Intravenous Morphine Titration Research Articles

Knowledge and Attitudes of Anesthesia Staff on Pain in the Hospitals of Niamey

Aim of the study: To assess the knowledge and attitudes of anesthesia staff on the management of pain in the hospitals of Niamey. Patients an method: This was a multicenter descriptive cross-sectional study carried out in five hospitals in Niamey (Republic of Niger) from July 3rd to December 3rd, 2021. Were been included in the study, all the anesthesia staff who agreed to answer the questionnaire. The variables studied were: age, gender, seniority, sector of activity and qualification, definition of pain, different types of pain, the impact of pain on the body, tools used for assessment of pain, difference between acute and chronic pain, knowledge about analgesics, the practical attitudes of pain management. The data were intered and processed with Epi info 7.2 software and the Microsoft Office 2019 pack. Results: Our study concerned 106 agents from the anesthesia and resuscitation department of the hospitals that served as our study framework. There is a female predominance of 55.42% with a sex ratio of 0.80. The 45-54 age group was the most represented with 40.07% of cases. The average age of respondents was 44.95 ± 8.9 years. Anesthesia nurses were the most represented with 90.36%. The operating theatre unit was the most represented sector of activity with 85.54%. All the respondents knew the definition of pain. The different types of pains were known by 45.78% of respondents. The most used pain scales were visual analog scale (VAS) and verbal descriptor scale (VDS) respectively in 53.01 % and 12.05 % of cases. Tramadol and paracetamol were the mostly used analgesics respectively in 98.80 % and 97.59%. Intravenous morphine titration was known to 67.47% of the respondents. Only 18.07% of the respondents benefited from a training on the management of pain. Conclusion: The knowledge and attitudes of anesthetists on pain deserve to be updated through theorical and practical training to improve the management of pain in our hospitals.

Comparison between two methods of intravenous titration of morphine: Optimizing BI mode of patient-controlled analgesia versus conventional method.

204 Background: The titration of opioids to the optimal dose without side effects is an important and essential gateway in cancer pain management. However, sufficient pain control may not be achievable until the titration is complete because the change in the dose of opioids is calculated based on the opioid demand over the previous 24 hours. A recent patient-controlled analgesia (PCA) device could perform in an optimizing B.I. mode in which the background infusion rate was adjustable in accordance with the patient’s use of a bolus button. Therefore, we aimed to compare the efficacy and safety of the conventional method and the optimizing B.I. method of PCA in the titration of intravenous morphine in patients with cancer pain. Methods: This was a prospective, randomized, open-label, active-controlled study. After randomization, the previously administered opioids were switched to intravenous morphine and dose titration was initiated. In the conventional group, the dosage of continuous infusion morphine over the next day was adjusted based on the total amount of morphine administered during the previous 24 hours. In the PCA group, morphine titration was performed by increasing or decreasing the background infusion rate immediately in accordance with the frequency and interval of pressing the bolus button. The patients received pain management in this manner for at least three days and we compared the two groups by collecting their pain-related outcomes via medical records and questionnaires. Results: A total of 39 patients were enrolled, of whom 20 were assigned to the conventional group and 19 to the PCA group. The number of breakthrough pain complaints (NRS ≥ 4) by patients to the medical staff decreased in the PCA group, showing a difference from the conventional group within 24 hours (p = 0.012). The total daily dose of morphine was increased significantly at 0–24 hours in the PCA group (p < 0.001) and then slightly increased until 72 hours. The patient-reported pain reduction rate increased at 24–48 hours (p = 0.022) and was maintained until 72 hours in the PCA group. There was no statistically significant change in the conventional group during the study period for the above items. The conversion rate to oral or transdermal opioids after 72 hours was higher in the PCA group (p = 0.010). There were no uncontrolled side effects due to morphine titration in either group. Conclusions: Patients using the PCA with optimizing B.I. mode showed faster intravenous morphine titration and higher morphine consumption than the conventional method and achieved tolerable and rapid pain relief. This study revealed that early active opioid titration is necessary for patients admitted for pain control. It also suggested that the patient's actual opioid demands for pain control may be greater than the amount of opioid used through conventional titration methods. Clinical trial information: KCT0004008.

Perioperative Outcomes in Patients Who Received Spinal Chloroprocaine for Total Hip or Knee Arthroplasty-Consecutive Case Series Study.

Spinal anaesthesia is an established component of perioperative management for fast-track lower limbs arthroplasty. Short-acting local anaesthetics may present an interesting option for primary non-complicated knee (TKA) and hip (THA) arthroplasty. We describe the perioperative outcomes in patients operated under fixed 50 mg spinal chloroprocaine for total hip and knee replacement. In this retrospective case series study, 65 patients were analysed (median age 65 years, 55% females, benefit from THA (n = 31), TKA (n = 25), and unicompartmental knee arthroplasty (n = 9)). In all cases, anaesthesia duration (87 min) was sufficient for successful surgery (52 min). Up to 45% of patients (THA and less in TKA) developed postoperative pain in the post-anaesthesia care unit (PACU), requiring intravenous morphine titration (up to 7.5 mg). One patient developed severe breakthrough pain requiring advanced regional analgesia. The median PACU stay was up to 97 min (less in TKA), and the incidence of nausea and urinary retention was low. All patients were able to start physical therapy on the same day of surgery. These findings encourage the use of a short-acting agent for spinal anaesthesia in patients with primary non-complicated arthroplasty; however, the relay analgesia should be systematically implemented to avoid breakthrough pain in PACU.

Hydroxyzine for lowering patient's anxiety during prehospital morphine analgesia: A prospective randomized double blind study.

Hydroxyzine is an antihistamine drug used for symptomatic relief of anxiety and tension. We hypothesized that managing the anxiety of patients with severe pain by adding hydroxyzine to a conventional intravenous morphine titration would relieve their pain more effectively. This was a randomized, double-blind, controlled group study of prehospital patients with acute pain scored greater than or equal to 6 on a 0-10 verbal numeric rating scale (NRS). Patients'anxiety was measured with the self-reported Face Anxiety Scale (FAS) ranking from 0 to 4. The percentage of patients with pain relief (NRS score≤3) 15min after the first injection was the primary outcome. One hundred forty patients were enrolled. Fifty-one percent (95% CI 39% to 63%) of hydroxyzine patients versus 52% (95% CI 40% to 64%) of placebo patients reported a pain numeric rating scale score of 3 or lower at 15min. Ninety-one percent (95% CI 83% to 98%) of patients receiving hydroxyzine reported no more severe anxiety versus 78% (95% CI 68% to 88%) of patients with placebo (p>0.05). Adverse events were minor, with no difference between groups (6% in hydroxyzine patients and 14% in placebo patients). Addition of hydroxyzine to morphine in the prehospital setting did not reduce pain or anxiety in patients with acute severe pain and therefore is not indicated based on our results.

The management of emergency hospital visits for inflammatory bowel diseases: A French national expert consensus report

BackgroundManagement of inflammatory bowel diseases (IBD) in the emergency department is often suboptimal. AimsTo develop a national consensus checklist of indicators to facilitate decision-making in emergency departments concerning hospitalisation and referral for abdominopelvic computed tomography (CT). MethodsA Delphi survey was used to obtain consensus on a checklist of clinical and biological variables. 119 healthcare professionals experienced in treating IBD were invited to participate. Panellists were provided with a literature survey and invited to agree or disagree with items on a prototype checklist. Two successive rounds of voting were organised. ResultsThe prototype checklist included fifteen clinical or laboratory indicators for hospitalisation or CT. Four indicators were not retained in the Delphi process and four additional indicators added. The final indicators retained were: abdominal signs/symptoms of disease exacerbation, intravenous morphine titration, fever, vomiting, dehydration, recent intestinal surgery, ano-perineal abscess, bowel obstruction, haemodynamic instability, anaemia, acute kidney failure and elevated C-reactive protein. Consensus for the retained indicators was >88%. ConclusionsUse of this consensus checklist for the management of IBD in the emergency department may help improve standards of care and thus reduce the burden of these diseases.

Nebulized versus intravenous morphine titration for the initial treatment of severe acute pain in the emergency department: study protocol for a multicenter, prospective randomized and controlled trial, CLIN-AEROMORPH

BackgroundIntravenous morphine titration (IVMT) is the French gold standard for opioid treatment in the emergency department (ED). Nebulized morphine titration (NMT) may represent an alternative without venous access, but it has not been adequately studied in adults. We test the hypothesis that NMT is at least as effective as IVMT to initially manage severe acute pain in the ED.Methods/designWe designed a multicenter (10 French EDs), single-blind, randomized and controlled trial. Adults between 18 and 75 years with visual analog scale (VAS) ≥ 70/100 or numeric rating scale (NRS) ≥ 7/10 will be enrolled. We will randomize 850 patients into two groups to compare two routes of MT as long as VAS > 30 or NRS > 3. In group A (425), patients will receive an initial NMT for 5–25 min associated with titration of an intravenously (IV) administered placebo of physiologic serum (PS). In group B (425), patients will receive IVMT plus nebulized PS placebo.NMT is defined as a minimum of 1 and a maximum of 3 5-min nebulized boluses of 10 mg or 15 mg (weight ≥ 60 kg), at 10-min fixed intervals. IVMT is defined as a minimum of 1 and a maximum of 6 boluses of 2 mg or 3 mg (weight ≥ 60 kg), at 5-min fixed intervals. Nebulized placebo titration will be performed every 10 min. IV titration of PS will be performed every 5 min. In both groups, after 25 min, if VAS > 30/100 or NRS > 3/10, routine IVMT will be continued until pain relief.Pain severity, vital signs, bronchospasm, and Ramsay score will be recorded every 5 min. The primary outcome is the rate of relief obtained 1 h from the start of drug administration. Complete pain relief in both groups will be compared with a non-inferiority design. Secondary outcomes are pain relief at 30 min (the end of NMT) and at 2 h and median pain relief. We will compare final doses, and study the feasibility and tolerance of NMT (protocol deviations, respiratory or hemodynamic depression, sedation, and minor vegetative side effects). Co-analgesia will be recorded. Discharge criteria from the ED and hospital are defined.DiscussionThis trial is the first multicenter randomized and controlled NMT protocol for severe pain in the ED using the titration concept. We propose an original approach of combined titration with an endpoint at 1 h and a non-inferiority design.Trial registrationClinicalTrials.gov, NCT03257319. Registered on 22 August 2017.

Intravenous morphine titration vs. oral hydrocodone/acetaminophen for adults with lower extremity displaced fracture in an emergency department setting: A randomized controlled trial.

The objective of the present study was to test the hypothesis that intravenous morphine titration provides superior analgesia to oral hydrocodone/acetaminophen for patients with lower extremity displaced fracture in an emergency department (ED) setting. A prospective, randomized clinical trial of ED patients suffering acute lower extremity displaced fracture pain was performed with a total of 206 participants included. After application of exclusion criteria, the cohort comprised 166 patients, 85 of which were randomly allocated to the oral hydrocodone/acetaminophen (5 mg/500 mg) group and 81 to the intravenous morphine titration (every 5 min by 3-mg increments) group. The main outcome was the visual analogue scale (VAS) at different time-points after the first dose of analgesic was administered. Secondary outcomes included the VAS change during the skeletal traction operation and short-term adverse events. The results demonstrated that the initial VSA of the participants was similar at the baseline on arrival at the ED (P=0.2582). At the time-points of 5, 15, 30 min after the first dose of analgesic administered, the intravenous morphine titration group exhibited a greater VAS reduction compared with that in the oral hydrocodone/acetaminophen group (P<0.01). The differences between the 2 groups were not statistically significant at 1 h or thereafter. The incidence of short-term adverse events was similar between the 2 groups but sedation, whose incidence in the morphine group was markedly increased, may not be arbitrarily attributed to adverse events. It was concluded that, compared with oral hydrocodone/acetaminophen, intravenous morphine titration provided a rapid and sufficient pain relief and equivalent short-term adverse events for patients with lower extremity displaced fracture in an ED setting.

Intravenous morphine titration as a rapid and efficient analgesia for adult patients with femoral shaft fractures after injury

This study aimed to compare the analgesic effects of intravenous ibuprofen and intravenous morphine titration for femoral shaft fractures in adult patients. In total, 293 participants were enrolled and randomly received intravenous ibuprofen or intravenous morphine titration. Their visual analogue scale (VAS) results were recorded every 5 minutes after the first administration. The VAS scores before and during transport were also measured. Meanwhile, the type and frequency of the adverse effects were also recorded in both groups. Patients treated with morphine showed a faster and greater reduction in the VAS than those in the ibuprofen group within 1 hour after the first administration. Interestingly, intravenous morphine titration provided consistent analgesia even during the further transport. No significant immediate adverse event was observed in all of the participants, except for sedation, which might be beneficial for keeping the patient quiet and might not be arbitrarily attributed to adverse effects. No addiction was noted in the morphine group. This study demonstrated that intravenous morphine titration is a faster and more efficient analgesia for femoral shaft fractures than ibuprofen in adult patients immediately after injury.

Preemptive submucosal infiltration with ropivacaine for uvulopalatopharyngoplasty.

To evaluate the preemptive analgesic effect of submucosal infiltration of ropivacaine for uvulopalatopharyngoplasty. Randomized controlled trial. Comprehensive clinical center and academic hospital. Fifty consecutive male patients scheduled for uvulopalatopharyngoplasty were divided randomly into group A and group B. In group A, 4 mL of 0.33% ropivacaine and normal saline with epinephrine was preincisionally injected under the mucosa on both sides of the tonsillar fossa, soft palate, and the lower part of palatoglossal arch, whereas the upper and middle parts of the palatoglossal arch and the upper part of the palatopharyngeal arch were infiltrated with 2 mL of the same mixture. In group B, an identical volume of normal saline with epinephrine was administered. In both groups, postoperative pain was initially controlled by intravenous morphine titration until patient-controlled analgesia with morphine could be used. Cumulative patient-controlled analgesic morphine consumption; visual analog scale scores at 4, 8, 12, 24, and 48 hours postoperatively at rest and during swallowing; and opioid-related adverse effects were recorded. The visual analog score was lower at rest during the 48-hour postoperative period and during swallowing within the first 12 hours for group A versus group B (P < .05). Patients in group A required 44.1%, 38.2%, and 41.1% less morphine during the first 24 hours, 24 hours to 48 hours, and 48 hours postoperatively, respectively, and fewer patients experienced nausea, vomiting, and pruritus (P < .05). Preemptive submucosal infiltration with 0.33% ropivacaine effectively controlled pain after uvulopalato-pharyngoplasty.

Pain assessment in the postanaesthesia care unit using pupillometry

Patients assess their own pain with a numerical rating scale (NRS). In the postanaesthesia care unit (PACU), NRS helps to determine and monitor analgesic administration, but is useless in patients who are unable to communicate. In non-PACU patients, acute pain increases pupillary diameter and pupillary light reflex amplitude (PLRA), the difference between pupillary diameter before and after light stimulation. To study the association between postoperative pain (NRS) and pupillary diameter or PLRA in PACU patients after routine anaesthetic care. Cross-sectional cohort study. Bichat-Claude Bernard Hospital, Paris. One hundred and forty-five patients undergoing planned surgery under general anaesthesia. NRS, pupillary diameter and PLRA were measured on arrival in the PACU. When NRS was more than 4, intravenous morphine titration was started and a second measurement performed. Association between NRS and pupillary diameter or PLRA was assessed with Pearson correlation coefficient (r) as was association between changes in these variables after morphine titration. Mean NRS was 4.7, and was more than 4 in 79 patients (55%). No statistically significant association was observed between NRS and pupillary diameter (r = 0.10, P = 0.54) or PLRA (r = 0.03, P = 0.72). Twenty-seven patients (19%) received morphine titration with significant decreases in NRS, pupillary diameter and PLRA afterwards. No association was observed between NRS changes and pupillary diameter or PLRA changes. Acute postoperative pain is not associated with pupillary diameter or PLRA. Further research is required to develop tools to assess pain in the PACU.

Titration morphinique intraveineuse en salle de surveillance post-interventionnelle (SSPI) après chirurgie bariatrique sous cœlioscopie

ObjectiveThere is limited information available regarding intravenous (IV) morphine admistration in obese patients in PACU. The aim of this study was to compare two IV morphine titration (IMT) regimen in two surgical centers. Study designObservational study. PatientsLaparoscopic bariatric surgery in one private (Saint-Grégoire Clinic) and one public (University Hospital of Amiens) surgical center. MethodsA strict and common protocol of IMT was implemented if PACU of both centers according to the recommendations of the French Society of Anaesthesia and Intensive Care. When pain score increased to>30, IMT was titrated every 5min in 3mg increments until pain relief (VAS≤30mm). Pain level, dose of morphine (per total and ideal body weight), effectiveness, and side events were recorded. ResultsData were recorded for 159 adult patients (129 women). Mean age and BMI were 42±12 yrs and 43.8±6.9kg/m2. Ninety-eight patients were eligible for IMT regimen but only 76 patients received IV morphine (47.8 %). Mean dose was 7.3mg±3.5mg [1–19mg], (60.4μg/kg and 115.8μg/kg). IMT was less frequent, mean dose was greater (8.6±4.2 vs 6.2±2.9mg) and number of patients with pain relief was higher (73.7 vs 35.6 %) in the public hospital. No severe adverse events have been recorded and there was no difference in both centers regarding these events. ConclusionImplementation of a IMT regimen in PACU was not associated with effective pain relief after laparoscopic surgery in obese patients.

Postoperative Analgesia in Elderly Patients

Elderly people represent the fastest-growing segment of our society and undergo surgery more frequently than other age groups. Effective postoperative analgesia is essential in these patients because inadequate pain control after surgery is associated with adverse outcomes in elderly patients. However, management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Physiological changes related to aging need to be carefully considered because aging is individualized and progressive. Assessment of pain management needs to include chronological age, biological age with regard to renal, liver and cardiac functions, and the individual profile of pathology and prescribed medications. In addition, ways in which pain should be assessed, particularly in patients with cognitive impairment, must be considered. Cognitively intact older patients can use most commonly used unidimensional pain scales such as the visual analogue scale (VAS), verbal rating scale (VRS), numeric rating scale (NRS) and facial pain scale (FPS). VRS and NRS are the most appropriate pain scales for the elderly. In older patients with mild to moderate cognitive impairment, the VRS is a better tool. For severe cognitively impaired older patients, behavioural scales validated in the postoperative context, such as Doloplus-2 or Algoplus, are appropriate. For postoperative pain treatment, most drugs (e.g. paracetamol, nonsteroidal anti-inflammatory drugs, nefopam, tramadol, codeine, morphine, local anaesthetics), techniques (e.g. intravenous morphine titration, subcutaneous morphine, intravenous or epidural patient-controlled analgesia, intrathecal morphine, peripheral nerve block) and strategies (e.g. anticipated intraoperative analgesia or multimodal analgesia) used for acute pain management can be used in older patients. However, in view of pharmacokinetic and pharmacodynamic changes in older persons, the higher incidence of co-morbidities and concurrent use of other drugs, each must be carefully adjusted to suit each patient. Evaluation of treatment efficacy and incidence and severity of adverse events should be monitored closely, and the concept of 'start low and go slow' should be adopted for most analgesic strategies.

Morphine consumption is not modified in patients with severe pain and classified by the DN4 score as neuropathic

Neuropathic pain has been poorly investigated in the emergency department, although it is known to be less sensitive to opioids than other forms of pain. We tested the hypothesis that morphine requirements are increased in patients having severe pain classified as neuropathic using the DN4 score. We included adult patients with acute severe pain (visual analog scale ≥70), assessed using the DN4 score, and treated with intravenous morphine titration (bolus of 2 or 3 mg [body weight >60 kg] with 5-minute intervals between each bolus). Pain relief was defined as a visual analog scale 30 or less. Patients were divided into 2 groups: control group (DN4 score <4) and neuropathic pain group (DN4 score ≥4). The main outcome was the total dose of morphine administered. Data are mean±SD or median (interquartile range). Among the 239 patients included (mean age, 43+14 years), 35 patients (15%) had a DN4 score 4 or more. The main characteristics of the 2 groups were comparable. There were no significant differences between the 2 groups in morphine dose (0.16+0.09 vs 0.17+0.11 mg/kg, P=.32), number of boluses administered (3.5 [3-5] vs 3 [3-6], P=.97), proportion of patients with pain relief (75 vs 83%, P=.39), or morphine-related adverse effects (11% vs 3%, P=.14). In conclusion, morphine consumption was not significantly modified in patients having severe pain classified as neuropathic using the DN4 score as compared with a control group, suggesting that specific detection of neuropathic pain may not be useful in the emergency department.

Objective Assessment of the Immediate Postoperative Analgesia Using Pupillary Reflex Measurement

The evaluation of pain intensity during the immediate postoperative period is a key factor for pain management. However, this evaluation may be difficult in some circumstances. The pupillary dilatation reflex (PDR) has been successfully used to assess the analgesic component of a balanced anesthetic regimen. We hypothesized that PDR could be a reliable index of pain intensity and could guide morphine administration in the immediate postoperative period. One hundred patients scheduled to undergo general surgery were included in this prospective observational study. Pain intensity was assessed by using a simple five-item verbal rating scale (VRS). After patients awoke from general anesthesia, those experiencing mild or more severe pain (VRS more than 1) received intravenous morphine titration. Before and after intravenous morphine titration, the PDR induced by a standardized noxious stimulus was measured with a portable pupillometer. A receiver-operating curve was built to estimate the accuracy of PDR in objectively detecting patients requiring morphine titration. Results are given as median (95% CI). On the initial evaluation, a correlation was found between VRS and PDR (ρ = 0.88 [0.83-0.92], P < 0.0001). In the 39 patients that had a VRS more than 1, PDR before and after morphine titration was respectively 35% (31-43) versus 12% (10-14); P < 0.0001. The PDR threshold value corresponding to the highest accuracy to have VRS more than 1 was 23%, with 91% and 94% sensitivity and specificity, respectively. In the immediate postoperative period, the PDR is significantly correlated with the VRS. The pupillometer could be a valuable tool to guide morphine administration in the immediate postoperative period.

Usefulness of nefopam in treating pain of severe uncomplicated renal colics in adults admitted to emergency units: a randomised double-blind controlled trial. The ‘INCoNU’ study

BackgroundRenal colic pain is a frequent cause of emergency department admissions (1–2% of admissions). It is extremely painful, often requiring intravenous morphine titration. The aim of this study was to...

Relationships between plasma concentrations of morphine, morphine-3-glucuronide, morphine-6-glucuronide, and intravenous morphine titration outcomes in the postoperative period

Although intravenous morphine titration (IMT) is widely used to control moderate to severe postoperative pain, the relationships between plasma concentrations of morphine and its metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), and IMT outcomes in the postanesthesia care unit (PACU) have not been yet investigated. IMT was administrated as a bolus of 2 or 3 mg every 5 min. Titration was interrupted in case of pain relief (visual analog score ≤30), adverse events, sedation, or failure of morphine titration. Blood samples were collected at the end of morphine titration to determine plasma concentration of morphine and its two metabolites. Data from 214 patients were analyzed; 143 (67%) of the patients achieved complete pain relief, 39 (18%) experienced adverse events, and 32 (15%) failure of morphine titration. At the end of titration, there were no significant differences in morphine, M6G, M3G concentrations between sedated and nonsedated patients (32 vs. 42 ng/mL (P = 0.07), 38 vs. 45 ng/mL (P = 0.51), 300 vs. 342 ng/mL (P = 0.29), respectively), or patients with or without adverse events (40 vs. 41 ng/mL (P = 0.95), 37 vs. 46 ng/mL (P = 0.51), 287 vs. 340 ng/mL (P = 0.72), respectively). Our study demonstrated a lack of relationship between plasma concentrations or ratios of morphine, M3G, and M6G, with IMT outcomes in PACU. This result suggests that the kinetics of morphine and its metabolites have limited value for explaining clinical effects of morphine in this clinical setting.

Opioids

OPIOIDS ARE POTENT analgesics and the mainstay of treatment for moderate to severe postoperative pain. The most commonly used intravenous (IV) opioids in the postanesthesia care unit are morphine, fentanyl, and hydromorphone. All of these agents are potent agonists at the mu-opioid receptor and, when administered in comparable doses, analgesic and adverse effects are similar. Clinicians are quite aware of variability in patient response to what is considered an appropriate dose of an IV opioid. If adequate analgesia is not achieved, increasing the dose and/or frequency of administration (to increase the plasma level) of the opioid does not always improve pain relief and could increase adverse effects. 1 Yassen A. Dahan A. Overdyk F. et al. Verbal pain scores are not linearly related to morphine plasma levels during PCA. Anesthesiology. 2007; 107: A1247 Google Scholar Furthermore, the relationship between opioid dose and pain intensity (using the visual analog scale) is not linear. 2 Aubrun F. Langeron O. Quesnel C. et al. Relationships between measurement of pain using visual analog score and morphine requirements during postoperative intravenous morphine titration. Anesthesiology. 2003; 98: 1415-1421 Crossref PubMed Scopus (189) Google Scholar Opioids have a narrow therapeutic index, necessitating patient-specific opioid therapy with frequent and responsive nurse monitoring to prevent serious events. Julie Golembiewski, PharmD, is a Clinical Associate Professor, Departments of Pharmacy Practice and Anesthesiology, University of Illinois at Chicago College of Pharmacy, Chicago, IL. Andrei M. Rakic, MD, is an Assistant Professor of Clinical Anesthesiology, University of Illinois at Chicago College of Medicine, Chicago, IL.

Intravenous morphine titration in immediate postoperative pain management: Population kinetic–pharmacodynamic and logistic regression analysis

Morphine is widely used to treat moderate to severe postoperative pain. The goal of this study was to characterize the pharmacodynamics of morphine-induced analgesia during intravenous morphine titration in the immediate postoperative period and to evaluate sedation occurrence according to morphine dose in this setting. Two hundred and twenty-eight patients undergoing major orthopedic surgery were included. They received intravenous (iv) morphine titration in the post-anesthesia care unit as boluses of 2 or 3mg, every 5min until analgesia was established. Pain was assessed using visual analogue scale (VAS) scores. Morphine analgesia-time data were analysed via a kinetic–pharmacodynamic population approach using non-linear mixed-effect modeling NONMEM. Sedation was assessed by the Ramsay score with scores >2 representing clinically significant sedation. The relationship between sedation occurrence and morphine dose was modeled using logistic regression. Morphine pharmacodynamic was best described by an indirect response model with an inhibitory function affecting pain onset, and it showed that decreasing delay between extubation and titration, decreasing initial VAS and intra-operative non-steroidal anti-inflammatory drug resulted in increased morphine potency. Logistic regression showed that a morphine dose of 20mg was associated with a high likelihood of sedation occurrence. Our study supported the possibility of modeling the time course of a complex response in the absence of pharmacokinetic data. The current data should lead to a more rational management of the immediate postoperative pain.

Intravenous morphine titration to treat severe pain in the ED

Purpose We assessed the safety of intravenous morphine titration in the emergency setting. Methods A total of 621 consecutive adult patients admitted in the ED with acute severe pain (visual analogue scale pain score >70) were included. Intravenous morphine titration was administered as a bolus of 2 (body weight ≤60 kg) or 3 mg (body weight >60 kg) with 5-minute interval between each bolus. Pain relief was defined as a visual analogue pain score of 30 or lower. Results The dose of morphine administered was 0.16 ± 0.10 mg/kg and the median number of boluses was 3. Pain relief was obtained in 512 (82%) patients. Morphine-induced adverse events occurred in 67 patients (11%) without severe adverse event. Titration was interrupted before pain relief had been obtained in 107 (17%) patients. In the remaining 514 patients, pain relief was obtained in 507 (99%) patients. Two variables were significantly associated with no pain relief: major protocol deviation (odds ratio, 17.3; 95% confidence interval, 10.0-30.1) and morphine-induced adverse effect (odds ratio, 13.0; 95% confidence interval, 6.7-25.3). Conclusion Intravenous morphine titration is a safe and effective option for severe pain when used according to a strict protocol.

Effet d’une infiltration sous-cutanée de ropivacaïne 0,75 % sur l’analgésie postopératoire après césarienne

Objective Evaluate the effects of skin infiltration with ropivacaine 0,75% on postoperative pain after caesarean section in the first 24 h. Patients and methods A prospective randomized double blind study was realized during three months in Auxerre Hospital. All ASA 1–2 patients presenting for elective caesarean section under spinal anesthesia were enrolled in the study. Drug addicts and patients with chronic pain were excluded from the study. The patients were randomly divided into two groups to receive skin infiltration 20 ml of ropivacaine 0,75% (Gr R) or skin infiltration of 20 ml of 0,9% saline solution. All patients received systematically propacetamol 1 g per six hours and ketoprofen 50 mg per six hours. Intravenous morphine titration was delivered to patients with a simple numerical scale greater or equal to three (SNS ≥ 3). Postoperative pain (SNS), morphine consumption and adverse reactions were compared. Results From July to September 2005, 42 patients were enrolled in the study. The SNS was lower in the Gr R. Total morphine consumption was reduced in the Gr R. The incidence of the adverse effects were higher in the Gr P. One case of parietal haematoma was detected in the Gr P, the evolution of which was favorable. Discussion and conclusion Skin infiltration of ropivacaine 0,75% is a simple technique able to reduce postoperative pain score and morphine consumption after caesarean section.