Intrathecal Morphine for Laparoscopic Segmental Colonic Resection as Part of an Enhanced Recovery Protocol

Abstract

Background and ObjectivesManagement of postoperative pain after laparoscopic segmental colonic resections remains controversial. We compared 2 methods of analgesia within an Enhanced Recovery After Surgery (ERAS) program. The goal of the study was to investigate whether administration of intrathecal bupivacaine/morphine would lead to an enhanced recovery.MethodsA single-center, randomized, double-blind controlled trial was performed (NL43488.101.13). Patients scheduled for laparoscopic segmental intestinal resections were considered. Exclusion criteria were patients in whom contraindications to spinal anesthesia were present, conversion to open surgery, and gastric and rectal surgery. The intervention group received single-shot intrathecal bupivacaine/morphine (12.5 mg/300 μg), with an altered dose for older patients. The control group received a sham procedure and a bolus of piritramide (0.1 mg/kg). Both groups received standardized general anesthesia and a patient-controlled intravenous analgesia pump as postoperative analgesia. All patients were treated according to an ERAS protocol. A decrease in days to “fit for discharge” was the primary outcome.ResultsFifty-six patients were enrolled. Intervention group patients were fit for discharge earlier (median of 3 vs 4 days, P = 0.044). Furthermore, there was a significant decrease in opioid use and lower pain scores on the first postoperative day in the intervention group. There were no differences in adverse events (except for more pruritus), time to mobilization, fluid administration, or patient satisfaction.ConclusionsThis randomized controlled trial shows that intrathecal morphine is a more effective method of postoperative analgesia in laparoscopic surgery than intravenous opioids within an ERAS program. Recovery is faster and less painful with intrathecal morphine. Other studies have confirmed these results, although data on faster recovery are new and require confirmation in future trials.Clinical Trial RegistrationThis study was registered at ClinicalTrials.gov, identifier NCT02284282.

Efficiency and safety of intrathecal morphine for analgesia after hysterectomy

“…The SFS with analgesia may be the most important factor when opting for postoperative analgesia. As many as 96% of the group A patients assessed analgesia as excellent, whereas only 20% of those from group B were of that opinion, which is in discrepancy with a similar study which showed almost equal satisfaction of patients with analgesia [29].…”

“…Itching is often mentioned in literature as a frequent side effect of intrathecal morphine, particularly in obstetrics, where gestation hormones may lead to certain changes on opioid receptors [28]. Some researchers from the Netherlands have shown that intrathecal administration of morphine for laparoscopic colon resection is followed with itching more often [29].…”

“…The intensity of postoperative pain after hysterectomy ranges from moderate to severe. The efficient pain control leads to the earlier mobilization of patients and their faster recovery, thus leading to shorter hospitalization and lower treatment expenses [2][3][4][5]. Controlling acute pain after surgery is important not only in the immediate postoperative phase but also to prevent chronic postsurgical pain, which can develop in as many as 10% of patients [6].…”

Effect of intrathecal morphine and epidural analgesia on postoperative recovery after abdominal surgery for gynecologic malignancy: an open-label randomised trial

“…Multimodal analgesic regime minimising opioid use has been shown to enhance recovery 2 30. ITM has become a well-documented component in several ERAS protocols29 31–34 and a protocol for a systematic review of ITM in abdominal and thoracic surgery patients has recently been published 35. Despite the higher rating of NRS at mobilisation during the first few days in the ITM group, the consumption of opioids was nearly three times lower in the same time period compared with the EDA group, and the QoL index did not differ between the groups.…”

Measurement of drug concentration and bacterial contamination after diluting morphine for intrathecal administration: an experimental study

“…A single dose of 100-300 µg produces analgesia that lasts over 24 hours. 1,2 However the fear for late respiratory depression typically occurring 6-11 hours after administration 3 limits the use of Intrathecal morphine.…”