Anesthesia, Spinal, Hysterectomy, Morphine, Pain, Postoperative
Conditions
Brief summary
Perioperative multimodal analgesia, defined by the use of various analgesic medications targeting different drug receptors, provides adequate pain relief with minimal or no opiate consumption. Therefore, it represents one of the cornerstone of Enhanced Recovery After Surgery (ERAS) protocols, as the reduction in opioid use and the associated side effects may eventually reduce length of hospital stay, increase patient satisfaction and minimise the risk of long-term opioid use. Regional and neuraxial anesthesia techniques are key interventions to provide successful analgesia in the context of a multimodal strategy. Intrathecal morphine, for its effectiveness and potential of reducing the need of intravenous postoperative opioids, seems an attractive option in the case of hysterectomy, one of the most common major surgical procedures performed in women, associated with severe postoperative pain even when performed laparoscopically. The aim of our observational retrospective study is therefore to compare the analgesic efficacy and the safety of morphine administered by intrathecal route versus intravenous route during the first 48 hours after performance of laparoscopic/laparotomic hysterectomy.
Interventions
PROCEDUREAdministration of morphine by intrathecal route
Lumbar puncture was performed before the induction of general anesthesia, in the operating room. Spinal anesthesia was performed in sitting position using a midline approach into the L3-L4 or L4-L5 interspaces with a 25ga pencil-point spinal needle administering 75-100 mcg morphine, with or without local anesthetic (levobupivacaine 0,5% 10-15 mg or bupivacaine 0,5% 10-15 mg or ropivacaine 0,5% 10-15 mg), depending on the anesthesiologist's preference. General anesthesia was then conducted according to clinical practice. All patients were transferred in the Post-Anesthesia Care Unit (PACU) at the end of surgery. Throughout the first 48 postoperative hours, all patients were regularly evaluated in the hospital ward by a member of the Acute Pain Service Team.
PROCEDUREAdministration of morphine by intravenous route
General anesthesia was conducted according to clinical practice and a morphine bolus was administered before emergence from anesthesia according to clinical needs. All patients were then transferred in the Post-Anesthesia Care Unit (PACU) at the end of surgery and received Patient-Controlled Analgesia (PCA) with morphine 1mg/mL (CADD®-Solis 2110 Infusion System, Smiths Medical ASD, Inc., USA, 1 mL bolus on demand, no background infusion, 7 minute lockout, max 8 mg/h). Throughout the first 48 postoperative hours, all patients were regularly evaluated in the hospital ward by a member of the Acute Pain Service Team.
Sponsors
Fondazione Policlinico Universitario Agostino Gemelli IRCCS
Study design
Observational model
CASE_CONTROL
Time perspective
RETROSPECTIVE
Eligibility
Sex/Gender
FEMALE
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult women American Society of Anaesthesiologists (ASA) physical status \<= 3, scheduled for elective hysterectomy under general anesthesia between January 1st 2019 and December 31st 2021.
Exclusion criteria
* patients with American Society of Anaesthesiologists (ASA) status \> 3, * opioid use or history of opioid dependence, * chronic use of analgesic medications, * psychiatric disorders.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Numeric pain rating scale (NPRS) | Time 0 (= baseline, i.e. at the time of Postoperative Anesthesia Care Unit arrival) | Numeric pain rating scale (NPRS) (ranging from 0, "no pain" and 10, "the worst pain imaginable") at rest |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Adverse events | After the end of surgery, in the first 48 postoperative hours | Any adverse event, like sedation, itching, nausea, motor weakness, signs of local anesthetic toxicity |
| Constipation | After the end of surgery, in the first 48 postoperative hours | The presence of opioid-induced constipation |
| Mobilization | After the end of surgery, in the first 48 postoperative hours | Time of first mobilization after the surgical procedure |
| Intraoperative opioid consumption | During the surgery | Total opioid consumption |
| Postoperative opioid consumption | After the end of surgery, in the first 48 postoperative hours | Total opioid consumption |
| Rescue analgesia | After the end of surgery, in the first 48 postoperative hours | The use of non-opioid rescue analgesics in case of NPRS \> 3, other than around the clock pain medications |
| Length of PACU stay | Time from admission to dismissal from PACU, an average of 1 hour | Length of stay in Postoperative Anesthesia Care Unit (PACU) |
| Length of hospital stay | Time from dismissal from PACU to dismissal from hospital, an average of 72 hours | The Length of Hospital Stay (LOS) after the surgery |
Countries
Italy
Contacts
PRINCIPAL_INVESTIGATORStefano Catarci
Fondazione Policlinico Universitario A. Gemelli, IRCCS
Outcome results
None listed