Daily Morphine Consumption Research Articles

Microwave ablation combined with vertebral augmentation under real-time temperature monitoring for the treatment of painful spinal osteogenic metastases

ObjectiveTo evaluate the safety and efficacy of computed tomography (CT)-guided microwave ablation combined with vertebral augmentation under real-time temperature monitoring in the treatment of painful osteogenic spinal metastases.MethodsThis retrospective study included 38 patients with 63 osteogenic metastatic spinal lesions treated using CT-guided microwave ablation and vertebral augmentation under real-time temperature monitoring. Visual analog scale scores, daily morphine consumption, and Oswestry Disability Index scores were used to evaluate efficacy of the treatment.ResultsMicrowave ablation combined with vertebral augmentation reduced the mean visual analog scale scores from 6.40 ± 1.90 preoperatively to 3.32 ± 0.96 at 24 h, 2.24 ± 0.91 at 1 week, 1.92 ± 1.32 at 4 weeks, 1.79 ± 1.45 at 12 weeks, and 1.39 ± 1.12 at 24 weeks postoperatively (all p < 0.001). The mean preoperative daily morphine consumption was 108.95 ± 56.41 mg, which decreased to 50.13 ± 25.46 mg at 24 h, 31.18 ± 18.58 mg at 1 week, 22.50 ± 16.63 mg at 4 weeks, 21.71 ± 17.68 mg at 12 weeks, and 17.27 ± 16.82 mg at 24 weeks postoperatively (all p < 0.001). During the follow-up period, the Oswestry Disability Index scores significantly reduced (p < 0.001). Bone cement leakage occurred in 25 vertebral bodies, with an incidence of 39.7% (25/63).ConclusionsThe results indicate that microwave ablation combined with vertebral augmentation under real-time temperature monitoring is a feasible, effective, and safe treatment for painful osteoblast spinal metastases.

Microwave ablation combined with cementoplasty under real-time temperature monitoring in the treatment of 82 patients with recurrent spinal metastases after radiotherapy

BackgroundThe spine is the most frequently affected part of the skeletal system to metastatic tumors. External radiotherapy is considered the first-line standard of care for these patients with spine metastases. Recurrent spinal metastases after radiotherapy cannot be treated with further radiotherapy within a short period of time, making treatment difficult. We aimed to evaluate the effectiveness and safety of MWA combined with cementoplasty in the treatment of spinal metastases after radiotherapy under real-time temperature monitoring.MethodsIn this retrospective study, 82 patients with 115 spinal metastatic lesions were treated with MWA and cementoplasty under real-time temperature monitoring. Changes in visual analog scale (VAS) scores, daily morphine consumption, and Oswestry Disability Index (ODI) scores were noted. A paired Student’s t-test was used to assess these parameters. Complications during the procedure were graded using the CTCAE version 5.0.ResultsTechnical success was attained in all patients. The mean VAS score was 6.3 ± 2.0 (range, 4–10) before operation, and remarkable decline was noted in one month (1.7 ± 1.0 [P < .001]), three months (1.4 ± 0.8 [P < .001]), and six months (1.3 ± 0.8 [P < .001]) after the operation. Significant reductions in daily morphine consumption and ODI scores were also observed (P < .05). Cement leakage was found in 27.8% (32/115) of lesions, with no obvious associated symptoms.ConclusionMWA combined with cementoplasty under real-time temperature monitoring is an effective and safe method for recurrent spinal metastases after radiotherapy.

Lidocaine and Ketamine Infusions as Adjunctive Pain Management Therapy: A Retrospective Analysis of Clinical Outcomes in Hospitalized Patients Admitted for Pain Related to Sickle Cell Disease.

ObjectiveIn this study, we aim to evaluate the efficacy of adjunctive lidocaine and ketamine infusions for opioid reduction in the treatment of sickle cell disease in patients with vaso-occlusive crisis (VOC).DesignWe retrospectively reviewed a cohort of 330 adult sickle-cell crisis hospital encounters with 68 patients admitted to our institution from July 2017 to August 2018.MethodsUpon institutional IRB approval, we obtained initial data from billing records and performed chart reviews to obtain pain scores and confirm total opioid consumption. If provided by the acute pain consultation service, the patients received either a lidocaine or a ketamine infusion of 0.5–2 mg/min or 2–3 mcg/kg, respectively, for a maximum of 24–48 h. We compared the change in opioid consumption before and after infusion therapy to patients that did not receive ketamine or lidocaine.ResultsCompared to patients that did not receive infusion therapy, ketamine and lidocaine accounted for respective relative decreases of 28 and 23% in average daily morphine consumption (p = 0.02). Patients that received either infusion were 3 to 4 times more likely to decrease their opioid consumption independent of treatment length or baseline opioid doses (p < 0.01). Ketamine and lidocaine therapies were not associated with change in pain scores. When a patient had multiple admissions, opioid reduction was strongly correlated with initiation of infusions in the later visits.ConclusionBoth ketamine and lidocaine infusion therapies are effective in reducing opioid consumption for patients with vaso-occlusive crisis. Lidocaine infusion is emerging as an agent for stabilizing opioid doses in VOC for patients with high daily MME.

Simultaneous C-arm Computed Tomography-Guided Microwave Ablation and Cementoplasty in Patients with Painful Osteolytic Bone Metastases: A Single-center Experience

To evaluate the clinical benefit of simultaneous percutaneous microwave ablation (PMA) and percutaneous cementoplasty (PC) for patients with painful osteolytic bone metastases under flat-detector C-arm computed tomography (CACT). Thirty patients (17 men and 13 women) with 42 osteolytic metastatic tumors were prospectively treated with PMA and PC simultaneously under CACT guidance. Technical success, major complications, local tumor control status, and daily morphine consumption were recorded. Visual analog scale, Oswestry disability index, and the short-form 36 questionnaire (SF-36, 8 domains) were used to evaluate pain, functional status, and quality of life (QoL), respectively. The technical success rate was 100% without major complications, and local tumor control rates were 100% and 75% for lesion diameter ≤3 cm and >3 cm, respectively. Daily morphine consumption, visual analog scale, and Oswestry disability index improved significantly from the respective pretreatment values of 75 mg, 7.4, and 59.2 to 17.3 mg, 1.7, and 22.9 at 1 week; 8.5 mg, 1.4, and 6.7 at 4 weeks; and 5.3 mg, 1.3, and 9.2 at 12 weeks, respectively (p< 0.01). The QoL assessments at 4 weeks showed significant improvements in physical function, role physical, bodily pain, general health and vitality (p < 0.05). Simultaneous PMA and PC under CACT guidance is effective to control pain and improve QoL in selective patients with painful osteolytic bone metastases.

Patient-controlled analgesia for background pain of major burn injury.

Studies have suggested that intravenous patient-controlled analgesia (IV-PCA) can be used safely for the treatment of background pain in burn patients. However, no comprehensive protocols have been published. How patient or surgical factors correlate with the amount of opioid consumption remains unclear. The aim of this study is to provide an IV-PCA protocol for alleviating pain for burn injuries, and to assess factors correlated with opioid consumption. At the Mackay Memorial Hospital, a retrospective analysis from June 27th to October 31st of 2015 was carried out to investigate the use of IV-PCA in relation to the demographic and clinical data of patients who suffered from burn injuries due to a massive explosion of flammable powder. A standardized morphine IV-PCA protocol with rapid escalation was implemented. Variables assessed included age, weight, gender, days of usage, total surface area burned (TBSAB) and operations. Among the 23 patients who received IV-PCA for burn pain control, it was noted that the larger the TBSAB and the higher the visual analogue scale (VAS), the more amount of morphine was consumed. Correlations between morphine consumption positively with weight (P<0.01), female gender (P<0.01), severity of injury (P=0.01), and negatively with receiving operations (P=0.01) were statistically significant. As the daily morphine consumption was positively correlated with TBSAB, VAS, weight, female gender, the use of our IV-PCA protocol was sufficient in the management of background pain for patients with major burn injury.

Thick cement usage in percutaneous vertebroplasty for malignant vertebral fractures at high risk for cement leakage.

To assess the feasibility and safety of transpedicular percutaneous vertebroplasty (PVP) using thick bone cement in patients with intractable metastatic vertebral pain and at high risk for cement leakage. Unilateral transpedicular PVP using firm bone cement was performed in 77 patients with intractable pain due to vertebral metastases in the thoracolumbar spine, who had one or more relative contraindication to PVP. Primary outcome measures were the severity of pain as assessed on a 100-mm visual analogue scale and daily morphine consumption. Secondary outcome measures were the degree of disability and the incidence of procedure-related adverse outcomes. The outcome measures were assessed at the preoperative visit and at 1 day, 1 week, 4 weeks and 12 weeks after the procedure. Sixty-three (81.8%) patients completed the 12-week follow-up period. There were 30 men and 33 women, with a mean age of 58±11 (SD) [range: 34-81 years]. Compared with pre-procedure value, all post-procedure pain scores were significantly lower (P<0.0001). Likewise, there was a statistically significant reduction in daily morphine consumption at all follow-up times (P<0.0001). The ambulation score, ADL, and ODI were all significantly lower at all assessment times compared with pre-procedure values (P<0.0001). No serious adverse effects were observed. PVP using thick bone cement could be administered with reasonable safety to patients suffering from intractable pain caused by vertebral metastases who were at high risk for cement leakage. The procedure was associated with significant improvement of pain and disability.

Effect of Intrathecal Dexmedetomidine on Spinal Morphine Analgesia in Patients with Refractory Cancer Pain

Systemic administration of dexmedetomidine has been shown to reduce opioid consumption and improve analgesia satisfaction. The purpose of this study was to investigate the effect of intrathecal dexmedetomidine on spinal morphine analgesia in patients with refractory cancer pain. A double-blinded crossover study was designed and performed. Patients were randomly allocated in one of the two phases. Phase M received intrathecal morphine administration. Phase M+D received intrathecal morphine plus dexmedetomidine administration. All patients were monitored for 7 days and crossed over to alternate phase for another 1-week observation. Daily average visual analog scale (VAS) pain score, pain frequency, sleep deprivation, daily morphine consumption, bolus dose injection times, and side effects were all recorded. Pain intensity and frequency were significantly decreased in both phases compared with baseline. Daily morphine consumption and bolus dose injection times during phase M+D were significantly decreased compared with phase M. The incidences of constipation were significantly reduced in both phases compared with baseline administration, but nausea and vomiting were significantly increased. No serious side effects such as respiratory inhibition were observed in this study. Intrathecal administration of dexmedetomidine and morphine reduced the morphine consumption in patients with refractory cancer pain. There were no serious side effects.

Efficacy of the Anterior Ultrasound-Guided Superior Hypogastric Plexus Neurolysis in Pelvic Cancer Pain in Advanced Gynecological Cancer Patients

Pelvic cancer pain is a chronic pain related to the involvement of viscera, neural, and pelvic muscular. The study was carried out to evaluate the efficacy of anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in gynecological cancer patients. The study was conducted after approval of our Institutional Ethics Committee. A total of 50 patients diagnosed with the advanced stage of a gynecological malignancy with severe pelvic pain were enrolled and randomly divided in two groups; in Group I, patients were given oral morphine, while in Group II, patients underwent anterior ultrasonography (USG)-guided superior hypogastric neurolysis. Oral morphine was given as rescue analgesia in both the groups. The parameters recorded were pain, functional capacity, global satisfaction score, and adverse effects. There was a significant decrease in visual analog scale (VAS) score in the both groups, but the decline in VAS scores from baseline in Group II was significantly (P < 0.05) greater. The daily morphine consumption in Group II decreased throughout the study, and more patients in Group II improved in their functional capacity, although it was statistically insignificant. It was observed that global satisfaction scores were better in Group II during the initial first (P = 0.001) week and 1 month (P = 0.04) compared with Group I. The anterior USG-guided superior hypogastric plexus neurolysis is a useful technique in relieving pelvic pain in gynecological malignancies. However, it requires expertise to perform the block. It also avoids the radiation exposure involved with computed tomography-guided and fluoroscopy-guided superior hypogastric block.

Postoperative consumption of opioid analgesics following correction of pectus excavatum is influenced by pectus severity: a single-centre study of 236 patients undergoing minimally invasive correction of pectus excavatum☆

Surgical correction of pectus excavatum (PE) is primarily performed to achieve cosmetic and psychological benefits for the patient. Minimally invasive repair of PE is often associated with severe postoperative pain. This study estimates the effect of the severity of PE on the postoperative consumption of opioid analgesics following this procedure to optimise pain management. A retrospective study was conducted on 236 consecutive patients undergoing minimally invasive repair of PE from 2005 to 2008. The collected data included depth of preoperative pectus excavation, patient demographics, peri- and postoperative information, including data on pain management. The consumption of opioid analgesics was registered after discontinuation of epidural analgesia and other types of opioid analgesics used during the study period were converted to morphine equivalents. Multiple linear regression analysis was performed to estimate the effect of the severity of PE on the postoperative consumption of opioid analgesics and to adjust for potential confounding. The total morphine consumption following minimally invasive repair of PE ranged between 20 and 370 mg day(-1). Multiple linear regression analysis explained approximately 30% of the variation in daily morphine consumption (R-squared=0.2957). There was a significant positive linear relationship between pectus severity and the daily consumption of morphine. Thus, postoperative consumption of morphine increased by 6% (95% confidence interval (CI): 0.3-11%) when preoperative PE depth deteriorated with 1cm. This study confirms that pectus severity has a significant impact on the consumption of opioid analgesics following minimally invasive repair of PE. We conclude that knowledge of pectus severity might be useful in the prediction of the expected morphine consumption in future patients, especially during the critical transition period from epidural analgesia to oral analgesia.

Is Intravenous Patient Controlled Analgesia Enough for Pain Control in Patients Who Underwent Thoracoscopy?

This prospective randomized study was conducted to evaluate the efficacy of two common analgesic techniques, thoracic epidural patient-controlled analgesia (Epidural PCA), and intravenous patient-controlled analgesia (IV PCA), in patients undergoing lobectomy by the video-assisted thoracic surgical (VATS) approach. Fifty-two patients scheduled for VATS lobectomy were randomly allocated into two groups: an Epidural PCA group receiving an epidural infusion of ropivacaine 0.2%+fentanyl 5 µg/mL combination at a rate of 4 mL/hr, and an IV PCA group receiving an intravenous infusion of ketorolac 0.2 mg/kg+fentanyl 15 µg/mL combination at a rate of 1 mL/hr. Pain scores were then recorded using the visual analogue scale at rest and during motion (VAS-R and VAS-M, 0-10) for five days following surgery. In addition, we measured the daily morphine consumption, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), satisfaction score, and the incidence of side effects. Thirty-seven patients out of 52 completed the study (18 in the Epidural PCA group, 19 in the IV PCA group). There were no differences in the pain scores, analgesic requirements, pulmonary function, satisfaction score, and the incidence of side effects between groups. This indicates that IV PCA and Epidural PCA are equally effective to control the postoperative pain after VATS lobectomy, which suggests that IV PCA may be used instead of Epidural PCA.

Superior Hypogastric Block: Transdiscal versus Classic Posterior Approach in Pelvic Cancer Pain

The classic posterior approach of superior hypogastric block has several technical difficulties. The transdiscal approach is a novel and easier approach for superior hypogastric which overcome these technical difficulties. Thirty patients were randomly allocated to two groups: The transdiscal group and the classic group; visual analog scale pain scores, daily morphine consumption, duration of the procedure and side effects were recorded. The duration of the procedure was significantly decreased in the transdiscal group (24.4+/-5.6 min) compared to the classic group (57.9+/-9.8 min). There were no significant differences between the 2 groups in daily morphine consumption and VAS pain scores. There was no discitis, disc rupture, or herniation in the transdiscal group. The transdiscal approach for superior hypogastric plexus block in pelvic cancer pain is easier, safer, and more effective with less side effects than the classic approach.

Double-blind evaluation of transdermal nitroglycerine as adjuvant to oral morphine for cancer pain management

Study Objectives: To examine analgesia and adverse effects following transdermal application of nitroglycerine (a nitric oxide generator) combined with oral morphine, in cancer pain patients. Design: Randomized, double-blind study. Setting: Teaching hospital. Patients: 36 patients suffering from cancer pain. Interventions: Patients were divided into two groups (n = 18). All patients were regularly taking oral amitriptyline 50 mg at bedtime. Pain was evaluated using a 10-cm visual analog scale (VAS). The morphine regimen was individually adjusted to a maximal oral dose of 80 to 90 mg/day, to maintain the VAS score less than 4/10 cm. When patients complained of pain (VAS equal or greater than 4/10), despite taking 80 to 90 mg of oral morphine daily, the transdermal test drug was supplemented as follows: the control group received a placebo patch daily, and the nitroglycerine group received a 5-mg/24-hour nitroglycerine patch daily. Patients were free to manipulate their daily morphine consumption at the time the test drug was administered, to keep VAS less than 4/10 cm. After the introduction of the transdermal test drug, patients were evaluated by the staff on a weekly basis as outpatients, over four consecutive weeks. Measurements and Main Results: The groups were similar in respect to demographic data and VAS pain scores before the treatment. The daily consumption of oral morphine was smaller in the nitroglycerine group compared with the control group after the 14th day of evaluation (p < 0.002). Patients from the control group in general complained of somnolence, compared with the nitroglycerine group. Conclusion: Transdermal nitroglycerine was an effective coadjuvant analgesic. In conjunction with its opioid tolerance sparing function, delivery of nitric oxide donors together with opioids may be of significant benefit in cancer pain management in delaying morphine tolerance and decreasing the incidence of adverse effects related to high doses of opioids.

Ketamine as an Adjunct to Morphine in Postthoracotomy Analgesia

Ketamine as an Adjunct to Morphine in Postthoracotomy Analgesia

Enhancement of opiate analgesia by nimodipine in cancer patients chronically treated with morphine: a preliminary report

The ability of nimodipine, a calcium-channel blocker, to enhance morphine analgesia and/or modify the development of tolerance was studied in patients with cancer pain who had needed successive increments of morphine for periods ranging from 21 to 780 days. Assessment of daily morphine consumption was the primary effect parameter. Nimodipine succeeded in reducing the daily dose of morphine in 16 of 23 patients (oral, n = 13; intrathecal, n = 3), and failed to modify it in 2 patients. Total oral daily dose was reduced by nimodipine (120 mg/day) from 282.6 ± 47.7 m g to 158.7 ± 26.2 mg (n = 15, P < 0.001). Intrathecal morphine was also reduced by 1–5 mg/day. Nimodipine was withdrawn in 5 patients during the first week of treatment due to intolerance (n = 3) or aggravation of the disease (n = 2). These preliminary results support experimental findings showing that pharmacological interference with Ca 2+-related events may modify chronic opioid effects, including the expression of tolerance.