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World Journal of Surgery

Published in:

01-09-2009

A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato-Pancreato-Biliary Surgery

Authors: Magdalena Sakowska, Elizabeth Docherty, David Linscott, Saxon Connor

Published in: World Journal of Surgery | Issue 9/2009

Abstract

Background

This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery.

Methods

All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay.

Results

During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3–11) liters vs. 5 (3–11) liters, P < 0.05) and in total (15.5 (5–48.5) liters vs. 9 (3–70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3–36) days vs. 7 (3–55) days, P < 0.01).

Conclusions

In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.

Werawatganon T, Charulusanun S (2005) Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev 25:CD004088

Ballantyne JC, Carr DB, de Ferranti S, Suarez T, Laau J, Chalmers TC et al (1998) The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trails. Anesth Analg 86:598–612PubMedCrossRef

Beattie SW, Badner NH, Choi P (2001) Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 93:853–858PubMedCrossRef

Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A et al (2000) Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 321:1493–1497PubMedCrossRef

Rigg JR, Jamrozik KM, Myles PS, Silbert BS, Peyton RJ, Parsons RW et al (2002) Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet 359:1276–1282PubMedCrossRef

Wind J, Polle SW, Fung Kon Jin PHP, Dejong MF, von Meyenfeldt DT et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809PubMedCrossRef

Conacher ID, Paes ML, Jacobson L, Phillips PD, Heaviside DW (1983) Epidural analgesia following thoracic surgery: a review of 2 years’ experience. Anaesthesia 38:546PubMed

Redai I, Emond J, Brentjens T (2004) Anaesthetic considerations during liver surgery. Surg Clin North Am 84:401–411PubMedCrossRef

Power GE, Warden B, Cooke K (2005) Changing patterns in the acute pain service: epidural versus patient-controlled analgesia. Anaesth Intensive Care 33:501–505PubMed

10.

Wang JN, Thomas LA (1979) Pain relief by intra-thecally applied morphine in man. Anesthesiology 50:149–151PubMedCrossRef

11.

Samii K, Chauvin M, Viars P (1981) Postoperative spinal analgesia with morphine. Br J Anaesth 53:817–820PubMedCrossRef

12.

Jacobson L, Chabal C, Brody MC (1988) A dose-response study of intra-thecal morphine: efficacy, duration, optimal dose, and side effects. Anesth Analg 67:1082–1088PubMedCrossRef

13.

Rawal N (2002) Incisional and intra-articular infusions. Best Practice Res Clin Anaesthesiol 16:321–343CrossRef

14.

Swart M, Sewell J, Thomas D (1997) Intra-thecal morphine for caesarean section: an assessment of pain relief, satisfaction and side-effects. Anaesthesia 52:373–377PubMedCrossRef

15.

Weber EW, Slappendel R, Gielen MJ, Dirksen R (1998) Intra-thecal addition of morphine to bupivacaine is not the cause of postoperative nausea and vomiting. Reg Anesth Pain Med 23:81–86PubMed

16.

Gwirtz KH, Young JV, Byers RS, Alley C, Levin K, Walker SG et al (1999) The safety and efficacy of intra-thecal opioid analgesia for acute postoperative pain: seven years’ experience with 5969 surgical patients at Indiana University Hospital. Anesth Analg 88:599–604PubMedCrossRef

17.

Devys JM, Mora A, Plaud B, Jayr C, Laplanche A, Raynard B, Lasser P, Debaene B (2003) Intra-thecal + PCA morphine improves analgesia during the first 24 hr after major abdominal surgery compared to PCA alone. Can J Anaesth 50:355–361PubMedCrossRef

18.

Cole PJ, Craske DA, Wheatley RG (2000) Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty. Br J Anaesth 85:233–237PubMedCrossRef

19.

Fleron MH, Weiskopf RB, Bertrand M, Mouren S, Eyraud D, Godet G et al (2003) A comparison of intra-thecal opioid and intravenous analgesia for the incidence of cardiovascular, respiratory, and renal complications after abdominal aortic surgery. Anesth Analg 97:2–12PubMedCrossRef

20.

Blay M, Orban JC, Rami L, Gindre S, Chambeau R, Batt M, Grimaud D, Ichai C (2006) Efficacy of low-dose intra-thecal morphine for postoperative analgesia after abdominal aortic surgery: a double-blind randomized study. Reg Anesth Pain Med 31:127–133PubMed

21.

Beaussier M, Weickmans H, Parc Y, Delpierre E, Camus Y, Funck-Brentano C, Schiffer E, Delva E, Lienhart A (2006) Postoperative analgesia and recovery course after major colorectal surgery in elderly patients: a randomized comparison between intra-thecal morphine and intravenous PCA morphine. Reg Anesth Pain Med 31:531–538PubMed

22.

Rawal N, Arner S, Gustafsson LL, Allvin R (1987) Present state of extradural and intra-thecal opioid analgesia in Sweden. A nationwide follow-up survey. Br J Anaesth 59:791–799PubMedCrossRef

23.

De Pietri L, Siniscalchi A, Reggiani A, Masetti M, Begliomini B, Gazzi M et al (2006) The use of intra-thecal morphine for postoperative pain relief after liver resection: a comparison with epidural analgesia. Anesth Analg 102:1157–1163PubMedCrossRef

24.

Ministry of Health, National Ethics Advisory Committee, Ethical Guidelines for Observational Studies http://www.neac.health.govt.nz. Accessed 2003

25.

Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH (2001) “Fast track” postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88:1533–1538PubMedCrossRef

26.

Fearon KC, Ljunggvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing resection. Clin Nutr 24:466–477PubMedCrossRef

27.

Basse L, Thorbol JE, Lossi K, Kehlet H (2004) Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 47:271–277PubMedCrossRef

28.

King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ et al (2006) The influence of an enhance recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513PubMedCrossRef

29.

Nygren J, Hausel J, Kehlet H, Revhaug A, Lassen K et al (2005) A comparison in five European centres of case mix, clinical management and outcomes following either conventional or fast-track preoperative care in colorectal surgery. Clin Nutr 24:455–461PubMedCrossRef

30.

Sistla SC, Sibal AK, Ravishankar M (2009) Intermittent wound perfusion for postoperative pain relief following upper abdominal surgery: a surgeon’s perspective. Pain Pract 9:65–70PubMedCrossRef

31.

Baig MK, Zmora O, Derdemezi J, Weiss EG, Nogueras JJ, Wexner SD (2006) Use of the ON-Q pain management system is associated with decreased postoperative analgesic requirement: double blind randomized placebo pilot study. Am Coll Surg 202:297–305CrossRef

32.

Liu SS, Richman JM, Thirlby RC, Wu CL (2006) Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg 203:914–932PubMedCrossRef

Title: A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato-Pancreato-Biliary Surgery
Authors: Magdalena Sakowska
Elizabeth Docherty
David Linscott
Saxon Connor
Publication date: 01-09-2009
Publisher: Springer-Verlag
Published in: World Journal of Surgery / Issue 9/2009
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-009-0131-2

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

A Change in Practice from Epidural to Intrathecal Morphine Analgesia for Hepato-Pancreato-Biliary Surgery

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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