Side Effects Of Epidural Morphine Research Articles

Pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia: a case control study

BackgroundPruritus is one of the most common side effects of epidural morphine administered for post-surgery analgesia, and pregnant women tend to be highly susceptible. The relative contributions of morphine concentration, local anesthetics, and level of pain to pruritus after epidural morphine for post-cesarean delivery analgesia remain unclear. Accordingly, the present study aimed to identify risk factors for pruritus after continuous administration of epidural morphine for post-cesarean delivery analgesia.MethodsThis case control study was based on routinely collected clinical data. Participants included women who had undergone cesarean section and adopted a patient-controlled analgesia pump for postoperative analgesia. A series of logistic regression analyses were performed. Interaction terms were added to explore the moderation effects of combined local anesthetics and pain level on associations between morphine concentration and pruritus. Robustness of the results was checked through sensitivity analysis using propensity scores matching approach.ResultsHigher morphine concentration, assisted reproductive treatment, and multipara and cesarean section history were significantly more prevalent in the pruritus group than in the control group. The probabilities of pruritus at morphine concentrations of 10, 15, 20, 25, 30 and 40 μg/mL increased sequentially from 0.05, 0.1, 0.2, 0.35, 0.54 to 0.84, respectively. The trend remained steep in the ropivacaine stratum and became flatter when combined with levobupivacaine. At mild pain combined with levobupivacaine, the incidence of pruritus increased from 0.33 (95% confidence interval [CI] 0.1–0.68) in the 10 μg/mL morphine group to 0.48 (95% CI 0.1–0.88) in the 40 μg/mL morphine group. In the stratum of moderate pain combined with levobupivacaine, the incidence increased from 0.4 (95% CI 0.04–0.92) to 0.56 (95% CI 0.03–0.98). The results in the sensitivity analysis were in consistent with above findings.ConclusionsHigher concentrations of morphine, multipara, and assisted reproductive treatment were factors associated with a higher probability of pruritus. Pain level or combined local anesthetics could moderate the association between morphine concentration and pruritus.

The post-operative analgesic effects of epidurally administered morphine and transdermal fentanyl patch after ovariohysterectomy in dogs

ObjectiveTo investigate the analgesic and side effects of epidural morphine or a fentanyl patch after ovariohysterectomy in dogs. Study designProspective, randomized clinical study. AnimalsTwenty female mongrel dogs undergoing ovariohysterectomy. MethodsThe dogs were allocated to one of two groups: epidural morphine or transdermal fentanyl patch. Anaesthesia was induced with propofol and maintained with isoflurane. Morphine (0.1 mg kg−1) was administered epidurally in the epidural morphine group and a transdermal fentanyl patch was applied 24 hours before the operation in the fentanyl patch group.The heart rate, respiratory rate, body temperature, plasma cortisol concentration, and sedation and analgesia scores were recorded during the 24 hour post-operative period. Adverse effects such as vomiting, anorexia, skin reactions, urinary retention, and time to start licking the surgical site were also recorded. p < 0.05 was considered significant. Statistical analyses utilized anova for repeated measures, Friedman tests, Mann-Whitney U-tests and independent sample t-tests as relevant. ResultsPain scores were lower in the epidural group than in the fentanyl group at all post-operative times. The dogs in the epidural morphine group were calm and relaxed, whereas discomfort and vocalization were recorded in the fentanyl patch group. The sedation scores were higher in the fentanyl patch group throughout the 12 hour period. Salivation and anorexia lasted longer in the fentanyl patch group than in the epidural morphine group. Plasma cortisol concentrations were high in the early post-operative period in both groups. The fentanyl patch group had higher cortisol concentrations than the epidural morphine group. Slight erythema was recorded in two dogs when the patches were removed. Conclusion and clinical relevanceEpidurally administered morphine provided better analgesia and caused fewer adverse effects than the fentanyl patch after ovariohysterectomy in dogs.

The Correlation between Genetic Polymorphism ofOPRM1(A118G) andMDR1(C3435T) with Analgesia and the Adverse Effects by Epidural Morphine

Background: The effect of a single nucleotide polymorphism (SNP) of the μ-opioid receptor gene at nucleotide position 118 (OPRM1:118A ＞ G) and the MDR1 gene (exon 26: C3435T) have an influence on the interindividual variability of clinical opioid pain therapy. This study aims to evaluate the correlation among pain control and side effects of epidural morphine and these pharmacogenetic modulators. Methods: 194 patients who were undergoing abdominal surgery were included in the study. Patients received a morphine 2 mg bolus and 2 mg/day via epidural route. The VAS score and opioid side effects were checked at postoperative 6, 24 and 48 hr. Patients were genotyped for the known SNPs of the OPRM1 and MDR1. Results: For the SNP of OPRM1, the mutated genotype frequency (homo-wild, heterozygous, and homo-mutants) were 36.8, 47.9 and 15.3%, respectively, and the mutated genotype frequencies for the MDR1 SNP were 46.7, 40.2 and 13.1%, respectively. There were no significant differences in the VAS scores and side effects among the three groups of OPRM1 and MDR1. Yet carriers of the mutated allele 3435 TT, CT of the MDR1 gene showed marginally greater significant sedation effects than did non-carriers (CC) (P = 0.065, the OR was 1.78, 95% CI 0.98-3.24, P = 0.059) and also a lower incidence of analgesic usage (P =0.058). Conclusions: In our data there was a large difference in OPRM1 SNP allele frequency for the Korean population compared to other populations. The SNP of OPRM1 and MDR1 genes did not have significant altered clinical morphine analgesia and side effects via the epidural route. But the SNP of MDR1 gene is more sensitive genetic predictor of the clinical side effects (especially for sedation) and analgesic effects by opioid. (Korean J Anesthesiol 2007; 52: 16~22)

Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia

Study Objective The purpose of this study is to assess the independent effect of epidural chloroprocaine on morphine used for pain relief after cesarean delivery. Design We used a randomized, double blind, placebo-controlled trial. Setting The study took place at the labor and delivery ward of an academic medical center. Patients Forty pregnant women undergoing elective cesarean delivery under spinal-epidural anesthesia. Interventions Patients were randomized to receive either 150 mg of 3% chloroprocaine or placebo, followed by 3 mg of epidural morphine. Measurements The primary outcome for this investigation was the duration of pain relief after morphine administration, defined as the time at first use of supplemental opioids for analgesia. Secondary outcomes included pain scores, blood pressure, heart rate, respiratory rate, anesthetic sensory level, nausea and vomiting, pruritus, supplemental use of nonsteroidal anti-inflammatory medications, and satisfaction. Main Results The groups were similar in demographics and duration of spinal anesthesia. Using Kaplan-Meier survival analysis of the duration of morphine analgesia, we found no difference between the groups (chloroprocaine, 1191 minutes, vs placebo, 1267 minutes, P = 0.52). There was no difference in pain scores or the need for supplemental analgesics. Side effects of epidural morphine were similar between the groups. Conclusions We found that epidural chloroprocaine did not reduce the duration or effectiveness of postoperative analgesia from epidural morphine.

Is intentional unilateral epidural catheterization reliable on pain management?

Aims: In this study we aimed to compare the efficacy of intentionally directed catheter towards the operative side with midline approach and two different doses of morphine for postoperative pain relief in unilateral epidural catheterization. Method: After obtaining approval of the ethical committee and written informed consent, 36 patients aged 18–65 years, with ASA physical status I-II, scheduled for elective open reduction and osteosynthesis for malleolar fracture were included in this study. The patients were randomly divided into three groups. A Tuohy needle was advanced at a 5° to 10° angle from midline and then the bevel of the needle was rotated 90° towards the operative side in Group I and Group II. In Group III, the needle was advanced by midline approach. An epidural catheter was inserted and 4 ml of 2% lidocaine was injected through the catheter as a test dose. 20 min later, 2 mg morphine in Groups I and III and 1 mg of morphine in Group II were administered through the catheter. The infusion started with 0.2 mg hr−1 in all groups with an epidural patient controlled analgesia device. Cardiorespiratory variables and pain scores were assessed postoperatively. Side effects of morphine, total morphine consumption, the number of the incremental doses asked and received were recorded postoperatively. Statistical analysis was performed by analysis of variance, paired t-test, and chi-squared test. Results: Total morphine consumption and incidence of urinary retention were lower in Group II than in Groups I and III (p ≤ 0.01). Conclusion: Our study shows that unilateral epidural catheterization with 1 mg morphine produces adequate analgesia for postoperative pain and also reduces side effects of epidural morphine.

A Comparison of the Analgesic and Side Effects of Continuous Epidural Morphine and Nalbuphine after a Cesarean Section

Background: Epidural morphine has been commonly used to provide postoperative pain relief, but it has many side effects such as pruritus, nausea, vomiting, and respiratory depression. The purpose of this study was to evaluate the analgesic efficacy and side effects of epidural morphine compared with epidural nalbuphine. Methods: Fifty nine patients were randomly divided into 2 groups. For group M (n = 30), a bolus of 7 ml of saline and 2 mg of morphine were administered and for group N (n = 29), a bolus of 7 ml of saline and 4 mg of nalbuphine were administered. Continuous epidural analgesia was induced with morphine 4 mg, 0.5% bupivacaine 20 ml, 2% lidocaine 20 ml and normal saline 60 ml by a 2day infuser in group M, and with nalbuphine 20 mg, 0.5% bupivacaine 20 ml, 2% lidocaine 20 ml and normal saline 58 ml by a 2day infuser in group N. We compared the analgesic effect and side effects of the two groups for 48 hours. Results: No significant hemodynamic changes were seen in any of the groups. The analgesic effects were good in the two groups (mean VAS < 3.0). The patients of group M had lower pain scores continually compared with group N and pain scores were statistically significant at 6, 12 and 24 hours. However, side effects occurred more frequently in group M. Conclusions: These results suggest that an adequate dosage of epidural morphine provides good analgesic effects and reduces the occurrence of side effects. (Korean J Anesthesiol 2001; 41: 59∼65) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Droperidol and the Side Effects of Epidural Morphine After Cesarean Section

Epidural morphine produces analgesia with a high incidence of side effects that include pruritus, nausea, and vomiting.This study investigated whether epidural or IV droperidol could alleviate these symptoms. In a prospective, double-blind, randomized, controlled trial, 97 pregnant women undergoing cesarean section were randomly assigned to three groups. All received standard continuous epidural anesthesia. After delivery, each received 5 mg of epidural morphine with either no droperidol injection, 2.5 mg of epidural droperidol, or 2.5 mg of IV droperidol. The incidence, onset, duration, and severity of pruritus; the onset and severity of pain; and satisfaction were similar for each group, but the incidence and severity of nausea and vomiting was lower in the group that received IV droperidol (P < 0.01). Sedation was minimal throughout the study. Thus, epidural droperidol failed to alleviate the side effects caused by epidural morphine, but IV droperidol reduced both the incidence and severity of nausea and vomiting. These results suggest that droperidol acts systemically to counter the effects of epidural morphine but that it is not entirely effective. Implications: A single dose of epidural morphine provides long-lasting pain relief for women who have undergone cesarean section, but it has some troublesome side effects (itching, nausea, vomiting). We performed a prospective, randomized, controlled trial in 97 such women to study whether droperidol could reduce these side effects. We found that IV droperidol reduced nausea and vomiting but did not prevent itching, and that epidural droperidol failed to prevent all side effects. (Anesth Analg 1998;86:532-7)

Comparison of epidural morphine and oxycodone for pain after abdominal surgery

To compare the efficacy and side effects of epidural morphine and oxycodone for pain following major abdominal surgery. Randomized, double-blind study. 4th Department of Surgery, Helsinki University Central Hospital. 44 adult ASA physical status I, II, and III patients scheduled for elective major abdominal surgery. Thirty-three patients were allocated randomly to one of two epidural groups and 11 patients received oxycodone intravenously (IV). The two epidural groups received either morphine (bolus 0.015 mg/kg followed by an infusion 0.003 mg/kg/hr) or oxycodone (bolus 0.15 mg/kg followed by an infusion 0.03 mg/kg/hr) before induction of standardized anesthesia and for 24 hours thereafter. A third group of patients was given the same dose of IV oxycodone as in the epidural group, serving as an open control group for epidural oxycodone. Blood samples were drawn for plasma opioid concentrations. Postoperatively, pain (at rest and during coughing), nausea, pruritus, sedation, respiratory rate, and hemodynamics were recorded until the end of the infusions. The epidural dose ratio between morphine and oxycodone was 1:8.4 to 9.8 to provide similar analgesia. Side effects occurred similarly in the three groups. Mild respiratory depression was seen in all groups, especially in the IV oxycodone group. In all groups, hemodynamic variables remained within normal limits. In the dosages reported, oxycodone can be used epidurally for acute post-operative pain. The analgesic effect was as good as that of epidural morphine.

Altering Epidural Morphine Side Effects with Butorphanol in Children

To the Editor: The conclusions by Bailey et al. [1] are not supported by the results presented in their prospective study comparing bolus administration of epidural butorphanol, intravenous butorphanol, or placebo given simultaneously with an epidural morphine bolus after major abdominal or thoracic surgery in pediatric patients. The abstract concludes that butorphanol has little or no effect on the side effects of epidural morphine. Yet the findings of Bailey et al. show that pruritus is actually decreased with epidural butorphanol (P <or=to0.05). Regarding other side effects: respiratory depression did not occur in any group, perhaps because the number of patients studied was too small; urinary retention defies accurate analysis since 53 of 60 patients (88%) had a urinary catheter in place; and vomiting cannot be accurately assessed since 37 of 60 patients (62%) had nasogastric tubes in place. Sedation was significantly increased only when the epidural butorphanol group was compared with the saline/morphine group at 3 h postoperatively. (The sedation effect was seen as beneficial to the patient by Bailey et al. and was associated with better analgesia.) The conclusion of the article states that epidural butorphanol 30 micro gram/kg does not significantly reduce the overall incidence of side effects of 60 micro gram/kg of epidural morphine postoperatively. In reality, the only side effects that warranted this overall conclusion were pruritus and sedation, and both were altered in a desirable manner when epidural butorphanol/morphine was given and compared with the other two groups. Even though Bailey et al. mention these positive aspects of epidural butorphanol, the manner in which the abstract and text conclusions are written is biased to give one the impression that epidural butorphanol at 30 micro gram/kg in combination with 60 micro gram/kg morphine is ineffective in modifying side effects in a desirable way. C. David Lawhorn, MD, FCCP Michael L. Schmitz, MD Division of Pediatric Anesthesia, Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR 72202-3591

Altering Epidural Morphine Side Effects with Butorphanol in Children

In Response: We thank Drs. Lawhorn and Schmitz for their interest and close perusal of our article. We are in agreement that epidural butorphanol offers benefits to some children receiving epidural morphine. Our hypothesis was that an agonist/antagonist would prevent undesirable side effects of epidural morphine. Our data did not support this. The actual incidence of pruritis, vomiting, urinary retention, and respiratory depression was not significantly different among the three groups. The numbers of patients without nasogastric tubes and urinary catheters were small; the fact that these patients experienced vomiting and urinary retention after butorphanol supports our contention that, with this dose, side effects are not prevented. The overall incidence of pruritis was not prevented, only reduced in its severity. We agree that this has its merits. The sedation is not a side effect of the morphine. This is a well-recognized effect of butorphanol. We agree that this is advantageous in some children, but our conclusions addressed attempting to reduce the epidural morphine side effects. We do not feel that we were biased in our conclusions. Correctly stated, the addition of butorphanol did not decrease the incidence of side effects attributed to epidural morphine. It did, however, add a beneficial side effect of its own, sedation! Ann Bailey, MD Robert D. Valley, MD Eugene B. Freid, MD Pauletta Calhoun, RN Department of Anesthesiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7010

Effect of Prior Anesthetic Solution on Epidural Morphine Analgesia

The quality and duration of analgesia and incidence of side effects following epidurally administered morphine after cesarean section are highly variable. Two suggested sources of this variability are prior use of epinephrine-containing solutions, which may enhance both analgesia and side effects of morphine, and prior use of 2-chloroprocaine, which may inhibit epidural morphine analgesia. To examine these proposed sources of this variability we performed two studies. In the first, designed to test epinephrine's effect, 30 women underwent testing for epidural catheter tip location with injection of 2-chloroprocaine, followed by either 0.5% bupivacaine alone or 0.5% bupivacaine with 5 micrograms/mL epinephrine for epidural anesthesia. Inclusion of epinephrine with bupivacaine decreased the bupivacaine dose needed to achieve a T-4 sensory block by 24% (P less than 0.05), but did not alter analgesic duration or the incidence of side effects of epidural morphine (5 mg). In the second study, designed to test the effect of 2-chloroprocaine, 30 women received 7 mL of either 2% 2-chloroprocaine or lidocaine for epidural catheter testing, followed by 0.5% bupivacaine for epidural anesthesia. Compared to lidocaine testing, 2-chloroprocaine decreased the duration of epidural morphine analgesia (median 16 h with 2-chloroprocaine vs 24 h with lidocaine; P less than 0.05) without altering the incidence of side effects. The authors conclude that addition of epinephrine to local anesthetic does not increase the incidence of side effects or the analgesic effect from epidurally administered morphine. 2-Chloroprocaine, even when administered in small doses remote to the time of morphine injection, interferes with the duration of epidural morphine analgesia.

Comparative side effects of epidural morphine and meperidine

A thin isotopic 94Zr target of thickness 520μg/cm2 has been prepared for recoil distance Doppler shift method (RDM) lifetime measurement by using an electron beam deposition method on tantalum backing of 3.5 mg/cm2 thickness at Inter University Accelerator Center (IUAC), New Delhi. To meet the special requirement of smoothness of surface for RDM lifetime measurement and also to protect the outer layer of 94Zr from peeling off, a very thin layer of gold has been evaporated on a 94Zr target on a specially designed substrate holder. In all, 143 mg of 99.6% enriched 94Zr target material was utilized for the fabrication of 94Zr targets. The target has been successfully used in a recent RDM lifetime measurement experiment at IUAC.

Reduction of side-effects of epidural morphine with epidural droperidol

Reduction of side-effects of epidural morphine with epidural droperidol

An Experience with Epidural Morphine in Lumbar Surgery Patients

A chart review of the patients who received epidural morphine for lumbar surgery during the first year of implementation of the procedure was conducted. This article reviews the pharmacology and side effects of epidural morphine, describes the procedure of administering epidural morphine, discusses side effects and technical problems encountered, and presents implications for nursing practice.