Preservative-free Morphine Research Articles

Neuraxial Analgesia for Scoliosis Correction: A Case Series in a Specialised Children's Centre.

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist due to the extensive nature of the surgery, the co-morbidities of the patients and the constraints on aesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Patients undergoing scoliosis surgery are considered to suffer severe pain, which may lead to a negative impact on patient psychology and physical well-being. By using effective postoperative pain regimens to enhance recovery after surgery, pain can be significantly reduced, leading to patient satisfaction, facilitating early mobilisation, promoting oral intake, lowering postoperative pain and shortening the length of hospital stay. Thus, the primary objectives of this study were to assess the postoperative pain management andfirst rescue analgesic medications, by using preservative-free morphine 50 mcg/kg and dexmedetomidine 4 mcg along with normal saline 0.5 ml kg caudally, as well as to look for thesecondary objectivesside effects, including respiratory depression, nausea, vomiting and pruritis, timing of postoperative ambulation and length of hospital stay. Methods: In this study, we retrospectively included children under 14 years of age and above three years who underwent scoliosis surgery under a caudal epidural-general anaesthesia using caudal morphine and the dexmedetomidine technique in the period from January to May 2023 at the National Guard Health Affairs Hospital (NGHA), Riyadh. We collected the data of seven cases using the electronic chart system of the Best Care database to extract the specific cases that meet the inclusion criteria for the study, which are idiopathic scoliosis patients, aged 3-14 years, and primary correction procedures. Results: The pain-free duration was between seven hours and 48 hours (about two days). There were four female cases (57.14%), and three cases were male (42.85%). The patients' American Society of Anesthesiologists (ASA) status were II to III. In all the cases, there was no documentation of any episodes of postoperative nausea and vomiting (PONV), respiratory distress or pruritus, except for one case where the patient had an episode of PONV. Conclusion: In this study, our aim was to present our experience with dexmedetomidine as an efficient medication when coadministered with morphine to be used in the operating room. We found a high level of reliability in prolonging analgesia time and delaying the usage of rescue medication. We encourage more studies on caudal dexmedetomidine for patients undergoing scoliosis surgery.

Impact of Neuraxial Preservative-Free Morphine in Vaginal Delivery on Opiate Consumption and Recovery: A Randomized Control Trial.

Neuraxial opioids are commonly used after cesarean delivery (CD). However, they are not commonly used after vaginal delivery (VD) though some studies have suggested they may be beneficial from a pain perspective. However, they did not evaluate other potential benefits including patient satisfaction, impact on postpartum depression and breastfeeding (BF) success, or side effects such as pruritus. Parturients who delivered vaginally with epidural analgesia were randomized to receive either 2 mg of preservative-free morphine (4 mL) or saline (4 mL) via the epidural catheter within 1 hour of VD. Routine analgesics were unchanged and included q 6-hour dosing of acetaminophen 975 mg orally and ketorolac 30 mg intravenous (IV). Hydromorphone 2 mg or oxycodone 10 mg were offered for breakthrough pain. Our primary outcome was opiate consumption in the first 24 hours after drug administration. Secondary outcomes included pain scores at 24 hours and 1 week postpartum as well as opiate consumption up to 1 week postpartum. Additional end points such as obstetric quality of recovery score (OBS-QOR10) breast feeding success, and an Edinburgh Postnatal Depression Score (EPDS) were also obtained. Data were analyzed for 157 parturients, 80 in the morphine group and 77 in the saline group. No difference was observed in the EDPS score predelivery or intention to BF. We found a statistically significant difference in the use of opioids in the first 24 hours, 3.8% (95% confidence interval [CI], 0.9%-11.3%) vs 14.3% (7.7%-24.5%) in the morphine and saline groups, respectively; and in total opioid dose, median (interquartile range, IQR [range]) of morphine milligram equivalent vs 0 (0-0 [0-47.5]) vs 0 (0-0 [0-72]), P = .023, in the morphine and saline groups, respectively. Verbal pain scores (0-10) at 24 hours were lower in the morphine group (median (IQR [range): 2.0 (1-4 [0-10]) vs 3.0 (1.5-5.0 [0-10]), P = .043. There was a greater incidence of pruritus in the morphine group versus saline group, 37.5% (95% CI, 27.1%-49.1%) vs 18.2% (95% CI, 10.6%-29.0%), P = .008. We did not find any differences in the OBS-QOR10, BF success, or EPDS at 6 weeks PP (P < .05). A single epidural dose of 2 mg preservative-free morphine after VD was effective at decreasing pain and opioid use at 24 hours after VD but came at the cost of increased pruritus. We did not detect any differences in BF, recovery scores, or PPD. Future studies should focus on elucidating the role of neuraxial preservative-free morphine after VD.

445 Evaluation of Low Dose Intrathecal Morphine Delivery in the Treatment of Chronic Pain

INTRODUCTION: The use of low-dose intrathecal morphine via a morphine drug delivery system is an alternative to oral analgesics in the treatment of chronic pain. METHODS: This was a retrospective chart-review. Patients were enrolled from June 2016 to April 2019. An out-patient intrathecal morphine trial was performed by injecting a single dose of 0.1-0.2 mg of preservative-free morphine in the lumbar intrathecal space. Following at least 60% reduction in pain, patients were weaned off oral analgesics completely over several weeks, and a permanent intrathecal catheter and morphine pump was implanted. Follow-up data was included at 3 and 6 months and 1 and 3 years. RESULTS: 20 patients were enrolled (median age 59, 60% female). 10 patients were diagnosed with CPS and 10 were diagnosed with PLS. Pain was significantly controlled and reduced at each time point post-implantation compared to baseline. (p &lt; 0.05). Intrathecal dosing did increase over the 3-year period on average, but the increase in dose was moderate. (p &lt; 0.01) (median increase: 0.09 mg/day over 3 years).All patients were on oral medication for their pain prior to implantation as summarized: Remarkably, no patients previously taking oral opiates/analgesics restarted oral opiate/analgesic therapy following implantation up to and including the 3 years follow-up. There were no infections or complications present in the study. CONCLUSIONS: Low dose intrathecal drug delivery was shown to significantly reduce pain following treatment at each follow-up time point. This study further characterizes the efficacy of the use of low-dose intrathecal drug delivery in the treatment of chronic pain. A future multi-center study is desired.

Caudal Morphine in Pediatric Patients: A Comparison of Two Different Doses in Children Undergoing Infraumbilical Surgery - A Prospective, Randomized, Double-Blind Study.

One of the most feared symptoms of any disease is PAIN. It is a complex phenomenal experience, especially in children. Various methods and medications have been administered through different routes. Regional anesthesia produces marvelous postoperative analgesia and cessation of stress response in infants and children. Caudal epidural analgesia is the most acceptable and popular method of providing intra- and postoperative analgesia for abdominal, perineal, and lower limb surgeries in children. The use of preservative-free morphine as an adjunct to ropivacaine increases the quality and duration of analgesia despite the various side effects. Various articles use various doses of morphine as an adjuvant in caudal epidural analgesia. Hence, we conducted the study to compare the two dosages of morphine that is 20 μg.kg-1 and 30 μg.kg-1 of caudal epidural morphine for infraumblical surgeries with regard to its efficacy and safety and side effect profiles. The study is a prospective, randomized, double-blinded study. Sixty patients were divided into two groups. Group A: 20 μg.kg-1 of morphine was added to 0.2% ropivacaine 1 mL.kg-1 and the solution was made. Group B: 30 μg.kg-1 of morphine was added to 1 mL.kg-1 of 0.2% ropivacaine. Heart rate, systolic blood pressure, diastolic blood pressure, SPO2, pain score, and sedation score were recorded immediately, after 15 min, 30 min, 45 min, 1 h, 2 h, 4 h, 8 h, 12 h, 16 h, 18 h, and 24 h were recorded. The mean duration of analgesia is similar in both groups (P = 0.011). The mean duration was 20.517 ± 1.9143 h in Group A and 22.233 ± 1.6853 h in Group B. Children with the requirement of one dose of rescue analgesia in Group A was 83.3% which was higher than Group B being 66.7%. Children with no analgesic requirement were 16.7% in Group A and 33.3% in Group B. The incidence of side effects was more in Group B (8 [26.7%] children with nausea and vomiting; 1 [3.3%] children with urinary retention) than in Group A (2 [6.6%] children with nausea and vomiting. From the above observations, it can be concluded that morphine of less dosage (20 μg.kg-1) when added to 0.2% ropivacaine for the caudal epidural block has better efficacy than morphine of higher dosage (30 μg.kg-1) as the duration of analgesia is similar with decreased incidence of side effects.

Comparative evaluation of the analgesic efficacy of ultrasound-guided erector spinae plane block versus intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery: A prospective randomized pilot study.

Existing research on erector spinae plane block and intrathecal morphine in patients undergoing percutaneous nephrolithotomy surgery is limited. In this prospective, randomized study, 60 patients aged between 18 and 60 years were randomized into two groups (erector spinae plane block and intrathecal morphine). In the erector spinae plane block group, ultrasound-guided erector spinae plane block was performed, following which a mixture of 20 mL of 0.375% ropivacaine and 0.5 mcg/kg of clonidine was injected. In the intrathecal morphine group, 150 mcg preservative-free morphine with 2 mL of normal saline was administered intrathecally. The primary outcome was to evaluate the perioperative opioid consumption in the first 24 h. The secondary outcomes were to evaluate hemodynamic response to surgical stimulus, visual analogue scale score, time to first analgesic requirement, postoperative nausea and vomiting, postoperative opioid consumption, urethral irritation, and incidence of drug-related adverse effects. Total perioperative opioid consumption in the erector spinae plane block group was 355.0 (265.0, 485.0) μg and 240.0 (145.0, 370.0) μg in the intrathecal morphine group (P = 0.09). However, the patients in the erector spinae plane block group had significantly greater postoperative fentanyl consumption (235.0 [120.0, 345.0] μg) compared with those in the intrathecal morphine group (105.0 [30.0, 225.0] μg). There were no statistically significant differences noted for intraoperative opioid consumption, postoperative visual analogue scale score, time to first analgesic request, postoperative nausea and vomiting, and catheter irritation between the two groups. Although no statistically significant difference in intraoperative opioid consumption was seen between the erector spinae plane block and intrathecal morphine groups, postoperative opioid consumption was significantly higher in the erector spinae plane block group than in the intrathecal morphine group in patients undergoing percutaneous nephrolithotomy surgery.

363 Efficacy of Flexible Intrathecal Morphine Delivery in the Treatment of Chronic Pain

INTRODUCTION: The use of intrathecal morphine via a morphine drug delivery system has been shown as a promising alternative to the treatment of chronic pain. These programmable devices can deliver morphine via simple or flexible programs. Simple programs release morphine continuously at the same rate over a 24-hour period, whereas flexible programs are optimized to release different dosages at different times. METHODS: Patients were enrolled at St. James Mercy Hospital, University of Rochester, New York from February 2016 to February 2020. An out-patient intrathecal morphine trial was performed by injecting a single dose of 0.1-0.3 mg of preservative free morphine in the lumbar intrathecal space. Following at least 60% reduction in pain compared to baseline, a permanent intrathecal catheter and morphine pump were implanted. The drug delivery system was programmed to deliver morphine doses in a simple continuous or flexible mode. Follow up visits occurred between 12 and 60 months, and the efficacy of the flexible dosing was assessed. RESULTS: 58 patients enrolled (34 female, 24 male, median age 59), 46 patients were on flexible dose morphine and 12 were on simple dose morphine. Statistical analysis found a significant difference in pain reduction between the two groups (p &lt; 0.01). The flexible sample had a mean reduction in pain of 8.72 and the simple sample had a mean reduction in pain of 8.17 out of 10 points on the 0-10 pain scale. There were no infections or complications present in the study. CONCLUSION: While both flexible and simple program intrathecal morphine drug delivery system proved effective in reducing chronic pain, flexible programs were significantly more effective. A future multi-center study with a larger sample size is desired.

Neuraxial administration of morphine combined with lidocaine induces regional antinociception in inland bearded dragons (Pogona vitticeps).

To assess the antinociceptive efficacy and safety of neuraxial morphine in inland bearded dragons (Pogona vitticeps). 10 healthy adult bearded dragons. Animals were sedated with alfaxalone (15 mg/kg) SC prior to neuraxial injections. In a randomized, blinded, placebo-controlled, crossover design, animals received preservative-free morphine (0.5 mg/kg) combined with lidocaine (2 mg/kg) or lidocaine (2 mg/kg) only (control treatment). For both treatments, saline (0.9% NaCl) solution was used for dilution to a total volume of 0.3 mL/kg. If the initial injection did not result in motor block of the pelvic limbs or cloaca relaxation within 10 minutes, a second injection was performed. Measurements consisted of bilateral mechanical stimulation of the limbs and at 25%, 50%, and 75% of the trunk's length as well as cloacal tone to assess spread and duration of motor block. Pelvic limb withdrawal latencies in response to a thermal noxious stimulus were measured over a 48-hour period to assess antinociception. Success rate following the first injection was 90% (18/20 injections) and increased to 100% following a second injection. Motor block occurred within 5 minutes with both treatments. Pelvic limb withdrawal latencies were significantly prolonged following neuraxial morphine versus control treatment for at least 12 hours after injection. By 24 hours, no effect of morphine on pelvic limb latencies was detectable. These results demonstrated that neuraxial administration of morphine results in regional antinociceptive effects for at least 12 hours and has no clinically relevant adverse effects in healthy bearded dragons. This technique has potential for providing regional analgesia in this species.

Addition of intrathecal atropine for prevention of postoperative nausea and vomiting in patients received intrathecal bupivacaine / morphine in lower limb surgeries

Abstract Background Intrathecal opioids administration is an attractive analgesic technique since the opioids is injected directly into the cerebrospinal fluid providing safe and effective postoperative analgesia for up to 24 hours. The most common adverse effects after intrathecal morphine are postoperative nausea, vomiting and pruritus. We evaluated the effect of intrathecal atropine on prevention of postoperative nausea and vomiting in patients receiving intrathecal hyperbaric bupivacaine and morphine in lower limb surgeries and on its effect on duration of postoperative analgesia. Methods 80 patients undergoing lower limb surgeries under spinal anesthesia were randomized into two groups. BM group Received spinal anesthesia with 15 mg of 0.5% hyperbaric bupivacaine (3ml) + 200 mcg of preservative-free morphine sulphate (0.2ml) + Normal saline (0.1ml). BMA group received spinal anesthesia with 15 mg of 0.5% hyperbaric bupivacaine (3ml) + 200 mcg of preservative-free morphine sulphate (0.2ml) + 100 mcg preservative-free atropine sulphate (0.1ml). Follow-up of both nausea and vomiting episodes was done during the first 24 hours postoperatively. Results Nausea and vomiting were noticed in 17 patients (42.5%) in group BM and 7 patients (17.5%) in group BMA, with significant differences (p = 0.015). As regards postoperative analgesia, there was no significant differences between BM and BMA group. Conclusions Intrathecal atropine has antiemetic effect after spinal anesthesia using bupivacaine and morphine for lower limb surgeries without affecting postoperative analgesia.

P.69 Evaluating the introduction of intrathecal morphine for caesarean section

Introduction: Due to ongoing supply issues with diamorphine,and, given the demonstrated safety profile of using central neuraxial morphine in obstetric patients, [1] Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg. 2013; 117:1368-70. Google Scholar it was decided to replace diamorphine with preservative free morphine for procedures in labour theatre. We evaluated whether this change had impacted on patients undergoing caesarean section, particularly with respect to analgesia requirements and occurrence of side effects.

Comparative study of efficacy of palonosetron, dexamethasone and glycopyrrolate in prevention of postoperative nausea and vomiting in patients undergoing lower abdominal surgeries under spinal anesthesia using bupivacaine with morphine

Introduction: Incidence of post-operative nausea vomiting (PONV) after spinal anesthesia is 21%, which increases to 50% when we add opioid (morphine) adjuvant intrathecally for better analgesia. This study is oriented to search a remedy for this commonest postoperative complication and to compare the efficacy of intravenous Palonosetron, Dexamethasone and Glycopyrrolate given preoperatively in prevention of PONV with intrathecal hyperbaric bupivacaine with morphine, in lower abdominal surgeries. Methods: After Ethical committee clearance, Informed written consent was obtained from 90 ASAI or II patients, between ages 18 and 65 years undergoing surgery under spinal anaesthesia and randomized into three groups to receive either injection Palonosetron 0.075 mg (Group P), injection Dexamethasone 8mg (Group D) or injection Glycopyrrolate 0.2mg (Group G) 15 minutes prior to spinal anesthesia with injection bupivacaine 0.5% hyperbaric 15mg with 100 micrograms preservative free morphine and observed for complete responders, number of episodes of vomiting post operatively over 48 hrs. Pain and sedation assessed by Visual analogue score & Ramsey Sedation Scale respectively. Injection ondansetron 4mg is used as rescue drug. Results: Demographic data and hemodynamic variables were similar in all the groups. The incidence of PONV in Palonosetron and Glycopyrrolate group was13.3 % & in Dexamethasone group was16.7% with p value 0.6 which was similar. Conclusion: The efficacy of premedication with i.v. Dexamethasone or Glycopyrrolate in lower abdominal surgeries in prevention of PONV was comparable with Palonosetron.

Comparative study of efficacy of intravenous dexamethasone and glycopyrrolate in prevention of PONV with intrathecal bupivacaine with morphine, in lower abdominal surgeries: A prospective randomised double blind study

Introduction: Intrathecal Morphine as adjuvant can provide safe and effective post-operative analgesia for up to 24 hours. Incidence of post-operative nausea vomiting (PONV) after spinal anesthesia is 21%, which increases to 50% when we add opioid (morphine) adjuvant. This study is oriented to search a remedy for PONV and to compare the efficacy of intravenous Dexamethasone and Glycopyrrolate given preoperatively in prevention of PONV with intrathecal hyperbaric bupivacaine with morphine, in lower abdominal surgeries. Methods: After Ethical committee clearance, Informed written consent was obtained from 60 ASA I or II patients, between ages 18 and 65 years undergoing surgery under spinal anaesthesia and randomized into two groups to receive either injection Dexamethasone 8 mg (Group D) or injection Glycopyrrolate 0.2 mg (Group G) 15 minutes prior to spinal anesthesia with injection bupivacaine 0.5% hyperbaric 15 mg with 100 micrograms preservative free morphine and observed for complete responders, number of episodes of vomiting post operatively over 48 hrs. Pain and sedation assessed by Visual analogue score & Ramsey Sedation Scale respectively. Injection ondansetron 4 mg is used as rescue drug. Results: Demographic data and hemodynamic variables were similar in all the groups. The incidence of PONV in Glycopyrrolate group was 16% & in Dexamethasone group was 12% with p value 0.5 which was similar. Conclusion: The efficacy of premedication with i.v. Dexamethasone or Glycopyrrolate in lower abdominal surgeries in prevention of PONV was comparable.

Intrathecal Morphine Versus Intrathecal Hydromorphone for Analgesia After Cesarean Delivery: A Randomized Clinical Trial

(Anesthesiology. 2020;132:1382–1391) The effectiveness of intrathecal morphine for postcesarean analgesia is widely established, and is used throughout the United States and across the world. However, drug shortages have affected the supply of preservative-free morphine throughout the United States, leading to the exploration of alternative analgesic options. This study aimed to compare both the effectiveness and side effects of intrathecal morphine when compared with intrathecal hydromorphone. The authors hypothesized that equipotent doses would yield a superior result for intrathecal morphine following a 24-hour period.

Short-term efficacy of epidural pain management in dogs undergoing cystoscopy.

BackgroundThe effects of epidural anesthesia in dogs undergoing cystoscopy are unknown.ObjectiveTo investigate the effect of epidural analgesia on postcystoscopy pain in dogs.AnimalsTwenty‐six dogs undergoing routine cystoscopy for lower urinary tract disease.MethodsProspective, randomized, blinded observational study. Dogs were assigned either to a treatment group that received epidural anesthesia (preservative free morphine sulfate, 0.09 mg/kg; 1% ropivacaine, 0.2 mg/kg; total volume delivered, 1 mL/4.5 kg of body weight to a maximum of 10 mL; n = 9) or to a nonepidural control group (n = 13). Vital signs were monitored for 24 hours, and sedation and pain scores, behavioral assessments, and presence or absence of complications was evaluated for 5 days postprocedure.ResultsAll dogs tolerated the epidural without complications. Four dogs were removed from the study because of status unblinding, lack of patient cooperation, or incomplete follow‐up. No significant differences were noted in postprocedural pain scores in dogs that received epidural analgesia. Significant differences in postprocedural pain scores were noted in the nonepidural control group. No significant differences were noted in vital signs, behavioral assessments, or the proportion of dogs with a 50% increase in pain scores between the epidural and nonepidural groups.Conclusions and Clinical ImportanceEpidural anesthesia was well‐tolerated. Dogs not receiving the epidural had poor postprocedural pain control. A consistent benefit for the epidural vs nonepidural group could not be identified. Additional studies are required to better assess the impact and efficacy of epidural anesthesia for cystoscopic procedures.

686 Impact of neuraxial preservative-free morphine (i.e. duramorph) on post-cesarean opioid consumption

To examine the association between neuraxial preservative-free morphine (PFM) (i.e. duramorph) and postoperative opioid consumption following cesarean delivery (CD). A retrospective cohort study of individuals delivered by CD between 2014 and 2019 at a single academic institution. Exposure was defined as PFM neuraxial injection. The primary outcome was defined as inpatient opioid consumption 24 hours after delivery standardized to morphine milliequivalents per hour (MME/hr). Secondary outcomes included requirement of ≥ 10 mg of oxycodone per dose and rates of MME/hr consumption in the top quartile and bottom quartile of all users. Univariable and multivariable analyses were used to investigate the association between PFM and the primary and secondary outcomes, controlling for maternal sociodemographic characteristics, clinical obstetric factors, and non-opioid pain control methods in the postpartum period. Of 1620 individuals who met eligibility criteria, 1256 received PFM (78%). Individuals who received PFM were more likely to be older, white, married, have received spinal anesthesia, and have a prior CD (p<0.001 for all comparisons). Individuals who did not receive PFM were more likely to be non-Hispanic black, use tobacco, and have received general anesthesia (p<0.001 for all comparisons). In univariable analysis, the rates of primary outcome - MME/hr, were significantly lower among individuals who received PFM (97.5 ± 105 vs. 67.5 ± 120, p<0.001). After controlling for confounders, this finding did not persist (Table 1). In regard to the secondary outcomes, individuals who received PFM were less likely to require ≥ 10 mg of oxycodone at a time, (aOR 0.59, 95% CI 0.44-0.78), were more likely to be in the bottom quartile of MME/hr consumption (aOR 1.79, 95% CI 1.27-2.52), and less likely to be in the top quartile of MME/hr consumption (aOR0.69, 95% CI 0.51-0.92) (Table 1). Receipt of preservative-free morphine/duramorph was associated with reduced consumption of oxycodone per dose and with the bottom quartile of MME/hr consumption.

Single-dose intrathecal analgesia: a safe and effective method of labor analgesia for parturients in low resource areas

BackgroundEpidural analgesia is often said the gold standard of the labor analgesia. But in the areas where the availability of epidural catheters, multiparameter monitors, trained staff is scarce, we need to rethink for single-dose intrathecal analgesia as an alternate yet effective method to provide labor analgesia. The combination we chose for single-shot spinal was heavy bupivacaine 2.5 mg + fentanyl 25 μg + morphine 250 μg, so as to provide an optimal time period of analgesia and lesser need for supplemental analgesics.MethodsThe prospective open-label study was conducted on 100 parturients. Group S (N = 50) received intrathecal injection of 0.5 ml of heavy bupivacaine (2.5 mg) and 0.5 ml of fentanyl (25 μg), and 1 ml of preservative free morphine (250 μg/ml) was given (total volume of 2 ml) using 26 G Quincke spinal needle. Group C (N = 50) were managed according to the institutional protocol of programmed labor for normal vaginal delivery. The duration of analgesia, VAS score, safety and side effects, and progress of labor was noted and compared.ResultsThe progress of labor, mode of delivery, and fetal parameters was similar in both the groups. But the parturients in the group S had lower VAS score with a pain-free period of 238.96 ± 21.88 min, without any noted side effects.ConclusionSingle-dose intrathecal analgesia with heavy bupivacaine 2.5 mg + fentanyl 25 μg + morphine 250 μg can be used efficaciously covering the complete duration of labor in both primigravida and multigravida with no increase in instrumental delivery or C-section rate or other side effects.Trial registrationInstitutional Ethics Committee, Indira Gandhi Medical College, Shimla. Number: ECR/533/IST/HP/2014. Registered on 12 August 2017

Ultrasound-guided epidural nerve block in a domestic dwarf rabbit (Oryctolagus cuniculus) undergoing ovariohysterectomy

A healthy 2-year-old entire female domestic dwarf rabbit (Oryctolagus cuniculus) was referred for ovariohysterectomy. The premedication included subcutaneous 3 mg/kg ketamine, 1 mg/kg midazolam and 0.05 mg/kg medetomidine. A CT...

Analgesic effect of topical and subconjunctival morphine in dogs after phacoemulsification: A pilot study.

To determine the efficacy of a single treatment of topical and subconjunctival 0.1% preservative-free morphine sulfate (PFMS) in providing analgesia following phacoemulsification in dogs. Ten diabetic and ten non-diabetic client-owned dogs treated with bilateral phacoemulsification. A prospective, randomized, masked, negative-controlled clinical trial was performed. All dogs received topical (0.2mL) and subconjunctival (0.1mL) 0.1% PFMS in one eye following phacoemulsification. The other eye received an equal volume and mode of administration of balanced salt solution (BSS). Ophthalmic examination, blinking rates, tearing, conjunctival hyperemia, aqueous flare, and central corneal esthesiometry (CCE) were evaluated in all eyes 1day prior to surgery and at 4, 24, and 48hours after surgery. Complete physical examination, ocular ultrasound, electroretinogram, hemogram, and serum biochemistry panel were performed in all dogs prior to phacoemulsification. All dogs received the standard of care treatment before and after surgery, including uniform anesthetic protocol. Baseline ophthalmic exams were unremarkable, except for the presence of cataracts, in all dogs. The mean CCE (±SD) at 4hours post-operatively was 1.76±1.27g/mm2 and 1.85±1.5g/mm2 for the negative control and PFMS groups, respectively. There were no statistical differences in blepharospasm, conjunctival hyperemia, tearing, aqueous flare, blinking rates, CCE, or intraocular pressure (IOP) between the treatment groups for any of the time points for the non-diabetic and diabetic dogs, or for all dogs combined (P>.05). Topical and subconjunctival 0.1% PFMS did not affect the evaluated parameters after phacoemulsification in the study dogs at the timepoints assessed.

The analgesic efficacy of IV acetaminophen for acute postoperative pain in C-section patients: a randomized, double-blind, placebo-controlled study

Background The rate of cesarean delivery is on the rise in the USA. Satisfactory postoperative analgesia remains a top priority for cesarean delivery. Multimodal analgesia with a reduction in opioid consumption and improvement in patient satisfaction is a goal for anesthesiologists caring for this patient population. Our study sought to assess whether IV acetaminophen in four divided doses over 24 h decreased pain scores and opioid requirements in patients undergoing cesarean delivery with neuraxial anesthesia. Methods 66 patients undergoing elective cesarean delivery under spinal anesthesia with hyperbaric bupivacaine 12 mg, fentanyl 10 µg, and preservative-free morphine 150 µg were randomized to receive either IV acetaminophen or IV placebo for four consecutive doses in the first 24 h postoperatively. The need for rescue medication using morphine equivalence, pain scores, patient satisfaction, and side effects were assessed by a blinded researcher in the first 24 and 48 h postoperatively. Results There was no difference in opioid requirements in the acetaminophen versus placebo group, 44.32 ± 23 mg versus 47.59 ± 28 mg (p = .607), respectively at 24 h. There was also no difference at 48 h, 57.95 ± 20 mg versus 56.59 ± 22 mg (p = .795). Postoperative pain scores, patient satisfaction, and adverse events were similar in both groups as well. Conclusions The results of this study failed to demonstrate any additional benefits of administering multiple doses of IV acetaminophen for treating postoperative pain in patients who have undergone CS surgery and receiving intra-thecal morphine as part of their anesthesia and analgesia. Trial Registry number NCT02069184

Comparison of Morphine and Clonidine as Adjuncts to Bupivacaine in Spinal Anaesthesia- A Double Blind Randomised Control Trial

Introduction: Spinal anaesthesia is a preferred choice for infraumbilical surgery. Various drugs have been added intrathecally to augment analgesia in the postoperative period. Morphine an opiate was among the first to be introduced. More recently the alpha-2 agonist Clonidine. Aim: To compare Clonidine and Morphine as adjuncts to bupivacaine in spinal anaesthesia on the quality of the block, the duration of postoperative analgesia, haemodynamic changes and complication. Materials and Methods: In this randomised double blind controlled study, one hundred patients between age 20-40 years of age and American Society of Anaesthesiologists (ASA) physical status 1 and 2 undergoing lower limb Orthopaedic procedures were studied to compare the effect of preservative free morphine (100 mcg) (Group BM) and clonidine (30 mcg) (Group BC) as an adjunct to 0.5% bupivacaine in spinal anaesthesia. Group BM received a mixture of 2.6 mL (13 mg) of hyperbaric bupivacaine (0.5%) with 0.1 mL of preservative free Morphine and 0.1 mL 0.9% saline. Group BC received a mixture of 2.6 mL (13 mg) of hyperbaric bupivacaine (0.5%) with 0.2 mL of clonidine (30 mcg).Total volume of solution in both the groups was 2.8 mL. The groups were compared for the onset and duration of sensory and motor blockade. Duration of analgesia, Sedation, Haemodynamic variations viz., Pulse rate, blood pressure and complications. Data obtained was analysed using Student t-test, Pearson chi-square test and ANOVA as appropriate. Results: Onset of sensory block was faster and duration of the sensory as well as motor block was more after addition of Clonidine (30 μg) to bupivacaine in spinal anaesthesia. The duration of postoperative analgesia was significantly prolonged to 10-13 hours in patients receiving Bupivacaine and morphine combination as compared to 6-8 hours noted in patients receiving Bupivacaine and Clonidine only. Incidence of hypotension, bradycardia, shivering, nausea and vomiting was not statistically significant. None of the patients in both groups showed any other side effects like respiratory depression, hypoxia, excessive sedation or any other spinal consequences. Conclusion: Clonidine improves the quality of spinal anaesthesia in terms of faster onset of sensory block and longer duration of sensory as well as motor block compared to morphine, when added as an adjunct. However, the duration of postoperative analgesia was prolonged more with the addition of Morphine compared to Clonidine.

Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study.

Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool. Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis. A total of 3876 patients were included. The median age was 4.4years (range 1day to 20years), and the median weight was 20.3kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good." This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.