Postoperative Morphine Use Research Articles

INDOMETHACIN IN CONJUNCTION WITH MORPHINE FOR BALANCED ANALGESIA AFTER CARDIAC SURGERY

Introduction. The combination of non-steroidal anti-inflammatory drugs (NSAIDs) with opioid analgesics produces additive actions with respect to postoperative pain relief. [1] In orthopedic, abdominal and thoracic surgery, the combined use of indomethacin and morphine has been shown to reduce pain and opioid consumption in postoperative surgery patients. [2-4] In addition, this opioid sparing effect may lead to less opioid related side effects. [1] The combination of NSAIDs with opioid analgesics for postoperative pain management has not been studied in cardiac surgery. Methods. With institution ethics approval, 67 adult patients (13 females: 54 males) with a mean age of 60 +/- 10 years (ranging 35-76 years) undergoing elective cardiac surgery were studied in a randomized double-blind trial. Group (P) received placebo suppositories; and Group (I) received indomethacin suppositories postoperatively, every 12 hours, for a 24 hour period, in conjunction with patient controlled intravenous morphine analgesia (PCA). Total analgesic requirements for 24 hours, pain intensity on a 10-cm visual analogue scale (VAS) (at rest and with cough), blood loss and time to extubation were recorded. The two treatments and pain scores assessed at five time periods (4, 6, 12, 18 and 24 hours postoperatively) were analyzed through 2 x 4 repeated measures analysis of variance (RANOVA). The 24 hour analgesic score, blood loss and time to extubation were compared for the two treatment arms through Student's t-test on independent samples. Results. Postoperative morphine use in the first 24 hours was less in the indomethacin group (23.16 +/- 14.10 mg) (mean +/- sd) than the placebo group (35.97 +/- 24.67 mg), P=0.0093 (Figure 1). Pain scores measured with a VAS were consistently lower in the indomethacin versus placebo group at rest for 4, 6, 12, 18 and 24 hours (P=0.0053) (Figure 2), but not with cough. There was no significant difference in blood loss (12 hours postoperatively) or time to extubation in both groups.Figure 1: Total Analgesic Requirement.Figure 2: Pain Scores at Rest.Discussion. Patients given indomethacin suppositories used 36% less morphine than patients given placebo, and at the same time obtained better postoperative analgesia, reporting 31% to 62% lower pain scores at rest. There was no difference in postoperative blood loss. The use of indomethacin significantly reduces postoperative pain scores and opioid requirement in post-cardiac surgery.

Differences in Morphine Consumption Administered by PCA and Traditional IV Methods in a Pediatric Population

The undertreatment of pediatric postoperative pain has been a persistent problem. This study compared postoperative morphine use between two groups of pediatric patients, those receiving intravenous (IV) morphine either as needed (PRN) or via patient-controlled analgesia (PCA). The study's objectives were to measure the mean amounts of morphine used by each group and lo determine if these amounts were significantly different. Data collection involved a retrospective review of 113 charts of patients who had undergone appendectomy surgeries. Results showed that patients in the IV PRN group used significantly less morphine postoperatively compared to the IV PCA group, controlling for demographic and clinical variables. Potential implications of these findings and recommendations for future research are offered.

Intrathecal Neostigmine for Post-Cesarean Section Analgesia

Intrathecal (IT) neostigmine produces analgesia in animals and humans and enhances systemic opioid analgesia.To examine the safety of IT neostigmine for eventual use in obstetrics, we studied 24 healthy, term pregnant patients scheduled to receive elective cesarean section using a combined spinal-epidural anesthetic. Using an open-label, dose-ranging design, patients received either IT placebo or neostigmine 10, 30, or 100 micro g in a 1-mL solution of 5% glucose in normal saline followed in 15 min by 2% epidural lidocaine for cesarean section. Neostigmine did not affect fetal heart rate tracings or Apgar scores. The women received patient-controlled analgesia intravenous morphine postoperatively. Compared with the glucose control, neostigmine produced a dose-independent reduction in postoperative morphine use. Cumulative average 24-h morphine use was 82 +/- 7 mg for women receiving IT placebo and 50 +/- 8 mg for women receiving IT neostigmine (P < 0.003). Hourly morphine use was significantly reduced in the neostigmine groups for 10 h postoperatively. These data indicate that IT neostigmine can produce 10 h of post-cesarean section analgesia without adverse fetal effects and support cautious further prospective study. (Anesth Analg 1997;84:1269-75)

Postoperative analgesia using a low-dose, oral-transdermal clonidine combination: Lack of clinical efficacy

To determine if a lower than previously reported oral-transdermal clonidine regimen could reduce postoperative morphine requirements without producing systemic side effects. Double-blind, randomized, placebo-controlled study. University-affiliated hospital. 29 healthy, ASA physical status I and II females undergoing elective abdominal hysterectomy. Patients received preoperative oral clonidine 4 to 5 mu/kg and a 7 cm2 transdermal clonidine patch (0.2 mg/24 hours) or a placebo tablet and patch. Postoperative patient-controlled analgesia pumps provided morphine during the 48-hour study period. Morphine use, hemodynamic changes, and nonhemodynamic side effects were recorded. Additionally, visual analog pain scales (VAPS) and plasma concentrations of morphine and clonidine were measured. We found that low-dose clonidine had no potentiating effect on morphine analgesia. Postoperative morphine use, VAPS, and morphine plasma levels were similar between the control and clonidine-treated groups. Nevertheless, patients in the clonidine group experienced a significantly greater incidence of intraoperative and postoperative hypotension and bradycardia than did the control group. No differences were noted in the incidence of nonhemodynamic side effects. The low-dose oral-transdermal clonidine regimen evaluated failed to reduce postoperative morphine requirements, although patients who received clonidine were still at risk for developing hypotension.

Gastroesophageal Reflux and Tracheobronchial Contamination After Cardiac Surgery

Nasogastric (NG) tubes are routinely used in patients undergoing cardiac surgery.This randomized study was designed to assess gastroesophageal reflux (GER) without a NG tube (control) compared with a NG tube managed either by gravity drainage (gravity) or continuous low-grade suction (suction). Antimony pH probes were placed in the lower esophagus and trachea after induction of anesthesia in 51 patients, and pH was recorded every 5 s until the time of tracheal extubation. GER was defined as reversible decrease in esophageal pH to less than 4.0. No significant difference was found between groups in age, weight, gender, duration of postoperative ventilation, morphine use, or antiemetic use. All indicators of GER were seen more frequently in the gravity group compared with the two other groups (P < 0.001). One episode of sudden decrease in tracheal pH was observed in a patient in the gravity group, indicating tracheal aspiration, which was associated with delayed extubation and postoperative pneumonia. The absence of a NG tube is not associated with reflux, probably since the gastroesophageal sphincter remains competent. NG tubes are not routinely necessary for cardiac surgery in patients without risk factors for GER, and increase reflux risk if managed without low-grade suction. (Anesth Analg 1996;83:228-32)

Therapeutic Suggestion Has No Effect on Postoperative Morphine Requirements

This study was designed to confirm the effect of therapeutic intraoperative auditory suggestion on recovery from anesthesia, to establish the effect of preoperative suggestion, and to assess implicit memory for intraoperative information using an indirect memory task. Sixty consenting unpremedicated patients scheduled for elective gynecologic surgery were randomly divided into three equal groups: Group 1 received a tape of therapeutic suggestions preoperatively, and the story of Robinson Crusoe intraoperatively; Group 2 heard the story of Peter Pan preoperatively and therapeutic suggestions intraoperatively; Group 3 heard the Crusoe story preoperatively and the Peter Pan story intraoperatively. A standardized anesthetic technique was used with fentanyl, propofol, isoflurane, and nitrous oxide. After surgery, all patients received patient-controlled analgesia (PCA) with a standardized regimen. In the 24 h postsurgery, morphine use was recorded every 6 h and at 24 h an indirect memory test (free association) was used to test for memory of the stories. Anxiety scores were measured before surgery and at 6 and 24 h postsurgery. There were no significant differences between groups for postoperative morphine use, pain or nausea scores, anxiety scores, or days spent in hospital after surgery. Seven of 20 patients who heard the Pan story intraoperative gave a positive association with the word "Hook," whereas 2 of 20 who did not hear the story gave such an association. Indirect memory for the Pan story was established using confidence interval (CI) analysis. (The 95% CI for difference in proportion did not include zero). No indirect memory for the Crusoe story could be demonstrated. This study did not confirm previous work which suggested that positive therapeutic auditory suggestions, played intraoperatively, reduced PCA morphine requirements. In contrast, a positive implicit memory effect was found for a story presented intraoperatively.

The Effect of Midazolam and Lorazepam on Postoperative Recovery After Cardiac Surgery

The Effect of Midazolam and Lorazepam on Postoperative Recovery After Cardiac Surgery

Effect of pregnancy and pain on cerebrospinal fluid immunoreactive enkephalins and norepinephrine in healthy humans

Endogenous spinal opioid or noradrenergic system activation may increase pain threshold during pregnancy and following a painful stress. Variation in spinal antinociceptive activity is also postulated to explain in part the large variability in postoperative opioid analgesic requirements. In this study, spinal noradrenergic and opioid activity, as reflected by the CSF concentrations of norepinephrine and immunoreactive enkephalins (total enkephalin-containing peptides), was determined in 58 women prior to surgery. The CSF concentration of these substances did not differ between pregnant and non-pregnant women. CSF norepinephrine tended to be greater in pregnant women who had experienced painful labor than in those who had not (1240 ± 300 vs. 570 ± 160 pmol/1; P = 0.056) and these women self-administered less morphine following cesarean section than those without labor pain (64 ± 4 vs. 86 ± 7 mg/24 h; P < 0.01). However, CSF concentration of norepinephrine or immunoreactive enkephalins did not correlate with postoperative morphine use. These results suggest that spinal immunoreactive enkephalin and noradrenergic activity are not increased during pregnancy. However, pain may activate spinal noradrenergic pathways affecting pain sensation.

IM Diclofenac Reduces Postoperative Morphine Use by One Third

IM Diclofenac Reduces Postoperative Morphine Use by One Third