Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain

Mhuircheartaigh, R. J. Ni; Moore, Richard A.; McQuay, Henry J

doi:10.1093/bja/aep300

Cited by 59 publications

(58 citation statements)

References 24 publications

(9 reference statements)

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“…Pain is measured using standard scales, usually a visual analogue scale (0 to 100), a numeric rating scale (0 to 10), or a verbal rating scale (none, mild, moderate, severe). People whose postoperative pain is below 30/100 (or 3/10, or none or mild) tend to rate their experience as very good or excellent, whereas people with higher levels of postoperative pain tend to be more dissatisfied ( Mhuircheartaigh 2009). This accords with people's attitudes more generally .…”

Section: Description Of the Conditionmentioning

confidence: 99%

Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

Moore¹,

Derry²,

Aldington

et al. 2015

Cochrane Database of Systematic Reviews

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Despite ongoing problems with the measurement, recording, and reporting of adverse events in clinical trials and in systematic reviews, the large amount of information available for single oral doses of analgesics provides evidence that adverse events rates are generally similar with active drug and placebo in these circumstances, except at higher doses of some drugs, and in combinations including opioids.

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Section: Description Of the Conditionmentioning

confidence: 99%

Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

Moore¹,

Derry²,

Aldington

et al. 2015

Cochrane Database of Systematic Reviews

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“…Prophylactic analgesia with EREM leads to a more satisfactory patient experience than IV PCA. In this review [16], there were three strong findings. Epidural morphine resulted in greater patient satisfaction, despite higher rates of adverse events.…”

Section: Current Clinical Use Of Epidural Opioidsmentioning

confidence: 80%

“…It can be administered as a bolus (30-100 μg/kg) or as continuous infusion (0.2-0.4 mg/h), which seems to induce better quality analgesia, and alone or together with local anesthetics, as synergy between the drugs increases the overall analgesic effect [11,14]. In addition, controlled studies [15,16] have demonstrated that a single-dose EREM (Extended Released Epidural Morphine) can provide up to 48 hours very good quality of postoperative analgesia with an acceptable and predictable side effect profile (dose < 15 mg). Prophylactic analgesia with EREM leads to a more satisfactory patient experience than IV PCA.…”

Section: Current Clinical Use Of Epidural Opioidsmentioning

confidence: 99%

Which Epidural Opioid is More Suitable for Postoperative Pain Management?

2017

JACCOA

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Opioids have always been considered the best option in clinical practice for the treatment of severe postoperative pain. However, the spinal administration of an opioid drug does not always guarantee selective action and segmental analgesia in the spine. This fact is due to partial reuptake to blood systemic circulation reaching brain receptors. Recent evidence from clinical studies indicates that bioavailability in the spinal cord biophase is negatively correlated with liposolubility, which is higher for hydrophilic opioids, than for lipophilic ones. Actually, clinical guidelines recommend using a mixture of local anesthetic plus a strong opioid to improve the global analgesic effect, minimize adverse effects and improve the overall patient´s satisfaction. Moreover, an opioid alone like morphine can be administered to provide a long period of postoperative analgesia for 24h, or even 48 h when an extended release epidural formulation is used. In this narrative review, practical information for correct spinal opioid selection is provided to help the physicians a better choice for postoperative epidural analgesia.

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“…3 Intravenous analgesia was inferior to neuraxial analgesia. Extended-release epidural morphine resulted in a small therapeutic gain.…”

Section: Commentmentioning

confidence: 99%

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-Release Epidural Morphine (DepoDur™) After Cesarean Delivery

Ralls¹,

Drover²,

Clavijo³

et al. 2012

Survey of Anesthesiology

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and treatment of nausea and vomiting in the setting of cesarean delivery. Currently, there is a dearth of effective therapies in the setting of established PONV. Ondansetron has limited success as a Brescue[ antiemetic when previously given as a prophylactic agent. In this circumstance, there is a potential role for the combined use of pharmacologic and nonpharmacologic treatments. Because ondansetron and acupuncture operate via different pathways, their antiemetic effects may be additive, or even synergistic. Ondansetron, a selective 5-HT 3 antagonist, blocks the proemetic influence of serotonin on peripheral vagal nerve terminals and on the central chemoreceptor trigger zone. Although the precise mechanism is not clearly defined, it has been suggested that acupuncture modulates endogenous neurotransmitters, influences nausea centers, and inhibits relaxation of the lower esophageal sphincter. Although this study focused on the role of acupuncture in the prevention of PONV, further studies are needed to explore the potential of this therapy as a combination technique, especially in the setting of established nausea and vomiting.A lthough extended-release epidural morphine (EREM) provides superior and prolonged analgesia after cesarean delivery compared with conventional epidural morphine, studies have indicated that an interaction between epidural lidocaine and EREM may negate the sustained-release effect and may result in higher peak serum morphine concentrations. No previous study has determined the pharmacokinetic and drug effects of a large volume of 2% lidocaine before EREM administration. This single-center, randomized, blinded study was undertaken to compare the pharmacokinetic profiles of EREM alone or after a large dose of 2% lidocaine.Thirty patients with a singleton pregnancy having a cesarean delivery during regional anesthesia were enrolled. Patients in group E (epidural) received an epidural top-up anesthetic of 2% lidocaine with epinephrine 1:200,000 and sodium bicarbonate. The lidocaine solution was given in 5-mL increments every 2.5 minutes until a T6 sensory level was reached. They also received fentanyl through the epidural catheter after 10 mL of the lidocaine solution had been administered. Group SE (spinal/ epidural) received a combined spinal-epidural anesthetic of 12 mg hyperbaric bupivacaine 0.75% with 20 Kg fentanyl, given intrathecally; no local anesthetic was given through the epidural catheter. At 1 hour after the intrathecal dose in group SE or after the initial lidocaine administration in group E, all patients received EREM 8 mg (DepoDur) through the epidural catheter. In group E, if patients had intraoperative pain during the delivery, additional epidural 2% lidocaine was administered. If additional doses of epidural lidocaine were required, EREM was not given for at least an additional 30 minutes after a bolus of 2.5 to 7.5 mL or an additional 60 minutes after a bolus of 7.5 to 15 mL. The maximum total lidocaine dose permitted was 35 mL. If a patient in group SE had intraoperative...

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Analysis of individual patient data from clinical trials: epidural morphine for postoperative pain

Cited by 59 publications

References 24 publications

Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

Adverse events associated with single dose oral analgesics for acute postoperative pain in adults - an overview of Cochrane reviews

Which Epidural Opioid is More Suitable for Postoperative Pain Management?

Prior Epidural Lidocaine Alters the Pharmacokinetics and Drug Effects of Extended-Release Epidural Morphine (DepoDur™) After Cesarean Delivery

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