Postoperative Patient-controlled Analgesia Morphine Research Articles

Bilateral ultrasound-guided erector spinae plane block for postoperative pain relief in major traumatic spine surgery: A randomized controlled trial.

Spine fixation surgery for traumatic vertebral fractures is associated with severe pain and is often difficult to control. Traditionally systemic opioids have been the mainstay of analgesia for these procedures, which can lead to hyperalgesia, nausea, ileus, sedation, cognitive impairment, dependence, etc., limiting usage of opioids. The Erector spinae plane block (ESPB) is a novel ultrasound-guided procedure with easily identifiable sonoanatomy. We hypothesized that a multimodal approach involving ESPB to a conventional analgesic regimen with local infiltration for patients undergoing major traumatic spine surgeries might provide better perioperative analgesia and reduce the need for postoperative opioid requirements. A randomized control prospective trial was conducted on 34 ASA grade I -II patients aged 18 to 65 years who were scheduled to undergo elective posterior spine fixation surgery with ASIA B to E after traumatic spine fracture under general anesthesia. Patients were randomized to Group A which included patients who received general anesthesia with ESPB, and Group B, or the control group, included patients who received general anesthesia with systemic analgesics and postoperative local infiltration without ESPB. Intraoperative total fentanyl consumption, VAS score at 0, 3, 6, 12, 18, and 24 hours, time to activate patient-controlled analgesia (PCA) pump, total morphine consumption, and opioid-related side effects were monitored and compared in both groups. Postoperative PCA morphine consumption was significantly lower in group A patients who received ESPB than those in the control group (17.06 ± 9.59 vs 37.82 ± 9.88 P value = <0.0001). VAS scores at rest and movement at 0, 3, 6, 9, 12, 18, and 24 hours were significantly lower (P value = 0.05) in the ESPB group compared with the control group at all time points. Bilateral ultrasound-guided Erector spinae plane block, when administered in traumatic spine patients undergoing spine fixation surgery, provides better analgesia with statistically decreased VAS scores and less postoperative opioid requirement.

Comparison of post-operative pain in short versus long stitch technique for abdominal wall closure after elective laparotomy: a double-blind randomized controlled trial.

Conventional mass closure uses suture-to-wound length ratio of 4:1 ('long stitch', LS). 'Short stitch' (SS) has a suture-to-wound length ratio of more than 4 and incorporates only the linea alba, which may reduce tension and pain. We compared the post-operative pain after laparotomy closure using LS and SS. Patients undergoing elective midline laparotomy through standardized incisions in two tertiary hospitals from February 2017 to September 2018 were randomized to either LS or SS. The primary outcome was post-operative patient-controlled analgesia morphine usage at 24 h. Secondary outcomes were presence of surgical site infection and length of hospital stay (LOHS). Categorical variables were analysed using chi-squared analysis. Outcomes of study were tested for normal distribution. Skewed data were analysed using Mann-Whitney U-test. Eighty-six patients were recruited (42 SS and 44 LS). The median age was 66 (interquartile range (IQR) 15). Majority were males (62.8%) and Chinese (50%). The median incision length was 17 cm in both groups. The median patient-controlled analgesia morphine usage 24 h post-operatively did not differ significantly (SS 21 mg, IQR 28.3; LS 18.5 mg, IQR 33.8, P=0.829). The median pain score at rest (SS 1, IQR 1; LS 1, IQR 2, P=0.426) and movement (SS 3, IQR 1; LS 3, IQR 2, P=0.307) did not differ significantly. LOHS was shorter in the SS group (SS 6, IQR 4; LS 8, IQR 5, P=0.034). The rate of surgical site infection trended lower in the SS group with no statistical difference. There were no differences in post-operative pain between SS and LS but we found that there were shorter LOHS in SS arm as secondary outcome.

Evaluation of Two Different Doses of Pre-Emptive Intravenous Magnesium Sulphate as Post- Operative Adjunct Analgesia after Gynaecological Surgery

This study compared the analgesic effects of pre-emptive intravenous magnesium sulphate of different dosages in patients undergoing lower abdominal gynaecological surgery. Fifty-six patients with Body Mass Index (BMI) &lt;35 kg/m2 who underwent lower abdominal gynaecological surgery were randomly recruited into two groups. Group I received one ampoule (2.47 g) of magnesium sulphate and Group II received 50 mg/kg magnesium sulphate (based on body weight), pre-operatively. Pain score and patient controlled analgesia (PCA) morphine requirement were compared at 30 minutes, 12 hours and 24 hours post-operatively. The pain score was comparable at all intervals between the two groups (30 minutes, p = 0.450; 12 hours, p = 0.402; and 24 hours, p = 1.000). Post-operative PCA morphine requirement was not statistically significant between the two groups at 30 minutes, 12 hours, and 24 hours (2.7 vs 2.4 mg, p = 0.545; 12.5 vs 9.8 mg, p = 0.154; 7.7 vs 6.4 mg, p = 0.323). The side-effects of magnesium sulphate on blood pressure, heart rate and sedation were not statistically significant between the two groups. In conclusion, the analgesic effects of pre-emptively administered intravenous MgSO4 of 2.47 g (one ampule) was comparable to 50 mg/kg in patients with BMI less than 35 kg/m2 following lower abdominal gynaecological surgery under general anaesthesia with negligible side effects.

Is intravenous morphine alone effective for postoperative analgesia in bilateral, single-port video-assisted thoracoscopic sympathectomy performed in the supine position?

Introduction The method of operation carried out by clip application that utilizes the supine position and single port for thoracoscopic sympathectomy has been defined in recent years. This method leads to less pain as less tissue damage occurs. There is no any recommendation about postoperative analgesia management. The aim of this study is to investigate whether intravenous morphine alone effective for postoperative analgesia in bilateral, single-port video-assisted thoracoscopic sympathectomy performed in the supine position. Methods After obtaining ethical committee approval, postoperative analgesia management of 28 patients who underwent bilateral, single-port video-assisted thoracoscopic sympathectomy was retrospectively investigated. The patients were divided into two groups; After induction of anaesthesia, intrathecal morphine was administered to a group at a dose of 0.6 mg/3 mL, and postoperative patient-controlled analgesia(PCA) was administered intravenously (IV) with a locked time of 1 mg bolus for 30 minutes(Group ITM,n=14). In the other group, IV morphine was applied in the same doses only by the PCA method(Group PCA,n=14). Visual analogue scale (VAS) values and IV total morphine consumption were recorded at the time of extubation and at the 6th, 24th and 48th hours postoperatively. For statistical significance p value was determined as 0.05. Results In terms of demographic and surgical data (mean age, gender, ASA scores, duration of operation), there was no statistically difference between the groups. At the time of extubation and at the postoperative 6th hour, VAS scores were statistically significantly lower in Group ITM than in the Group PCA (Comparison of the recorded VAS score after extubation: 0.71±1.20 in Group ITM, 2.43±1.74 in Group PCA, p=0.012. Postoperative 6th hour VAS score comparison: 0.21±0.57 in Group ITM, 1.57±1.60 in Group HKA, p=0.011). There was no significant difference between the groups in terms of VAS values at the postoperative 24th and 48th hours. In Group PCA, total IV morphine (mg) consumption at the postoperative 24th and 48th hours was statistically significantly higher than the Group ITM (total morphine consumption at the postoperative 24th hour: 14.57±20.18 vs. 4.14±5.62, p Discussion The results of this study show that in the management of pain after thoracoscopic sympathectomy operations performed with this method, we believe that even though an adequate analgesia is provided through ITM, IV PCA morphine provided clinically acceptable analgesic efficacy, and a regional administration may not be required in patients who will be operated with this method.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block on postoperative pain and morphine consumption in varicocelectomy.

Objectives:To evaluate the analgesic effect of transversus abdominis plane (TAP) block administered before varicocele surgery.Methods:This study was completed at the Faculty of Medicine, Çanakkale Onsekiz Mart University, Çanakkale, Turkey, between January 2011 and April 2013. In a prospective, double blind, randomized, placebo controlled clinical study, 40 male patients scheduled for elective varicocele operations were randomized to group T (treatment group) or group C (controls). After receiving general anesthesia, group T received a TAP block using 20 mL 0.25% bupivacaine on the operation side, whereas group C received a control block using 20 mL 0.9% Sodium chloride. During the first 24 hours after surgery, the patient pain was evaluated using the visual analogue scale (VAS) at rest and while coughing. Postoperative patient controlled analgesia morphine consumption, VAS scores, and side effects were recorded.Results:Of 34 patients, Group T (n=18) had significantly lower VAS pain scores than Group C (n=16) both at rest and while coughing. The total morphine consumed was lower (7.7 ± 4.0) versus 21.6 ± 12.4 mg, p<0.001) in the 24 hours after surgery.Conclusion:As part of a multimodal analgesic regime after varicocelectomy surgery, morphine consumption and VAS pain scores were significantly lower among those receiving 20 mL 0.25% bupivacaine administered for a TAP block than among controls.

Intraoperative Dexmedetomidine Promotes Postoperative Analgesia in Patients after Spinal Surgery

Surgery-induced acute postoperative pain may lead to prolonged convalescence. The present study was designed to investigate the effects of intraoperative administration of dexmedetomidine (DEX) on postoperative patient-controlled analgesia (PCA) following spinal surgery. Seventy-two patients scheduled for spinal surgery under general anesthesia were randomly assigned into two groups, which were maintained with propofol/remifentanil/dexmedetomidine (PRD) or propofol/remifentanil/saline (PRS) for genral anesthesia. Patients in PRD group had a lower Bispectral index (BIS) value during surgry, which indicated a deeper anesthetic state, and a higher sedation score right after extubation than patients in PRS group. During the first 24 hours post surgery, PRD patients consumed less PCA morphine, and had a lower score in visual analogue scale (VAS) than those from PRS group. Collectively, intraoperative administration of dexmedetomidine appears to promote the analgesic property of morphine-based PCA in patients after spinal surgery.

Combination of oral clonidine and intravenous low-dose ketamine reduces the consumption of postoperative patient-controlled analgesia morphine after spine surgery

ObjectiveBecause ketamine, clonidine, and morphine modulate nociceptive pain, coadministration of these drugs would augment the activity of postoperative analgesic drugs. The purpose of this study was to evaluate the effects of coadministration of ketamine and clonidine on postoperative morphine consumption in patients after spine surgery. MethodsThe patients undergoing spine surgery were allocated randomly to one of the four study groups, which are as follows: group M (n = 12), intravenously (IV) administered patient-controlled analgesia (PCA) morphine alone; group MK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine; group MC (n = 13), IV-PCA morphine plus oral clonidine premedication; group MCK (n = 12), IV-PCA morphine plus intra- and postoperative ketamine and clonidine premedication. The patients in the MC and MCK groups received 4 μg/kg clonidine orally, whereas those in the MK and MCK groups received IV bolus of ketamine (10 mg) at a rate of 2 mg/kg/hour during anesthesia. Patients were arranged to use IV-PCA mode for administration of drugs, which was programmed to deliver a bolus dose of 2-mg morphine (groups M and MC), or boluses of 2-mg morphine and 2-mg ketamine (groups MK and MCK). Scores of visual analog scale (VAS) for pain, morphine requirement, vital signs, nausea, sedation, and other side effects were followed up to 60 hours after surgery. ResultsAlthough there were significant differences in VAS pain scores at rest 24–48 hours after the surgery, the VAS pain score at movement was similar among the groups. The number of PCA request and cumulative morphine requirement were significantly lower in the MCK group than in the M group. ConclusionThis study results show that the administration of perioperative low-dose ketamine combined with clonidine premedication could reduce the consumption of postoperative PCA morphine following spine surgery.

Erratum: Continuous infusion of two doses of remifentanil immediately after laparoscopic-assisted vaginal hysterectomy (Korean J Anesthesiol 2010; 58(6): 537-541)

[This corrects the article on p. 537 in vol. 58, PMID: 20589178.].

Fentanyl and clonidine as adjunctive analgesics with levobupivacaine in paravertebral analgesia for breast surgery

The addition of fentanyl or clonidine to levobupivacaine was evaluated in patients undergoing breast surgery under general anaesthesia with intra- and postoperative paravertebral analgesia. Patients were randomly allocated to four groups: Group L received 19 ml bolus levobupivacaine 0.25% plus 1 ml saline followed by an infusion of levobupivacaine 0.1%; Group LF received 19 ml bolus levobupivacaine 0.25% plus fentanyl 50 microg followed by an infusion of levobupivacaine 0.05% with fentanyl 4 microg x ml(-1); Group LC received 19 ml bolus levobupivacaine 0.25% plus clonidine 150 microg followed by an infusion of levobupivacaine 0.05% with clonidine 3 microg x ml(-1); Group C (control) received general anaesthesia without paravertebral analgesia. All groups received postoperative i.v. morphine patient controlled analgesia (PCA). Although mean (SD) postoperative PCA morphine consumption was decreased in LF [7.9 (4.1) mg] and LC [5.9 (3.5) mg]vs L [27.7 (8.6) mg] or C patients [21.7 (5.5) mg], p < 0.01, paravertebral fentanyl and clonidine were associated with significantly increased vomiting and hypotension, respectively.

Remifentanil compared with morphine for postoperative patient-controlled analgesia after major abdominal surgery

This randomized, double-blinded clinical study was designed to compare the efficacy and safety of remifentanil and morphine administered using intravenous (i.v.) patient-controlled analgesia (PCA) for postoperative analgesia after major abdominal surgery during the first 24 postoperative hours. Sixty-nine patients were randomly allocated into two groups, each receiving remifentanil or morphine. The first group received i.v. remifentanil PCA with a loading dose of 45 microg, a maintenance dose of 1 microg min(-1), a bolus dose of 15 microg and a lockout interval of 10 min during the first 24 postoperative hours. The second group received i.v. morphine PCA with a loading dose of 5 mg, a maintenance dose of 0.3 mg h(-1), a bolus dose of 1 mg and a lockout interval of 15 min. Age, weight, sex, history of general anaesthesia, duration of surgery and time spent in the post-anaesthesia care unit were recorded. Preoperative pulse rate, systolic and diastolic blood pressures (BP), respiration rate and arterial blood gases were collected. Pulmonary function was tested before induction of anaesthesia, as well as at 4 and 26 h after operation. Pulse rate, systolic and diastolic BP, respiration rate, arterial blood gases, sedation and visual analogue scores, and presence of side-effects in the recovery room and on the ward for 24 h were recorded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation. Total drug use, number of boluses delivered, number of boluses demanded and delivery/demand ratio were collected. Sixty patients were evaluated. The groups did not differ in age, weight, sex, history of general anaesthesia, duration of surgery or time spent in the recovery unit. There were also no clinically relevant differences between the groups with regard to haemodynamic and respiratory parameters as well as sedation and visual analogue scores (P > 0.05). More bolus doses were demanded and delivered and the delivery/demand ratio was significantly higher in the remifentanil group (P < 0.05). There was no finding suggesting acute opioid tolerance during remifentanil or morphine PCA. The i.v. remifentanil PCA with the chosen dosage regimen after abdominal surgery produces postoperative analgesia and has cardiovascular side-effects similar to those achieved with i.v. morphine. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.

Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery

Studies of pre-emptive analgesia in humans have shown conflicting results. This prospective, randomized, double-blind, controlled study was designed to test the hypothesis that a reduction in postoperative morphine consumption can be achieved by tramadol administered after induction of anaesthesia. Ninety patients were allocated randomly to receive i.v. tramadol (1 mg kg(-1)) (Group T), morphine (0.1 mg kg(-1)) (Group M) or saline 2 ml (Group S) after induction of anaesthesia. At peritoneal closure, a standardized (0.1 mg kg(-1)) morphine loading dose was given to all patients for postoperative pain management. Patients were allowed to use a patient-controlled analgesia (PCA) device giving bolus doses of morphine 0.025 mg kg(-1). Discomfort, sedation, pain scores, cumulative morphine consumption, and side-effects were recorded at 1, 2, 6, 12 and 24 h after the start of PCA. There were no significant differences between groups in mean pain, discomfort, and sedation scores at any study period. Cumulative morphine consumption was significantly lower in Group M at 12 and 24 h after starting the PCA than in Group S. In Group T, it was lower only after 24 h (28% less in Group M and 17% less in Group T; P<0.017). There were no significant differences in morphine consumption between Groups T and M. Tramadol (1 mg kg(-1)), administered after induction of anaesthesia, offered equivalent postoperative pain relief, and similar recovery times and postoperative PCA morphine consumption compared with giving morphine 0.1 mg kg(-1). These results also suggest that presurgical exposure to systemic opioid analgesia may not result in clinically significant benefits .

Effect of preoperative oral dextromethorphan on immediate and late postoperative pain and hyperalgesia after total abdominal hysterectomy

Dextromethorphan is a noncompetitive N-methyl- d-aspartate (NMDA) receptor antagonist known to inhibit wind-up and NMDA-mediated nociceptive responses of dorsal horn neurons. Experimental and clinical studies indicate that NMDA-receptor antagonists may potentiate the effect of analgesics such as morphine, local anesthetics and NSAIDs. Results from previous clinical studies of dextromethorphan in postoperative pain are conflicting, possibly related to administration of insufficient doses of the drug. Fifty patients scheduled for non-malignant elective abdominal hysterectomy in general anesthesia were randomized to receive oral dextromethorphan 150 mg, or placebo 1 h before surgery. The patients received patient-controlled analgesia with morphine for 24 h postoperatively as the only analgesic. Patient-controlled analgesia (PCA) morphine consumption was reduced with 30% from 0–4 h after operation in patients receiving dextromethorphan compared with placebo ( P=0.02); no differences were observed from 5–24 h postoperatively. There were no significant differences between groups for visual analogue scale scores at rest, during cough, or during mobilization, pressure pain detection thresholds, von Frey hair pain detection thresholds, or peak flow. At 24 h after operation, hyperalgesia to von Frey hair stimulation proximal to the surgical wound was easily detected in 23 of 25 patients receiving dextromethorphan, and in 22 of 25 patients receiving placebo, with no significant difference between groups. Pooled data from both groups showed a weak but significant correlation between the extent of hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption ( Rs=0.28, P=0.05). Three months postoperatively, hyperalgesia was still detectable in 18 of 22 examined patients in the dextromethorphan group, and in 16 of 23 patients in the placebo group, without statistical differences between groups. There were no significant differences in side-effects (nausea, vomiting, sedation). In conclusion, oral dextromethorphan 150 mg reduced PCA morphine consumption immediately (0–4 h) after hysterectomy, without prolonged effects on pain or wound hyperalgesia. A positive correlation between the magnitude of wound hyperalgesia at 24 h after operation, and total 24 h postoperative PCA morphine consumption was demonstrated.

Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine

Increased nausea and dizziness when using tramadol for post-operative patient-controlled analgesia (PCA) compared with morphine after intraoperative loading with morphine