Comparison of intravenous vs. intramuscular morphine for postoperative pain relief on the multidisciplinary care path implemented ward.

Objective: To compare the efficacy and side effects of intravenous and intramuscular morphine injection for postoperative pain relief on the multidisciplinary care path implemented ward and to study the attitude of nurses and doctors in using these two routes of analgesia. Methods: We performed a prospective, single-blind, randomized controlled trial in 80 patients undergoing elective gynecologic surgery. They were randomly allocated into two groups. Group IM received 10 mg morphine intramuscular (IM) injection for pain prn every 4 hours. Group IV received intravenous (IV) morphine for pain prn every 2 hours. The dose of morphine was given based on pain score: <7 gave 1 mg, >7 gave 2 mg. In the recovery room (RR) both groups received IV morphine until they felt enough pain relief. We recorded patients’ pain scores at the time discharged from RR, at the time arrival to the ward, 24 and 48 hours postoperation, and the amount of morphine received. We interviewed the patients on their satisfaction for pain relief. The questionnaire was sent to nurses and doctors working in the ward. Results: The numbers of patients having pain scores > 4 and > 7 within 48 hours in the IV group and the IM group were not different (95% and 42.5% vs. 97.5% and 45%, respectively). More than half of them felt no need to ask for analgesic very often and they received analgesic quite soon. Patients in the IM group had more pain on injection than the IV group (p<0.001). The time they started to experience pain relief after each dose of analgesic was not different in both groups, but more patients in the IV group felt much overall pain relief (p=0.005). The IV group had less nausea, vomiting and dizziness than in the IM group (p=0.002, p<0.001 and p=0.003, respectively). No respiratory depression found in this study. Both groups were satisfied with the treatments. Nurses found no difference in their convenience for administration of morphine between the 2 routes but doctors felt that they were called by nurse for the same patient because of inadequate pain relief more often after the IM route than after the IV route (p=0.007). Conclusion: There is no difference in postoperative pain relief in 48 hours between giving 2 mg morphine IV prn every 2 hours and 10 mg morphine IM prn every 4 hours in patients undergoing major gynecological operations on the multidisciplinary-care-path-implemented ward. However, patients in the IV group feel less pain on injection, and less nausea and vomiting, although both groups give similar satisfaction scores. Nurses give their opinion of no differences in their convenience for administration of morphine between these two routes. Doctors, however, feel that they are called because of inadequate pain relief more often in the IM group than in the IV group.

Effectiveness of lightwand (Trachlight) intubation by 1st year anesthesia residents.

Transillumination of the soft tissue of the neck using a lighted stylet (lightwand) is an effective and safe intubating technique in experienced hands. The goal of this study was to determine the effectiveness and safety of this device in intubating the trachea of elective surgical patients by non-experienced hands. One hundred and fifty, paralysed, anesthetized, adult patients (ASA I-II, no known or potential problems with intubation) were studied. Failure to intubate was defined as lack of successful intubation after three attempts. The duration of each attempt was recorded as the time from insertion of the device into the oropharynx to the time of its removal. The total time to intubation (TTI) was defined as the sum of the durations of all (as many as three) intubation attempts. Complications, such as mucosal bleeding, lacerations, dental injury and sore throat were recorded. The mean TTI was 42.0 +/- 34.3 seconds. The overall intubation success rate was 92 per cent. Of all the successful intubations, 87.68 per cent were successful after one attempt. There were significantly fewer traumatic events (5.33%). Most of the trauma consisted of minor mucosal bleeding or mucosal laceration. We conclude that lightwand intubation is an effective and safe technique in non-experienced hands.

Adding droperidol to morphine patient-controlled analgesia: effect on nausea and vomiting.

This prospective, double-blind, randomized, controlled trial was performed to evaluate the antiemetic effectiveness and side effects of adding droperidol to morphine delivered via a patient-controlled analgesia (PCA) device in 94 women undergoing transabdominal hysterectomy with a standardized anesthetic regimen. They were randomly allocated to receive postoperative PCA as either bolus doses of morphine I mg or a combination of morphine 1 mg and 0.0625 mg droperidol with a lockout interval of 5 minutes and no continuous infusion. The incidence of nausea 6-18 hours postoperatively and 18-24 hours postoperatively was significantly lower in the morphine and droperidol group than in the morphine only group and its severity 2-6 hours, 6-18 hours, and 18-24 hours postoperatively was significantly lower. The number needed to treat to prevent nausea comparing the morphine only group at 6-18 and at 18-24 hours postoperatively were 4 and 4 (95% CI 2-27 and 2-11, respectively). The amount of morphine used 6-18 hours postoperatively in the droperidol group was lower than in the morphine only group. Although the incidence of vomiting and the amount of rescue antiemetics were lower in the morphine and droperidol group, the difference was not statistically significant. Postoperative pain scores were not different between the groups. No patients were oversedated. A series of extrapyramidal reactions were observed in one patient in the morphine and droperidol group. The drug and consumable item cost was not different between the groups. We conclude that droperidol added to morphine in PCA reduces nausea. The appropriate dose of droperidol should be further investigated to reduce the incidence of vomiting.

Postoperative analgesic effects of intravenous lornoxicam and morphine with pre-emtive ropivacaine skin infiltration and preperitoneal instillation after transabdominal hysterectomy.

To investigate the effectiveness of intravenous lornoxicam and morphine with the preemptive effects of ropivacaine local skin infiltration and peritoneal instillation in reducing postoperative pain after transabdominal hysterectomy, a randomized, double blinded, placebo-controlled study was done in 88 patients undergoing transabdominal hysterectomy under general anesthesia. The patients were allocated into 4 groups to receive: (group A) only intravenous morphine 10 mg; (group B) intravenous morphine 10 mg and lornoxicam 16 mg; (group C) intravenous morphine 10 mg, lornoxicam 16 mg with 0.5 per cent ropivacaine local skin infiltration before skin incision and 1 per cent ropivacaine instillation before peritoneal incision; (group D) intravenous morphine 10 mg, lornoxicam 16 mg with 1 per cent ropivacaine instillation after peritoneal closure and 0.5 per cent ropivacaine local skin infiltration before skin closure. Pain was assessed by patients using visual analog scales (VAS) at 2, 6, 12, 18, 24, 48 hours after surgery. Time to first analgesic requirement and morphine requirement during the first 6 h were significantly lower in the groups using lornoxicam (group B, C, D) as compared with the group using only morphine (group A). However there was no significant difference between group B and group C or group D which means that the additional analgesic effects of using local anesthetic infiltration and instillation either before (pre-emptive) or after the incision could not be seen in this study. Implication: Intravenous 16 mg of lornoxicam with 10 mg of morphine significantly reduced postoperative pain during the first 6 h after abdominal hysterectomy. Additional effects of using local anesthetic wound infiltration to the use of lornoxicam could not be demonstrated.

Starting intravenous morphine in the postanesthesia care unit yielded better postoperative analgesia.

The administration of morphine intravenously in the Postanesthesia Care Unit (PACU) was practiced in many parts of the world, but not routinely done in Thailand. This prospective randomized controlled trial was performed to reassure Thai personnel that this practice was safe, to find the optimum dose of morphine for administration in the PACU, and to find the pain level at which patients needed no more analgesics. Eighty gynecological patients, ASA class I or II, were randomly allocated into two groups. Group A received morphine intramuscularly on demand for pain every 6 hours as is conventional. Group B received morphine intravenously by titration (with pain) in the PACU. On the ward, they received intramuscular morphine for pain as required. No patients had respiratory depression or oversedation. The amount of morphine needed in the PACU was related to and could be calculated from the pain score at which they first needed analgesics. Time to the first requirement of intramuscular morphine on the ward in group B was significantly longer than in group A. The amount of morphine and the number of analgesic requests on the ward in group B were significantly less than in group A. We concluded that giving morphine intravenously in the PACU was safe, effective and reduced postoperative analgesic requirement. The dose of morphine in the PACU could be calculated from the pain score at patients' first request for analgesics. Most patients declined additional analgesics when their pain was acceptable and tolerable.