Intraspinal Morphine Research Articles

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

<p><strong>Background & Objectives:</strong> 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.</p>
 <p><strong>Methods:</strong> 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’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.</p>
 <p><strong>Results: </strong>Lower cortisol and renin was measured in the combination group than in the morphine group immediately after caesarean sections (<em>P</em> < 0.05), while no significant differences were found in serum potassium between two groups at each time point (<em>P</em> > 0.05). Lower VAS scores were measured in the combination group than in the morphine group 12 and 24 hours after caesarean sections (<em>P</em> < 0.05); however, no significant differences were seen in the OAA/S score (<em>P</em> > 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 (<em>P</em> < 0.05).</p>
 <p><strong>Conclusion:</strong> Dex-morphine combinations achieve a higher efficacy and lower incidence of adverse events than morphine alone for post-caesarean analgesia.</p>

A study of haemodyanamine changes: a comparative pain score evaluation of lumbar epidural block using 0.5% bupivacaine and 0.5% bupivacaine with ketamine in orthopaedic surgery cases

Epidural block using local anaesthetic drugs are used in clinical practice since many years. It further got revolutionized with the better understanding of opioid receptors by Martin & Coworkers in1976. Intra spinal morphine was first used in 1979, which opened up a new exciting way of pain management. Intrathecal and epidural administration of opioids are widely used even now. Opioid administration intrathecally or epidurally causes dependable method of pain relief without affecting motor functions or other sensory modalities such as touch sensation. This study is an effort to find the haemodynamic changes of lumbar epidural block using 0.5% bupivacaine vs 0.5% bupivacaine with ketamine.

307. Zero PCA is an achievable target for postoperative rapid recovery management of AIS patients

BACKGROUND CONTEXT Narcotic substance addiction has been on a rise across all patient populations. Narcotics are often given in the form of patient controlled analgesic (PCA) during postoperative hospital stay as well as take-home medication. PURPOSE The objective of this study was to report on one institution's use of intrathecal single micro-dose duramorph during surgery and its comparison to patients that had undergone traditional PCA. STUDY DESIGN/SETTING Prospective study. PATIENT SAMPLE A total of 270 patients (209 PCA; 61 Duramorph). OUTCOME MEASURES Pain score, levels fused, Cobb angle, length of stay, refills, surgical time, anesthesia time, cardiac complications, respiratory complications, days to ambulation, days to first meal, transfusion rate. METHODS In 2018, we instituted RRP for scoliosis patients undergoing PSF utilizing intrathecal micro dose duramorph. PCA used to be the mainstay for postop pain management. In the duramorph protocol, patients receive 1mcg/kg intraspinal morphine diluted in 1 cc saline administered preop by anesthesiologists or intraop by surgeon. AIS patients undergoing PSF from 2011 – 2018 were reviewed. PCA patients were included in Group 1(G1) and Duramorph in Group 2(G2). Periop data were analyzed. Fisher's exact test and Wilcoxon tests were utilized. RESULTS A total of 270 patients (PCA: 209;Duramorph:61). Median Cobb in G1 was 54° and 50° in G2(p CONCLUSIONS Using single use micro-dose Duramorph can eliminate the need for PCA with similar postoperative outcomes in a RRP. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Surgical site infection in bariatric surgery: results of a care bundle.

to present a descriptive analysis of the results of a care bundle applied to obese patients submitted to bariatric surgery, regarding infection control. a care bundle was designed to control surgical site infection (SSI) rates in patients undergoing bariatric surgery. The bundle included smoking cessation, bathing with 4% chlorhexidine two hours before surgery, cefazolin (2g bolus) in anesthetic induction associated with a continuous infusion of the same drug at a dose of 1g over a two-hour period, appropriate trichotomy, glycemic control, supplemental oxygen, normothermia, intraspinal morphine for the relief of pain, and sterile dressing removal 48 hours after surgery. All patients were followed up for 30 days. among the 1,596 included patients, 334 (20.9%) underwent open surgery and 1,262 (79.1%) underwent videolaparoscopic surgery. SSI rates were 0.5% in the group submitted to laparoscopic surgery and 3% in the one submitted to open surgery. The overall incidence of SSI was 1%. Intra-abdominal, respiratory tract, and urinary tract infections occurred in 0.9%, 1.1%, and 1.5% of the sample, respectively. Higher body mass index was associated with higher incidence of SSI (p=0.001). Among patients with diabetes, 2.2% developed SSI, while the rate of infection among non-diabetics was only 0.6%. the established care bundle, structured by core evidence-based strategies, associated with secondary measures, was able to maintain low SSI rates after bariatric surgery.

A History of Intraspinal Analgesia, a Small and Personal Journey

There is a large and robust literature on the spinal use of opioids and non-opioids alike, but unless one is my age and older, very few persons know how we got here. This small history offering tells us how we got to where we are today regarding the science, clinical uses, and management of intraspinal analgesia. I have reviewed the literature bases of Google Scholar and the National Library of Medicine using the key words: history, opium, spinal analgesia, spinal morphine, intrathecal (IT), opioid receptors, endogenous opioids, IT delivery of opioids, and IT side-effects/complications. In this personal review of the history of intraspinal analgesia, I relate my own early and later experiences of the science and clinical uses of intraspinal morphine, other opioids, and non-opioids alike to a historical context. This review outlines a rather small history of opium, the historical use of opium and its various compounds, and the search for and answer to the question, "why was the poppy created for wondrous medicinal uses for mankind?" This search led to the discovery of endogenous opioid like chemicals, the discovery of opiate receptors for these endogenous opioids, the first uses of intraspinal opioids in animal models and man, and, finally, our understanding of the appropriate and inappropriate clinical uses of intraspinal analgesia. Within this paper, I acknowledge the works of my colleagues and the "heroes" who have laid the foundation for our understanding of intraspinal analgesia. The history of the use of intraspinal analgesia is rich and guides us to advance the science and clinical use of intraspinal analgesia without reinventing the wheel.

Efficacy of intrathecal drug delivery system for refractory cancer pain patients: A single tertiary medical center experience

Between 10% and 20% of cancer pain patients fail to obtain adequate pain relief despite comprehensive medical management. The totally implantable programmable intrathecal drug delivery system (IDDS) is an attractive option for managing refractory cancer pain. In suitable patients, IDDS can provide reliable long-term analgesia without any permanent nerve or plexus destruction. IDDS can also allow patient care on an outpatient basis. In Taiwan, however, the experience of using IDDS in terminally ill cancer patients is very limited. This retrospective study, describes experience of managing totally implantable programmable IDDS in 6 refractory cancer pain patients including patient selection, intraspinal morphine trial, surgical techniques, complications, and drug adjustment. Pain scores and functional status were compared before and after IDDS. By delivering liberal dose of intrathecal morphine, patients' pain scores decreased from 10 to 3.5. Due to much better pain control and improved quality of life, Eastern Cooperative Oncology Group performance status also improved in 4/6 patients. During the mean 5±4.1 months of follow-up, two patients experienced pocket seroma, and resolved spontaneously after short-term abdominal binder compression. Otherwise, no serious complication was noted. Intrathecal morphine delivery by using totally implantable programmable IDDS is an effective method to relieve refractory cancer pain.

Ondansetron and Tropisetron Do Not Prevent Intraspinal Morphine- and Fentanyl-Induced Pruritus in Elective Cesarean Delivery

Ondansetron and Tropisetron Do Not Prevent Intraspinal Morphine- and Fentanyl-Induced Pruritus in Elective Cesarean Delivery

Ondansetron and tropisetron do not prevent intraspinal morphine‐ and fentanyl‐induced pruritus in elective cesarean delivery

Although intraspinal morphine has been shown to be effective in providing analgesia after cesarean delivery, pruritus as a side-effect remains a common cause of dissatisfaction. The role of ondansetron has been studied in preventing pruritus but the results have been contradictory. We randomized 98 parturients undergoing elective cesarean section using combined spinal-epidural anesthesia into a double-blinded trial to receive tropisetron 5 mg (T group) or ondansetron 8 mg (O group) or placebo (NaCl group) after delivery, when intrathecal morphine 160 microg and fentanyl 15 microg were used for post-operative pain control. The patients additionally received ketoprofen 300 mg per day. Post-operative itching, nausea and vomiting, sedation and need for rescue analgesics were registered every 3 h up to 24 h, and all patients were interviewed on the first post-operative day. Seventy-six percent of the parturients in the placebo group, 87% in the ondansetron, and 79% in the tropisetron group had itching. The incidence of post-operative nausea and vomiting was 21%, 20% and 11% of the patients in the placebo, ondansetron and tropisetron groups, respectively. Medication for pruritus was needed by 31%, 23% and 39% of the patients in the placebo, ondansetron and tropisetron groups, respectively. In the post-operative questionnaire, the patients reported less post-operative nausea in the tropisetron group than in the placebo group (P < 0.01). Neither ondansetron nor tropisetron prevent itching caused by intrathecal morphine with fentanyl. However, tropisetron reduced post-operative nausea.

The conversion challenge: From intrathecal to oral morphine

Numerous articles have described the methodologies used and outcomes achieved with the intrathecal (IT) administration of morphine for pain. However, only one case report has been published that describes converting a patient's IT morphine to an oral regimen. This case report describes the experience of converting a patient's IT morphine to oral morphine and discusses the scarcity of published data to validate suggested equianalgesic intraspinal morphine recommendations. The calculated equianalgesic oral to IT ratio in this case was 12:1. This is substantially lower than the 300:1 ratio published by Krames and the 90:1 ratio employed by a commercially available software program for calculating equianalgesic opioid doses. We recommend caution when applying existing guidelines for conversion of morphine from an IT to an oral regimen.

The effect of intraspinal bupivacaine plus morphine on postoperative pain relief during patient-controlled IV analgesia

The effect of intraspinal bupivacaine plus morphine on postoperative pain relief during patient-controlled IV analgesia

The effect of intraspinal bupivacaine plus morphine on postoperative pain relief during patient-controlled IV analgesia

The effect of intraspinal bupivacaine plus morphine on postoperative pain relief during patient-controlled IV analgesia

Spinal Morphine in Nonmalignant Chronic Pain: A Retrospective Study in 39 Patients

It was the purpose of this study to retrospectively test the safety and efficacy of the use of intraspinal analgesics in a diverse population of patients with chronic nonmalignant pain. This study was conducted in 39 patients, refractory to conventional therapies for intrathecal therapy. Twenty-two patients had neuropathic pain and 17 had nociceptive pain. The mean follow-up of this patient population was 2.2 years with a range of 36 months to 6.5 years. Analgesia with intraspinal morphine, initial and final dose of intraspinal agents used, stability of morphine dose over time, and side effects and complications with or without bupivacaine and/or clonidine was assessed after 6 months of treatment, and at the end of study. After 6 months, three patients discontinued the study for differing reasons, 28 patients (77.8%) reported excellent results, and five patients (14%) reported good results. One patient reported no pain relief with intraspinal morphine and bupivacaine and five patients reported insufficient or no pain relief. At final assessment, 20 patients (55.6%) reported excellent results with no differences based on pain type or pain syndrome and eight patients (22.2%) reported good analgesia. Morphine doses remained stable throughout treatment, with an average dose of 2 mg per patient. Ninety-one percent of patients were satisfied with the method used and considered it superior to all previous therapeutic techniques tried, improving their quality of life. As for complications, one patient developed a clostridial infection during the immediate postoperative period which required pump removal and one patient developed severe urinary retention requiring system removal. There were three catheter obstructions (two in the same patient) and one catheter disconnection. Other patient-reported side effects were not considered significant by the authors to be mentioned here. After more than 6 years of experience with spinal infusion of morphine, either alone or admixed with other spinal analgesics, in patients with pain of nonmalignant origin, we consider the technique to be helpful in selected patients not responding to oral treatment or when untoward side effects exist with oral treatment. The advantages, as regards to analgesic efficacy and quality of life, clearly outweigh the drawbacks of the long-term use of spinal morphine.

Intraspinal Morphine for Chronic Pain

Intraspinal Morphine for Chronic Pain

Intraspinal morphine for chronic pain: A retrospective, multicenter study

Intraspinal opioids are frequently used in the treatment of cancer and noncancer pain, but few studies have evaluated the efficacy of this technique. This multicenter, retrospective study surveyed physcians in the United States regarding their standard practices when using intraspinal opioids delivered via an implanted drug administration device. Thirty-five physicians (50.0%) responded, providing 429 usable patient forms (52.4%), which sought information about screening, outcomes, dosing, and adverse effects. Patients with malignant (32.7%) and noncancer (67.3%) pain had been treated for an average of 14.6 ± 0.57 months (range, 8–94 months) at the time of form completion. For all patients, the mean percent relief was 61.0% ± 1.35%. Patients with somatic pain tended to have greater relief, as measured by a global rating of pain relief, than did patients with other types of pain (Mann-Whitney test, P = 0.0003). After titration during the first 3 months, intrathecal morphine doses increased only twofold from 6.84 ± 0.65 mg/day at 3 months to 13.19 ± 1.76 mg/day at 24 months. Compared to those with noncancer pain, malignant pain patients had a higher average initial dose. The average dose used by cancer patients escalated quickly and then stabilized, whereas the average doses used by noncancer pain patients exhibited a more gradual, linear increase in dose. Long-term adverse drug effects were uncommon, but system malfunction, usually catheter related, occurred in 21.6% of patients. Prospective, randomized, controlled clinical studies of long-term efficacy and adverse effects are warranted.

Epidural and Intravenous Opioid-induced Neuroexcitation

Epidural and Intravenous Opioid-induced Neuroexcitation

What can the neurosurgeon offer in peripheral neuropathic pain?

Neurosurgery has much to offer in the treatment of peripheral neuropathic pain but selection of the best procedure for a given patient remains problematic: planning of the treatment must be based on an analysis of the pathophysiological mechanism in the given case but the identification of this mechanism is often difficult. Available procedures are: 1) Nerve repair, neurolysis and nerve relocation; 2) Interventions on the sympathetic nervous system; 3) Neurostimulation; 4) Intraspinal morphine; 5) Ablative lesions. Neurosurgeons have, or should have, the necessary neuroscience background and microsurgical skills to be important partners of the team caring for patients with peripheral neuropathic pain.

Endogenous opioid system down-regulation during hibernation in amphibians

In late summer, Northern grass frogs, Rana pipiens, intraspinally administered dynorphin produces a potent, dose-dependent antinociceptive action as measured by the acetic acid test used to evoke a hindlimb wiping response. Surprisingly, in fall, frogs which have entered hibernation, intraspinal dynorphin produces no antinociception action. Intraspinal morphine shows a decreased effect in fall frogs while systemic morphine is equi-effective in summer and fall frogs. Immobilization stress, previously shown to be mediated by endogenous opioid systems in this amphibian, produces a robust increase in nociceptive thresholds in summer frogs while the nociceptive thresholds of fall frogs are unaffected by this procedure. Summer frogs adapted to cold room (4 °C) show a significant decrease in nociceptive thresholds, compared to cohorts kept at room temperature, and cold-adapted frogs returned to room temperature show a naloxone-attenuated increase in nociceptive threshold. Collectively, these data suggest that endogenous opioid systems in these northern frogs are down-regulated during fall hibernation.

Analgesia for Post-Cesarean Delivery Pain

Summary A recent survey by Gibbs et al27 indicates that of the cesarean sections performed in this country 41 per cent are conducted using general anesthesia, 34 per cent are conducted using spinal anesthesia, and 21 per cent are conducted using epidural anesthesia. This survey identifies three separate populations of patients and three different routes by which we may tailor the patient’s postoperative analgesia. These routes that involve epidural, intrathecal, and patient-controlled IV analgesic administration are gaining in popularity and are replacing traditional IM analgesics. It has become clear over the past few years that intraspinal narcotics and PCAs can provide the post-cesarean patient with superior analgesia compared with IM narcotics.24, 32 It has also become clear that these techniques can be delivered safely with very little risk to the patient, perhaps no greater than conventional analgesic techniques. The benefits of these new techniques is not limited to better analgesia. Patients given epidural morphine following cesarean section become ambulatory earlier than those given IV morphine for relief of pain.17 Epidural opiate analgesia has been shown to reduce morbidity in high-risk surgical patients and thereby improve outcome.48, 69 There is also evidence that even the low-risk cesarean section patients given intraspinal morphine for postoperative pain relief may have a shorter hospital stay than those given IV and IM narcotics.56 Finally, recent studies by Harrison et al32 and Eisenach et al24 have compared IM, PCA, and epidural narcotics for providing post-cesarean analgesia. They demonstrated that, in terms of providing analgesia, PCA was superior to IM narcotics, and that epidural narcotics were superior to PCA. A surprising finding, and one that deserves further study, was that even though those patients given epidural narcotics reported better analgesia than those given IM or PCA, those patients given PCA reported higher levels of satisfaction compared with prior cesarean deliveries than those patients given epidural narcotics.24 Again, it is not a direct comparison but an implied or inferred comparison. Thus, in those instances when epidural or intrathecal narcotic administration is impossible or undesirable, PCA can provide an attractive alternative, offering excellent analgesia and a high degree of patient satisfaction. In this article we reviewed the analgesic options available for the post-cesarean patient and attempted to outline the risks, benefits, and implementation of three new techniques for providing analgesia. With each new year these techniques have been finding, and will undoubtedly continue to find, wider clinical application, thereby improving the care for women having cesarean deliveries.

Continuous intraspinal morphine administration for management of cancer pain

Continuous intraspinal morphine administration for management of cancer pain

Cisternal Cerebrospinal Fluid Concentrations of Morphine following Intrathecal and Epidural Administration in the Baboon

Eleven baboons, anaesthetised with ketamine, had catheters introduced into the cisterna magna. Morphine was injected at lumbar level intrathecally in six and epidurally in five. Cisternal CSF was sampled hourly and the morphine concentration measured using a high pressure liquid chromatograph. In two cases following intrathecal injection peaks of 180 ng/ml at 4 hours, and 2,200 ng/ml at 3 hours were detected. In the latter case there was associated error in sampling therefore this baboon had a repeat injection four weeks later. The maximum level of morphine obtained then was 139 ng/ml at 4 hours. In the epidural group peaks of 113 ng/ml and 53 ng/ml at 1 hour were measured in 2 baboons and 27 ng/ml at 6 hours in a third. In all six other baboons following either procedure no morphine was detected in the cisterna. We conclude that morphine injected either intrathecally or epidurally in primates does migrate centrally in varying quantities. This finding would seem to have some bearing on the unpredictability of reported episodes of respiratory depression following intraspinal morphine.