Epidural Administration Of Morphine Research Articles

A Randomized Controlled Study of Epidural Morphine Sulfate-soaked Gelfoam and Morphine Sulfate Instillation in the Management of Postoperative Pain following Lumbar Spinal Fixation Surgery

Abstract Background: Lumbar spinal fixation surgeries play a pivotal role in addressing pain which can be nociceptive, neuropathic, mixed, and nociplastic; however, these surgeries can also cause significant postoperative pain and discomfort, leading to prolonged hospital stays and delayed return to normal activity. Aims and Objectives: The aim of the study was to provide effective postoperative analgesia and to compare the analgesic efficacy by application of Gelfoam-soaked morphine sulfate placed in the epidural space and direct instillation of morphine sulfate in the epidural space in patients undergoing lumbar spinal fixation surgery under general anesthesia. Materials and Methods: A total of 60 patients planned for Lumbar spinal fixation surgeries were selected and sorted into two groups of 30 each after a computer-based randomization. In Group G, a 5 cm × 1 cm piece of absorbable gelatin sponge soaked in 5 mg of morphine sulfate diluted in 0.9% normal saline up to 5 mL was placed in the epidural space. In Group I, 5 mg of morphine sulfate diluted in 0.9% normal saline 5 mL was instilled over the intact epidural space. Pulse rate, mean arterial pressure (MAP), respiratory rate (RR), and peripheral oxygen saturation (SpO2) were observed hourly for the first 6 h, then at 2 hourly intervals till 12 h, and at 4 hourly intervals till 48 h. Postoperatively, pain intensity is assessed by the Visual Analog Scale (VAS) for 24 h, and the time of the first analgesic dose is noted. VAS ranges from 0 (no pain) to 10 (severe pain). Preoperative instructions were given to the patients about the use of VAS. Results: In this study, Group G demonstrated lower postoperative VAS scores and delayed need for rescue analgesia compared to Group I (P < 0.05, P < 0.0001, respectively). Group I had a higher total analgesic requirement (P < 0.0001) and consistently higher heart rates (P < 0.0001) compared to Group G. MAPs were lower in Group G compared to Group I (P < 0.0001). RRs, SpO2, sedation scores, and incidence of nausea and pruritus were similar between the two groups (P > 0.05). Conclusion: Epidural administration of morphine using Gelfoam as a vehicle for sustained release of morphine is a safe and effective method of postoperative analgesia in lumbar spinal fixation surgeries and results in better hemodynamics, prolonged duration of analgesia, and reduced requirement of rescue analgesics, compared to epidural instillation of morphine.

Effectiveness of epidural morphine for the treatment of cancer pain in patients with gastrointestinal neoplasm-a systematic review.

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients.

Comparison of the ED50 of prophylactic butorphanol in preventing morphine-induced pruritus with or without palonosetron: a prospective, double-blinded, randomized dose–response trial using an up-down sequential allocation method

Background Butorphanol has been used to reduce the incidence and severity of neuraxial morphine-induced pruritus. Palonosetron is a commonly used antiemetic for the prevention of postoperative nausea and vomiting. The aim of our study was to compare the effective dose in 50% of subjects (ED50) of intravenous butorphanol infusion with or without a single intravenous bolus of palonosetron for preventing pruritus induced by epidural administration of morphine. Methods A total of 120 parturients were randomly assigned to receive an intravenous bolus injection of palonosetron plus continuous infusion of butorphanol (Group P + B) or an intravenous bolus of saline plus continuous infusion of butorphanol (Group B) after epidural administration of morphine. The antipruritic effect was graded as satisfactory (numerical rating scale (NRS) of pruritus ≤3) or unsatisfactory (NRS >3) within 48 h after morphine treatment. The first patient in each group received butorphanol infusion at a rate of 4 µg/kg/h. The infusion dose for each subsequent patient in the corresponding group was increased by 0.2 µg/kg/h after an unsatisfactory response or decreased by 0.2 µg/kg/h after a satisfactory response. The ED50 was calculated for each group and compared using up-down sequential analysis. Results The ED50 (mean [95% confidence interval (CI)]) of the dose of intravenous butorphanol infusion for preventing moderate to severe pruritus was lower in Group P + B (3.29 µg/kg/min [3.25–3.34 µg/kg/min]) than in Group B (3.57 µg/kg/min [3.47–3.67 µg/kg/min]) (p < 0.05). Conclusions Under the conditions of the present study, a prophylactic use of 0.25 mg palonosetron reduced the ED50 of prophylactic infusion of butorphanol by approximately 8% to achieve a satisfactory antipruritic effect after epidural morphine for post-caesarean analgesia.

Cost-effectiveness analysis of epidural morphine/ropivacaine treatment in patients with cancer pain.

Cancer pain is one of the main causes of human suffering, which can generate disabilities and compromise quality of life, giving rise to several psychosocial and economic consequences. This quantitative study sought to perform a cost-effectiveness pharmacoeconomic analysis to assess the impact of implanting epidural morphine associated with ropivacaine treatment in gastrointestinal cancer patients with pain that is difficult clinical control, compared with conventional oral treatment. The study population consisted of 24 patients with gastrointestinal neoplasia who underwent treatment for cancer pain that was difficult to clinically control. 12 patients each were recruited into the control and intervention groups, respectively. While patients in the control group were administered drug treatment orally, patients in the intervention group underwent a surgical procedure for subcutaneous implantation of a catheter that allowed epidural administration of morphine and ropivacaine. For pain assessment, the Visual Analogue Scale was applied. Data analysis had a descriptive character of costs, taking into account the costs for the year 2021. The study perspective was the Brazilian public healthcare provider, referred to as the Unified Health System (Sistema Único de-SUS in Portuguese). Costs were computed over the time horizon corresponding to the duration of treatment, from the first medical consultation (when the treatment was defined) to the end (end of treatment, disease progression, or death). Treatment duration was divided into three phases (first 60 days, support with palliative care, and end-of-life care). To assess the robustness of the economic analysis, sensitivity analyses were performed, considering the effectiveness of pain reduction on the Visual Analogue Scale, and a comparison of results using the median prices of pharmaceutical components used in the study. The mean age of patients was 59.3 years. The results from the cost-effectiveness analysis showed the epidural morphine/ropivacaine treatment to be more effective with regard to pain reduction on the pain scale, particularly for end-of-life care, when compared to the conventional oral treatment, however, at a significantly higher cost. From the accomplishment of this research, it was observed that the application of the pain assessment scale is a way to better interpret and understand the patient's pain, facilitating care planning and decision-making by health professionals, as well as monitoring the effectiveness of the proposed new treatment. To present a better cost-effectiveness ratio, a reduction in the cost of the new epidural technology or an increase in the value of the existing oral intervention would be required. However, the latter is not feasible and unlikely to occur. A value judgement to decide whether the incremental benefit associated with the use of the new intervention is worth the extra cost will have to be made by the healthcare provider. Interventions that can relieve cancer pain symptoms should be investigated continuously, in search of evidence to support clinical practice and promote better quality of life for patients.

EXPERIENCE OF USING EPIDURAL ANESTHESIA IN ONCOSURGERY:&#x0D; A CLINICAL CASE

Relevance: Surgical intervention is the most radical method in the complex specific therapy of malignant neoplasms. Oncosurgical operations&#x0D; are among the most traumatic; the volume of surgical intervention depends on the stage of the tumor process and its prevalence, the presence of&#x0D; metastases, germination in neighboring tissues and organs, and concomitant diseases. Particular importance is attached to the anesthetic management of the perioperative period.&#x0D; Regional anesthesia is practically not used for several reasons in oncosurgical reconstructive and plastic interventions on the abdominal organs. In choosing the method of anesthesia, the qualification of the anesthetist plays a role, especially when performing high epidural anesthesia,&#x0D; which is quite technically complicated. The emergence of highly effective anesthetics and high-quality sets for epidural anesthesia has significantly&#x0D; expanded the scope of this type of anesthesia in oncosurgical practice.&#x0D; This study aimed to demonstrate the possibilities and advantages of epidural anesthesia in the perioperative period using the described clinical case as an example.&#x0D; Methods: Patient N. was admitted to the clinic for surgical treatment for a malignant neoplasm of the transverse colon without clinical signs&#x0D; of obstruction of the lumen of the large intestine. She underwent laparotomy, subtotal colectomy with anastomosis, resection of the omentum, and&#x0D; lymph node dissection. Epidural anesthesia with catheterization of the epidural space and administration of ropivacaine and morphine was used&#x0D; as an anesthetic aid.&#x0D; Results: Adequate pain relief, relaxation, the absence of clinically significant autonomic reactions in the intraoperative period, and adequate&#x0D; pain relief without narcotic analgesics in the postoperative period were achieved. The patient was activated on Day 3-5 after surgery. Subjectively,&#x0D; the patient emphasized the comfortable course of the perioperative period.&#x0D; Conclusion: Thus, our experience in the use of regional (epidural) anesthesia in oncosurgical practice as an isolated method of anesthesia,&#x0D; subject to technically competent and accurate execution of the procedure, allows us to recommend it as a reasonable alternative or component of&#x0D; generally accepted traditional general anesthesia in order to reduce the risk of anesthesia, adequate and effective anesthesia in the perioperative&#x0D; period and optimization of economic and logistical costs in the postoperative period.

Comparison of cervical epidural morphine with intravenous morphine administration on antinociception in adult horses using thermal threshold testing

ObjectiveTo compare the antinociceptive effects of morphine administered via cervical epidural catheter to intravenously administered morphine using a thermal threshold (TT) testing model in healthy adult horses. Study designProspective, randomized, blinded experimental study. AnimalsA total of six university-owned adult horses. MethodsHorses were instrumented with a cervical (C1–C2) epidural catheter and TT testing device with probes at withers and thoracic limb coronary bands. All horses underwent three TT testing cycles including cervical epidural morphine administration (treatment EpiM; 0.1 mg kg–1), systemic morphine administration (treatment SystM; 0.1 mg kg–1) and no morphine administration (treatment Control). Baseline TT was established prior to treatments, and TT was tested at 15, 30, 60, 90, 120, 150, 180, 240, 300, 360, 420, 480, 600 and 720 minutes following treatment. Horses underwent a 5 day washout period between treatments and the order of treatment was randomized. Differences between treatments were analyzed with repeated measures anova. ResultsSystemic and epidural morphine administration resulted in significantly higher TT values compared with baseline and control treatment. The duration of effect was significantly longer in treatment EpiM (10–12 hours) than in treatment SystM (1.5–2.0 hours). Horses in treatment EpiM had significantly higher TT values at time points 180–600 minutes (withers) and 300–600 minutes (coronary band) than horses in treatment SystM. Conclusions and clinical relevanceCervical epidural administration of morphine provided antinociceptive effects as measured by increased TT for 10–12 hours compared with 1.5–2.0 hours for intravenously administered morphine. No complications or adverse effects were noticed following epidural placement of a C1–C2 catheter and administration of morphine. The use of a cervical epidural catheter can be considered for analgesia administration in treatment of thoracic limb and cervical pain in the horse.

Efficacy of dexmedetomidine in combination with morphine for pain management in patients with cesarean section

&lt;p&gt;&lt;strong&gt;Background &amp;amp; Objectives:&lt;/strong&gt; Intraspinal morphine shows a high analgesic efficacy but high incidence of adverse events and dexmedetomidine (Dex) improves anesthesic actions and anesthesia-related adverse reactions. This study compares the efficacy and safety of intravenous Dex and epidural morphine administration versus morphine alone for post-caesarean analgesia.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Eighty women receiving caesarean sections were assigned to the Dex-morphine combination group and morphine group. Subjects in both groups were given morphine after caesarean sections. After delivery, women in the combination group were given Dex, while subjects in the morphine group were given physiological saline. Serum cortisol, renin and potassium was measured before anesthesia, immediately and 24 hours after caesarean sections, and the visual analog scale (VAS) and observer&amp;rsquo;s assessment of alertness/sedation scale (OAA/S) scores were assessed 4, 8, 12 and 24 hours after caesarean sections. In addition, post-operative adverse events were recorded, and intraoperative urine volume and urine 24-hour volume after caesarean sections were measured.&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Lower cortisol and renin was measured in the combination group than in the morphine group immediately after caesarean sections (&lt;em&gt;P&lt;/em&gt; &amp;lt; 0.05), while no significant differences were found in serum potassium between two groups at each time point (&lt;em&gt;P&lt;/em&gt; &amp;gt; 0.05). Lower VAS scores were measured in the combination group than in the morphine group 12 and 24 hours after caesarean sections (&lt;em&gt;P&lt;/em&gt; &amp;lt; 0.05); however, no significant differences were seen in the OAA/S score (&lt;em&gt;P&lt;/em&gt; &amp;gt; 0.05). Lower incidence of shivering and nausea/vomiting was seen in the combination group than in the morphine group after caesarean sections, and greater intraoperative urine volume and urine volume within 24 hours after caesarean sections were measured in the combination group than in the morphine group (&lt;em&gt;P&lt;/em&gt; &amp;lt; 0.05).&lt;/p&gt;&#x0D; &lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Dex-morphine combinations achieve a higher efficacy and lower incidence of adverse events than morphine alone for post-caesarean analgesia.&lt;/p&gt;

RISK FACTORS, CLINICAL MANIFESTATION AND PREVENTION OF POST-DURAL PUNCTURE HEADACHE IN THE OBSTETRIC FIELD

Introduction: Over the past decades, the number of wo­men choosing to have epidural analgesia or undergoing spinal anesthesia during labor is steadily increasing. Con­sequently, a risk for complications is increasing. Post-dural puncture headache (PDPH) is considered one of the most common complication following accidental dural puncture (ADP). Sources and a method: A literature overview were con­ducted via search engine “PubMed (Medline)” and “Goo­gle Scholar”. Randomized controlled trials, meta – analy­sis, retrospective, prospective trials and systemic reviews on PDPH were selected. Aim of the review: To evaluate the most commonly des­cribed risk factors, clinical presentation and prevention of PDPH in the obstetric field. Results: The occurrence of ADP during neuraxial anest­hesia reported in the literature is relatively small – 0,1 – 1,5%. PDPH is a potentially expected complication after any lumbar punction. It presents as a headache within five days of the puncture due to low cerebrospinal fluid pressure. The pain is often bilateral, located in the frontal or occipital areas. Symptoms, such as vision and hearing impairment, neck pain and nausea might follow. Usually, the symptoms fade out spontaneously within two weeks. Risk factors for PDPH are modifiable (technique of the injection and anesthesiologist’s skills) and non-modifia­ble (pregnancy, low body mass index (BMI), dehydra­tion, history of PDPH). The goal of preventing PDPH is to identify and correct the risk factors associated with this condition. Main described means being equipment and experience, conservative measures, administration of epidural morphine, intravenous dexamethasone or co­syntropin, epidural blood patch and intrathecal catheter. Conclusions: 1. PDPH manifests as an orthostatic hea­dache with or without ocular, neural, hearing and other symptoms. 2. Young pregnant women with low BMI are more likely to suffer from PDPH. 3. PDPH preven­tion consists of risk factor correction and proper medi­cal techniques.

Preperitoneal ropivacaine infusion versus epidural ropivacaine–morphine for postoperative analgesia in dogs undergoing ovariohysterectomy: a randomized clinical trial

ObjectiveTo assess the effect of continuous wound infusion (CWI) with preperitoneal ropivacaine on postoperative analgesia and compare it with the epidural administration of ropivacaine and morphine in bitches undergoing ovariohysterectomy. Study designA parallel, randomized, clinical, prospective and nonblinded study. AnimalsA group of 38 Greyhound bitches. MethodsIn the catheter group (CathG), CWI with ropivacaine 1% (1 mg kg–1 + 0.8 mg kg–1 hour–1) was applied to the preperitoneal space over the surgical incision. In the epidural group (EpiG), ropivacaine 0.5% (1.3 mg kg–1) and morphine (0.1 mg kg–1) were epidurally administered. Occipital-coccygeal length was used to calculate the volume for the epidural. Pain was scored using a dynamic interactive visual analogue scale (DIVAS) and Glasgow composite measure pain scale–short form (CMPS-SF) before anaesthesia and at 2, 4, 6, 18, 21 and 24 hours after extubation. Incisional sensitivity using a dynamometer (MWTs-incision) was evaluated simultaneously. Plasma ropivacaine and cortisol concentrations, degree of sedation, motor blockade and response to interdigital clamping were measured or assessed. A two-way mixed analysis of variance and a Mann–Whitney U test were used to analyse data; p < 0.05. ResultsNo differences were detected in the DIVAS (p = 0.301), CMPS-SF (p = 0.600) scores, MWTs-incision measurements (p = 0.257) and cortisol values (p = 0.878) between the groups. Rescue analgesia was required in two dogs, one in each group, at 2 hours. Sedation, motor blockade and negative response to interdigital clamping were detected in EpiG at 2, 4 and 6 hours. Mean plasma ropivacaine values were higher in CathG (0.475 ± 0.164 ng mL–1) than in EpiG (0.184 ± 0.213 ng mL–1; p = 0.001). Conclusion and clinical relevanceCompared with epidural ropivacaine and morphine, CWI with preperitoneal ropivacaine is an effective analgesic technique for postoperative pain management in bitches undergoing ovariohysterectomy without motor blockade.

The pain and the itch

Itch Spinal and epidural morphine administration is used in the clinical setting as an analgesic for surgical procedures and in women during labor. However, delivery through these routes is associated with the development of itch. The molecular basis of this unwanted side effect has been unclear. Nguyen et al. found that morphine-induced itch did not involve mast cells but rather was mediated by the activity of spinal dynorphin neurons and subsequent inhibition of kappa-opioid receptor–expressing neurons in mice. Concomitant administration of morphine and nalfurafine, a selective kappa-opioid receptor agonist, inhibited itch without affecting morphine's analgesic properties in mice and monkeys, suggesting that this approach might also be effective in the clinical setting. Sci. Transl. Med. 13 , eabc3774 (2021).

Pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia: a case control study

BackgroundPruritus is one of the most common side effects of epidural morphine administered for post-surgery analgesia, and pregnant women tend to be highly susceptible. The relative contributions of morphine concentration, local anesthetics, and level of pain to pruritus after epidural morphine for post-cesarean delivery analgesia remain unclear. Accordingly, the present study aimed to identify risk factors for pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia.MethodsThis case control study was based on routinely collected clinical data. Participants included women who had undergone cesarean section and adopted a patient-controlled analgesia pump for postoperative analgesia. A series of logistic regression analyses were performed. Interaction terms were added to explore the moderation effects of combined local anesthetics and pain level on associations between morphine concentration and pruritus. Robustness of the results was checked through sensitivity analysis using propensity scores matching approach.ResultsHigher morphine concentration, assisted reproductive treatment, and multipara and cesarean section history were significantly more prevalent in the pruritus group than in the control group. The probabilities of pruritus at morphine concentrations of 10, 15, 20, 25, 30 and 40 μg/mL increased sequentially from 0.05, 0.1, 0.2, 0.35, 0.54 to 0.84, respectively. The trend remained steep in the ropivacaine stratum and became flatter when combined with levobupivacaine. At mild pain combined with levobupivacaine, the incidence of pruritus increased from 0.33 (95% confidence interval [CI] 0.1–0.68) in the 10 μg/mL morphine group to 0.48 (95% CI 0.1–0.88) in the 40 μg/mL morphine group. In the stratum of moderate pain combined with levobupivacaine, the incidence increased from 0.4 (95% CI 0.04–0.92) to 0.56 (95% CI 0.03–0.98). The results in the sensitivity analysis were in consistent with above findings.ConclusionsHigher concentrations of morphine, multipara, and assisted reproductive treatment were factors associated with a higher probability of pruritus. Pain level or combined local anesthetics could moderate the association between morphine concentration and pruritus.

Presumed generalised seizure following caudal epidural administration of morphine and detomidine in a pony

SummaryA 9‐year‐old show pony mare became acutely lame following removal of a bone sequestrum of the distal phalanx of the right thoracic limb. The mare also suffered from ongoing right dorsal colitis secondary to previous long‐term nonsteroidal anti‐inflammatory drug (NSAID) use. To avoid further NSAID use, a protocol for caudal epidural administration of morphine and detomidine in an increased volume was used to provide analgesia to the thoracic limbs. A total volume of 50 mL (0.2 mL/kg bwt) was administered over approximately 90 s. Immediately following the injection, the pony collapsed into lateral recumbency and experienced an apparent generalised seizure characterised by loss of consciousness and frantic paddling of all four limbs. The pony recovered rapidly without intervention, and no residual neurological deficits were noted. The epidural analgesia resulted in a marked improvement in comfort levels. The speed of injection is thought to have caused a change in epidural and intracranial pressures resulting in a generalised seizure and highlights the importance of administering large volumes slowly.

Prophylactic Intrathecal Morphine and Prevention of Post–Dural Puncture Headache

Prophylactic epidural morphine administration after unintentional dural puncture with a large-bore needle has been shown to decrease the incidence of post-dural puncture headache. The authors hypothesized that prophylactic administration of intrathecal morphine would decrease the incidence of post-dural puncture headache and/or need for epidural blood patch after unintentional dural puncture. Parturients with an intrathecal catheter in situ after unintentional dural puncture with a 17-g Tuohy needle during intended epidural catheter placement for labor analgesia were enrolled in this randomized, double-blind trial. After delivery, subjects were randomized to receive intrathecal morphine 150 µg or normal saline. The primary outcome was the incidence of post-dural puncture headache. Secondary outcomes included onset, duration, and severity of post-dural puncture headache, the presence of cranial nerve symptoms and the type of treatment the patient received. Sixty-one women were included in the study. The incidence of post-dural puncture headache was 21 of 27 (78%) in the intrathecal morphine group and 27 of 34 (79%) in the intrathecal saline group (difference, -1%; 95% CI, -25% to 24%). There were no differences between groups in the onset, duration, or severity of headache, or presence of cranial nerve symptoms. Epidural blood patch was administered to 10 of 27 (37%) of subjects in the intrathecal morphine and 11 of 21 (52%) of the intrathecal saline group (difference 15%; 95% CI, -18% to 48%). The present findings suggest that a single prophylactic intrathecal morphine dose of 150 µg administered shortly after delivery does not decrease the incidence or severity of post-dural puncture headache after unintentional dural puncture. This study does not support the clinical usefulness of prophylactic intrathecal morphine after an unintentional dural puncture.

Incidence of Respiratory Depression After Epidural Administration of Morphine for Cesarean Delivery: Findings Using a Continuous Respiratory Rate Monitoring System

(Int J Obst Anesth. 2019;38:32–36) Epidural morphine is widely used for postcesarean analgesia. However, because of the risk of respiratory depression after neuraxial administration of morphine, the American Society of Anesthesiologists (ASA) recommends frequent respiratory rate monitoring in the 24 hours after administration. This has typically been assessed through intermittent manual counting of the respiratory rate—a practice that is prone to observer error and does not allow continuous monitoring. Using this technique has resulted in documented rates of respiratory depression after epidural or intrathecal morphine administration of 0% to 0.9%.This study aimed to estimate the incidence of respiratory depression using the Nellcor respiratory rate monitoring system, which allows continuous monitoring, in patients who received 3 mg of epidural morphine for postcesarean analgesia.

Morphine plasmatic concentration in a pregnant mare and its foal after long term epidural administration

BackgroundEpidural administration of morphine has been shown to be an effective analgesic strategy in horses; however, the possible occurrence of side effects limits its usage. In order to decrease their frequency, it is important to target the minimal effective plasma concentration and avoid overdosing. As to date species-specific pharmacokinetics data are not available for epidural morphine, the dosing regimen is usually established on the basis of clinical reports and personal experience. In certain physiological conditions, like gestation, the outcome of an empirical dosing scheme can be unpredictable. The aim of this case report is to describe the pharmacological profile of morphine and its metabolites after prolonged epidural administration in a pregnant mare and her foal.Case presentationA 20 years old pregnant mare was presented to our hospital because of severe lameness, 2 months before delivery. Following an ineffective systemic pain treatment, an epidural catheter was inserted and morphine administered (initial dose 0.1 mg/kg every 8 h). Due to its efficacy in controlling pain, it was continued until end of gestation. Plasmatic concentration of morphine and its metabolites were assessed in the mare 6 weeks after starting the treatment, and in both the mare and foal during the first days after delivery. Plasmatic values similar to those previously reported in the literature following morphine short term administration through various routes and not accompanied by side effects were found in the mare, except during an excitatory period. Moreover, no evidence of dangerous drug accumulation or significant milk passage was noticed in the foal. Mild reduction of feces production with no signs of colic and two self-limiting episodes of excitement occurred during treatment in the mare. No side effects occurred during gestation and first phases of life in the foal.ConclusionProlonged epidural administration of morphine in a pregnant mare allowed good pain control in absence of clinically relevant side effects, in both the mare and her foal. Sudden increase in morphine plasmatic concentration can occur and side effects appear; careful treatment to the lowest effective dose and continuous monitoring of the clinical condition of the treated horse should be performed.

Opiate Intoxication Caused by Epidural Infusion of Morphine: A Case Report of a Near Fatal Medication Error

Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative-and peripartum-periods. Selection of the opioid, appropriate dosing, and follow-up by the acute pain service are critical in providing safe postoperative epidural analgesia. A 71-year-old man was scheduled for a parastomal hernia repair with midline laparotomy. The parastomal hernia was a complication from a previously performed colectomy for ulcerative colitis. Preoperatively, the patient received a lower thoracic epidural catheter. The epidural infusate (0.2% ropivacaine with 0.5µg/mL sufentanil) was prepared and double-checked by holding area nurses. The fact that the right prescription medication label partially covered a morphine label went unnoticed. The intraoperative phase was characterized by stable parameters. Postoperatively, it was not possible to demonstrate an epidural nerve block. No pain was reported, and the patient could be transferred to the ward. The patient developed coma and delayed respiratory depression after discharge to the surgical ward, requiring intensive care unit admission and naloxone administration. Analysis of the syringe content revealed the presence of morphine (1mg/mL). Color-coded prefilled syringes combined with the use of an epidural specific syringe connector to prevent cross-connections should become standard practice. In addition, delayed respiratory depression should be considered after epidural administration of morphine.

Pruritus and myoclonus following five consecutive doses of morphine administered through an epidural catheter in a dog

A 2-year, 10-month-old male entire whippet had an epidural catheter placed to provide postoperative analgesia following lateral thoracotomy. He received 0.1 mg/kg preservative free morphine every 12 hours via the...

The use of epidural morphine in patients with severe traumatic injury

Objective. Assessment of the efficacy and safety of epidural morphine in patients with severe concomitant injury.&#x0D; Material and methods. 70 patients with severe combined injury (1745 points for ISS) were divided into two groups: in group 1 (n = 37), 2 mg of morphine was administered epidurally followed by morphine infusion 0.4 mg / h, in the 2nd group (n = 33), intravenous administration of fentanyl was used at a rate of 50100 g / h. The level of pain syndrome was assessed by a 10-point visual analogue scale (VAS). The mean arterial pressure (MAP) and heart rate (HR) at rest and with activation were recorded, the gas composition of the blood (pH, SaO2, PaCO2) was measured, and the vital capacity (VC) was measured. The evaluation of delirium was carried out according to the RASS and CAM-ICU scales. In addition, they recorded the frequency of itching.&#x0D; Results. The intensity of a pain syndrome at rest was more expressed at patients of the 2nd group (p 0.05). Against the background of activation of 10,8% of patients of the 1st group and 36,4% of patients of the 2nd group experienced a pain syndrome intensity of 47 points on VAS. In patients of the 2nd group, with activation, there was an increase (p 0.05) in the indices of MAP and HR. VC in patients of the 1st group was 45.4 5.8%, in the 2nd 41.3 4.7% (p 0.005). Patients of the 1st group had a lower level of PaCO2 (p 0.05) compared with the 2nd group. Postoperative delirium developed in the 1st group in 16.2%, in the 2nd in 30.3% of patients (p 0.05). Pruritus occurred in the 1st group at 21.6% and was absent in the group with systemic administration of opioids. Opioid-induced ileus, nausea and vomiting in the 1st group were not recorded, in the 2nd group were noted in 18.2% and in 9.1% of cases (p 0.05), respectively.&#x0D; Conclusion. The use of epidural morphine in patients with severe traumatic injury effective pain relief was observed, not accompanied by of the respiratory depression and changes in blood gas composition. Epidural administration of morphine in patients undergoing massive blood loss and hemorrhagic shock was not accompanied by arterial hypotension. Effective anesthesia contributed to reducing the incidence of postoperative complications.

Incidence of respiratory depression after epidural administration of morphine for cesarean delivery: findings using a continuous respiratory rate monitoring system

BackgroundEpidural morphine is widely used for postoperative analgesia after cesarean delivery. However, respiratory depression can occur after neuraxial administration of morphine. Previous reports describing respiratory depression in obstetric patients have relied on intermittent visual counting of the respiratory rate. In this study, we estimated the incidence of respiratory depression in patients who had received epidural morphine after cesarean delivery, using a continuous respiratory rate monitoring system with a finger sensor. MethodsOne hundred patients scheduled to undergo elective cesarean delivery and receive intraoperative neuraxial morphine between April and December 2016 were recruited for this single-center, prospective observational study. Postoperatively, all patients received epidural morphine 3 mg and were equipped with the Nellcor respiratory rate monitoring system. Respiratory depression was defined as both bradypnea (respiratory rate ≤10 breaths/min) and oxygen desaturation (mild ≤95%; moderate ≤90%; severe ≤85%) for longer than one minute. The number of patients with respiratory depression between administration of morphine and first ambulation was recorded hourly. ResultsComplete monitoring was obtained for 89 of 100 women. The median duration of monitoring was 19.0 hours. Forty-six patients (52%) developed mild respiratory depression at least once before ambulation, but only one (1%) developed moderate respiratory depression. None required supplemental oxygen or naloxone. ConclusionsApproximately half the women experienced mild respiratory depression, but only one developed moderate respiratory depression. Continuous respiratory rate monitoring until ambulation may assist in early identification of respiratory depression after neuraxial administration of morphine.

Influence of caudal epidural analgesia on cortisol concentrations and pain-related behavioral responses in mares during and after ovariectomy via colpotomy.

To determine the influence of epidural detomidine and morphine on serum corticosteroid concentrations and pain-related behavioral responses in mares during and after ovariectomy via colpotomy. Blinded prospective study. Nine university-owned mares. Five of 9 horses received caudal epidural detomidine hydrochloride (0.01 mg/kg) and morphine sulfate (0.1 mg/kg) prior to surgery. All horses received local anesthetic around the ovarian pedicle, 0.02 mg/kg butorphanol IV at the start of the procedure and after first ovary removal, were sedated as required throughout the procedure, and were monitored for leg lifting, grunting, and abdominal tensing. Horses were monitored hourly for pain postoperatively. Heart rate was recorded every 4 hours, and photographs were taken to assess pain according to the horse grimace scale (HGS). Control group horses (n = 4) were treated with butorphanol (0.02 mg/kg IV) every 4 hours for 24 hours postoperatively. All horses received oral phenylbutazone 18 hours postoperatively. Serum cortisol was measured prior to the procedure, after first and second ovary removal, and 8 and 24 hours postoperatively. No differences were detected between horses receiving caudal epidural detomidine and morphine and those that received systemic opioids. A decrease in HGS score occurred after phenylbutazone administration. Administration of caudal epidural detomidine and morphine resulted in similar pain-related behavior and corticosteroid concentrations as did administration of systemic butorphanol every 4 hours for 24 hours postoperatively. Caudal epidural detomidine and morphine may mitigate the requirement for frequent systemic opioid administration after a potentially painful procedure.