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1.
Spine (Phila Pa 1976) ; 43(2): E98-E104, 2018 Jan 15.
Article in English | MEDLINE | ID: mdl-28538591

ABSTRACT

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: The aim of this study was to demonstrate that intrathecal morphine (ITM) and oral analgesics provide effective pain control after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS), and this protocol has a low complication rate so patients can be admitted to a general care floor. SUMMARY OF BACKGROUND DATA: Previous studies have shown that ITM combined with intravenous patient-controlled analgesia or epidural infusion (EPI) provides effective pain control after PSF for AIS. Owing to concerns for respiratory depression, ITM patients were routinely admitted to the intensive care unit (ICU) postoperatively. There are little data on ITM combined with oral analgesics. METHODS: We identified AIS patients aged 10 to 17 years who had undergone PSF. Twenty-eight patients who received ITM were matched to 28 patients who received a hydromorphone EPI. The ITM group received oral oxycodone starting at 16 hours postinjection. The EPI group received oxycodone after the epidural catheter was removed on postoperative day 2. Pain scores, adverse events, and length of stay were recorded. RESULTS: A higher number of EPI patients received fentanyl (11 vs. 3, P = 0.014) in the post-anesthesia care unit (PACU). The ITM group had lower pain scores between PACU discharge and midnight (mean 2.9 vs. 4.2, P = 0.034). Pain scores were similar during the remaining postoperative periods. All ITM patients transitioned to oxycodone without intravenous opioids. Time to ambulation (19.9 vs. 26.5 hours, P = 0.010) and Foley catheter removal (21.3 vs. 41.9 hours, P < 0.001) were earlier in the ITM patients. Length of hospital stay was shorter in the ITM group (3.1 vs. 3.5 days, P = 0.043). Adverse events occurred at similar rates in both groups. CONCLUSION: ITM and oral analgesics provide safe and effective pain control after PSF for AIS. Routine postoperative admission to the ICU is not necessary. LEVEL OF EVIDENCE: 3.


Subject(s)
Analgesics, Opioid/therapeutic use , Morphine/therapeutic use , Pain, Postoperative/drug therapy , Scoliosis/surgery , Spinal Fusion/methods , Adolescent , Analgesia, Epidural/methods , Analgesia, Patient-Controlled/methods , Analgesics, Opioid/administration & dosage , Child , Female , Fentanyl/administration & dosage , Fentanyl/therapeutic use , Humans , Male , Morphine/administration & dosage , Oxycodone/administration & dosage , Oxycodone/therapeutic use , Pain Management , Pain Measurement , Pain, Postoperative/etiology , Postoperative Period , Retrospective Studies , Spinal Fusion/adverse effects , Treatment Outcome
2.
Paediatr Anaesth ; 27(1): 91-97, 2017 Jan.
Article in English | MEDLINE | ID: mdl-27878902

ABSTRACT

BACKGROUND: Posterior spinal fusion to correct idiopathic scoliosis is associated with severe postoperative pain. Intrathecal morphine is commonly used for analgesia after adolescent posterior spinal fusion; however, anticipating and managing the increase in pain scores after resolution of analgesic effect of intrathecal morphine analgesia is challenging. In 2014, we developed a clinical protocol detailing both the administration of intrathecal morphine intraoperatively and the transition to routine, scheduled oral analgesics at 18 h postoperatively. The goal of our study was to examine the efficacy of our intrathecal morphine protocol vs epidural hydromorphone for postoperative analgesia after posterior spinal fusion. METHODS: Following IRB approval, we retrospectively identified developmentally intact children of ages 10-20 years in our electronic database with a diagnosis of idiopathic scoliosis who had undergone elective posterior spinal fusion surgery from June 2014 to April 2015. For the intrathecal morphine group, intrathecal morphine was administered in a dose of 12 µg·kg-1 (max 1000 µg) prior to incision. Postoperatively, all children in the intrathecal morphine group had an order to receive oral oxycodone (0.1 mg·kg-1 , max 5 mg) starting at 18 h postintrathecal morphine injection. For the epidural hydromorphone group, catheters were placed by the surgeon and bolused with 5 µg·kg-1 hydromorphone (max 200 µg) and 1 µg·kg-1 fentanyl (max 50 µg), followed by a continuous infusion of 40-60 µg·h-1 , and patient-controlled bolus doses of 5 µg with a lockout interval of 30 min. All patients in both groups had postoperative orders for acetaminophen, diazepam, and ketorolac. RESULTS: During the study time period, 20 patients received intrathecal morphine and were successfully matched with 20 patients who received epidural hydromorphone. All patients in the intrathecal morphine group were transitioned to oral analgesics on the first postoperative day, without need for intravenous opioids after discharge from the postanesthesia care unit. Compared to the epidural hydromorphone group, the intrathecal morphine group reported lower pain scores in the postanesthesia care unit (difference in means -4.26 [95% CI -6.56, -1.96], P = 0.001) and first 8 h after surgery (difference in means -1.88 [95% CI -3.84, 0.082, P = 0.060) and higher pain scores on the 2nd postoperative day (difference in means 1.60 [95% CI 0.10, 3.10], P = 0.037). The documented time to ambulation and time of Foley catheter removal were statistically earlier in the intrathecal morphine group, and the hospital length of stay was significantly shorter (3.0 ± 0.5 days vs 3.5 ± 0.7 days; P = 0.03). Adverse events did not significantly differ between the groups. CONCLUSION: The efficacy of intraoperative intrathecal morphine for postoperative analgesia in the posterior spinal fusion patient population has been shown previously; however, the pain and analgesic trajectory, including transition to other analgesics, has not previously been studied. Our findings suggest that for many patients, use of intrathecal morphine in addition to routine administration of nonopioid medications facilitates direct transition to oral analgesics in the early postoperative period and earlier routine ambulation and discharge of posterior spinal fusion patients.


Subject(s)
Analgesia, Epidural/methods , Hydromorphone/therapeutic use , Morphine/therapeutic use , Pain, Postoperative/drug therapy , Scoliosis/surgery , Spinal Fusion , Adolescent , Adult , Analgesics, Opioid/therapeutic use , Child , Female , Humans , Injections, Spinal , Male , Retrospective Studies , Treatment Outcome , Young Adult
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