Intravenous Injection Of Morphine Research Articles

Evaluation of Postoperative Pain in Posterior Segment Surgery of the Eye at the CHU-IOTA

Postoperative pain is predictable and therefore preventable; its management should be a priority. Posterior segment surgery is an underestimated source of pain. The objective of this work is to highlight the intensity of postoperative pain in this type of surgery. This was a 6-month prospective descriptive longitudinal study. Involving 67 patients operated for a pathology of the posterior segment. The simple verbal scale was used to assess pain in the postoperative period at HO, H8, H16 and H24. During the period, posterior segment surgery accounted for 1.88% of the institute's surgical activities. Male predominates with 88%; The mean age was 45.7 years with extremes of 7 and 75 years, vitrectomy accounted for 71.6% and scleral cryoindentation 28.4%. Peribulbar anaesthesia combining bupivacaine and xylocaine was the most commonly used with 80.6%. Intravenous injection of morphine intraoperatively was associated with peribulbar anesthesia in 19.4% of cases of scleral cryoindentation. In the immediate postoperative period (H0), pain was intense in 37%, moderate in 52% and low in 11% of patients after cryoindentation while it was absent in 52% and low in 48% of patients after vitrectomy. At H8 and H16, severe pain was reported in 47% of cryoindentations; It was reported as weak to moderate after vitrectomy in 91.66%. At H24, after treatment, patients had moderate pain in 69%, and low pain in 31% after cryoindentation; It was low in 85.71% after vitrectomy. This work allowed us to highlight the feelings of patients operated on in the posterior segment and to propose a postoperative management protocol. Keywords: Pain, Posterior segment, Locoregional anesthesia, Verbal scale.

Morphine timing-dependent modulation of TRPV1 phosphorylation correlates with differential morphine effects on myocardial ischemia/reperfusion injury

Opioids are used for pain relief in patients suffering from acute myocardial ischemia or infarction. Clinical and laboratory studies demonstrate that morphine treated patients or the experimental animal model suffering acute myocardial ischemia and reperfusion, may worsen myocardial viability. As transient receptor potential vanilloid 1 (TRPV1) plays important roles in pain sensation and cardio-protection, we query whether opioids may exacerbate myocardial viability via interaction with TRPV1 activity in the pain relief. We found the co-expressions of TRPV1 and opioid μ, δ and κ receptors in adult rat cardiomyocytes. Intravenous injection of morphine (0.3 mg/kg) at 20 min after induction of myocardial ischemia, in the rat model of acute myocardial ischemia and reperfusion, induced significant reduction of phosphorylated TRPV1 (p-TRPV1) in the ventricular myocardium and increase in serum cardiac troponin I (cTnI), compared with the ischemia/reperfusion controls (all P < 0.05). The effects of morphine were completely reversed by selective opioid μ, δ and κ receptor antagonists. While significant upregulation of p-TRPV1 (P < 0.05) and improvement of ±dP/dt max (all P < 0.05) were detected in the animals giving the same dose of morphine before induction of myocardial ischemia. The changes in p-TRPV1 correlate with the alterations of cTnI (r = −0.5840, P = 0.0283) and ±dP/dt max (r = 0.8084, P = 0.0005 and r = −0.8133, P = 0.0004, respectively). The findings of this study may indicate that potentiation and attenuation of TRPV1 sensitivity correlate with the improvement of the cardiac performance and the aggravation of myocardial viability, respectively, by giving morphine before and during myocardial ischemia and reperfusion.

How an Aggressive Treatment of No-reflow Phenomenon in Primary Percutaneous Coronary Intervention with High Thrombus Burden can Achieve a Grade III TIMI-flow: A Case Report

Abstract Introduction The management of the no-reflow phenomenon is still being debated by experts as there is no specific algorithm, limited recommended drug choices, and insufficient data regarding the combination of drugs in currently available guidelines. Thus, in this case report, we would like to propose a new combination of drugs as an alternative to the recommended drugs of choice in the treatment of no-reflow phenomenon. Case Presentation A 41-year-old man arrived at the emergency department complaining of chest pain 30 minutes prior to arrival. However, the patient was later diagnosed with extensive anterior ST-elevation myocardial infarction, KILLIP classification I, which was caused by the entire blockage of the proximal left anterior descending coronary artery. Angiography was conducted after stent placement during the main percutaneous coronary intervention and revealed grade I thrombolysis in myocardial infarction (TIMI)-flow with no coronary artery blockage. We then used an intracoronary approach to give nitroglycerin, heparin, and eptifibatide. The findings of posttreatment angiography revealed an improvement in coronary blood flow with a grade II TIMI flow. Furthermore, intravenous injection of eptifibatide and morphine effectively restored perfusion to a grade III TIMI flow. Conclusion Aggressive and precise treatment with a drug of choice is required to counteract the no-reflow phenomenon. Presently, only a limited range of first-line medications are available to treat this condition. Not only that, but several of the prescribed medications are not easily accessible, especially in developing countries. Therefore, we offer a novel combination medicaments consisting of nitroglycerin, heparin, and glycoprotein IIb/IIIa inhibitor as an alternative treatment of the no-reflow phenomenon.

Impact of timing of morphine treatment on infarct size in experimental animal model of acute myocardial ischemia and reperfusion

Morphine is generally used in clinical treatment for the patients who have not been effectively alleviated for chest pain after the treatment with nitrites or who contraindicate nitrite drugs. However, it was reported that the treatment with morphine in acute myocardial infarction or acute coronary artery syndromes induced increase in myocardial injury even increase of the mortality of the patients. After comparing the reported laboratory studies showing the cardioprotective effects and the clinical observations presenting the harmful consequences, we query whether the timing of the morphine treatment makes the difference in the prognosis of the ischemic/infarct myocardium. We found that intravenous injections of morphine (0.3 mg/kg) at 15 min before the acute myocardial ischemia, at 5 min and 20 min or 60 min after ligation of the coronary artery in separate groups of rats scheduled for acute myocardial ischemia, for 30 min or 90 min followed by reperfusion for 120 min, induced different results, reduction in the size of infarction, no effect and increases of the infarct sizes, respectively. The opioid μ- and kappa-receptors mediated the detrimental effect of morphine on the myocardial injury. The findings of this study suggest that administration of morphine may cause different consequences when used at different time in the pathology of acute myocardial ischemia and reperfusion. The underlying mechanisms in the pathology of acute myocardial ischemia warrant further study.

Tempol Reverses the Negative Effects of Morphine on Arterial Blood-Gas Chemistry and Tissue Oxygen Saturation in Freely-Moving Rats.

We have reported that pretreatment with the clinically approved superoxide dismutase mimetic, Tempol (4-hydroxy-2,2,6,6-tetramethylpiperidine-N-oxyl), blunts the cardiorespiratory depressant responses elicited by a subsequent injection of fentanyl, in halothane-anesthetized rats. The objective of the present study was to determine whether Tempol is able to reverse the effects of morphine on arterial blood-gas (ABG) chemistry in freely-moving Sprague Dawley rats. The intravenous injection of morphine (10 mg/kg) elicited substantial decreases in pH, pO2 and sO2 that were accompanied by substantial increases in pCO2 and Alveolar-arterial gradient, which results in diminished gas-exchange within the lungs. Intravenous injection of a 60 mg/kg dose of Tempol 15 min after the injection of morphine caused minor improvements in pO2 and pCO2 but not in other ABG parameters. In contrast, the 100 mg/kg dose of Tempol caused an immediate and sustained reversal of the negative effects of morphine on arterial blood pH, pCO2, pO2, sO2 and Alveolar-arterial gradient. In other rats, we used pulse oximetry to determine that the 100 mg/kg dose of Tempol, but not the 60 mg/kg dose elicited a rapid and sustained reversal of the negative effects of morphine (10 mg/kg, IV) on tissue O2 saturation (SpO2). The injection of morphine caused a relatively minor fall in mean arterial blood pressure that was somewhat exacerbated by Tempol. These findings demonstrate that Tempol can reverse the negative effects of morphine on ABG chemistry in freely-moving rats paving the way of structure-activity and mechanisms of action studies with the host of Tempol analogues that are commercially available.

Effect of Intravenous Morphine Injection on Neurological Examination of Dogs With Thoracolumbar Intervertebral Disk Extrusion.

Objectives: We aimed to determine the effect of intravenous morphine injection on the modified Frankel scores of dogs with thoracolumbar intervertebral disk extrusion (IVDE).Methods: This was a prospective, blinded, randomized, and placebo-controlled study. We included dogs with a presumptive diagnosis of thoracolumbar IVDE that did not undergo analgesic, anti-inflammatory, or sedative treatment within the last 12 h. A neurological examination was performed and the deficits were graded using the modified Frankel score (MFS). Subsequently, each dog was randomly allocated to receive an intravenous injection of either morphine or placebo. After 30 min, the dogs were re-evaluated by the same veterinary officer who was blinded to the contents of the injections. Dogs were included in the study if IVDE was ultimately confirmed by surgery within one week of initial presentation.Results: Among the 79 dogs initially enrolled, 62 dogs met the inclusion criteria. Among them, thirty-two dogs received intravenous morphine injections and there was no difference between the pre- and post-injection modified Frankel scores. Thirty dogs received an intravenous placebo injection. One dog had a worsening of the MFS by one grade in the post-injection examination.Clinical Significance: In dogs with thoracolumbar intervertebral disk extrusion, an intravenous injection of morphine does not affect the modified Frankel score after 30 min compared with the pre-injection value. These findings support the use of an analgesic morphine dose if the neurological examination can be performed 30 min or later after the injection.

COMPARISON BETWEEN SUPERFICIAL CERVICAL BLOCK AND MORPHINE TO REDUCE ANALGESIC REQUIREMENTS DURING AND AFTER TOTAL THYROIDECTOMY OPERATIONOPERATION

Background: More than 230 million people undergo surgery each year worldwide, and the number is increasing annually. Surgery causes commonly postoperative pain that should be alleviated as soon as possible to reduce suffering, and to promote the healing process and rehabilitation, and to prevent complications. Pain after thyroid surgery is regarded as being of moderate intensity and short duration. However, during the first 24 h after surgery, some patients require opioid and non-opioid analgesics. Objectives: The aim of this work was to compare the effect of superficial cervical block combined with general anesthesia, intravenous morphine in patients undergo thyroidectomy operation as regard as the heamodynamics intraoperative and post-operative analgesia. Patients and Methods: After obtaining the approval of the Al-Azhar University Ethical Committee, eighty patients of American Society of Anethesiologists (ASA) physical status I or II, scheduled for thyroidectomy operation under general anesthesia were enrolled in this randomized, prospective, clinical trial study. Information about the study were given comprehensively both orally and in written forms to the patients. All patients gave their written informed consents prior to their inclusion in the study. The study was carried out in Al-Azhar University Hospitals (AL- Hussein &Sayed Galal Hospitals). Eighty patients were randomly divided into two equal groups: Group {A} received a bilateral superficial cervical block (15ml per side) with bupivacaine 0.25% after induction of general anesthesia, and Group {B} recived morphine (0.1 mg kg body weight) 15 minutes before induction of general anesthesia. Results: The results of the present study revealed that mean arterial pressure (MAP) and heart rate (HR) were significantly lower in Group (A) compared with group (B). Pethidine requirements during the first 24 h after thyroidectomy were significantly reduced in Group (A) compared with Group (B). At post-operative care unit (PACU) admission, pain scores were significantly lower in Group (A) than in Group (B). Pain scores decreased in the two groups during the 24 h after surgery. Thirty-four patients (42.2%) developed post-operative nausea and vomiting (PONV) in the post-operative care unit (PACU), 8 patients in Group (A), 26 patients in Group (B). Conclusion: Bilateral superficial cervical plexus block (BSCPB) was an effective technique to reduce analgesic requirements during and after thyroid surgery and improved the anethetic outcome more than intravenous injection of morphine.

Effect of Morphine Administration on Social andNon-Social Play Behaviour in Calves.

Simple SummaryPlay can be used as an indicator of welfare in animals, because animals play more when all their basic needs are met. Opioids have a modulatory effect on social play behaviour in rodents and primates, however little is known regarding the central mechanisms involved in play behaviour in ruminants. In ruminants, we need to know more about what factors influence play behaviour, to determine which elements of play may more accurately be used as indicators of positive welfare. Therefore, the objective of this study was to evaluate the effect of morphine on social and non-social play behaviour in calves. In an arena test, morphine administration increased the performance of social play events but had no effect on locomotor play in calves. Similar to research in rodents and primates, morphine administration appears to increase social but not non-social elements of play in calves, suggesting that increased social play may be more indicative of a positive affective state.The objective of this study was to evaluate the effect of morphine on social and non-social play behaviour in calves. Twelve calves experienced four treatments in a cross over 2 × 2 factorial design: Calves received an intravenous injection of morphine or saline 10 min prior to being tested individually or in pairs in an arena for 20 min. Play behaviour was continuously recorded in the arena test. Lying times were recorded in the home pen. Cortisol concentrations were measured before and after testing. In the arena test, calves given morphine tended to perform more social play events than calves given saline, however, morphine administration had no effect on locomotor play. Calves given morphine spent less time lying than calves given saline during the first 4 h after returning to the home pen. Cortisol concentrations were suppressed in calves given morphine. Administration of morphine appeared to increase social play but had no effect on locomotor play in calves. This study highlights the importance of investigating different aspects of play behaviour in animals as some may be more indicative of a positive affective state than others. More studies investigating the effects of morphine on play are needed to confirm the results found in this study.

Bilateral carotid sinus nerve transection exacerbates morphine-induced respiratory depression

Opioid-induced respiratory depression (OIRD) involves decreased sensitivity of ventilatory control systems to decreased blood levels of oxygen (hypoxia) and elevated levels of carbon dioxide (hypercapnia). Understanding the sites and mechanisms by which opioids elicit respiratory depression is pivotal for finding novel therapeutics to prevent and/or reverse OIRD. To examine the contribution of carotid body chemoreceptors OIRD, we used whole-body plethysmography to evaluate hypoxic (HVR) and hypercapnic (HCVR) ventilatory responses including changes in frequency of breathing, tidal volume, minute ventilation and inspiratory drive, after intravenous injection of morphine (10 mg/kg) in sham-operated (SHAM) and in bilateral carotid sinus nerve transected (CSNX) Sprague-Dawley rats. In SHAM rats, morphine produced sustained respiratory depression (e.g., decreases in tidal volume, minute ventilation and inspiratory drive) and reduced the HVR and HCVR responses. Unexpectedly, morphine-induced suppression of HVR and HCVR were substantially greater in CSNX rats than in SHAM rats. This suggests that morphine did not compromise the function of the carotid body-chemoafferent complex and indeed, that the carotid body acts to defend against morphine-induced respiratory depression. These data are the first in vivo evidence that carotid body chemoreceptor afferents defend against rather than participate in OIRD in conscious rats. As such, drugs that stimulate ventilation by targeting primary glomus cells and/or chemoafferent terminals in the carotid bodies may help to alleviate OIRD.

Comparison of electroencephalographic changes in response to acute electrical and thermal stimuli with the tail flick and hot plate test in rats administered with opiorphin

BackgroundThe objective of this study was to compare the changes in the electroencephalogram (EEG) in response to noxious stimuli with tail flick and hot plate responses of rats administered opiorphin.MethodsFemale Sprague -Dawley rats (n = 8 per group) randomly received intravenous (IV) injection of morphine (1 mg/kg,) or opiorphin (2 mg/kg,) or saline (0.5 ml,) in each of the three testing methods (EEG, tail flick and hot plate). Each type of test (n = 24 per test) was conducted in different population of rats on separate occasions. The tail flick and hot plate latencies were recorded until 5 min after test drug administration to conscious rats. The EEG was recorded in anaesthetised rats subjected to noxious thermal and electrical stimuli after test drug administration. At the end of 5 min in each of the testing methods rats were administered naloxone subcutaneously (SC) (1 mg/kg) and the test procedure was repeated.ResultsThere was no significant increase in the median frequency and spectral edge frequency (F50 & F95) of EEG, indicators of nociception, of morphine and opiorphin groups after noxious stimulation. Noxious stimuli caused a significant increase in both F50 and F95 of the saline group. An injection of naloxone significantly increased the F50, thus blocking the action of both opiorphin and morphine. There was a significant increase in the tail flick latency after administration of opiorphin and morphine as compared to the baseline values. Rats of morphine group spent significantly longer on the hot plate when compared to those of the opiorphin and saline groups. There was no significant difference in the hot plate latencies of opiorphin and saline groups.ConclusionThe results of this study suggest that the analgesic effect of opiorphin occurs at the spinal level and it is not as effective as morphine at supraspinal level. It may be due to rapid degradation of opiorphin or limited ability of opiorphin to cross the blood brain barrier or a higher dose of opiorphin is required for its action in the brain. Pharmacokinetic/pharmacodynamics studies along with in vivo penetration of opiorphin in the cerebrospinal fluid are required for further evaluation of opiorphin analgesia.

Pharmacokinetics and Pharmacodynamics of Morphine and its Major Metabolites Following Intravenous Administration of Four Doses to Horses

ObjectiveTo understand the pharmacokinetics of morphine and correlate the serum values of morphine and its metabolites to pharmacodynamic data.Materials and MethodsUsing a balanced randomized 5‐way crossover design; ten horses received an intravenous injection of saline and morphine at doses of 0.05 mg/kg, 0.1 mg/kg, 0.2 mg/kg, and 0.5 mg/kg. This was repeated until all horses received all treatments. A minimum washout period of 2 weeks was observed between treatments. Blood samples were collected at various time post drug administration, concentrations of morphine, M3G and M6G determined using liquid chromatography‐mass spectrometry and pharmacokinetic analysis performed. Horses were outfitted with step counters and Holter monitors. Gastrointestinal borborygmi, respiration, defecation, and overall demeanor were assessed. Concentrations of parent compound, M3G and M6G were correlated to pharmacodynamic data to better understand the effects of the active metabolites.ResultsMorphine is metabolized into two metabolites in the horse: morphine‐ 6 glucuronide (M6G) and morphine‐3 glucuronide (M3G). Both metabolites and parent compound were detected in the serum as soon as 5 minutes after administration. M3G was found in much higher concentrations than both M6G and parent compound. Concentrations of metabolites and parent compound were dose dependent with the highest concentrations seen in the 0.5 g/kg dose group. Plasma concentrations of morphine fit best in a three‐compartment model and were characterized by rapid distribution and slower elimination phases. Individual pharmacokinetic parameters for metabolites were obtained by noncompartmental analysis. Higher concentrations of M3G correlated with an increase in step count, increase in heart rate, and decrease in gastrointestinal borborygmi seen in the high dose group.Conclusions and Potential ImpactThis project delivers basic pharmacokinetic and pharmacodynamic knowledge of morphine administration to horses and provides valuable information regarding morphine metabolism in horses and the characteristics of these metabolites. The large amount of M3G may be contributing to the neuroexcitatory effects seen in horses after high doses of morphine. Further exploration of the individual effects of the metabolites would be helpful in potentially identifying a novel analgesic. This would be a large advance in veterinary medicine as the number of analgesics available to equine patients currently is limited an often come with severe side effects such as renal failure, gastrointestinal slowing, and increased CNS activity.Support or Funding InformationCalifornia Horse Racing Board Pharmacology Research FundsThis abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Sublingual buprenorphine versus intravenous morphine as a premedicant and postoperative analgesic in laparoscopic appendectomy under general anesthesia—A randomized control trial

Background: Minimally invasive surgery aims to minimize trauma, cause rapid mobilization, and thus achieve a satisfactory therapeutic result. But the challenging fact with the laparoscopic surgery is its hemodynamic changes because of pneumoperitoneum and the complex visceral pain in the postoperative period. Aim: To find a safe, reliable, and highly effective drug as a premedicant in laparoscopic appendectomies under general anesthesia. Materials and Methods: A total of 110 patients undergoing laparoscopic appendectomies were randomized into two groups: group M (morphine) and group B (buprenorphine) with 55 patients in each group. Group B patients received 0.4 μg of buprenorphine tablet sublingually 1 h before surgery and group M patients received 0.1 mg/kg of intravenous morphine 10 min before anesthesia induction. Intraoperative hemodynamics, postoperative pain score, rescue analgesic requirement, and complications were recorded. Results: Intraoperative vitals that is heart rate and mean arterial pressure were significantly stable in group B compared to group M. Only 11 % patients in group B required dexmedetomidine infusion compared to 37% in group M, to control intraoperative hypertension. Visual analog scale (VAS) values in group B at 2nd (1.30 ± 0.46), 4th (1.31 ± 0.54), and 6th hour (1.33 ± 0.63) were significantly less than group M at 2nd (4.56 ± 0.65), 4th (5.68 ± 0.72), and 6th h (4.45 ± 1.15). Duration of analgesia in postoperative period in group B (260.0 ± 28.52 min) was significantly longer than group M (124.10 ± 20.832 min). Conclusion: Sublingual buprenorphine premedication is an alternative to intravenous injection of morphine with perioperative hemodynamic stability and better postoperative analgesia.

Efficacy of intra-articular magnesium for postoperative analgesia in total hip arthroplasty

The aim of the present study was to compare the efficacy of intra-articular magnesium sulphate and a saline placebo for postoperative pain control following total hip arthroplasty (THA). Sixty patients underwent THA and were randomly allocated into two groups to receive intra-articular injections of either 10 ml magnesium sulphate (100 mg/ml; magnesium group, n=30) or 10 ml normal saline solution (control group, n=30). Postoperative analgesia was maintained by intravenous morphine injection. The outcome measurements were visual analogue score (VAS), morphine consumption and Harris hip score (HHS). The two groups were well matched. The outcome of VAS at rest was significantly lower at postoperative hours 6 and 12 in the magnesium group as compared with the control group, although the difference was insignificant preoperatively and at postoperative hours 2, 4, 24 and 48, and days 3, 7 and 14. This indicator during activity was also lower in the magnesium group at postoperative hour 24 than that of the control group, although the difference was insignificant preoperatively and at hour 48, and days 7 and 14. The consumption of morphine (the total quantity) at 0-6, 6-12 and 0-48 h in the magnesium group was significantly lower than in the control group, although no significant differences were observed at 12-24 and 24-48 h between the groups. The improvements of HHS from preoperative to postoperative scores were statistically significant, however, no significant differences were identified between groups. Thus, the findings indicate that intra-articular magnesium sulphate injections provided improved pain control and reduced the need for morphine when compared with a saline placebo following THA.

Observation of patient-controlled analgesia （PCA） by subcutaneous and intravenous injection of morphine among patients underwent total knee arthroplasty

Objective To compare the knee of patient controlled subcutaneous injection of morphine analge-sia after hip joint replacement （ PCSA ） and intravenous morphine patient-controlled analgesia （ PCIA ） effect and safety of postoperative analgesia.Methods 60 patients undergoing artificial total knee arthroplasty patients were selected and randomly divided into PCIA group of 30 cases,30 cases in group PCSA, two patients were completed under epidural anesthesia in the operation.Group PCIA and group PCSA single dose divided into 1mg/and 2.5mg/, lock time divided into 5min,20min,in the postoperative pain perception,from the patient＆#39;s own pain medication.After 4h,8h,12h,24h record patient morphine dosage,frequency,pain score （VAPS）,mean arterial blood pressure and re-spiratory rate,compose degree,analgesic effects were compared between the two groups.Results In group PCSA after 24h treatment for the total dose was （30.41 ±10.00） mg,significantly higher than that of group PCIA （18.03 ± 6.04）mg,there was significant difference between the two groups （t=3.98,P〈0.05）;but after each time point of the two groups of patients the average dosage had no statistically significant difference （P〉0.05）.PCIA group after 0-4h and 〉4-8h analgesia and sedation were better than those in PCSA group （t=3.4,3.2,3.5,3.7,all P〈0.05）, PCIA group,the incidence rate of nausea and vomiting was 30%,higher than 12%in the PCSA group,there was sig-nificant difference between the two groups （χ^2 =5.76,P〈0.05）.Conclusion The two kinds of methods of analge-sia has a good analgesic effect,but PCSA analgesia is slower,less adverse reactions,should be given a loading dose at the beginning before PCSA,in order to improve the early analgesia effect. Key words: Analgesia,patient-contro; Morphine; Injection,subcutaneous; Joint replacement,knee

Ultrasound-guided regional anesthesia for the pain management of elderly patients with hip fractures in the emergency department.

ObjectiveWe examined the pain-relieving effect of ultrasound-guided regional anesthesia performed by emergency physicians on elderly hip fracture patients.MethodsThis study is a prospective, non-randomized, case-control study. The subjects were patients older than 65 years who visited the emergency department with a hip fracture. After we obtained informed consent, two emergency physicians performed an ultrasound-guided three-in-one femoral block using 20 mL of 0.5% bupivacaine. The pain score was measured just before regional anesthesia, and 0.25, 0.5, 1, 2, 3, and 4 hours after the procedure. Another group of patients was given multiple doses of morphine to control the pain. We compared the change in pain score and the development of adverse reactions between the two groups.ResultsA total of 47 patients were enrolled in this study, of which 25 were given regional anesthesia. Successful pain control (pain score<4) was significantly higher in the regional anesthesia group (96.0% vs. 40.9%; P<0.001). The decrease in pain score was significantly higher in the regional anesthesia group (7 [interquartile range, 6 to 7] vs. 4 [interquartile range, 3 to 5]; P< 0.001). The only adverse reaction observed was mild nausea in 4 patients (1 out of 25 from the regional anesthesia group and 3 out of 22 from the morphine group).ConclusionUltrasound-guided regional anesthesia administered by emergency physicians treating elderly hip fracture patients provided faster pain relief and a larger decrease in pain than conventional intravenous injections of morphine.

Opium: Reality’s Dark Dream by Thomas Dormandy (review)

Reviewed by: Opium: Reality’s Dark Dream by Thomas Dormandy Eric C. Schneider Thomas Dormandy. Opium: Reality’s Dark Dream New Haven, Conn.: Yale University Press, 2012. x + 366 pp. Ill. $40.00 (978-0-300-17532-5). In a traditional narrative account, Thomas Dormandy traces the history of opium from the ancients to the moderns. Divided into thirty-four chapters, most only ten or fewer pages in length, the book necessarily breezes through large swathes of history and geography, with an eye for the telling anecdote, and is strongest when dealing with medical and scientific issues and prominent literary figures. The first section of the book reviews archaeological findings, Greek and Roman texts, medical writings from Arab and European sources, and the literary work of European, especially English, romantic writers through the nineteenth century in order to trace opium’s worldwide spread. Dormandy documents the use and abuse of opium, especially by elites, and the gradual dissemination of opiates into a broader population through laudanum, patent medicines, morphine, and heroin. Dormandy also offers a brief history of palliative care and cautiously questions the criminalization of drug use. When Dormandy ventures further afield into the political economy of drug dealing, especially in the twentieth century, the book is far weaker and does not synthesize more recent scholarship. Dormandy discusses the expansion of the opium trade, the opium wars with China, and Britain’s reliance on the opium trade to finance its empire in a well-told, though hardly new, narrative. Here Dormandy seems unaware of more nuanced assessments of opium addiction in China that argue that for many users the ritualized, communal, and ceremonial nature of opium smoking limited its addictive potential, especially when compared to the more solitary and directly addictive effects of intravenous injection of either morphine or heroin that came later. Dormandy’s account of the heroin trade—hampered (as the book is generally) by a lack of citations—is badly flawed, presenting Mafia- and Central Intelligence Agency–dominated conspiracy theories for which there is little or no evidence. Dormandy seems to accept whole cloth the self-serving argument made by the Federal Bureau of Narcotics director Harry Anslinger that Charles (Lucky) Luciano masterminded a worldwide heroin exporting scheme from exile in Italy, when Luciano’s FBI file contains nothing but wishful thinking about his kingpin role. Luciano did serve time for trafficking, but Dormandy seems unaware that it was for trafficking in women, not drugs, as he was charged with being New York’s master pimp. Dormandy is similarly mistaken about the CIA. In Europe, the CIA used Corsican gangsters to undermine the Communist Party in Marseilles during the postwar period, and turned a blind eye to their drug dealing, but the CIA did not involve itself in trafficking. Alfred McCoy, whose work Dormandy cites, concludes about the opium trade in Southeast Asia (for which the best evidence of CIA [End Page 281] involvement exists) that the CIA did not participate in drug trafficking to finance its operations, although it did facilitate the opium trading of its tribal allies in order to preserve their loyalty during the Vietnam War. These are perhaps nuances, but Dormandy glosses over them entirely for the more inflammatory charges. The author comes to other curious conclusions as well, arguing, for example, that Chinese coolies suffered greater exploitation and loss of life than African American slaves. The latter, Dormandy asserts, “enjoyed a measure of legal protection” (p. 154), a conclusion that most historians of the American South would find peculiar. The point is not at all essential to Dormandy’s narrative but is typical of the unsubstantiated opinions with which the book is rife. Dormandy implies that opium use was increasing at the end of the nineteenth century in the United States, when David Courtwright’s authoritative account of that period argues the opposite.1 Per capita consumption was declining, and the passage of the Harrison Act (1914) was due to the changing social status of opiate users, from middle-class women addicted to opium through medical practice to working-class ethnic males addicted to heroin through its recreational use. In discussing the late twentieth century, Dormandy asserts that drug use was...

Morphine three‐dimensional T1 gadoxetate MR cholangiography of potential living related liver donors

To assess low-dose morphine for distension and improved visualization of intrahepatic bile ducts on T1 MR cholangiography (MRC) in preoperative imaging of potential liver donors. Sixty-nine consecutive potential living related liver donors (mean age, 39 years; age range, 20 to 59 years) referred for pre-transplant MRI evaluation were evaluated without (n=30) or with (n=39) intravenous morphine injection (0.04 mg/kg). Morphine was injected pre-MRI while establishing intravenous access to allow ∼1 h for biliary distension before T1 MRC. Three radiologists reviewed intrahepatic biliary branch order visualization, common bile duct (CBD) diameter, and overall image quality. In 25 patients undergoing liver donation surgery, T1 MRC findings were correlated with intraoperative findings. This retrospective study was approved by the institutional review board. Biliary visualization was improved post-morphine administration with biliary duct branch order visualization score of 3.2 and 3.3 at 45 and 60 min, respectively, compared with 2.7 without morphine (P<0.002); CBD diameter measured 5.3 and 5.5 versus 4.1 mm (P<0.005), and overall image quality score was 2.4 and 2.6 versus 1.8 (P<0.0006). Operative notes confirmed T1 MRC findings in 6/11 donors without morphine and 14/14 donors with morphine. Intravenous low-dose morphine distends and improves visualization of bile ducts on T1 gadoxetate MRC.

Impact of patient-controlled analgesia on pain relief after coronary artery bypass graft surgery: a randomized clinical trial.

Pain has been pointed out as one of the concerns of cardiac surgery patients. Acute pain management has been a challenge for health professionals and several regiments have been described. We designed this study to evaluate the effectiveness of pain control with patient-controlled analgesia (PCA) versus conventional nurse-controlled analgesia (NCA) during the postoperative period in the intensive care unit (ICU) after coronary artery bypass graft (CABG) surgery. In this randomized clinical trial, 80 elective CABG candidates were selected by convenience sampling. They were randomly allocated to two groups to receive either PCA or NCA. PCA plus continuous infusion of morphine started immediately after transferring the patients to the ICU. NCA was based on intravenous injections of morphine on demand. Pain was assessed using a verbal rating scale (VRS). Sedation level and morphine consumption were also evaluated from extubation until 48 hours after surgery. Data was analyzed using SPSS13. VRS scores were higher in the NCA group compared to the PCA group [3.27 (1.17) vs. 0.75 (0.66); p < 0.001]. Morphine consumption was significantly higher in the PCA group compared to the NCA group [28.43 (7.15) mg vs. 8.37 (5.36) mg; p < 0.001]. PCA was safe and respiratory depression was not observed in any of the subjects. Mean sedation scores did not differ between the two groups. PCA with background infusion of morphine increases morphine consumption and improves pain relief. It appears to be superior to NCA and can be recommended for patients after CABG surgery.

8-OH-DPAT abolishes the pulmonary C-fiber-mediated apneic response to fentanyl largely via acting on 5HT1Areceptors in the nucleus tractus solitarius

Intravenous bolus injection of morphine causes a vagal-mediated brief apnea (∼3 s), while continuous injection, via action upon central μ-opioid receptor (MOR), arrests ventilation (>20 s) that is eliminated by stimulating central 5-hydroxytryptamine 1A receptors (5HT(1A)Rs). Bronchopulmonary C-fibers (PCFs) are essential for triggering a brief apnea, and their afferents terminate at the caudomedial region of the nucleus tractus solitarius (mNTS) that densely expresses 5HT(1A)Rs. Thus we asked whether the vagal-mediated apneic response to MOR agonists was PCF dependent, and if so, whether this apnea was abolished by systemic administration of 8-hydroxy-2-(di-n-propylamino)tetral (8-OH-DPAT) largely through action upon mNTS 5HT(1A)Rs. Right atrial bolus injection of fentanyl (5.0 μg/kg, a MOR agonist) was performed in the anesthetized and spontaneously breathing rats before and after: 1) selective blockade of PCFs' conduction and subsequent bivagotomy; 2) intravenous administration of 5HT(1A)R agonist 8-OH-DPAT; 3) intra-mNTS injection of 8-OH-DPAT; and 4) intra-mNTS injection of 5HT(1A)R antagonist WAY-100635 followed by 8-OH-DPAT (iv). We found the following: First, fentanyl evoked an immediate apnea (2.5 ± 0.4 s, ∼6-fold longer than the baseline expiratory duration, T(E)), which was abolished by either blocking PCFs' conduction or bivagotomy. Second, this apnea was prevented by systemic 8-OH-DPAT challenge. Third, intra-mNTS injection of 8-OH-DPAT greatly attenuated the apnea by 64%. Finally, intra-mNTS microinjection of WAY-100635 significantly attenuated (58%) the apneic blockade by 8-OH-DPAT (iv). We conclude that the vagal-mediated apneic response to MOR activation depends on PCFs, which is fully antagonized by systemic 8-OH-DPAT challenge largely via acting on mNTS 5HT(1A)Rs.

Evidence for tryptaminergic and noradrenergic involvement in the antisecretory action of morphine in the rat jejunum.

Experiments have been performed to determine whether the antisecretory (antidiarrhoeal) effect of morphine in the intestine is mediated by a direct action of morphine on enteric nerves. Rats were pretreated with 6-hydroxydopamine (6-OHDA) or p-chlorophenylalanine (PCPA) to deplete intestinal stores of noradrenaline and 5-hydroxytryptamine (5-HT). Intraperitoneal injection of 6-OHDA (3 doses at 50 mg kg-1) caused a selective reduction in the level of noradrenaline in the jejunum to 7.3% of control. Intraperitoneal injection of PCPA (200 mg kg-1) selectively reduced the jejunal level of 5-HT to 30.5% of control. Groups of rats that had been treated as described above were anaesthetized and then injected intravenously with saline or with blocking doses of either atropine (0.25 mg kg-1), hexamethonium (20 mg kg-1), ketanserin (30 micrograms kg-1), methysergide (30 micrograms kg-1), phentolamine (2 mg kg-1) or propranolol (1 mg kg-1). Following perfusion of the lumen of the jejunum, the rate of glucose absorption was measured to assess the integrity of the mucosa. Glucose absorption was unaltered in animals pretreated with hexamethonium and propranolol but there was a small enhancement in animals pretreated with atropine, PCPA, methysergide, 6-OHDA and phentolamine. The rate of net water absorption from the lumen of the jejunum and the rate of fluid secretion into the lumen following intra-arterial infusion of vasoactive intestinal peptide (VIP, 0.8 microgram min-1) were unaltered by any of the drug treatments. Intravenous injection of morphine (10 mg kg-1) did not alter the levels of noradrenaline or 5-HT in the whole jejunum. However, this dose of morphine did cause a 63.5% decrease in the VIP-induced change in water transport. This antisecretory effect of morphine was unaltered in animals pretreated with atropine, hexamethonium and propranolol. In contrast, methysergide, ketanserin and 6-OHDA abolished the antisecretory effect of morphine. PCPA and phentolamine produced a partial inhibition of morphine's antisecretory effect. It is concluded that morphine produces its antisecretory effect in the jejunum by activation of noradrenergic and tryptaminergic systems.