Use Of Morphine Sulfate Research Articles

The Effect of Tizanidine on Postoperative Pain Management After Lumbar Fusion Surgery

Abstract Lumbar fusion is one of the most commonly used surgical procedures to improve the pain and instability of the spinal vertebrae. After surgery, patients experience varying degrees of pain. The aim of this study was to determine the effect of tizanidine for the management of postoperative pain after lumbar spinal fusion surgery. This randomized clinical trial study was performed on 50 patients who were selected for spinal fusion surgery. Patients were randomly divided into two groups of 25 patients. Patients in the tizanidine and placebo groups received 4 mg oral tizanidine and placebo one hour before surgery and 24 hours after that. Severity of pain, presence of nausea, vomiting, pruritus, headache, vertigo, xerostomia, somnolence, bradycardia and excess opiate in the two groups were evaluated and recorded prior to exit from recovery and 2, 4, 6, 12, 24 and 48 hours after surgery. Data were analyzed by SPSS software version 24. There was a significant difference in pain score in tizanidine group at 24 and 48 hours after surgery compared with placebo (P <0.005). In the control group, the use of morphine sulfate was more than the tizanidine group. There was no significant difference in the incidence of side effects in the two groups (P> 0.05). Low dose tizanidine in postoperative pain management is effective without significant side effects. Due to its simpler administration, it is recommended to use for postoperative pain control after lumbar fusion surgery.

The Case | Fluctuating serum creatinine and crystals in urine

A 39-year-old woman was referred for increased serum creatinine levels. She had a surgical treatment of ureteropelvic junction obstruction 2 decades earlier, and an 18-year history of flank pain and vomiting, with daily use of morphine sulfate and acetaminophen. Persistent pain led to the discovery of a carcinoma of the left kidney treated by a partial nephrectomy 1 year before. The patient’s serum creatinine level was 65 μmol/L at that time. Over the last 6 months, her serum creatinine levels fluctuated between 99 μmol/L and 162 μmol/L.

Risk assessment of using off-label morphine sulfate in a population-based retrospective cohort of opioid-dependent patients.

Several addictovigilance studies have described the off-label use of morphine sulfate (MS) for nonchronic pain in opioid use disorder (OUD) patients as an alternative to conventional opioid substitution treatments (OSTs). This study primarily sought to compare the incidence of unintentional opioid-related overdose in the year following the prescription initiation in off-label MS users, compared to OST-maintained patients. Sequential cohorts of OUD patients who were regularly dispensed MS, buprenorphine, or methadone, between 1 April 2012 and 31 December 2014, were retrospectively identified using the French nationwide healthcare data system. The incidence of overdoses, deaths, doctor shopping, and complications of a viral, bacterial or thrombotic nature, was compared using the Cox regression method. Overall, 1075, 20834 and 9778 OUD patients without chronic-pain were included in the MS, buprenorphine, and methadone cohorts, respectively. Overdose incidence was 3.8 (P<.01 [95% confidence interval (CI): 2.1-6.8]) and 2.0 (P=.02 [95%CI: 1.1-3.6]) higher in the MS cohort vs buprenorphine and methadone, respectively. Death incidence was 9.1 (P < .01 [95%CI: 3.2-25.9]) and 3.9 (P < .01 [95%CI: 1.4-10.7]) higher in the MS cohort vs buprenorphine and methadone, respectively. The incidences of other associated risks were significantly higher in the MS group vs OSTs, except for hepatitis C viral infection and thrombotic complications. This first French comprehensive nationwide study reveals increasing overdose, death, bacterial infection, abuse and diversion risks when off-label MS is initiated as alternative to OST. These results question the relevance of prescribing MS as a safe opioid maintenance treatment, considering its health risk profile.

The contribution of morphine sulfate to the development of necrotizing enterocolitis in preterm infants: a matched casecontrol study.

Zvizdic Z, Milisic E, Jonuzi A, Terzic S, Zvizdic D. The contribution of morphine sulfate to the development of necrotizing enterocolitis in preterm infants: a matched case-control study. Turk J Pediatr 2019; 61: 513-519. The aim of the study was to determine whether morphine sulfate administration is associated with an increased risk of necrotizing enterocolitis (NEC) in preterm infants supported by mechanical ventilation due to respiratory failure. The matched case-control retrospective study was carried out at the Neonatal Intensive Care Unit (NICU) of the University Clinical Center Sarajevo, on 122 preterm infants classified into total NEC group and control group. The total NEC group was further divided into medical NEC and surgical NEC subgroups. The association between the use and duration of morphine sulfate infusion and the development of NEC was evaluated in both unadjusted and adjusted analysis. Preterm infants who developed NEC were on mechanical ventilation more frequently compared to premature infants without signs of NEC (Mann- Whitney U test; p=0.0031). A positive correlation between the frequency of receiving morphine sulfate and the development of NEC was observed (Chi square test of independence; p=0.0001). The risk of NEC in preterm infants was increased by the use of morphine sulfate. Validation of this observation in other populations is warranted.

Adult emergency department patients with sickle cell pain crisis: results from a quality improvement learning collaborative model to improve analgesic management.

The aims of this study were to 1) estimate differences in pain management process and patient-reported outcomes, pre- and postimplementation of analgesic protocols for adults with sickle cell disease (SCD), and 2) examine the effects of site and visit frequency on changes in pain scores and time to analgesic. A multicenter, prospective, longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009. All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled. Sites formed a SCD quality improvement (QI) team and implemented standard nurse-initiated emergency department (ED) analgesic protocols; outcomes were compared between study periods defined as pre- and postimplementation of protocols. Medical record review was conducted to measure time to administration of initial analgesic, opioids used, route of opioid administration, the change in pain scores from arrival to discharge (negative numbers reflect a decrease in pain scores), and the number of ED visits per individual patient during the study period at each site. On day 7 after the ED visit, a follow-up phone interview was conducted. Patients were queried about their ED pain management using a scale from 1 to 10 (1 = outstanding, 10 = worst). Descriptive statistics are used to report the results. Ordinary least-squares regression models were constructed to measure the effect of time period, site, and number of visits per patient on change in pain score. During the study period, 342 unique patients (57% female, mean ± SD age = 32 ± 11 years) were enrolled and had a total of 2,934 visits. There was no difference in time to administration of the initial analgesic between study periods. Overall, there was a significant decrease in pain scores from arrival to discharge between the pre- and postintervention study periods: the average difference in arrival to discharge pain scores (cm) was greater during the postimplementation period than during the preintervention period (-4.1 vs. -3.6, t = 2.6, p < 0.01). Site 1 had significant improvement between study periods (mean difference = -0.87, t = 2.63, p < 0.01; F = 14.3, p < 0.01). Patients with few ED visits (one to six annual visits, mean difference = -1.55, t = 2.1, p = 0.04) and those with frequent ED visits (7 to 19 annual visits, mean difference = -1.65, t = 3.52, p < 0.01) had a significant decrease in pain scores compared to patients with very frequent ED visits (>19 visits). There was an overall decrease in the use of morphine sulfate (MS) and increase in the use of hydromorphone (χ(2) = 105.67, p < 0.001) between study periods and a significant increase in the use of oral (PO) and subcutaneous (SC) routes, with a corresponding decrease in the intravenous (IV) route (χ(2) = 13.67, p < 0.001). There were no statistically significant differences in patient-reported satisfaction with the attempt to manage pain in the ED between study periods (p = 0.54). While the use of a learning collaborative and implementation of nurse-initiated analgesic protocols was not associated with improvement in time to administration of the initial analgesic, improvements in the decrease in the arrival to discharge pain score and increased use of hydromorphone and the SC route were noted in adults with SCD in the ED.

Impact of Liberalization of Protocols for the Use of Morphine Sulfate in an Urban Emergency Medical Services System

Objective. To investigate the impact of liberalization of paramedic management protocols for the use of morphine sulfate (MS). Methods. A retrospective database analysis tallied andcategorized MS use into seven conditions during two intervals—six months before (control) andsix months after (study) the protocol change. Results. In the control interval, 760 of 34,020 (2.2%) patients received MS. In the study interval, 999 of 30,320 (3.3%) received the drug, a 50% relative increase in MS use. MS use dramatically increased in two assessment categories: other painful medical conditions (19.0% vs. 2.8% of transports, relative risk [RR] 6.8, 95% confidence interval [CI] 5.2–8.9) andnontraumatic abdominal pain (9.2% vs. 1.9% of transports, RR 4.8, 95% CI 3.3–6.9). Conclusion. Liberalization of pain management protocols resulted in an appreciable increase in the use of MS only in medical categories, predominantly abdominal pain, with no apparent safety or misuse issues.

Paroxysmal Sympathetic Storms (“Diencephalic Seizures”) After Severe Diffuse Axonal Head Injury

We describe a patient with a severe traumatic head injury who exhibited paroxysmal sympathetic storms, similar to those described in "diencephalic seizures." No epileptiform activity was evident on electroencephalography, and therapeutic levels of anticonvulsants failed to alter the spells; however, use of morphine sulfate abolished them. The features of this and several previously reported cases refute the primary roles of the diencephalon and seizures in this syndrome. Rather, in the setting of already compromised autonomic neuronal integrity, subtle fluctuations in intraventricular pressure or activation of reflexes triggered from muscle mechanoreceptors or chemoreceptors during episodes of hypertonia are more likely. "Paroxysmal sympathetic storms," a more appropriate descriptive term for these phenomena, should be recognized; thus, unnecessary diagnostic evaluations can be minimized, and appropriate therapy can be initiated.

Safety of pre-hospital therapy with morphine sulfate

The safety of prehospital pharmacologic therapy has not been well studied. The authors evaluated field use of morphine sulfate (MS) in San Francisco County over a 6-month period. Paramedics assessed patients for ischemic chest pain (ICP) and/or pulmonary edema (PE), made base hospital contact, and administered 2- to 4-mg doses of intravenous morphine according to treatment protocols. Clinical assessments and patient responses to therapy were recorded by both field paramedics and emergency department (ED) physicians. Safety was evaluated by determining the (1) accuracy of paramedic field assessment, (2) appropriateness of field administration of MS, and (3) therapeutic complications. During the study period, paramedics administered MS to 84 patients. In 69 cases paramedic assessment of either ICP and/or PE corresponded to ED physician diagnosis. In five cases paramedics correctly recognized ICP but missed physical findings of PE. In this group the paramedics' assessment was considered inaccurate but the judgement to give MS was considered appropriate. In the remaining 10 cases paramedics identified ICP or PE but the ED physician diagnosed a different condition. These assessments were considered inaccurate and the management inappropriate. Therefore, overall paramedic accuracy was 77% (true rate 73% to 82%, 95% confidence interval); appropriateness of therapy was 88% (true rate 85% to 92%, 95% confidence interval); and the overall complication rate was 6% (true rate 2% to 12%, 95% confidence interval). Complications of respiratory depression or hypotension occurred in only one of the cases in which MS was inappropriately administered. The authors conclude that paramedics functioning within a system of base hospital medical direction can safely administer MS. The frequency of inappropriate MS administration and the complication rate from both erroneous and appropriate drug administration is acceptably low.

Colonic Pseudoobstruction Associated With Patient-Controlled Analgesia After Total Joint Arthroplasty

Patient-controlled analgesia (PCA) is a concept that permits patients to administer a prescribed dose of narcotic to themselves when they experience pain. Six patients developed colonic pseudoobstruction after the use of morphine sulfate administered via a PCA infuser. Early recognition and prompt treatment make this a transient, reversible illness. Treatment includes discontinuing the use of the PCA morphine, eliminating oral intake, ensuring adequate hydration and electrolyte balance, placing a nasogastric tube, rolling the patient, and closely observing for signs and symptoms of worsening colonic distention and possible rupture.

Management of life-threatening asthma in children. A preliminary study of the use of morphine in respiratory failure.

The management of five asthmatic children with respiratory failure who received controlled ventilation was facilitated by administration of morphine sulfate. Indications for the use of morphine sulfate and controlled ventilation included a depressed level of consciousness, diminished response to stimuli, agitation, increasing hypoxemia, and hypercapnea. Volume-regulated ventilators appeared to be more effective than pressure-limited respirators in these cases.

Intravenous Use of Morphine Sulfate

Abstract The intravenous use of morphine sulfate is advocated in certain cases because the desired full analgesic effect is obtained immediately from an accurately regulated and individualized dose of the drug.

Intravenous use of morphine sulfate

The intravenous use of morphine sulfate is advocated in certain cases because the desired full analgesic effect is obtained immediately from an accurately regulated and individualized dose of the drug.

Pulmonary pathology with special emphasis on bronchial asthma

1. 1. In addition to our original series—thirty-one males and seventeen females—of so-called “fatal asthma,” we wish to add an entirely new one which has been accumulated in the past five years. Each individual has been subjected to a more critical post-mortem examination because of the interest created by our original work. The new series contains four female children, twenty-five adult females, and fifty-seven adult males. None of these case records has been previously published. 2. 2. The diagnosis of “asthma” has been made on each patient and frequently has appeared on the death certificate. We have carefully reviewed the records for each patient and have indicated in the chart whether the diagnosis was at any time tenable, and if so, whether the condition was present in the last ten to twelve hours of life. A great majority of these individuals have been under our personal observation for an extended period of time. 3. 3. The series of four children seems too small a group to permit many conclusions, but they have failed entirely to demonstrate evidence of “general lymphoid hyperplasia.” 4. 4. The adult females averaged 46.2 years at death, and this figure is approximately a mid-point between the average of all cases published prior to 1937 and our series of forty-eight patients reported at that time. The duration of dyspnea in those who probably had had asthma varies from six to sixty-five years with an average of nineteen years. Protracted and rather typical asthma may leave few stigmata in the pulmonary tissue. In others, atypical asthma of relatively short duration may result in many changes in the lungs. In but seventeen of the twenty-five patients in this group did the diagnosis of bronchial asthma appear possible. 5. 5. The male patients were similarly grouped and their average age at death was 55 years, a figure considerably in excess of the average of 48 years which represents all cases reported prior to 1937, and still somewhat in excess of the average age of 52 years for our original series published at that time. Although, in general, the life expectancy of females is greater than that of males, the trend seems definitely to be the reverse in our own as well as other series of “fatal asthma.” In approximately 42 per cent (twenty-four patients) of the males, it appeared that asthma had been present at some time during life. In fact, it averaged approximately thirty years in duration. 6. 6. A wide variety of conditions simulated the clinical and pathologic findings of asthma. Among the male patients especially, these conditions may have been present in many instances for a long period before the onset of asthma. They varied from most marked interstitial emphysema in the youngest male, to extensive atelectasis of all five lobes in the third male of the series. As other examples of the predisposing conditions, one might mention distortion of the thorax and pressure from without the respiratory and pulmonary vascular tree, as well as conditions due to actual diseases of the lung and of the heart and great vessels. Pulmonary fibrosis due to a long-standing tuberculosis or pneumoconiosis, as well as proved bronchitectasis are some of the more common pulmonary conditions which have induced the symptoms of asthma. Rheumatic heart disease of long duration, as well as hypertension and syphilitic aortitis with or without aneurysm, are the more conspicuous among the circulatory dysfunctions which engender asthma, and this condition may be clinically a counterpart of true allergic asthma rather than the orthodox cardiac asthma. 7. 7. Conspicuous abnormalities of the heart and circulation rarely, if ever, result from bronchial asthma. 8. 8. A considerable number of patients in this, as well as in other series, died shortly after the use of morphine sulfate. It would appear that this drug is definitely contraindicated, although it must be admitted that several individuals were in a near moribund state when the drug was employed. 9. 9. We are in complete accord with the concise conclusion of Tuft 7 that “there is at present no known pathologic picture either gross or microscopic which may be considered characteristic or pathognomonic of asthma.”