Continuous Intravenous Morphine Research Articles

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.

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.

Serratus intercostal interfascial plane block in supraumbilical surgery: a prospective randomized comparison.

Upper abdominal wall surgical incisions may lead to a severe postoperative pain. Therefore, adequate analgesia is important. Here we investigate whether the low serratus-intercostal interfascial plane block (SIPB) achieves an effective analgesia, considering opioids consumption, pain control and recovery quality in upper abdominal surgeries. This blinded, randomized controlled study was conducted on 102 patients undergoing open upper abdominal wall surgery under general anesthesia. All patients who received serratus-intercostal plane block at the eighth rib as analgesic technique were included in SIPB group and in control group those who received continuous intravenous morphine analgesia. Pain scores in numeric verbal scale (NVS) and opioids consumption at 0, 6, 12, 24 and 48 hours postoperatively were assessed. The quality of the postoperative recovery was evaluated using the QoR-15 questionnaire at 24 hours. This study showed lower postoperative opioid consumption at 24 hours (P<0.0001; 4.17 mg vs. 41.52 mg of morphine) and better pain control (P<0.005) with mean pain scores (NVS 1.8±1.5 vs. 4.8±1.6) in group 0 (SIPB). The global QoR-15 scores 24 hours postoperatively were higher (better quality) in the SIPB group (122 vs. 100). The low serratus-intercostal interfascial plane block (SIPB) provides efficient analgesia leading to a saving of opioids and improvement of the recovery quality in patients undergoing upper abdominal wall surgeries.

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.

Comparative study between continuous adductor canal block and intravenous morphine for postoperative analgesia in total knee arthroplasty

BackgroundPostoperative pain after total knee arthroplasty (TKA) is known to range from moderate (30% of patients) to severe (60% of patients). Inadequate management for postoperative pain may induce various immobility-related complications, muscle weakness, and chronic pain. Therefore, post-TKA analgesia is crucial, not only for patients’ satisfaction, but for improving surgical outcomes and reducing complications. The present study aims to compare the effect of ultrasound-guided adductor canal block ACB (saphenous nerve block) versus incremental dose of intravenous morphine after total knee arthroplasty surgery.ResultsThe results of this study revealed no difference between group A and group B as regards postoperative quadriceps muscle strength; maximal knee flexion, total distance ambulated, and postoperative vital data (heart rate per minute and respiratory rate per minute). However, group A showed better postoperative pain control, lower doses of intravenous morphine consumption and lower incidence of nausea and vomiting.ConclusionContinuous adductor canal block (saphenous nerve block) is superior to intravenous morphine in decreasing postoperative pain and decreasing total morphine consumption and adverse effects as nausea and vomiting, but both are equivalent in preserving quadriceps muscle power.

Continuous intravenous to oral morphine switch in very premature ventilated infants: A retrospective study on efficacy, efficiency, and tolerability.

BackgroundContinuous intravenous (IV) morphine is commonly used in ventilated neonates. Oral route is theoretically feasible but data on oral morphine in ventilated premature infants are lacking.ObjectiveTo assess the efficacy, efficiency, and tolerability of a continuous intravenous to oral morphine switch protocol.DesignRetrospective study.SettingSingle level III center's neonatal intensive care unit.PatientsVentilated premature infants hospitalized in the NICU in 2016 and 2017, receiving continuous IV morphine with an expected ventilation course of at least 72 more hours. We excluded patients treated for withdrawal syndrome or palliative care.InterventionsContinuous IV to oral morphine switch with the same initial cumulated daily dose.Main outcome measuresPain scores (ComfortNeo scale) and morphine doses were analyzed over time using Friedman's test in the 24 hours preceding and the 48 hours following the oral switch. Adverse effects attributable to opioids were collected.ResultsSeventeen infants were included with a median [IQR] gestational age at birth of 25.9 [24.6‐26.9] weeks and a median postnatal age at oral switch of 30 [22‐36] days. One patient's intravenous treatment had to be resumed because of a high ComfortNeo score. All others remained on oral morphine. No significant change over time was observed for ComfortNeo scores (P = .15). Median [IQR] doses were 13.5 [10‐20] µg/kg/h in the IV period and significantly increased to 15 [10‐25] µg/kg/h in the oral period (P = .009). No short‐term respiratory, digestive, or urinary adverse event was observed. After a median [IQR] duration of 13 [4‐20] days of oral morphine treatment, 11 (65%) patients showed signs of withdrawal. Upon hospital discharge, 16 infants (94%) had bronchopulmonary dysplasia and none had severe cerebral abnormality on brain imaging.ConclusionOral morphine might be useful in ventilated neonates in the NICU but deserves further studies and additional safety assessment.

P145 OPTIMAL PERIOPERATIVE PAIN MANAGEMENT IN ESOPHAGEAL SURGERY

Abstract Aim To compare paravertebral analgesia with epidural analgesia in thoracolaparoscopic Ivor Lewis esophagectomy. Background In esophagectomy, thoracic epidural analgesia (TEA) is standard of care for perioperative pain management. Although TEA is effective, it has unwanted side-effects, such as hypotension, urinary retention and epidural haematoma. Thoracoscopic guided paravertebral analgesia (PVA) is an alternative that is being applied more in thoracic surgery and supposedly has less side-effects. Methods In this feasibility study, TEA was compared with PVA for efficacy in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In PVA the catheter was placed by the surgeon under direct thoracoscopic vision. TEA consisted of continuous bupivacaine and sufentanil with a patient-controlled bolus function. PVA consisted of continuous bupivacaine and intravenous morphine patient-controlled analgesia. Primary outcome was the highest recorded Numeric pain Rating Scale (NRS) every 8 hours. Secondary outcomes included opioid consumption, vasopressor consumption, fluid administration and length of hospital stay. Results In both groups, the NRS was acceptable (below 5) during the first three postoperative days with no difference in overall pain. Patients with PVA had a higher NRS the first postoperative night (median 4 vs 0, p&lt;0.001). Opioid consumption was significantly lower in patients with PVA. In TEA three catheters failed after successful insertion, in PVA only two. There was no difference in vasopressor consumption, fluid administration and length of hospital stay. Conclusion PVA seems to be a safe and effective alternative for TEA in thoracolaparoscopic Ivor Lewis esophagectomy. This hypothesis should be confirmed in a randomized trial.

Equianalgesic Oxycodone, Continuous Intravenous Morphine in Post- Long Bone Surgery

Oxycodone and morphine are powerful analgesic drugs used for post-operative pain management. There is no studies have been conducted to assess the dose equivalency between the two drugs. To get an equianalgesic dose of Oxycodone and Morphine. This study was using a double-blind randomized clinical trials, 48 samples, ages 21-60 years, PS ASA I-II, which will get an elective orthopedic surgery using general anesthesia tech-niques. Oxycodone (group A) : Morphine (group B) (Initial 5mg than continuous 1 mg/hour : initial dose 4mg than continuous 0,5 mg/hour). Average drug dose for group that takes morphine and oxycodone (3.90 ± 0.46 mg : 1.46 ± 0.51 mg). No significant difference between the average dose (p &lt;0.05). Equianalgesic dosein group Oxycodone and Morphine is 1.4 mg: 3.9mg.

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...

Intravenous morphine versus intravenous paracetamol after cardiac surgery in neonates and infants: a study protocol for a randomized controlled trial

BackgroundMorphine is worldwide the analgesic of first choice after cardiac surgery in children. Morphine has unwanted hemodynamic and respiratory side effects. Therefore, post–cardiac surgery patients may potentially benefit from a non-opioid drug for pain relief. A previous study has shown that intravenous (IV) paracetamol is effective and opioid-sparing in children after major non-cardiac surgery. The aim of the study is to test the hypothesis that intermittent IV paracetamol administration in children after cardiac surgery will result in a reduction of at least 30% of the cumulative morphine requirement.MethodsThis is a prospective, multi-center, randomized controlled trial at four level-3 pediatric intensive care units (ICUs) in the Netherlands and Belgium. Children who are 0–36 months old will be randomly assigned to receive either intermittent IV paracetamol or continuous IV morphine up to 48 h post-operatively. Morphine will be available as rescue medication for both groups. Validated pain and sedation assessment tools will be used to monitor patients. The sample size (n = 208, 104 per arm) was calculated in order to detect a 30% reduction in morphine dose; two-sided significance level was 5% and power was 95%.DiscussionThis study will focus on the reduction, or replacement, of morphine by IV paracetamol in children (0–36 months old) after cardiac surgery. The results of this study will form the basis of a new pain management algorithm and will be implemented at the participating ICUs, resulting in an evidence-based guideline on post-operative pain after cardiac surgery in infants who are 0–36 months old.Trial registrationDutch Trial Registry (www.trialregister.nl): NTR5448 on September 1, 2015. Institutional review board approval (MEC2015–646), current protocol version: July 3, 2017

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.

P1465Clincal aspects of continuous intravenous morphine for palliative care in patients with advanced heart failure from experience with 55 cases

P1465Clincal aspects of continuous intravenous morphine for palliative care in patients with advanced heart failure from experience with 55 cases

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.

Serum and urine concentrations of morphine and morphine metabolites in patients with advanced cancer receiving continuous intravenous morphine: an observational study

BackgroundThe feasibility and clinical implication of drug monitoring of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) need further investigation. This study aimed to determine what predicts serum concentrations of morphine in cancer patients receiving continuously intravenous morphine, the relationships between serum concentration of morphine/its metabolites and urinary concentrations, and the relation between morphine concentrations and with clinical outcomes.MethodsWe collected serum and urine samples from 24 patients with advanced cancer undergoing continuously intravenous morphine therapy. Serum samples were obtained at day one. Spot urine samples were collected once daily on three consecutive days. Pain and adverse drug events were assessed using the Korean version of MD Anderson Symptom Inventory.ResultsA total of 96 samples (72 urine and 24 serum samples) were collected. Median dose of morphine was 82.0 mg/24 h. In a multivariate analysis, total daily morphine dose was the most significant predictors of both serum and urine concentration of morphine. Morphine, M6G, and M3G in serum and urine were statistical significantly correlated (correlation coefficient = 0.81, 0.44, 0.56; p values < 0.01, 0.03, 0.01, respectively).ConclusionSpot urine concentrations of morphine and its metabolites were highly correlated to those of serum. Total dose of daily morphine was related to both serum and urine concentration of morphine and its metabolites.

The relationship between age and morphine infusion rate in children

We performed a retrospective audit of intravenous morphine infusion administered to children in an effort to characterize the relationship between dose and age. A retrospective audit of morphine infusions was reviewed for a 24-months period and included all children who received continuous intravenous nurse-controlled morphine infusions and patient-controlled analgesia; a population undergoing acute and elective surgical procedures, as well as medical and oncological treatments. The relationship between age and infusion rate was investigated using nonlinear mixed effects models. There were 886 children whose data were acceptable for review. Morphine dose increased with age from 9.97 (CV 28%) μg · kg(-1) per h in neonates. The Hill equation with an exponential of 1.5 best described these changes. Morphine rate reached 90% of its mean final rate of 22.5 (CV 167%) μg · kg(-1) per h, observed in teenagers, at approximately 5 years of age. There was considerable uncertainty of this age-morphine rate profile, and the maturation half-life of this profile was 20 months of age (CV 632%). An increase in dosing variability was observed with increasing age. Morphine infusions at steady-state did not mirror clearance maturation in children nursed in our hospital. We suggest that initial infusion rates in children are started at 10 μg · kg(-1) per h in neonates, 15 μg · kg(-1) per h in toddlers and 25 μg · kg(-1) per h in children above the age of 5 years. The large variability associated with infusion rates means that subsequent infusion rates will depend on feedback from pain scores, adjuvant medications and adverse effects.

Adverse Effects of Morphine and Fentanyl for Stomatitis in Patients Receiving Allogeneic Hematopoietic Cell Transplantation—A Single Center Retrospective Analysis

Opioids are widely used as analgesics for oral mucositis in allogeneic hematopoietic cell transplantation (allo-HCT). Their main adverse events are nausea, vomiting, constipation, psychological symptoms, and respiratory depression. In our institute, continuous intravenous morphine was generally used until 2007, followed by intravenous fentanyl as the first-line agent because of its potential fewer adverse events. We retrospectively analyzed 99 patients who underwent allo-HCT in the University of Tsukuba Hospital from 2004 to 2009. Out of 99 patients, 64 were treated with opioids (morphine, 32 and fentanyl, 32). The attending physicians were in charge of providing stable pain control. Median age, sex, stem cell source, preparative regimen, and GVHD prophylaxis were similar in the two groups. There were no significant differences in psychological symptoms, drowsiness, nausea, and vomiting in both groups. Defecation ratio (the days having a bowel movement/the days taking opioids) was 63% and 94% in the morphine and fentanyl group, respectively (P < 0.0001). The percentage of patients who needed to use purgative drugs was 25% and 6% in the morphine and fentanyl group, respectively (P = 0.04). It is suggested that fentanyl has less adverse effects on gastrointestinal movement and is safer than morphine when used for oral mucositis in allo-HCT.

A Prospective Randomized Trial Comparing Epidural Morphine Through Intraoperatively Placed Epidural Catheter and Intravenous Morphine in Major Lumbar Spinal Surgery

A randomized, controlled trial. To compare the efficacy of pain control and complications between patients utilizing continuous infusion epidural morphine versus intravenous morphine in posterior spinal surgery. Recently, there has been increased interest in the use of epidural infusion analgesia for spinal surgery. By simply placing the tip of catheter at the level of operation before the wound closure, a continuous infusion of local anesthetics is directly delivered into the epidural space. Techniques used in the literature vary as per analgesic agents, number of catheters, and the infusion method. Few are the randomized control studies. A total of 120 patients, who had posterior spinal operations, were randomly assigned to receive either continuous epidural infusion morphine, continuous epidural infusion morphine with Bupivacaine, or intravenous morphine as a postoperative analgesia. Visual analogue Pain scale (Pain VAS) was evaluated every 4 hours the first day, and at 36 and 48 hours postoperatively. Additional doses of intravenous Nalbuphine hydrochloride, complications, and the satisfaction score were recorded. Baseline characteristics of the 3 groups were similar. The mean Pain VAS in the epidural morphine group (groups 1 and 2) were less than that of group 3 at all times up to 48 hours postoperatively (P<0.05). Pain VAS for group 1 was more than that of group 2 at the 16- and 24-hour marks (P<0.05). Pruritus was a common complication in the epidural morphine group. There was no respiratory depression in this study. Patients in groups 1 and 2 had a high proportion of excellent and very good satisfaction (70% to 80%). Epidural infusion analgesia is safe and effective for posterior spinal surgery.

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.