Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

A COMPARISON BETWEEN INSTILLATION OF INTRAPERITIONEAL BUPIVACAINE & MORPHINE vs. BUPIVACAINE ALONE IN ANALGESIA AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Background Pain after laparoscopic cholecystectomy remains a challenging issue to this relatively less invasive surgery, In this study we try to tackle this problem through intraperitoneal injection of drugs particularly morphine and bupivicaine to reduce post-operative pain. Objectives The Aim of this study is to assess postoperative pain in laparoscopic cholecystectomy by comparing between administering intraperitoneal bupivacaine alone versus intraperitoneal bupivacaine with intravenous morphine; Using the VAS scale and measuring time for rescue analgesic administration. Methods and material This prospective double blinded randomized clinical trial study was conducted in Ain Shams University hospital after approval of the anesthesia department and the local ethics and research committee over 6 months and after obtaining a written informed consent. Sixty patients underwent laparoscopic cholecystectomy were included in the study their ages range between 18 and 60 years old and classified as ASA I and II. The patients were randomly divided using computer generated randomization into two groups 30 patients in each (n = 30), Group BM received 30 ml of mixture of bupivacaine and 2 mg morphine while group BO received bupivacaine only Results This study showed that Morphine bupivacaine admixture had made dramatic decline in shoulder and abdominal pain VAS scores specifically at the 18th and24th hour; 15 patients in the BM group had either VAS score zero or 1 when compared to BO group whom their scores at the 18th and 24th hour was between 4 and 8. Also, there was more decrease in postoperative analgesic consumption in BM group. Conclusions We conclude that intraperitoneal instillation of 2 mg to bupivacaine 0.5% in elective LC significantly reduced post-operative shoulder pain and analgesic requirement when compared to bupivacaine 0.5% alone.

Randomized Control Trial of Short Infusion of Low Dose Ketamine Vs Intravenous Morphine as Adjunct Analgesia for Acute Long Bone Fracture Pain in Emergency Department

BackgroundKetamine is known as an alternative for pain control, but reports of emergency reactions limits its widespread use. We assessed the efficacy of short infusion of low dose ketamine (LDK) compared with intravenous morphine (MOR) as adjunct analgesia for acute long bone fracture pain.MethodsPatients aged 18-60 years old, with acute long bone fracture and with numerical pain rating scale (NPRS) of 6 or more after 3mg intravenous morphine were eligible for enrolment. Subjects were consented and randomized to either short infusion LDK (0.3mg/kg) over 15 minutes or intravenous morphine (MOR) (0.1mg/kg) over 5 minutes. Evaluations of NPRS score and vital signs occurred at 15, 30, 60, 90 and 120 minutes. The primary outcome from this study was the mean reduction of numerical pain rating scale (NPRS) score from baseline and the mean time to achieve ³ 3 score reductions in NPRS. The secondary outcomes were the incidence of adverse events and mean consumption of rescue analgesia.ResultsFifty-eight subjects were enrolled (MOR 27, LDK 31). Demographic variables and baseline NPRS scores MOR (8.33) vs LDK (8.84) were similar. The mean reduction of NPRS were significantly different between LDK (Mean= 3.1, SD=2.03) and MOR (Mean =1.8, SD 1.59), p= 0.009 at 30 minutes. Incidence of dizziness was reported higher in Ketamine group 19.4% (p=0.026).ConclusionWhen used as an adjunct, short infusion low-dose ketamine at 0.3mg/kg over 15minutes provides greater analgesic effect in comparison to intravenous morphine alone for acute long bone fracture pain but has higher incidence of dizziness.Trial RegistrationNational Medical Research Register: https://www.nmrr.gov.my/ Registered 24 November 2017 ID:NMRR-17-3184-38970

Treatment with dopamine β-hydroxylase (DBH) inhibitors prevents morphine use and relapse-like behavior in rats

Background Opioid use disorders are serious contributors to the harms associated with the drug use. Unfortunately, therapeutic interventions for opioid addicts after detoxification have been limited and not sufficiently effective. Recently, several studies have led to promising results with disulfiram (DSF), a dopamine β-hydroxylase (DBH) inhibitor, showing that it is a potent agent against not only alcohol but also addiction to various drugs. Materials and methods This study was designed to examine whether DSF and nepicastat (NEP; another DBH inhibitor) modify morphine intake and reinstatement of seeking-behavior using the rat model of intravenous morphine self-administration. Additionally, we intended to estimate the effects of both inhibitors on the locomotor activity as well as on extracellular dopamine and its metabolite levels in the nucleus accumbens using microdialysis in naive rats. Results We demonstrated that both DBH inhibitors reduced responding to morphine self-administration. Moreover, DSF and NEP administered acutely before reinstatement test sessions consistently attenuated the reinforcing effects of morphine and a morphine-associated conditioned cue. The observed effects for lower doses (6.25–25 mg/kg; ip) of both DBH inhibitors seem to be independent of locomotor activity reduction and dopamine level in the nucleus accumbens. Neither DSF nor NEP administered daily during morphine abstinence with extinction training sessions had any effect on active lever-responding and changed the reinstatement induced by morphine priming doses. Reinstatement of drug-seeking behavior induced by a conditioned cue previously associated with morphine delivery was attenuated following repeated administration of DSF or NEP during the abstinence period. Conclusion These results seem to point to the significance of DBH inhibition as a potential pharmacotherapy against morphine use disorders. Graphic abstract

Evaluation of Analgesic and Sedative Effects of Ketamine Infusion against Intravenous Morphine in Relieving Fracture Pain of Long or Short Bones of Upper and Lower Limbs

Introduction and Purpose: The importance of pain control in patients with limb trauma in the emergency department and its complications is the main issue in post-emergency care and plays an important role in accelerating the improvement of patients' general status. Therefore, the present study aimed to evaluate the analgesic and sedative effects of ketamine infusion against intravenous morphine in relieving fracture pain of long or short bones in the upper and lower limbs. Materials and Methods: We examined the effect of ketamine and morphine as ketamine infusion at a dose of 0.4 mg/kg/IV/10min and intravenous morphine at a dose of 0.1 mg/kg/IV in patients aged 18-65 years with limb trauma who visited the hospital emergency department. We also compared the duration of analgesia, the amount of pain relief according to the Visual Analogue Scale (VAS) in each of the drugs and complications of the above methods, including apnea, bradycardia, tachycardia, decreased level of consciousness, nausea, vomiting, hypertension and hypotension, seizures, and disturbed sleep, and mentioned the preferred method. Results: In the study, we studied 120 patients, 60 of whom received ketamine and 60 received morphine. The mean age of patients was 13.02±13.67 years with a minimum age of 19 years and a maximum age of 70 years, and 89(74.2%) patients were male. There was not any difference between ketamine and morphine in the factors at different times. Conclusion: The results indicated that the potency of low-dose ketamine in relieving pain in patients was very similar to morphine. Keywords: Bone fracture; Ketamine; Morphine.

Feasibility and postoperative opioid sparing effect of an opioid-free anaesthesia in adult cardiac surgery: a retrospective study

Background No previous study investigated the dexmedetomidine-based opioid-free anesthesia (OFA) protocol in cardiac surgery. The main objective of this study was to evaluate the feasibility and the postoperative opioid-sparing effect of dexmedetomidine-based OFA in adult cardiac surgery patients. Methods We conducted a single-centre and retrospective study including 80 patients above 18 years old who underwent on-pump cardiac surgery between November 2018 and February 2020. Patients were divided into two groups: OFA (lidocaine, ketamine, dexmedetomidine, MgSO4) or opioid-based anaesthesia (remifentanil and anti-hyperalgesic medications such as ketamine and/or MgSO4 and/or lidocaine at the discretion of the anesthesiologist). The primary endpoint was the total amount of opioid consumed in its equivalent of intravenous morphine during the first 48 postoperative hours. Secondary outcomes included perioperative hemodynamics, post-operative maximal pain at rest and during coughing and adverse outcomes. Data are expressed as median [interquartile range]. Results Patients in the OFA-group had a higher EuroSCORE II, with more diabetes, more dyslipidemia and more non-elective surgery but fewer smoking history. In the OFA group, the median loading dose of dexmedetomidine was 0.6 [0.4–0.6] μg.kg− 1 while the median maintenance dose was 0.11 μg.kg− 1.h− 1 [0.05–0.20]. In 10 (25%) patients, dexmedetomidine was discontinued for a drop of mean arterial pressure below 55 mmHg. The median total amount of opioid consumed in its equivalent of intravenous morphine during the first 48 postoperative hours was lower in the OFA group (15.0 mg [8.5–23.5] versus 30.0 mg [17.3–44.3], p < 0.001). While no differences were seen with rest pain (2.0 [0.0–3.0] versus 0.5 [0.0–5.0], p = 0.60), the maximal pain score during coughing was lower in OFA group (3.5 [2.0–5.0] versus 5.5 [3.0–7.0], p = 0.04). In OFA group the incidence of atrial fibrillation (18% versus 40%, p = 0.03) and non-invasive ventilation use (25% versus 48%, p = 0.04) were lower. The incidence of bradycardia and the intraoperative use of norepinephrine were similar between both groups. Conclusion Dexmedetomidine-based OFA in cardiac surgery patients is feasible and could be associated with a lower postoperative morphine consumption and better postoperative outcomes. Further randomized studies are required to confirm these promising results and determine the optimal associations, dosages, and infusion protocols during cardiac surgery. Graphical abstract