic blood pressure, and mean arterial pressure, on comparing the two groups, had showed no statistically significant difference during the entire postoperative period. The mean values of IL-6, cortisol, and glucose were increased significantly in group M relative to group D at 6 and 24 h postoperatively. Time to successful tracheal extubation was significantly shorter in patients of group D than in patients of group M. Visual analogue scale for pain score and Motor Activity Assessment Scale for sedation score showed no significant difference when both groups were compared during the entire postoperative period. The total number of patients with delirium was significantly fewer in group D than group M. The incidences of nausea and vomiting events were insignificantly lower in group D than group M. Conclusion The administration of dexmedetomidine exerted a potent negative chronotropic effect with decreased heart rate. Both dexmedetomidine and morphine equivalently decreased the blood pressure (systolic blood pressure, diastolic blood pressure, and mean arterial pressure) in a range of 15-20% in relation to the preoperative readings. Dexmedetomidine significantly attenuated the surgical stress response and the neuroendocrine response in comparison with morphine through the suppression of the postoperative increase of IL-6 and cortisol, respectively. Dexmedetomidine had promoted earlier recovery and tracheal extubation than morphine, with no accompanying respiratory depression. Both dexmedetomidine and morphine were efficient sedative/analgesics for postoperative cardiac surgery. Dexmedetomidine significantly reduced the incidence and duration of delirium after cardiac surgery.

Cooperation between Heart Failure Center of Hiroshima University Hospital and a regional medical facility: Option for an end-of-life heart failure patient receiving palliative care

A 64-year-old woman with recurrent mitral valve stenosis was hospitalized 30 years after open commissurotomy. Severe right cerebral embolism occurred at age 58, with left hemiparesis. She was debilitated with cardiac cachexia. Based on symptomatic valvular disease findings, surgery was considered, but deemed too high risk due to the combined insufficiencies. She refused this surgical operation and requested conservative therapy. Optimized medication and cardiac rehabilitation improved her general condition allowing transfer to another hospital. We explained the short life expectancy both to her and to her family. They decided to transfer to a hospice at a chronic care hospital and she was given best supportive care. Eventually, her urine output decreased and respiration deteriorated. She and her family refused resuscitation in the event of cardiopulmonary arrest, requesting only suffering reduction. Thus, continuous intravenous infusion of morphine was started. The optimized doses for pain alleviation were determined in consultation with palliative care specialists and maximized her consciousness level for the last four days.“Heart-failure hospice” is potentially a place to die for end-of-life patients, attended by their families and healthcare providers. They need prognostic information and options for end-stage. Our experience confirms results about palliative care from previous studies conducted overseas demonstrating the effectiveness of opioids relieving end-stage symptoms.<Learning objective: Perform an appropriate end-of-life assessment for patients with irreversible severe heart failure. Formulate appropriate plans for further evaluation and management, including referral and consultation to palliative care specialists when necessary. Develop an appropriate regional cooperation, with consideration given to the less common optional treatment for cardiac dysfunction, “heart-failure hospice.”>

Intrathecal neurolytic block in a patient with refractory cancer pain

We report the successful treatment of refractory cancer pain by bilateral intrathecal neurolysis using phenol-glycerol. A 60-year-old man had recurrent sigmoid cancer and metastases to the lumbar (L4-5) and sacral bones. He complained of refractory pain in the lower back and lower extremities despite high-dose opioid treatment based on the WHO ladder. On admission to our hospital, he received continuous intravenous infusion of morphine (7,000mg/day) with ketamine (300mg/day) and lidocaine (700mg/day). Intravenous midazolam was required to treat extreme anxiety. Because of inadequate pain relief and severe drowsiness, intrathecal phenol-glycerol neurolytic block was performed twice at the L2/3 intervertebral space. His analgesia was greatly improved and high-dose intravenous opioid was retitrated and ceased. He remained comfortable and lucid at home for 2months, until 2days before his death at hospital. Intrathecal neurolytic block may be appropriate for some patients suffering from refractory pain that is resistant to conventional opioid analgesic treatment.

Continuous Intravenous Morphine Infusion for Postoperative Analgesia Following Posterior Spinal Fusion for Idiopathic Scoliosis

A retrospective study of postoperative pain management. Evaluate the efficacy and safety of continuous intravenous morphine infusion for postoperative pain management in patients with idiopathic scoliosis (IS) undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI). Postoperative pain is a common problem following surgery for IS. There are no published reports regarding the use of a continuous intravenous morphine infusion for this patient population. We retrospectively reviewed data regarding 339 consecutive patients with IS who underwent PSF and SSI between 1992 and 2006. All patients received intrathecal morphine after the induction of general anesthesia. Following surgery, preordered morphine infusion (0.01 mg/kg/h) was started at first reported pain. The infusion rate was titrated based on vital signs, visual analog scale (VAS) pain scores (0-10), and clinical status. It was continued until patients were able to take oral analgesics. We reviewed intrathecal morphine dosage, VAS pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirements in the first 48 hours, and any adverse reactions (nausea/vomiting, pruritus, respiratory depression, and pediatric intensive care unit admission). Mean intrathecal morphine dose was 15.5 +/- 3.9 microg/kg and mean interval to start of the intravenous morphine infusion was 17.5 +/- 5 hours. Mean VAS pain scores were 3.1, 4.5, 4.5, and 4.6 at 12 hours, 1, 2, and 3 days after surgery, respectively.The total mean morphine dose in the first 48 hours postoperatively was 0.03 +/- 0.01 mg/kg/h. Total morphine received was 1.44 +/- 0.5 mg/kg. Nausea/vomiting and pruritus, related to the morphine infusion occurred in 45 patients (13.3%) and 14 patients (4.1%), respectively. No patients had respiratory depression or required Pediatric Intensive Care Unit admission. A low frequency of adverse events and a mean postoperative VAS pain score of 5 or less demonstrate that a continuous postoperative morphine infusion is a safe and effective method of pain management in patients with IS following PSF and SSI.

Safety and efficacy of continuous morphine infusions following pediatric cranial surgery in a surgical ward setting

Morphine is avoided by many neurosurgeons following cranial surgery. There exists a concern regarding the potential complications and a perception that cranial surgery is less painful than other surgical procedures. At British Columbia Children's Hospital continuous morphine infusions (CMI) have been used to control pain in pediatric neurosurgical patients. The purpose of this study was to compare the safety and efficacy of continuous intravenous morphine infusion to standard oral analgesics in a neurosurgical ward setting. A retrospective review of medical records for 71 children was completed. The patients underwent either cranial reconstruction (2002-2007) or craniotomies for intradural pathology (2005-2007) at British Columbia Children's Hospital. Outcome measures included pain control and adverse events. Comparison was made between patients receiving a CMI and patients receiving acetaminophen and codeine. Thirty-seven children received CMI on the ward (30 cranial reconstruction and 7 craniotomy), while 34 (10 cranial reconstruction and 24 craniotomy) received acetaminophen and codeine. There was no statistical difference in pain control. There was significantly more nausea on post-operative day one in the CMI group (p = 0.002). There were no other significant adverse events. These findings suggest that CMI is comparable to acetaminophen and codeine with respect to analgesia and serious side effects. We recommend the use of CMIs as an alternative when pain is poorly controlled in post-operative pediatric neurosurgical patients to prevent the potential adverse consequences of inadequate analgesia.

Management of Pain in Terminal Lung Cancer Patients Role of Continuous Intravenous Infusion of Morphine

Management of Pain in Terminal Lung Cancer Patients Role of Continuous Intravenous Infusion of Morphine

Evaluation of a local anesthetic delivery system for the postoperative analgesic management of canine total ear canal ablation – a randomized, controlled, double-blinded study

ObjectiveTo determine if a constant rate local anesthetic delivery system is more effective than continuous intravenous (IV) morphine infusion for postoperative analgesia. AnimalsTwenty client-owned dogs undergoing total ear canal ablation. MethodsDogs were randomly assigned to the lidocaine group (LID) or the morphine group (MOR). The LID group received a constant rate infusion of lidocaine locally and a continuous IV infusion of saline, while the MOR group received a constant rate infusion of saline locally and a continuous IV infusion of morphine. The primary investigator evaluated each patient and determined a hospital behavior score, anesthesia recovery score, preoperative pain score, and serial postoperative pain and sedation scores over 38 hours. Pain and sedation observations were videotaped and scored by three additional evaluators. Evaluators were blinded to treatment assignments. ResultsThere were no significant differences in age, weight, hospital behavior scores or anesthesia recovery scores. The primary investigator's pain scores were not significantly different, but sedation scores were significantly lower for the LID group. Sedation and pain scores by the video evaluators were not significantly different between groups. Kappa agreement between observers was poor, but better agreement was noted between sedation scores than pain scores. Drug-related complications were significantly lower in the LID group (n = 0) compared with the MOR group (n = 5). Wound complications were not significantly different (LID = 4, MOR = 4). Intravenous delivery complications occurred in 12 (60%) patients. Local delivery complications occurred in five (25%) dogs. Delivery complications were not significantly different between groups. Conclusions and clinical relevanceContinuous incisional lidocaine delivery was an equipotent and viable method of providing postoperative analgesia compared with IV morphine. Lidocaine delivery resulted in a trend toward lower pain scores, significantly lower sedation scores, and no dogs requiring analgesic rescue. Wound complications secondary to local infusion were minor and self-limiting. Drug-related complications occurred only in the MOR group.

Postoperative pain and pulmonary complications: Comparison of three analgesic regimens

In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05).

A Randomized Controlled Trial of Patient Controlled Analgesia Versus Continuous Infusion of Morphine during Vaso-Occlusive Crisis in Sickle Cell Disease.

Pain during vaso-occlusive crisis (VOC) in sickle cell disease (SCD) is commonly treated with continuous intravenous infusion (CI) of morphine. During CI the treating physician titrates the dose of morphine until adequate relief of pain has been established. Patient controlled analgesia (PCA) allows the patient to self-administer doses of morphine for the relief of pain and has shown to be equianalgesic in post surgical patients with lower morphine consumption than with CI of morphine. Morphine has many dose-related side-effects and high plasma levels of morphine are associated with serious complications. Therefore, we conducted the first randomized controlled trial to compare the administration of morphine with PCA versus CI in sickle cell patients with VOC. 26 consecutive episodes of VOC in 21 patients with SCD were included. Patients were randomized between PCA and CI of morphine within 24 hours after hospital admission. Endpoints of the study were: the mean and cumulative morphine dose, pain intensity and quality of life (QoL). Pain intensity was measured daily using a ten-point-scale verbal pain score. Reduction of pain intensity was measured by subtracting a pain score on a ten point visual analogue scale (VAS) before randomization from the same measurement two days after randomization. QoL was measured using the Medical Outcomes Study 36-item Short Form Healthy Survey (SF36).Patients with PCA demonstrated to have significant lower morphine consumption as compared to patients randomized to CI. The mean and total cumulative morphine dose was 0.5 mg/h and 33 mg in the PCA-group versus 2.3 mg/h and 275 mg in the CI-group, respectively (p=0.02 and p<0.001). The pain intensity was not different between the groups. The mean daily ten-point-scale verbal pain score was 5.1 in the PCA group versus 5.3 in the CI-group (p=0.20). Reduction in pain intensity (VAS) two days after randomization was −2.4 in the PCA-group versus −3.8 in the CI-group (p=1.00). Also no difference in QoL was found.We conclude that the use of PCA in sickle cell patients with VOC results in adequate pain relief at a significant lower morphine dose as compared to morphine administration by continuous infusion. [Display omitted]

As-Needed Morphine: Yes, but at What Dose and at What Interval?

In response to a clinical case of a patient with severe pain requiring large doses of morphine, a question arose about the appropriate dose and schedule of as-needed (PRN) rescue morphine. After receiving varied local opinions, this question was investigated further by providing the following case scenario to several clinicians recognized for their expertise in pain management. Mrs Smith is an elderly woman with advanced, incurable cancer. She has recently been requiring large doses of morphine to control her pain. Her oral morphine dose for the last 2 weeks has been 1,000 mg of sustainedrelease morphine every 8 hours (a total of 3,000 mg/d). She has not had any undue toxicity from this dose. She is awake and alert and her constipation is controlled with appropriate laxatives. During the previous 2 weeks, she has developed exacerbated pain with an average daily pain score of 8 of 10. It is decided to admit her to the hospital and give her parenteral morphine to improve her pain control. For this exercise, assume that an appropriate evaluation was done, and no treatment other than narcotics is deemed necessary. After admitting her to the hospital, the attending physician calculates that she ought to have a 50% increase in her morphine equivalent dose. This equates to 4,500 mg/d of oral morphine. It is decided to translate this into an intravenous dose by dividing this by one third. This is calculated to be 1,500 mg/d of intravenous morphine. It is opted to administer this as a continuous intravenous morphine infusion of 60 mg/h. Because the physician is working with an experienced group of oncology nurses with hospice experience, and the physician plans to leave the hospital grounds (and will be available by pager for questions and emergencies, of course), she decides to order a PRN morphine dose for uncontrolled and/or breakthrough pain. She asks you for advice. The following two questions were asked of the experts: (1) What is the most appropriate intravenous bolus morphine PRN dose that should be given to this patient in the event that she still has severe pain (with a pain score of 7 to 8 of 10)? ___ mg. (2) At which intervals can this PRN morphine dose appropriately be repeated, assuming that the patient still has uncontrolled pain? ___ 10 minutes, ___ 15 minutes, ___ 30 minutes, ___ 60 minutes, ___ or other, please describe _____________________. The expert clinicians listed in Table 1 replied; their responses are listed in Table 2 Given the above-illustrated opinion conflicts, with a 10-fold variation in dose and a six-fold variation in timing interval, a search through published sources was conducted, mirroring a wide range of combinations regarding recommendations for both the PRN narcotic doses and the appropriate intervals at which they should be repeated in the event of continued pain. Data from 22 review articles and texts that review guidelines for the treatment of cancer pain, presented in Table 3, provided a 20-fold variation in recommended narcotic doses (1% to 20% of daily doses) along with scattered opinions, or no direction, regarding appropriate dose intervals for potential repeat doses. From the Department of Medicine and Department of Oncology, Mayo Clinic, Rochester, MN.