The Role of Intrathecal Morphine for Postoperative Analgesia in Primary Total Joint Arthroplasty under Spinal Anesthesia: A Systematic Review and Meta-Analysis

Abstract

Objective To assess the efficacy and safety of intrathecal morphine (ITM) for postoperative analgesia in primary total joint arthroplasty (TJA) under spinal anesthesia and to explore the dose-response relationship for analgesic efficacy or risk of side effects. Methods We searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for any studies meeting the inclusion criteria. All the data were summarized using the random effects model. Subgroup analyses were performed based on the surgical procedure and dose of ITM. Meta-regression was used to explore the dose-response relationship. Results Eighteen randomized controlled trials were included. Compared with the placebo or blank control, ITM reduced the postoperative 24-h morphine consumption by 10.07 mg and prolonged the duration of analgesia. However, ITM significantly increased the risk of pruritus by 2.79 fold, with a tendency to increase the risk of postoperative nausea and/or vomiting (P = 0.08). No difference was observed regarding the length of stay (LOS) and incidence of respiratory depression or urinary retention. Furthermore, meta-regression showed a linear dose-response relationship for the postoperative 24-h morphine consumption but no linear dose-response relationship for the risk of side effects. Conclusions Adding morphine to intrathecal anesthetics provides a prolonged and robust analgesic effect without significantly increasing the risk of side effects other than pruritus. Although we found a linear dose-response relationship for the postoperative 24-h morphine consumption, the optimal dose of ITM remains to be further explored in high-quality RCTs with a large sample size.

Progress in Immunoassays of Toxic Alkaloids in Plant-Derived Medicines: A Review

“…Modified toxic alkaloids and their derivatives are haptens usually carrying carboxyl or amino groups, but a few contain other groups such as aldehyde. The carbodiimide method ( Figure 2 B) [ 73 , 80 , 81 ], mixed anhydride method ( Figure 2 D) [ 53 , 82 ], and active ester method ( Figure 2 E) [ 31 , 52 , 53 , 78 , 83 ] are the most widespread and universal coupling methods used for hapten containing carboxyl groups. The glutaric dialdehyde methods ( Figure 2 C) [ 72 , 84 ] are often used for haptens containing amino groups.…”

“…Poisoning of people and livestock caused by improper treatment, accidental ingestion, homicide, or accident frequently occurs and seriously limits the safety of clinical use of plant-derived medicines [ 29 ]. Morphine, codeine, and cocaine, the first isolated secondary metabolites, have been transformed into important drugs due to the effect of local anesthesia [ 30 , 31 ]. Yet people’s abuse or long-term use of these alkaloids can cause an irregular heart rate and myocardial infarction and disrupt the balance of various physiological tissues in the body.…”

Analgesic efficacy and risk of low-to-medium dose intrathecal morphine in patients undergoing cardiac surgery: An updated meta-analysis

“…Intrathecal morphine (ITM), which enables rapid action of morphine on the central nervous system by enhancing its access to the cerebrospinal fluid, is being increasingly used in a variety of surgeries to provide effective analgesia and decrease opioid consumption (12)(13)(14)(15). In addition to its analgesic advantages, other beneficial effects may include a potentially reduced hospital length of stay (LOS) and enhanced recovery after surgery (15)(16)(17).…”

“…In addition to its analgesic advantages, other beneficial effects may include a potentially reduced hospital length of stay (LOS) and enhanced recovery after surgery (15)(16)(17). However, its use may be associated with side effects such as nausea, vomiting, itching, and even respiratory depression (12)(13)(14)(15). Although ITM has been used for decades in patients undergoing cardiac surgery, its possible association with respiratory depression as reported in a previous meta-analysis (i.e., odds ratio of 7.86) has raised a clinical concern that may restrict its application in this patient population (18).…”

Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta‐analysis with meta‐regression and trial sequential analysis

“…Notably, there have been no recent studies synthesising data on the efficacy and safety of intrathecal morphine in lower limb arthroplasty, with older data no longer representing current peri‐operative practice [ 9 ]. One recent meta‐analysis attempted to examine this question but failed to provide sufficient clinically useful evidence as the results were subject to significant bias, including the absence of registration before publication; incomplete literature search; exclusion of relevant studies; and no assessment of patient‐centred outcomes such as pain score [ 10 ].…”