Use Of Epidural Morphine Research Articles

Multimodal Anaesthesia in a Crab-eating Fox (Cerdocyon thous) Undergoing Hemilaminectomy and Sacrococcygeal Stabilization

Background: Several researches have shown the impacts of roads more directly to wildlife in Brazil. The crab-eating fox (Cerdocyon thous) is a frequent run over victim. Dissociative drugs are commonly used, but inhalation anesthesia is indicated in cases of extensive and prolonged surgeries. Despite their similarity with domestic dogs, the literature is scarce regarding the association of new anesthetic techniques and protocols in wild canids. The aim of this paper was to report the viability of multimodal anesthesia in a crab-eating fox, victim of running over, undergoing hemilaminectomy and sacrococcygeal stabilization.Case: An adult male specimen of crab-eating fox was rescued after being run over and taken to a wild animal screening center. Physical examination showed superficial and deep pain, lack of support for the pelvic limbs and proprioception, increased reflexes, and reduced tail mobility. Chemical restraint with intramuscular (IM) tiletamine-zolazepam (6.0 mg/kg) and morphine (0.5 mg/kg) was performed. Meloxicam (0.2 mg/kg IM) and enrofloxacin (5.0 mg/kg IM) were also administered. The animal was sequentially admitted to the veterinary hospital. Radiographic images showed compaction of the spinal column of the T10 and T11 thoracic vertebrae and the sacrococcygeal region. Sixty min after chemical restraint, the anesthesia was supplemented with IM tiletamine-zolazepam (4.5 mg/kg), and fluid therapy with 0.9% NaCl (10 mL/kg/h) was started. Ten min later, intravenous propofol dose-effect (2.5 mg/kg) was administered and general anesthesia was maintained with isoflurane (FiO2 = 1.0). Thirty min after the induction of anesthesia, the animal was urdergoing hemilaminectomy and sacrococcygeal stabilization. Constant rate infusions (CRI) of dexmedetomidine (0.5 μg/kg/h) and ketamine (0.6 mg/kg/h) were started. Lidocaine (7.0 mg/kg) and bupivacaine (2.0 mg/kg) were administered into the surgical site on the T10 and T11 vertebrae at 35 and 80 min into the surgery, respectively. The isoflurane requirement was adjusted often to keep the animal in the surgical anesthetic plan. At the end of the surgery (total time, 95 min), lumbosacral epidural analgesia was performed with morphine (0.1 mg/kg). No important abnormalities were detected in heart rate, systolic arterial pressure, mean arterial pressure, diastolic arterial pressure, respiratory rate, oxygen saturation, or body temperature during the surgical period. The time intervals between the end of anesthesia, and the following events: extubation, the first head movement, and the establishment of sternal were 18, 34 and 73 min, respectively. Recovery was considered calm and peaceful, with no signs of pain or excitement.Discussion: Considering the painful discomfort and the need for manipulation, dissociative anesthesia was initially used to move the animal to hospital care. Due to the immediate indication for surgery, it was decided to use propofol in a sufficient dose for orotracheal intubation, keeping anesthesia with isoflurane. With the expectation of severe pain during the surgical procedure, CRI of dexmedetomidine and ketamine were used, in addition to lidocaine and bupivacaine at the lesion site. Although the minimum alveolar concentration of isoflurane has not been recorded, the physiological parameters were kept relatively stable, ratifying the adequate plan of anesthesia compatible with the observed eye reflexes. Based on the experience with other canids, the use of epidural morphine was performed, aiming at postsurgical analgesic extension. Although a certain lack of coordination was observed, the animal’s recovery was characterized by stillness, with no signs of pain or excitement, confirming the effectiveness of the anesthetic protocol. The present report may aid in the choice of balanced anesthetic approaches in wild canids.

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.
 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.
 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.
 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.

EPIDURAL MORPHINE IN PEDIATRIC ONCOLOGIC SURGERY

Epidural administration of opioids effectively prevents the sensitization of nociceptive neurons of the posterior horn of the spinal cord, induced by surgical trauma, without the development of motor and autonomic blockade. Study includes 52 patients aged 1 month to 18 years with malignant tumors who underwent surgical treatment at the Pediatric Oncology and Hematology Research Institute, during 2009-2016 years. Surgeries were combined (thoraco-laparotomy). The method of epidural use of morphine in pediatric oncosurgery is presented.

A comparison of epidural analgesia provided by Bupivacaine plus Pethidine, Bupivacaine plus Morphine, or Bupivacaine plus Morphine plus Midazolam for lower limb Orthopaedic surgery

Epidural anaesthesia and analgesia in orthopaedic surgeries helps to prevent thromboembolic phenomenon by increasing venodynamics. Adequate post operative analgesia with good patient satisfaction has been observed with this technique. The objective of this study was to assess the duration of postoperative analgesia and complications in patients receiving epidural anesthesia with morphine, midazolam and pethidine in combination with bupivacaine. We prospectively studied 75 Patients who were scheduled for elective lower limb orthopaedic surgery with epidural anaesthesia. This study was conducted from March 2010 to March 2012 at Lumbini Medical College Palpa. They were randomly divided by lottery method into three equal groups. Group ‘A’ (BP) received 50 mg epidural pethidine (3 ml) with 0.5 % bupivacaine 13 ml. Group ‘ B’ (BM) received 5 mg (3 ml) epidural morphine with 13 ml of 0.5% bupivacaine and Group’ C’ (BMM) received 5 mg (1 ml) epidural morphine with 13 ml 0.5% bupivacaine and 2 mg (2 ml) epidural midazolam. All the patients were observed for 24 hours for quality of analgesia and other side effects like nausea vomiting, and pruritus. Data were analysed by SPSS-16.0 software. The result of the study shows the duration of analgesia was prolonged in BMM group than BM, and BP group and was statistically significant (P value <0.001). Incidence of nausea and vomiting in BMM group was lower than that of BP and BM group but was statistically insignificantly (P value 0.489). Pruritus was absent in BP group and was more with BM and BMM group (P value 0.007). In conclusion the use of epidural morphine and midazolam in combination with bupivacaine is the satisfactory method of post operative analgesia. By adding midazolam, duration of analgesia can be increased with decrease in incidence of nausea, vomiting and pruritus. DOI: http://dx.doi.org/10.3126/jcmc.v4i1.10842 Journal of Chitwan Medical College 2014; 4(1): 19-21

A comparison of epidural analgesia provided by Bupivacaine plus Pethidine, Bupivacaine plus Morphine, or Bupivacaine plus Morphine plus Midazolam for lower limb orthopaedic surgery

Background: Epidural anaesthesia and analgesia in orthopaedic surgeries helps to prevent thromboembolic phenomenon by increasing venodynamics. Adequate post-operative analgesia with good patient satisfaction has been observed with this technique. Objective: To assess the duration of postoperative analgesia and complications in patients receiving epidural anaesthesia with Morphine, Midazolam and Pethidine in combination with Bupivacaine. Methods: We prospectively studied 75 patients who were scheduled for elective lower limb orthopaedic surgery with epidural anaesthesia at Lumbini Medical College, Palpa from 2010 March to 2012 March. They were randomly divided by lottery method into three equal groups. Group ‘A’ (BP) received 50 mg epidural Pethidine (3 ml) with 13 ml of 0.5% Bupivacaine. Group ‘B’ (BM) received 5 mg (3 ml) epidural Morphine with 13 ml of 0.5% Bupivacaine and Group ‘C’ (BMM) received 5 mg (1 ml) epidural Morphine with 13 ml 0.5% Bupivacaine and 2 mg (2 ml) epidural Midazolam. All the patients were observed for 24 hours for quality of analgesia and other side effects like nausea, vomiting and pruritus. Data were analysed by Statistical Package for Social Sciences (SPSS-16) software. Results: The result of the study shows the duration of analgesia was prolonged in BM group than BP group and even more so in BMM group (p value <0.001). Incidence of nausea and vomiting in BMM group was lower than in BP and BM group but statistically the difference was not significant (p value: 0.489). Pruritus was absent in BP group, less in BMM group while significantly higher in BM group. Conclusion: The use of epidural Morphine and Midazolam in combination with Bupivacaine is the satisfactory method of post operative analgesia. When Midazolam is added, duration of analgesia can be increased with decrease in incidence of nausea, vomiting and pruritus.Journal of Kathmandu Medical College Vol. 2, No. 3, Issue 5, Jul.-Sep., 2013 Page: 117-121DOI: http://dx.doi.org/10.3126/jkmc.v2i3.9961Uploaded date : 3/4/2014

Comparison of Intravenous Morphine, Epidural Morphine With/Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique

Background and objectivesThe aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. MethodsSixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphineropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30th and 60th minutes and the 2nd, 4th, 6th, 12th, 24th, 36th, 48th, and 72nd hour. ResultsDiclofenac sodium requirement during the study was lower in Group EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48th hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30th and 60th minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30th minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. ConclusionsMorphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.

Comparison of Intravenous Morphine, Epidural Morphine With/ Without Bupivacaine or Ropivacaine in Postthoracotomy Pain Management With Patient Controlled Analgesia Technique

Background and objectivesThe aim of this randomized, double-blinded, prospective study was to determine the effectiveness and side effects of intravenous or epidural use of morphine, bupivacaine or ropivacaine on post-thoracotomy pain management. MethodsSixty patients undergoing elective thoracotomy procedure were randomly allocated into 4 groups by the sealed envelope technique. Group IVM, EM, EMB and EMR received patient controlled intravenous morphine, and epidural morphine, morphine-bupivacaine and morphineropivacaine, respectively. Perioperative heart rate, blood pressure and oxygen saturation and postoperative pain at rest and during cough, side effects and rescue analgesic requirements were recorded at the 30th and 60th minutes and the 2nd, 4th, 6th, 12th, 24th, 36th, 48th, and 72nd hour. ResultsDiclofenac sodium requirement during the study was lower inGroup EM. Area under VAS-time curve was lower in Group EM compared to Group IVM, but similar to Group EMB and EMR. Pain scores at rest were higher at the 12, 24, 36, and 48th hour in Group IVM compared to Group EM. Pain scores at rest were higher at the 30th and 60th minutes in Group EM and Group IVM compared to Group EMB. Pain scores during cough at the 30th minute were higher in Group EM compared to Group EMB. There was no difference between Group IVM and Group EMR. ConclusionsMorphine used at the epidural route was found more effective than the intravenous route. While Group EM was more effective in the late period of postoperative, Group EMB was more effective in the early period. We concluded that epidural morphine was the most effective and preferred one.

Ensayo clínico aleatorizado, controlado, doble ciego, para evaluar la analgesia posparto con morfina epidural: efectividad analgésica de dos dosis diferentes, comparadas con placebo

IntroductionPrior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor. ObjectiveTo determine the efficacy of 2 and 3mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo. Patients and methodsDouble-blind randomized clinical trial with 114 patients, in which 38 patients received 10ml of anesthetic solution with 2mg of epidural morphine, 39 received 3mg of epidural morphine, and another 37 received 10ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated. ResultsThe dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2mg (NNT=4.56), as well as in the group receiving 3mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT =1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period.The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%. ConclusionsThe use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient.

Randomized double-blind controlled clinical trial for the evaluation of post-partum analgesia using epidural morphine: analgesic effectiveness of different dose regimes compared with placebo

Introduction: Prior studies have shown that the conventional management of post-partum pain (acetaminophen, NSAIDS) is insufficient. In our setting, no advantage is taken of the epidural catheter placed as part of the analgesic management of pregnant women during labor. Objective: To determine the efficacy of 2 and 3 mg doses of epidural morphine used for analgesia during vaginal post-partum in patients receiving epidural analgesia for labor, compared to placebo. Patients and methods: Double-blind randomized clinical trial with 114 patients, in which 38 patients received 10 ml of anesthetic solution with 2 mg of epidural morphine, 39 received 3 mg of epidural morphine, and another 37 received 10 ml of 0.9% epidural saline solution (control group), 1 hour after labor. The analgesic efficacy and the side effects occurring within the first 24 hours after administration were evaluated. Results: The dose of morphine was effective at controlling pain after delivery, making it possible to reduce the need for additional analgesia in the group receiving 2 mg (NNT=4.56), as well as in the group receiving 3 mg of morphine (NNT=3.66). The outcome was more marked in patients who needed perineorrhaphy (NNT = 1.6) and in primiparity cases (NNT 2.4). In the experimental group, the analgesic effect extended over the 24-hour follow-up period. The incidence of side-effects in each of the treatment groups was as follows: pruritus, 30% and 36%; nausea, 18.4% and 15.4%; vomiting, 7.9% and 15.4%. Conclusions: The use of epidural morphine during the immediate post-partum period is effective for managing pain ensuing after labor. Although there was evidence of adverse side effects at the doses used, they were tolerable and did not require treatment. The present management of post-partum analgesia is insufficient.. © 2012 Sociedad Colombiana de Anestesiología y Reanimación. Published by Elsevier. All rights reserved. Introducción: Estudios previos han demostrado que el manejo convencional de dolor posparto (acetaminofén, AINE) es insuficiente. En nuestro medio se desaprovecha el uso del catéter epidural que es colocado como parte del manejo analgésico de las gestantes en el trabajo de parto. Objetivo: Determinar la eficacia de dosis de 2 mg y de 3 mg de morfina epidurales versus placebo, empleadas para analgesia durante el posparto vaginal en pacientes que recibieron analgesia epidural para su trabajo de parto. Pacientes y métodos: Ensayo clínico, doble ciego y aleatorizado realizado con 114 pacientes. 38 pacientes recibieron 10 ml de solución anestésica con 2 mg de morfina epidural, 39 pacientes recibieron 3 mg de morfina epidural, y 37 otras 10 ml de solución salina al 0,9% por vía epidural (grupo control), 1 hora después de la atención del trabajo de parto. Se evaluó la eficacia analgésica así como los efectos secundarios presentados durante las 24 horas posteriores a la administración. Resultados: La dosis de morfina fue efectiva para el control del dolor consecutivo al parto y se logró disminuir la necesidad de analgésico adicional tanto en el grupo de 2 mg (NNT 4,56) como en el de morfina 3 mg (NNT = 3,66). El resultado fue más marcado en el grupo de pacientes con necesidad de perineorrafia (NNT = 1,6) y en las madres primíparas (NNT 2,4). En el grupo experimental, el efecto analgésico se extendió a las 24 horas de seguimiento. En nuestro estudio, la incidencia de efectos secundarios fue la siguiente: prurito, 30% y 36%; náuseas, 18,4% y 15,4%; y vómito, 7,9% y 15,4% para cada uno de los grupos experimentales. Conclusiones: El uso de morfina epidural en el posparto inmediato es eficaz para el manejo del dolor que sobreviene al trabajo de parto. Si bien se evidenció una importante presencia de efectos adversos a las dosis usadas, estos fueron tolerables y no requirieron de tratamiento. El manejo actual de la analgesia posparto es insuficiente. © 2012 Sociedad Colombiana de Anestesiología y Reanimación. Publicado por Elsevier. Todos los derechos resevados.

Nystagmus caused by epidural fentanyl

Anesthesiologists commonly use opioids for pain control in the operating room and postanesthesia care unit, and are constantly vigilant in looking for possible adverse outcomes. Therefore, common complications such as nausea, vomiting, and pruritus are well known. However, neurologic complications after opioid administration are relatively rare except for reduced consciousness, for example drowsiness or sedation. We recently experienced a case in which a 73-year-old woman presented predominantly vertical nystagmus as a neurological complication after epidural administration of fentanyl. A few previous reports on opioids as causative agents for nystagmus have all after use of epidural morphine, and there are yet no publications reporting epidural fentanyl as the cause of nystagmus. Physicians should keep in mind that epidural fentanyl could cause the nystagmus as a neurological complication even though it is used within conventional dosage ranges, although this is very rare. Also, when a patient develops nystagmus after epidural fentanyl, it could be a benign side effect caused by epidural fentanyl as we have experienced, but it could also be a sign of serious central nervous system lesions especially in patients with underlying risk factors such as old age, diabetes mellitus, hypertension, and cerebrovascular disease, and thus special attention should be paid to this.

Thoracic Epidural Analgesia and Acute Pain Management

AIN continues to be a significant problem for many patients after major surgery. In addition to improving patient satisfaction and decreasing pain scores, enhanced perioperative pain control can improve clinical outcomes. Thoracic epidural analgesia (TEA) remains a critical tool for anesthesiologists to use in acute pain management. TEA is particularly effective for reducing pain after thoracic and upper abdominal surgery and likely permits major surgical procedures to be performed on patients with moderate to severe comorbid diseases, who several years ago may have been determined to be too great a risk for surgery. In the past 10 yr, peripheral nerve blockade has improved perioperative analgesia for patients undergoing extremity surgery. Although nerve blocks have reduced the use of continuous lumbar epidural analgesia, anesthesiologists must understand the indications, placement techniques, solutions administered, potential complications, and evidence-based outcomes for TEA in acute pain management. Indications

Uso de morfina peridural em pacientes com disautonomia após traumatismo craniencefálico

Resumo Introdução: A disautonomia ou hiperatividade simpática paroxística (HSP) pode ocorrer em até um terço dos pacientes vítimas de trauma de crânio grave, entretanto ainda é uma entidade sem tratamento estabelecido. O uso de morfina intravenosa é descrito para o tratamento da HSP, sendo observada melhora principalmente na diminuição das frequências respiratória e cardíaca. Partindo desses preceitos, este estudo analisa os efeitos da morfina peridural nos pacientes com HSP. Pacientes e métodos: Foram avaliados três pacientes (dois masculino e um feminino), com idade média de 20,6 anos, vítimas de trauma de crânio grave, que apresentaram durante a evolução quadro clínico sugestivo de disautonomia. Os dados coletados incluíram detalhes do trauma, parâmetros fisiológicos, medicações utilizadas e evolução dos sintomas. Nesses pacientes, foi realizada infusão de morfina 4-6 mg/d no espaço peridural, em nível torácico, com média de 25,6 dias. Resultados: Dois pacientes tinham sinais radiológicos de lesão axonal difusa e um paciente tinha um volumoso hematoma extradural que foi operado. Os principais sintomas encontrados nos três pacientes foram sudorese, taquicardia, hipertermia e posturas distônicas. Em dois pacientes a hipertonia era global e em um paciente a postura distônica predominava no hemicorpo esquerdo. Após a passagem do cateter epidural com infusão de morfina, foi observada, já na primeira semana, melhora dos sintomas da hiperatividade simpática e da hipertonia nos grupos musculares envolvidos. Conclusão: O uso de morfina peridural pode ser uma alternativa de tratamento nos pacientes com HSP refratários ao tratamento clínico.

Uso de morfina, xilazina e meloxicam para o controle da dor pós-operatória em cadelas submetidas à ovariossalpingo-histerectomia

Foram realizados estudos empregando-se analgésicos por via epidural e subcutânea em cadelas de diferentes raças e idades, submetidas à castração mediante celiotomia. Vinte animais foram tranquilizados e anestesiados com tiletamina-zolazepam, e aleatoriamente distribuídos em quatro grupos (n=5), de acordo com o fármaco e a via de administração. Os do grupo morfina (GM) foram submetidos à anestesia epidural no espaço lombossacro, com morfina (0,1mg/kg) associada ao cloreto de sódio a 0,9%. Aos do grupo xilazina (GX), foram administrados xilazina (0,2mg/kg) e cloreto de sódio a 0,9%. Os do grupo meloxicam (GME) receberam 0,2mg/kg do anti-inflamatório meloxicam associado ao cloreto de sódio a 0,9%, injetado pela via subcutânea. Os do grupo-controle (CG) receberam apenas cloreto de sódio a 0,9%. O volume final para as injeções epidurais foi padronizado para 0,3mL/kg. A mensuração inicial da concentração de cortisol plasmático, do ritmo cardíaco, da frequência respiratória e os parâmetros comportamentais foram registrados imediatamente antes do procedimento cirúrgico (M1). Registros adicionais foram apresentados às 2, 6, 12 e 24 horas após o procedimento cirúrgico (M2, M3, M4 e M5, respectivamente). As variáveis comportamentais foram avaliadas por meio de sinais clínicos e seus respectivos escores. Em GX foram observadas depressão respiratória, bradicardia e concentração de cortisol mais alta do que o registrado no GM. A analgesia obtida pelo meloxicam foi considerada ineficiente. É possível concluir que a morfina, via epidural, promoveu menor incidência de efeitos colaterais e melhor analgesia e bem-estar animal.

Downbeat nystagmus related with epidural opioid side effect

Summary Background Downbeat nystagmus is a vertical downlook nystagmus associated with craniocervical injury or pharmacological intoxications. Case report We describe a clinical case of a patient who presented with a downbeat nystagmus as the only side effect associated with the use of epidural morphine. The vertical oscillopsia resolved when epidural morphine was withdrawn. Conclusions Downbeat nystagmus is an unfrequent complication but should be considered when utilising perineural morphine anaesthesia. A thorough differential diagnosis should be done previously too.

Efficacy of Postoperative Epidural Morphine for Postpartum Tubal Ligation

To the Editor: Marcus et al. (1) suggest that postoperative pain relief is better in patients undergoing postpartum tubal ligation when epidural morphine is administered, as also suggested by Campbell et al. (2). There are several drawbacks to the use of epidural morphine in these patients. Most significantly, epidural morphine is associated with delayed respiratory depression, which may appear up to 24 h after administration. With increasing pressure on hospitals to limit the duration of stay of patients, postpartum patients undergoing tubal ligation the day after delivery are commonly discharged on the same day as the surgery. Such patients should not receive epidural morphine, as they will not be adequately monitored for ventilatory depression. There might be a case for epidural morphine if there were no acceptable alternatives and if all such patients remained in hospital for 24 h after their procedure. However, there are numerous alternatives, including infiltration by the obstetricians with local anesthetic, IV agents such as ketorolac and short-acting opioids, and traditional oral analgesics. More than 75% of such procedures worldwide are done using local anesthesia alone (3). In our view, epidural morphine may be excessive for a procedure that produces only modest postoperative pain of short duration (4). Philip J. Balestrieri, MA, MD Paul H. Ting, MD Randal S. Blank, MD, PhD Obstetric Anesthesia Department of Anesthesiology University of Virginia [email protected]du

Laparoscopic Ovariectomy Using the Endo‐GIA Stapling Device and Endo‐Catch Pouches and Evaluation of Analgesic Efficacy of Epidural Morphine Sulfate in 10 Mares

To evaluate use of ENDO-GIA staples and ENDO-Catch pouches for ovariectomy in mares and to evaluate the efficacy of epidural morphine analgesia. Randomized clinical trial. Mares (n = 10) with normal ovaries. An Endo-GIA II stapler (United States Surgical Corp., Norwalk, CT) was used to amputate the ovaries bilaterally, in standing mares, and Endo-Catch II pouches (United States Surgical Corp.) were used for retrieval. Epidural morphine was used in 5 mares, and procedure duration, volume of lidocaine required to desensitize the ovarian pedicle, and sedation were compared with horses not administered epidural morphine. Use of the Endo-GIA II stapling device was an easy and an efficient method of ovariectomy, which was facilitated by use of epidural morphine. For the epidural group, the mean (+/-SD) surgical time was 69.2 +/- 10.2 minutes compared with 124.4 +/- 21.2 minutes for mares not administered morphine. Less systemic sedation was required for mares administered epidural morphine. Minimal ovarian manipulation was required to apply the stapler, hemorrhage was slight, and none of the mares had complications. Epidural morphine provided effective analgesia, improving patient comfort, and reduced the sedation needed to perform ovariectomy. Endo-GIA II staples are an efficient method for ovariectomy in normal mares. Epidural morphine should be considered to facilitate ovariectomy because less sedation and local anesthetic administration is required.

A Prospective Randomized Study of Preemptive Analgesia for Postoperative Pain in the Patients Undergoing Posterior Lumbar Interbody Fusion

A prospective randomized clinical trial in preemptive analgesia for postoperative pain was conducted. To compare the efficacy of three preemptive analgesics combined with local anesthesia: continuous subcutaneous morphine (SC), continuous epidural morphine (ED), and diclofenac sodium (DS). Systemic opioids are known to be effective methods of postoperative pain control. The use of epidural morphine for postoperative analgesia has been a standard treatment in spinal surgery. Only a few studies in the literature have investigated the efficacy of preemptive analgesia using morphine. This is the first prospective randomized clinical trial to assess both subcutaneous and epidural continuous administration of opioids for preemptive analgesia. For this study, 73 patients were assigned randomly to one of three treatment groups: SC, ED, or DS. All patients underwent posterior lumbar interbody fusion with instrumentation. Pain management was assessed using the visual analogue scale (VAS). Usage of supplemental analgesics, the time to first request of them, and side effects were also investigated. Twenty-two patients were randomized to SC, 23 to ED, and 27 to DS. No baseline variable differences among the three groups were seen. The results showed no significant difference in analgesic effects among those three preemptive analgesics. Only immediately after surgery (at 0 hours), the VAS of the DS group was lowest among three groups. But the DS group took more supplemental analgesic drugs until 72 hours, and the time to first request of this group was shorter than that of the other two groups. High rates of minor side effects were seen in both the ED and DS groups. SC gave moderate analgesic effects as well as the other two groups with few adverse effects. DS provided a favorable effect immediately after surgery, but the effective time was short and the patient needed more supplemental drugs after that. ED did not give the expected effect, with comparatively high rates of side effects. Continuous epidural anesthesia did not seem to be suitable for preemptive analgesia. Continuous subcutaneous morphine brought some analgesic effects with a low rate of complications. It can be an attractive method for postoperative analgesia with technical ease.

A history of neuraxial administration of local analgesics and opioids.

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.

Oral Herpes Simplex Reactivation After Intrathecal Morphine: A Prospective Randomized Trial in an Obstetric Population

There is now evidence for an association between the use of epidural morphine and reactivation of herpes simplex labialis (HSL). There are no studies that definitively demonstrate the relationship between HSL reactivation and spinal intrathecal morphine. To investigate this relationship, we randomized and prospectively studied 100 obstetric patients with a history of HSL undergoing cesarean delivery under spinal anesthesia. One group received intrathecal morphine plus IV morphine via patient-controlled analgesia (ITM+PCA group) for postoperative analgesia, and a second group received only IV morphine via patient-controlled analgesia for postoperative analgesia (PCA-only group). Patients were followed for a 30-day period. In the ITM+PCA group 19 (38%) patients had HSL reactivation whereas eight (16.6%) had HSL reactivation in the morphine PCA-only group (P = 0.028). The incidence of pruritus in the ITM+PCA group was also more frequent in the early postoperative period. Our data show HSL reactivation in both the ITM+PCA group and PCA-only morphine group, with a more frequent incidence in the ITM+PCA group.

A history of neuraxial administration of local analgesics and opioids

The history of intrathecal and epidural anaesthesia is in parallel with the development of general anaesthesia. As ether anaesthesia (1846) is considered the first modern anaesthetic since its use by Morton 157 yr ago, so Bier made history by using cocaine for intrathecal anaesthesia in 1898. The first published report on opioids for intrathecal anaesthesia belongs to a Romanian surgeon, Racoviceanu-Pitesti, who presented his experience at Paris in 1901. It was almost a century before the opioids were used for epidural analgesia. Behar and his colleagues published the first report on the epidural use of morphine for the treatment of pain in The Lancet in 1979. Epidural and intrathecal opioids are today part of a routine regimen for intra- and postoperative analgesia. Over the last 30 yr, the use of epidural opioids has became a standard for analgesia in labour and delivery, and for the management of chronic pain. Finally, epidural opioids have been shown to have a pre-emptive effect, when used before major surgery. We present the evolution of neuraxial anaesthesia and the history of intrathecal and epidural administration of opioids.