Epidural Analgesia Using High Dose Morphine in a Terminal Lung Cancer Patient: A case report / 대한통증학회지

Pain control is very important in managing terminal cancer patients and there are several modalities to alleviate their pain. A high dosage of epidural morphine is effective to control terminal cancer pain. Furthermore, to decrease the amount of morphine, adding an alternative adjuvant like ketamine to the morphine regimen is considered helpful for controlling the pain of a terminal cancer patient. A 45 year old male patient with terminal lung cancer had neck pain that was caused by multiple bone metastases. Continuous epidural block was started with 2 mg/day of morphine and the dosage was gradually increased to 90 mg/day in 86 days. 30 mg/day of ketamine was then added to it. Overall, the morphine and ketamine dosages were increased to 564 mg/day and 140 mg/day, respectively, in 11 months until the patient expired. In this case, the high dosage of epidural morphine, 580 mg/day, was administered to control cancer pain without any severe adverse effects.

Cancer Pain Management by Continuous Epidural Morphine Infusion via Subcutaneous Tunneling / 대한통증학회지

BACKGROUND: Most terminal cancer patients suffered from intractable pain. For the treatment of these patients, opioids, via various routes, are usually administered. Continuous epidural opioid, especially morphine, administration is a good method for the management of intractable cancer pain. METHODS: We retrospectively analyzed 347 terminal cancer patients, who had been treated with continuous epidural morphine infusion, between 1999 and 2004. For the epidural infusion, an epidural catheter was inserted, tunneled subcutaneously and exited from the anterior chest or abdomen. Multiday Infursor(R) (Baxter, 0.5 ml/h) was used for the continuous infusion. RESULTS: Of the 347 patients studied, there were 211 males and 136 females. The mean treatment time was 54.7 days, ranging from 5 to 481 days. The mean starting and termination doses of morphine were 32.4 (for 5 days) and 100.0 mg, respectively. The doubling time of the morphine dose was 26.3 days, corresponded to a 3.8 percent increase per day. Incidental catheter removal was the most common side effect, which occurred 130 times in 61 cases. CONCLUSIONS: The procedure of epidural catheterization, with subcutaneous tunneling, was simple and inexpensive. Despite the disadvantages, such as incidental catheter removal, it is a useful method for the control of terminal cancer pain.

The Optimal Dose Range of Epidural Naloxone to Minimize Nausea during Continuous Epidural Infusion of Morphine / 대한마취과학회지

BACKGROUND: This study was designed to determine the optimal dose range of epidural naloxone that can preserve analgesia while minimizing nausea, one of the most common side effects caused by epidural morphine. METHODS: Seventy-four patients undergoing combined epidural and general anesthesia for hysterectomy were randomly assigned to one of three groups. All received 2 mg epidural morphine bolus just before closing abdominal cavity and a continuous epidural infusion was started containing 4 mg morphine in 100 ml bupivacaine 0.125% with either no naloxone (Group 1, n = 24), 0.167 mg/kg/hr of naloxone (Group 2, n = 19) or 0.412 mg/kg/hr of naloxone (Group 3, n = 31) for postoperative pain control. Analgesia and nausea were evaluated by blinded observers. RESULTS: The combination of epidural morphine and bupivacaine provided good analgesia. Pain scores in group 3 were lower than in group 1 after surgery, but there were no significant statistical differences except at 16 hr. Group 2 showed the lowest pain scores at 8, 16 and 24 hr (P < 0.05). Nausea scores were lower in group 2 and 3 than in group 1 at 16 and 24 hr (P < 0.05). CONCLUSIONS: Epidural administration of naloxone below 0.412 mg/kg/hr was optimal and safe dose range that maintained the analgesic effects of morphine while minimizing nausea.

Preventive Effect of Intravenous Ondansetron on Postoperative Nausea and Vomiting related to Epidural Morphine after Abdominal Surgery / 대한마취과학회지

BACKGROUND: A prospective study was performed to evaluate the preventive effect of intravenous (IV) ondansetron on postoperative nausea and vomiting (PONV) due to epidural morphine for postoperative pain control after major abdominal surgery. METHODS: One hundred patients undergoing elective major abdominal surgery were randomly devided into two groups, group O (n = 50) receiving IV ondansetron and group C (n = 50) receiving IV saline. After bolus epidural morphine were injected to all patients thirty minutes before the end of surgery, group O received ondansetron 8 mg and group C received normal saline intravenously. Incidence and severity of nausea, episodes of vomiting, patient's satisfaction, side effects such as pruritus, headache, dizziness related to epidural morphine were checked at 6, 24 hours after operation. RESULTS: The incidence and severity of nausea were significantly decreased in group O than group C during the first 24 hours after surgery. There were no significant differences in postoperative pain scores and patient's satisfaction between groups. The patients who didn't experienced PONV were significantly more satisfied than those who experienced PONV after surgery. CONCLUSION: Ondansetron decrease the incidence and severity of nausea in patients receiving epidural morphine for postoperative pain control after major abdominal surgery.

The Effect of Ondansetron and Metoclopramide on the Prevention of Postoperative Nausea and Vomiting After Using Epidural Morphine-Butorphanol Mixture / 대한마취과학회지

BACKGROUND: Neuroaxial morphine may produce nausea and vomiting due to cephalad migration. Though it improves post- operative pain, it may have serious complication delaying recovery. The aim of this study was to investigate the efficacy of prophylactic antiemetics such as conventional metoclopramide or more expensive ondansetron. METHODS: Eighty-seven patients who underwent orthopedic knee arthroscopic surgery under epidural anesthesia were randomly assigned to three groups, which are (a) normal saline intravenous injection control group (Group C), (b) metoclopramide intravenous injection and intranasal spray study group (Group M), (c) ondansetron inravenous injection group (Group O). Before the end of surgery, all patients were given 3 mg of morphine and 2 mg of butorphanol mixture via epidural catheter for postoperative pain control. The anesthesia were all standardized. Post-operative nausea and vomiting were observed and used as outcome variables and postoperative pain, itching, somnolence, dizziness, urinary retention were also observed. RESULTS: The incidence of postoperative nausea was significantly lower in Group M (P = 0.0296) and Group O (P = 0.005) compared with Group C. The incidence of postoperative vomiting was significantly lower in Group O (P = 0.01) compared with Group C. But statistically no difference was noted in vomiting between Group C and Group M (P = 0.0579). CONCLUSIONS: The results suggest that ondansetron and metoclopramide are effective in reducing the incidence of post-operative nausea. But ondansetron is more effective in reducing the incidence of post-operative morphine induced vomiting.

Comparison of Postoperative Analgesia and Side Effects according to Different Loading Doses of Morphine with the Same Total Dose / 대한마취과학회지

BACKGROUND: Epidural coadministration of opioids and local anesthetics has provided excellent analgesia during the postoperative period. The appropriate amount of epidural morphine for pain control with minimum side effects has been studied. Recently, we gave 6 mg of epidural morphine for 2 day pain control and discovered it was a safe and effective dose like the previous study result. This study was performed to compare postoperative analgesia and side effects according to different loading and infusion doses of morphine with the same total dose. METHODS: Forty-three patients having epiduro-general anesthesia for a hysterectomy were randomly divided into 2 groups. The patients received 2 mg (Control group, n = 19) or 3 mg (Experimental group, n = 24) of epidural morphine by bolus and a continuous epidural infusion was started using a two day infusor containing 4 mg (Control group) or 3 mg (Experimental group) of morphine in 100 ml of 0.125% bupivacaine. Visual analog scale (VAS) for pain, severity of nausea, itching and respiratory depression were assessed at 2, 4, 8, 16, 32 and 48 hours postoperatively. All data was evaluated with unpaired t-test for significances between the two groups. RESULTS: Analgesia between the two groups showed good results. The VAS in the experimental group were higher than the control group in the early postoperative period. Nausea scores were no different between the two groups. The itching scores in the experimental group were lower than the control group at postoperative 16 and 32 hours. No respiratory depression was reported in either group. CONCLUSIONS: This study suggests that different loading and infusion doses of the same total epidural morphine between two groups provided good postoperative pain relief without any differences in side effects.

Comparison of Continuous Epidural Analgesia with Fentanyl-Bupivacaine Versus Intravenous Patient-Controlled Analgesia with Morphine for Postoperative Pain Control / 대한마취과학회지

BACKGROUND: The postoperative pain control has improved with use of continuous epidural analgesia(CEA) and intravenous patient-controlled analgesia (IV-PCA). We compared the efficacy and safety of CEA using fentanyl-bupivacaine with IV-PCA using morphine in the postoperative pain control after total hysterectomy. METHODS: Sixty women undergoing hysterectomy were assigned to receive an epidural bolus of morphine 1 mg and 0.125% bupivacaine 10 ml, followed by a CEA with 0.00036% fentanyl and 0.075% bupivacaine at a rate of 5 ml/hr(CEA group) or intravenous bolus of morphine 2 mg followed by a IV-PCA with 0.1% morphine(IV-PCA group). Visual analog scales(VAS) for pain were recorded at 1, 6, 12, 24 and 48hr postoperatively and side effects and degree of satisfaction were noted. RESULTS: Resting and dynamic pain scores were significantly lower in the CEA group than in the IV-PCA group throughout the study period. The average pain scores using VAS in two groups were less than 4. There were no significant differences in side effects and degree of satisfaction between two groups. CONCLUSIONS: The continuous epidural infusion of fentanyl and bupivacaine provided better postoperative analgesia than IV-PCA morphine. The average pain scores of IV-PCA group was less than 4 and the incidence of side effects and degree of satisfaction were not significantly different between two groups. So, we think IV-PCA morphine is a convenient and effective alternative to CEA fentanyl -bupivacaine in patients declining to receive CEA.

Effect of postoperative analgesia with epidural morphine after cesarean section on prolactin and coiostrum / 中华麻醉学杂志

In order to observe the effect of postoperative analgesia with epidural morphine on the prolactin and colostrum after cesarean section. Method: Forty healthy full-term parturients undergoing elective cesarean section under epidural anesthesia, were randomly divided into two groups: the analgesic group (group A, n=20)and the controlled group (group C, n=20). Postoperative follow-up time was 48 hours. The plasma prolactin level was determined with radioimmunoassay. Result: The VAS of group A was significantly lower than that of group C (P

Epidural Morphine Spray for Pain Relief after Spine Surgery / 대한마취과학회지

Adequate postoperative pain control is in highlight because it has been known that uncontrolled pain has adverse effects on postoperative cardiopulmonary, immunologic functions and in turn, possibly prolongs patient's recovery. One hundred and two patients who underwent spine surgery including laminectomy, fusion and fixation were given 10mg of morphine into operative field (exposed epidural area) just prior to wound closure for relief of postoperative pain. These patients were compaired with 51 patients who did not received epidural morphine. The median of the numerical rating scale of epidural morphine spray group (Group A) at 4, 12, 24 hours after operation revealed 2, 3, 5 respectively and no epidural morhine group (Grade B) revealed 4, 5 and 5. In conclusion, postoperative pain relief of group A is superior to that of group B.

Effect of the Injected Volume Changes in Epidural Morphine on the Postoperative Pain Control after Caesarean Section / 대한마취과학회지

The epidural injection of 4 mg of morphine in a volume of 4 ml, 7 ml, and 10 ml (groups I, II, and III) for post-operative analgesia after Caesarean section(30 patients), was evaluated. Thirty patients received continuous epidural anesthesia with 2% lidocaine 20 ml, 8.4% bicarbonate 2 ml and epinephrine 1: 200,000. Patients were established to T4 level anesthesia with above local anesthetics, supplemented with 2% lidocaine, when necessary. Each patient received 4 mg of morphine epidurally after delivery of baby. The postoperative pain relief was considered good in all three groups. The duration of of pain relief in each group, I, II, and III was 22.2+/-2.9, 20.6+/-4.6 and 21.6+/-4.2 hours, respectively, which showed no statistical difference between any two youps. The quality of pain relief was almost same, except during 12~18 hours after observation, In tbat period, there was better pain relief in group I than the other two groups (p<0.05). With the result of this study, it might be suggested that we'd better use 4ml of injected volume when we give 4mg of epidural morphine after Caesarean section for postoperative pain control, even though the small difference was seen only after 12~18 hours.

Analgesic Effect of Epidural Morphine and Incisional Site Infiltration with Bupivacaine in the Lower Abdominal Surgery / 대한마취과학회지

IIn a randomized double-blind study, postoperative pain was assessed in 60 patients undergoing gynecologic surgery with three types of anesthesia; inhalation anesthesia only (enflurane-N2O-O2-vecuronium)(G); inhalation anesthesia with local infiltration (infiltration of the abdominal wall with 40 ml 0.25% bupivacaine along the line of the proposed incision)(GI); and inhalation anesthesia with epidural analgesia (morphine 2 mg mixed with 10 ml 0.125% bupivacaine)(GE). The severity of constant incisional pain, movement-associated incisional pain, and pain upon pressure applied to the surgical wound using 5 pounds of weight was assessed with a visual analogue scale at 2, 6, 12, 24, and 48 hours after surgery. The duration of analgesia (time from the end of the surgery to the first request for analgesic) was 7.9+/-3.1 hours in group G, 22.8+/-4.8 hours in group GI, and 33.1+/-3.9 hours in group GE, with statistically significant differences between group G and other two groups. Forced vital capacity (FVC), peak expiratory flow, and forced expiratory volume in 1 second (FEV1) were measured with the patients in a semisitting position. In all groups, there were no differences in above parameters, These results indicate that postoperative pain after lower aMominal surgery would be managed satisfactorily with infiltration of local anesthetic as well as epidural analgesia.

The Comparative Study of the Intrathecal Morphine Injection and Epidural Bupivacaine with Morphine Mixture Administration for Post - Operative Pain Relief / 대한마취과학회지

There are many methods for postoperative pain relief. For example,intramusoular or in- travenous administration of analgesics,nerve block,wound infiltration or intravenous injaction with local anesthetics, epidural or intrathecal injection of opioids or local anesthetics, TENS, cryoanalgesia, psychological support are available, We managed postoperative pain by means of intrathecal morphine injection or epidural morphine with bupivacaine mixture administration. In the group 1, morphine 0.2mg was injected intrathecally just after the operation. In the group 2, the mixture of morphine with bupivacaine was infused into epidural space continuously for 3days. The results were as follows; 1. The pain score was significantly decreased in group 2 compared to group 1.(P<0.05) 2. In group 1,there was signficantly more itehing sensation than in group 2.(P<0.05), but there were no significst differences in other complications 3. There was no significant difference in gas passing time. 4. The feeling of satisfaction was high in both groups,and there was no significant difference. 5. It was technically more difficult and the cost was higher in group 2.

The Effect of Transdermal Scopolamine Patch on Nausea and Vomiting after Epidural Injection of Morphine / 대한마취과학회지

Sixty patients, undergoing major gynecologic surgery with lumbar epidural anesthesia, were randomly selected 32 patients to apply a transdermal scopolamine patch (Kimite MyoungMoon, Korea) on the skin behind one ear. We were divided into 2 groups. Control group; epidural morphine 4mg were given and not applied scopolamine patch. Experimental group; epidural morphine 4mg were given and applied transdermal scopolamine patch on the skin behind her ear at the night before surgery. They were followed up for 3 days postoperatively and statistical analysis was done. There was a significant (p<0.05) reduction in nausea and vomiting between experimental group and control group. There was no significant incresed incidence in scopolamine side effects. However, despite receiving transderrnal scopolamine patch there was still a high incidence (43.8%) of nausea and vomiting.

Analgesic effects of continuous epidural infusion of morphine and bupivacaine after cesarean section / 대한마취과학회지

This study was undertaken to evaluate the analgesic effect of the combination of epidural morphine and bupivaeaine versus epidural morphine alone for postoperative pain. In a ran- domized study, epidural infusions of morphine combined with bupivacaine were compared with bolus epidural injection of morphine alone for postoperative analgesia at rest and dur- ing mobilization and coughing in 80 patients after elective cesarean section. Eighty patients were divided into 2 groups ; M (control) group ; bolus administration of morphine (4mg) and bolus reinjection (4mg) after 24 hours, MB (experimental) group ; bolus administration of morphine (1.5mg) and continuous administration of bupivscaine and morphine (7mg morphine in normal saline 7ml plus 100ml of 0.2% bupivacaine) with the Baxter infusor. Static and dynamic pain scores at 6, 12, 24, 36, 48 hours after operation were examined and side effects were recorded. The results were as follows ; 1) Static VAS was significantly lower in group MB compared with group M at 12, 24, and 36 hours (p< 0.05). 2) Dynamic VAS was significantly lower in group MB compared with group M throughout the study (p<0.01). 3) Pruritus was greater in group MB than in group M but statiscally not significant. 4) Nausea was greater in group M than in group MB but stetiscally not significant. 5) None of patients had respiratory depression. We concluded that continuous epidural infusion of bupivacaine and morphine is more useful than morphine alone for post operative pain management after cesarean section.

Epidural morphine on ventilatory function in chest trauma and thoracotomy patients

Epidural morphine injection was done in nineteen patients who had been admitted from March to August 1990 to the Intensive Care Unit, Severance Hospital, Yonsei Medical Center for respiratory care including ventilator care. Morphine suplphate, 2.67 +/- 0.27 mg was injected one to three times to four patients after chest trauma, and to fifteen patients after thoracotomy. Tidal volume and vital capacity were increased from 4.45 +/- 0.48 and 8.31 +/- 0.50 to 6.91 +/- 0.41 and 12.81 +/- 0.73 mg/kg. However, respiratory rates decreased from 26.07 +/- 1.41 to 20.07 +/- 1.16/min. Inspiratory force increased from -13.40 +/- 1.31 to -26.53 +/- 1.82 cmH2O. Pain score decreased from 9.22 +/- 0.57 to 3.56 +/- 0.83 during this period. PaCO2 did not differ significantly (39.33 +/- 1.13 and 39.48 +/- 1.42 mmHg). Side effects such as pruritis and urinary retention were treated with naloxone 7 approximately 10 ng/kg/min. Mean arterial pressure and pulse rates stayed stable during the study periods. Ventilator hours and ICU stays differed from the control group. However, the duration was not statistically significant. The control group consisted of patients who were admitted during the six months from September 1989 to February 1990 to the ICU for respiratory care, without epidural morphine injection.

Epidural Morphine Does not Reduce Mean Inspired Concentration of Isoflurane in Humans during General Anesthesia / 대한마취과학회지

The effect of epidural morphine on the mean inspired concentration of isoflurane was inves- tigated in 34 patients undergoing hepatoma surgery, The patients were randomly assigned to the control(CTRL), epidural morphine(MORP) or epidural bupivacaine(BUPI) groups. Before induction of anesthesia, epidural catheter was inserted beween T6-10 intervertebral space in the right lateral decubitus position. MORP group(n=13) received morphine sulfate 4 mg in 4 ml normal saline and BUPI group(n=10) received 0.5% bupivacame 10 md through epidural eatheter. CTRL group(n=11) wss treated in an identical fashion except that, after placement of epidural catheter, nothing was injected. After endotracheal intubation, general anesthesia was maintained during surgery with oxygen-nitrous oxide(1:1 ratio) and isoflurane. Inspired concentration of isoflurane was adjusted to maintain blood pressure in the range of blood pressure at the ward during surgery. Mean inspired concentration of isoflurane was monitored from incision to last skin suture. Mean inspired concentration of isoflurane(+/-SD) of CTRL, MORP and BUPI group was 1.41+/-0.36, 1.52+/-0.39 and 0.37+/-0.16 vol%, respectively. There was no difference in mean inspired concentration of isoflurane between CTRL and MORP group. Under the condition of this study, epidural morphine did not reduce inspired concentration of isoflurane during surgery even though epidural morphine is effective for post operative pain control.

Peroperative Administration of Epidural Morphine for postoperative Analgesia in Spinal Surgery (A double blind study) / 대한정형외과학회잡지

These days, the epidural administration. of morphine is commonly used for postoperative pain re lief because even small amount of morphine (3mg) is enough to have an effect on specific opiates receptors of the spinal canal. We report a prospective double blind study of the efficacy of a single epidural dose of morphine on pain after spinal decompression. Postoperative pain was assessed by a linear analogue pain score and by the additional require ment for systemic analgesics. The results obtained are as follows:l. In spinal decompression, the adminitration of epidural morphine is easy, effective and safe because the epidural space has been already exposured during operation. 2. After operation the epidural route of morphine administration will give pain relief for up to 12 hours excellently. 3. When epidural morphine is given at the time of operations, the use of systemic analgesics is much reduced. 4. The side effects of epidural morphine are much reduced due to the small amount of morphine required. This simple procedure is recommended as an effective and safe method of reducing postoperative pain.

Intrathecal and Epidural Morphine for Postoperative Pain Control after Lumbar Laminectomy

A number of reports have shown that intrathecal and epidural administration of morphine provides acute or chronic pain relief. We report the use of morphine for postoperative pain control in 84 lumber laminectomy patients. These patients were compared to the 24 control patients. Single dose of morphine in 0.5ml saline was administered under the direct vision into the intrathecal or the epidural space just before the closure of the lumbar operative wound. Intrathecal group was divided into 4 subgroups 0.2mg, 0.5mg, 1mg and 2mg and epidural group was also divided into 2 subgroups 2mg, 5mg, respectively. Under the visual pain analogue scale, postoperative pain control were statistically significant in intrathecal 0.5mg, 1mg and epidural 2mg, 5mg group, respectively(P<0.01). Respiratory depression was occurred in 2 cases of intrathecal 2.0mg group and nausea with vomiting was occurred in 10 cases but prutitus was not occurred. Urinary Retention was developed between 86.7% and 100% of study group compared to 45.8% of control group.

Transient Cauda Equinal Irritation due to the Subarachnoid Spread of Epidural Morphine Through a Previous Dural Puncture Site / 대한마취과학회지

Signs and Symptoms consistent with the irritation of the cauda equina developed during epidural morphine therapy for the relief of pain from osteosarcoma in a 10-year-old female patient. This was considered to be due to a subarachnoid diffusion of the epidurally administrated morphine through the dural opening formed by a previous inadvertent dural puncture. The subarachnoid diffusion of the drug was confirmed by fluoroscopy following injection of the contrast media through the indwelling epidural catheter. The chemical inflammation of the cauda equina might be due to substances formed by chemical reactions with a certain preservative vehicle rather than the morphine itself. Spinal steroid therapy may be effective for the suppression of a chemical inflammatory reaction.

Epidural Morphine for Control of Pain after Lumbar Laminectomy

Epidural morphine has been used successfully for the relief of acute or chronic pain by direct injection or catheter method. We report the use of morphine for postoperative pain control in 18 herniated lumbar disc patients. These patients were compaired with 25 others who were not received epidural morphine. Without using of epidural catheter, single small dose morphine(3~5mg) in 1.5ml normal saline was administered under the direct infution into the epidural space just before closure of the lumbar operative wound. Epidural morphine group required only 2 times of parenteral narcotics injections within the first 24 hours after lumbar laminectomy, whereas nonmorphine group required 48 injections. The average narcotics injection frequencies were statistically significant(p<0.01). Hypotension were occured in three cases and pruritus in two cases. But more investication and study were needed for hypotension which was true side effect or not. Respiratory depression was not occured.