Combinations of Morphine with Ketamine for Patient-controlled Analgesia

2003 ◽  
Vol 98 (5) ◽  
pp. 1195-1205 ◽  
Author(s):  
Gorazd Sveticic ◽  
Andrea Gentilini ◽  
Urs Eichenberger ◽  
Martin Luginbühl ◽  
Michele Curatolo
Keyword(s):  
Lumbar Spine ◽  
Side Effects ◽  
Drug Concentration ◽  
Optimization Procedure ◽  
Hip Surgery ◽  
Patient Controlled Analgesia ◽  
Pain Scores ◽  
Lockout Interval ◽  
Novel Method ◽  
Low Incidence

Background According to previous studies, the addition of ketamine to morphine for intravenous patient-controlled analgesia (PCA) may be beneficial. The authors developed and applied a new model to optimize the combination of morphine, ketamine, and a lockout interval for PCA after lumbar spine and hip surgery. Methods One-hundred two patients undergoing lumbar spine or hip surgery participated in the study. The analgesic effect of PCA during 48 h after surgery was optimized under restrictions dictated by side effects. Initially, eight combinations of morphine, ketamine (expressed as drug concentration in the solution administered), and a lockout interval (i.e., minimal allowed time between two consecutive PCA boluses) were empirically chosen and investigated. To determine subsequent combinations, an optimization model was applied until three consecutive steps showed no decrease in pain score. Results The authors analyzed 12 combinations with an allowed morphine and ketamine range in a PCA solution of 0-2 mg/ml and a lockout interval range of 5-12 min. During the optimization procedure, a reduction in mean pain scores with a low incidence of side effects was observed. The procedure converged to a morphine-to-ketamine ratio of 1:1 and a lockout interval of 8 min. Conclusions Using a novel method to analyze drug combinations, the study supports combinations of morphine with ketamine in a ratio of 1:1 and a lockout interval of 8 min for postoperative PCA following spine and hip surgery.

Early postoperative patient-controlled analgesia ratio predicts 24-hour morphine consumption and pain in children undergoing scoliosis surgery

2014 ◽  
Vol 10 (1) ◽  
pp. 39 ◽  
Author(s):  
Clyde T. Matava, MBCHB ◽  
Mark W. Crawford, MBBS ◽  
Carolyne Pehora, RN ◽  
Basem Naser, MD ◽  
Conor McDonnell, MBCHB
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Hospital Stay ◽  
Univariate Analysis ◽  
Morphine Consumption ◽  
Scoliosis Surgery ◽  
Patient Controlled Analgesia ◽  
Duration Of Hospital Stay ◽  
Pain Scores ◽  
Severe Postoperative Pain

Background: The identification of patients at risk for developing severe postoperative pain and/or opioid-related side effects is difficult due to a lack of sensitive indicators. The patient-controlled analgesia (PCA) ratio of demands to deliveries is a potential tool for early identification of patients who experience severe postoperative pain. The authors hypothesized that the PCA ratio is able to predict morphine requirement in the first 24 hours after scoliosis surgery.Methods: The authors performed a retrospective study of adolescents who had surgery for idiopathic scoliosis. They collected data describing PCA demands and deliveries, morphine consumption, numerical rating scale (NRS) pain scores, opioidrelated side effects, and duration of hospital stay. Spearman rank analysis assessed association among 4-hour PCA ratios, NRS pain score, and 24-hour morphine consumption. Patients were divided into groups on the basis of PCA ratios <1.5 and ≥1.5. Univariate analysis and multiple regression were used to identify independent factors predictive for increased 24-hour morphine. Mann-Whitney rank-sum and Fisher exact tests were used to compare data. p < 0.05 was considered statistically significant.Results: One hundred forty-seven patients were included in the analysis, mean (SD) age and weight were 15 (1.8) years and 55 (27) kg, respectively. There was a significant positive correlation between the 4-hour PCA ratio and initial 24-hour cumulative morphine consumption (r = 0.33, p = 0.0002). Patients with a 4-hour PCA ratio ≥1.5 demonstrated a significantly greater initial 24-hour morphine consumption (p = 0.0002), greater pain scores at 24 hours after surgery (p = 0.02), a greater incidence of at least one opioid-related side effect within the initial 24 hours after surgery, and a longer duration of hospital stay (p = 0.04) compared with those patients with a 4-hour PCA ratio <1.5. PCA ratio ≥1.5, age, and patient sex were predictive for 24-hour morphine consumption.Conclusions: The authors have demonstrated that a PCA ratio of demands/deliveries ≥1.5 is predictive of increased opioid requirements and is associated with greater pain scores in the initial 24 hours after surgery, an increased incidence of opioid-related side effects, and duration of hospital stay.

Combinations of Bupivacaine, Fentanyl, and Clonidine for Lumbar Epidural Postoperative Analgesia

2004 ◽  
Vol 101 (6) ◽  
pp. 1381-1393 ◽  
Author(s):  
Gorazd Sveticic ◽  
Andrea Gentilini ◽  
Urs Eichenberger ◽  
Eleonora Zanderigo ◽  
Valentina Sartori ◽  
...  
Keyword(s):  
Side Effects ◽  
Epidural Analgesia ◽  
Regression Model ◽  
Pain Score ◽  
Postoperative Analgesia ◽  
Clinical Investigation ◽  
Optimization Procedure ◽  
Optimization Method ◽  
Hip Surgery ◽  
First Time

Background The authors developed and applied a method to optimize the combination of bupivacaine, fentanyl, and clonidine for continuous postoperative lumbar epidural analgesia. Methods One hundred eighteen patients undergoing knee or hip surgery participated in the study. Postoperative epidural analgesia during 48 h after surgery was optimized under restrictions dictated by side effects. Initially, eight combinations of bupivacaine, fentanyl, and clonidine (expressed as drug concentration in the solution administered) were empirically chosen and investigated. To determine subsequent combinations, an optimization model was applied until three consecutive steps showed no decrease in pain score. For the first time in a clinical investigation, a regression model was applied when the optimization procedure led to combinations associated with unacceptable side effects. Results The authors analyzed 12 combinations with an allowed bupivacaine concentration range of 0-2.5 mg/ml, a fentanyl concentration range of 0-5 microg/ml, and a clonidine concentration range of 0-5 microg/ml. The best combinations of bupivacaine, fentanyl, and clonidine concentrations were 1.0 mg/ml-1.4 microg/ml-0.5 microg/ml, 0.9 mg/ml-3.0 microg/ml-0.3 microg/ml, 0.6 mg/ml-2.5 microg/ml-0.8 microg/ml, and 1.0 mg/ml-2.4 microg/ml-1.0 microg/ml, respectively, all producing a similarly low pain score. The incidence of side effects was low. The application of the regression model to combinations associated with high incidence of motor block successfully directed the optimization procedure to combinations within the therapeutic range. Conclusions The results support further study of the combinations of bupivacaine, fentanyl, and clonidine mentioned above for postoperative analgesia after knee and hip surgery. This novel optimization method may be useful in clinical research.

Comparison of Oxycodone and Sufentanil for intravenous patient-controlled analgesia after hip surgery: a prospective, randomized controlled trial

2019 ◽  
Author(s):  
Jingyi Li ◽  
Haibei Zhu ◽  
Ren Liao
Keyword(s):  
Adverse Reactions ◽  
Rating Scales ◽  
Analgesic Efficacy ◽  
Hip Surgery ◽  
Controlled Clinical Trial ◽  
Patient Controlled Analgesia ◽  
Safety And Efficacy ◽  
Randomized Controlled ◽  
Pain Scores ◽  
Long Acting

Abstract Background Intravenous patient-controlled analgesia (PCA) after hip surgery should be focused on the balance of sufficient analgesia and the risk of associated adverse reactions. Sufentanil has high analgesic efficacy as a common used drug for PCA while with obvious side effects. Oxycodone is a semi-synthetic opioid which has been reported to have good analgesic effect and lower incidence of adverse reactions related to long-acting opioid. We hypothesize that in hip surgery, compared with sufentanil PCA, the equipotency dose of oxycodone PCA could achieve the same postoperative analgesic efficacy and may also reduce the incidence of adverse reactions associated with long-acting opioids. Methods/Design This trial is a prospective, randomized, controlled clinical trial comparing the safety and efficacy of oxycodone and sufentanil for postoperative patient-controlled analgesia in patients undergoing hip surgery. A total of 570 subjects undergoing hip surgery will be randomly allocated to either sufentanil PCA group or oxycodone PCA group. The primary outcome is the resting numerical rating scales (NRS) pain scores at 30 min, 2 h, 6 h, 24 h, 48 h, and 72h after surgery. The secondary outcomes include postoperative NRS pain scores on movement, in-hospital complications, range of motion of hip joints, mobilization time, length of hospital stay, total in-hospital cost, and readmission rate by 30 days after discharge from the hospital. Discussion This trial is designed to compare the safety and efficacy of oxycodone and sufentanil PCA in patients undergoing hip surgery, in order to find an optimal postoperative analgesic regime with fewer adverse reactions and promoting patients’ rehabilitation. The results will provide evidence for anesthetic choice in clinical practice.

Effect of Combining Naloxone and Morphine for Intravenous Patient-controlled Analgesia

2003 ◽  
Vol 99 (1) ◽  
pp. 148-151 ◽  
Author(s):  
James B. Sartain ◽  
John J. Barry ◽  
Christopher A. Richardson ◽  
Helen C. Branagan
Keyword(s):  
Side Effects ◽  
Controlled Trial ◽  
Symptomatic Treatment ◽  
General Anesthetic ◽  
Patient Controlled Analgesia ◽  
Double Blind ◽  
Pain Scores ◽  
Patient Recall ◽  
Background Infusion ◽  
Pain At Rest

Background An early study showed that a naloxone infusion decreased the incidence of morphine-related side effects from intravenous patient-controlled analgesia. The authors tested the hypothesis that a more convenient combination of morphine and naloxone via patient-controlled analgesia would decrease the incidence of side effects compared to morphine alone. Methods Patients scheduled for hysterectomy under general anaesthesia were enrolled in a double-blind, randomized, placebo-controlled trial. Patients received a standardized general anesthetic and postoperative patient-controlled analgesia. They were randomized to receive 60 mg patient-controlled analgesia morphine in 30 ml saline or 60 mg morphine in 30 ml saline with naloxone 0.8 mg. Parameters for patient-controlled analgesia were a 1-mg bolus of morphine with a 5-min lockout and no background infusion. Patient recall of nausea, vomiting, itching, and pain (at rest and with movement) were assessed at 6 and 24 h postoperatively by verbal rating score. Pain was also assessed by a 0- to 100-mm visual analog score, and sedation was assessed by an observer. The amount of morphine used and the requirements for symptomatic treatment were also recorded. Results Ninety-two patients completed the study, with no significant differences in outcomes between groups. At 24 h, the incidence of nausea was 84.8% in each group; the incidence of pruritus was 56.5% in the naloxone group and 58.7% in the placebo group. There were also no differences in symptomatic treatment requirements, pain scores, morphine use, or sedation between groups. The median dose of naloxone received equated to 0.38 microg x kg-1 x h-1 over 24 h. Conclusions There was no benefit from administering naloxone combined with morphine via patient-controlled analgesia.

scholarly journals Can Combination of Peripheral Nerve Block and Non-opioidal Patient Controlled Analgesia Be an Effective Postoperative Pain Control Method?

2019 ◽  
Vol 4 (4) ◽  
pp. 2473011419S0023
Author(s):  
Chan Kang ◽  
Gi Soo Lee ◽  
Dong Yeol Kim ◽  
Jeong-kil Lee ◽  
Ki Jun Ahn ◽  
...  
Keyword(s):  
Side Effects ◽  
Postoperative Pain ◽  
Pain Control ◽  
Control Method ◽  
Patient Controlled Analgesia ◽  
Ultrasound Guided ◽  
Bone Surgery ◽  
Pain Scores ◽  
Group A ◽  
Group B

Category: Ankle, Pain medicine Introduction/Purpose: Even though bone surgery is very painful after operation, there is no established method to control postoperative pain due to efficacy and side effects. Ultrasound-guided peripheral nerve block (PNB) and nonsteroidal anti- inflammatory drugs (NSAIDs) patient controlled analgesia (PCA) can effectively control pain and reduce side effects. Methods: We conducted a prospective study of 150 patients over 18 years of age who underwent bone surgery from June 2018 to December 2018. All operations were performed under anesthetic ultrasound-guided PNB and additional PNB was performed to control postoperative pain. Among the 120 patients who participated in the final study, NSAIDs PCA was used in group A (65 patients) and NSAIDs PCA was not used in group B (55 patients) for pain control. Postoperative management except PCA was same in both groups. Pain scores are measured at 6, 12, 18, 24, 36, 48, and 72 hours after the operation and they were compared using visual analogue scale (VAS) pain scores. Survey was done on satisfaction of patients, and their willingness to reconsider same method of pain control when they undergo same surgery next time. Also, we evaluated possible side effects that might happen during process of controlling pain. Results: VAS pain score were significantly different only at 24 h postoperatively (p=0.004). In Group A, three patients were prescribed 3 amples of pethidine intramuscular injection as rescue analgesic. In group B, 35 patients were prescribed 50 amples of pethidine and 12 patients of them were received additional 18 amples of ketorolac intramuscular injection as rescue analgesic(p=0.000). In group A, all patients were satisfied with the pain control method, but 5 of the group B patients were dissatisfied (p=0.001). 3 patients responded to severe pain after operation and 2 of them due to postoperative nausea and vomiting (PONV). In group A, there were no patients complaining of PONV, but in group B, 5 patients complained of symptoms (p=0.018), and 3 of them were prescribed additional antiemetics (p=0.093). Conclusion: Combined use of ultrasound-guided PNB and NSAIDs PCA seems to be an effective postoperative pain control method in foot and ankle surgery. Because, pain can be effectively controlled and PONV can be reduced.

Comparison of the effect of adding remifentanil to patient-controlled tramadol or morphine for postoperative analgesia after major abdominal surgery

2018 ◽  
Vol 5 (5) ◽  
pp. 247 ◽  
Author(s):  
Hakki Unlugenc, MD ◽  
Sibel Tetiker, MD ◽  
Selim Büyükkurt, MD ◽  
Tayfun Guler, MD ◽  
Geylan Isik, MD
Keyword(s):  
Side Effects ◽  
Abdominal Surgery ◽  
Outcome Measure ◽  
Major Abdominal Surgery ◽  
Morphine Consumption ◽  
Patient Controlled Analgesia ◽  
Double Blind ◽  
Rescue Analgesia ◽  
Pain Scores ◽  
To Receive

Objective: In this study, the authors investigated the effect of the addition of remifentanil to tramadol or morphine for patient-controlled analgesia (PCA).Design: Prospective, randomized, double-blind, controlled study.Setting: University Hospital.Patients, participants: The authors randomly allocated 133 patients undergoing major abdominal surgery to receive IV PCA with tramadol alone, tramadol plus remifentanil, morphine alone or morphine plus remifentanil.Interventions: Bolus doses of tramadol (0.2 mg/kg), tramadol (0.2 mg/kg) plus remifentanil (0.2 μg/kg), morphine (0.02 mg/kg), or morphine (0.02 mg/kg) plus remifentanil (0.2 μg/kg) were available every 10 minutes without time limit or background infusion.Main outcome measure(s): Discomfort, sedation, pain scores, side effects, and total and bolus tramadol and morphine consumption were recorded for up to 24 hours after the start of PCA.Results: Pain scores at rest and movement were greater with tramadol alone than in the other groups at 1, 2, and 6 hours (p < 0.0125). The addition of remifentanil reduced cumulative tramadol consumption at 6, 12, and 24 hours, but not morphine consumption. More patients required supplementary rescue analgesia with meperidine, and with greater dosage, with tramadol alone (p < 0.001), and the incidence of nausea was greater with tramadol alone. The addition of remifentanil not only significantly improved discomfort scores in remifentanil groups, but also increased the degree of sedation in morphine-remifentanil group.Conclusions: After major abdominal surgery, adding remifentanil to PCA tramadol resulted in better pain scores, lower analgesic consumption, and fewer side effects when compared with tramadol alone. However, analgesic outcome with remifentanil was not prominent in MR group as much as in TR group.

scholarly journals Do Orthopedic Surgeons or Neurosurgeons Detect More Hip Disorders in Patients with Hip-Spine Syndrome? A Nationwide Database Study

2021 ◽  
Vol 11 (4) ◽  
pp. 485
Author(s):  
Tsung-Cheng Yin ◽  
Adam M. Wegner ◽  
Meng-Ling Lu ◽  
Yao-Hsu Yang ◽  
Yao-Chin Wang ◽  
...  
Keyword(s):  
Lumbar Spine ◽  
Spine Surgery ◽  
Hip Surgery ◽  
Lumbar Spine Surgery ◽  
Research Database ◽  
X Rays ◽  
Replacement Surgery ◽  
Orthopedic Surgeons ◽  
Spine Pathology ◽  
Sh Group

Background: Disorders of the hip and lumbar spine can create similar patterns of pain and dysfunction. It is unknown whether all surgeons, regardless of orthopedic or neurosurgery training, investigate and diagnose concurrent hip and spine pathology at the same rate. Methods: Data were retrieved from Taiwan’s National Health Insurance Research Database (NHIRD). Enrolled patients were stratified into hip and spine surgery at the same admission (Both), hip surgery before spine surgery (HS), or spine surgery before hip surgery (SH). The SH group was further subdivided based on whether spine surgery was performed by an orthopedic surgeon (OS) or neurosurgeon (NS), and differences in preoperative radiographic examinations and diagnoses were collected and analyzed. Results: In total, 1824 patients received lumbar spine surgery within 1 year before or after hip replacement surgery. Of these, 103 patients had spine and hip surgery in the same admission (Both), 1290 patients had spine surgery before hip surgery (SH), and 431 patients had hip surgery before spine surgery (HS). In the SH group, patients were categorized into spine surgery by orthopedic surgeons (OS) (n = 679) or neurosurgeons (NS) (n = 522). In the SH group, orthopedic surgeons investigated hip pathology with X-rays more often (52.6% vs. 38.1%, p < 0.001) and diagnosed more cases of hip disease (43.6% vs. 28.9%, p < 0.001) than neurosurgeons. Conclusions: Of patients in Taiwan’s NHIRD who had concurrent surgical degenerative hip and lumbar spine disorders who had spine surgery before hip surgery, orthopedic surgeons obtained hip images and made hip-related diagnoses more frequently than did neurosurgeons.

scholarly journals No relationship between bone mineral density and syndesmophyte formation at the same level in the lumbar spine of patients with radiographic axial Spondyloarthritis

RMD Open ◽  
2020 ◽  
Vol 6 (3) ◽  
pp. e001391
Author(s):  
Mary Lucy Marques ◽  
Sofia Ramiro ◽  
Pedro M Machado ◽  
Desirée van der Heijde ◽  
Floris A van Gaalen
Keyword(s):  
Bone Mineral Density ◽  
Lumbar Spine ◽  
Bone Mineral ◽  
Axial Spondyloarthritis ◽  
Mineral Density ◽  
Multivariable Analyses ◽  
Low Incidence ◽  
Post Hoc ◽  
Generalised Estimating Equations ◽  
Specific Definition

ObjectiveTo investigate if in radiographic axial Spondyloarthritis (r-axSpA) low vertebral bone mineral density (BMD) is associated with development of new syndesmophytes at the same vertebral level.MethodsIn a post-hoc analysis from the ASSERT trial (infliximab vs placebo), dual-energy X-ray absorptiometry was used to measure baseline BMD (g/cm2) of the lumbar spine L1 to L4. Syndesmophyte formation was assessed in the same vertebrae on conventional radiographs defined as an increase in modified Stoke Ankylosing Spondylitis Spine Score from 0 or 1 to 2 or 3 after 2 years. Radiographs were scored by two readers. Generalised estimating equations (GEE) adjusted for within-patient correlation across multiple vertebrae, taking potential confounders into account.ResultsWe analysed 599 vertebrae in 165 r-axSpA patients (78% male, mean (SD) age 38 (10) years, 67% with at least one syndesmophyte anywhere in the spine). In total, 24 to 74 new syndesmophytes developed in 9 (5%) to 30 (18%) patients and 13 (2%) to 39 (7%) vertebrae, if either a syndesmophyte was seen by both or only one of the readers (ie, specific and sensitive definitions) respectively. In multivariable analyses, no association was found between baseline local vertebral BMD and new syndesmophyte formation after 2 years: adjOR (95% CI): 0.56 (0.01, 44.45) (specific definition) and 0.26 (0.03, 2.63) (sensitive definition).ConclusionIn patients with active and established r-axSpA, with an observed low incidence of lumbar spine syndesmophyte formation over 2 years, no relationship was found between baseline BMD and new radiographic syndesmophyte formation at the same vertebra.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

2021 ◽  
pp. 1-9
Author(s):  
Marie-Jacqueline Reisener ◽  
Alexander P. Hughes ◽  
Ichiro Okano ◽  
Jiaqi Zhu ◽  
Artine Arzani ◽  
...  
Keyword(s):  
Side Effects ◽  
Spine Surgery ◽  
Effect Size ◽  
Lumbar Fusion ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Chi Square ◽  
Opioid Prescribing ◽  
Pain Scores ◽  
Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

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