The E cacy of Intrathecal Morphine for Postoperative Patient Controlled Epidural Analgesia after Laparoscopic Bariatric Surgery

Head & Assistant Professor of Anesthesia & Pain Medicine Department, Medical Research Institute, Alexandria University, Egypt. Fellow Degree of Interventional Pain Practice-WIP. Postgraduate Certi cate in Pain Management, Cardi University, UK.
BACKGROUND: In this prospective, randomized, double-blind and placebo controlled study, two doses of intrathecal (IT) morphine were evaluated for the e cacy on the postoperative patient controlled epidural analgesia (PCEA) after laparoscopic bariatric surgery. METHODS: Fifty one patients were randomly enrolled into three groups: M4 group (n=17) in whom patients received IT morphine in a dose of 400 g, M5 group (n=17) in whom patients received IT morphine in a dose of 500 g and MP group (n=17) (Placebo) in whom patients received IT saline without morphine. Combined spinal-epidural technique was performed for every patient and the postoperative PCEA was administrated via an epidural catheter. The primary objective was to determine the cumulative fentanyl consumption during the rst 24 postoperative hours. The secondary objectives; the intraoperative IV fentanyl requirements, the rst request for PCA rescue, numeric pain score at rest and on coughing and the possible adverse e ects, were recorded. RESULTS: Fentanyl consumption in the rst 24 postoperative hours was signi cantly decreased in the morphine groups with insigni cant di erence between the morphine groups. However, statistical signi cant di erences was shown when either M4 or M5 groups compared with placebo group (P1<0.05, P2 <0.001, respectively). Intraoperative IV fentanyl requirements showed statistical signi cant di erences when either M4 or M5 groups compared with placebo group (P1<0.01, P2<0.01, respectively). The rst request for PCA rescue, were signi cantly delayed in morphine groups. The numeric pain scores at rest and on coughing were signi cantly lower in the M4 group until the 16th postoperative hours and until the 24th postoperative hours in M5 group. CONCLUSIONS: IT morphine provided a signi cant reduction in postoperative cumulative fentanyl consumption during the rst 24 postoperative hours after laparoscopic bariatric surgery. Moreover, the administration of IT morphine had additional advantages without serious adverse e ects. When the patient in PACU reported a numeric pain score of 4, all patients received epidural fentanyl via PCA device for the rst 24postoperative hours, (neither background infusion nor bolus dose was used), PCA (demand) dose of 20 g with a lockout interval of 5 minute, and a maximum limit/4hour of 500 g). If pain relief was inadequate at any time the lockout interval was reduced. Postoperative pain management was achieved by PCEA. The numeric pain score (NPS) at rest and on coughing (0 = no pain and 10 = the worst imaginable pain) was collected regularly during the rst 24 hours at 2,4,6,8,12,16,20,and 24 hours. The NPS on coughing was standardized and registered with patients in the semi-setting position. An overall satisfaction score according to postoperative analgesia (nil = 0; mild = 1; good = 2; excellent = 3) was recorded for 24 hours. Patients were assessed using a sedation scale (wide awake = 0; mildly sleepy and responsive to verbal command = 1; moderately sleepy and responsive to nociceptive stimulation = 2; extremely sleepy and unresponsive to nociceptive stimulation = 3).

Ahmed Fawzi El Molla (MD, FIPP, PGcert)

Table (3): Incidence of postoperative side e ects in the study groups

M4 N=17 No. Nausea Vomiting Pruritus Drowsiness Respiratory depression 6 2 13 7 % 35.3 11.7 76.5 41.2 No. 7 3 14 9 M5 N=17 % 41.2 17.6 82.3 52.9 MP N=17 No. % 5 2 9 6 29.4 11.7 52.9 35.3 0.048* 0.452 0.031* 0.41 -

P<0.05 is signi cant * signi cant with MP group. Data are numbers expressed inpercentage. MP group= placebo group; M4 group=morphine group (400 g); M5 group=morphine group (500 g).

RESULTS
Cumulative fentanyl consumption in the rst 24 postoperative hours showed statistically signi cant reduction in the morphine groups, when compared with MP group. No statistical signi cant di erence between the morphine groups (table 2).

DISCUSSION
The hypothesis of the current study was that, preoperative IT morphine may improve the quality of postoperative pain relief when preceded to patient-controlled epidural fentanyl analgesia. The assumed bene t was reduction in the total amount of the postoperative opioids in such critical morbid obese patients, as they are prone to postoperative ventilatory problems, particularly the respiratory depression. The current study demonstrated a decrease in the postoperative cumulative fentanyl consumption induced by IT morphine with either dose of 400 g or 500 g which was manifested by signi cant reduction of static (at rest) and dynamic (on coughing) pain intensity when compared to the placebo group. Thus, single-shot IT morphine may be an e ective and simple method for reducing the opioid requirements in such critical morbid obese patients with minimal side e ects, as the average duration of analgesia after IT morphine injection is approximately 24 hours.(16) The current study demonstrated that preoperative IT morphine provides better and signi cant analgesia both at rest and on coughing when compared with placebo group, as manifested by signi cant reduction in postoperative cumulative fentanyl consumption in the rst 24 postoperative hours and a signi cant delay in the PCA rescues in the morphine groups when compared with the placebo group. In contrast some previous studies showed no signi cant di erence in fentanyl dose requirements between lumbar or thoracic epidural and i.v. routes with equivalent analgesia (26). Other studies showed signi cant decrease of fentanyl requirement when administered epidurally with equivalent analgesia (27). Our ndings are consistent with the latter studies, which may be attributed to two factors rstly, the predominant analgesic e ect of epidural fentanyl administration by direct spinal action rather than an indirect action of systemic fentanyl administration (26,28). Secondly, may be attributed to the use of preemptive IT morphine. One limitation of the current study is that, the sample size may be su cient to evaluate IT morphine's e ectiveness on excellent pain relief, as illustrated by the signi cant reduction in the postoperative cumulative fentanyl consumption and signi cant reduction in the numeric pain scores in the morphine groups. It may be warranted to validate the results of the current study by conducting a study with a larger sample size. Second limitation was that the opioid-sparing e ect of IT morphine can be achieved for the 48 hours after the surgery.(33) Therefore, the length of postoperative follow-up might be better to extent for 48 postoperative hours. Final limitation is that the measurement of oxygen saturation levels was only intermittently (every two hours); thus, signi cant hypoxemia between observations cannot be excluded. However, there were no episodes of respiratory depression that required treatment. Future studies taking into account these issues might be needed. Nevertheless, more controlled clinical trials with large sample size with assessment for more than 24 postoperative hours may be required. To this moment, IT morphine in bariatric surgery should not be performed as a routine clinical practice.

Table (2): Comparison between the study groups regarding the cumulative fentanyl consumption for the rst postoperative 24 hours.
Postoperative cumulative fentanyl consumption for the irst 24 hours M4 1090 1350 1199.41 83.70 0.001*

MP Min Max ( g) Mean SD ( g) P1 P2

M5

INTRODUCTION
The increasing incidence of obesity is a growing problem in national health care, which causes an increase in bariatric surgery. (1) Obese patients may be sensitive to respiratory depressant e ect of opioid analgesic drugs and are more likely to require postoperative ventilation to avoid hypoxic episodes. (2) The clinicians are often challenged to come up with an analgesic technique that is e ective yet ensures patient safety. Intrathecal (IT) morphine is often used for postoperative analgesia after surgery. IT morphine provides excellent postoperative analgesia but may result in many side e ects, including postoperative nausea and vomiting, pruritus, and respiratory depression, particularly at larger doses. (7) However, these techniques have been evaluated poorly in bariatric surgery. In this prospective, randomized, double-blind and placebo controlled study, two doses of IT morphine were evaluated for the e cacy on the postoperative patient controlled epidural analgesia (PCEA) for elective laparoscopic Roux-en-Y gastric bypass (RYGBP) surgery. The primary objective was to determine the cumulative fentanyl consumption during the rst 24 postoperative hours. The secondary objectives; the intraoperative fentanyl requirements, the rst request for PCA rescue, numeric pain score at rest and on coughing and the possible adverse e ects, were recorded.

1600 1900 1762.35 93.71

1000 1200 1117.65 60.06 0.001* 0.105

*P is signi cant at 0.05 P1 is the signi cant di erence between group MP and the other groups P2 is the signi cant di erence between group M4 and M5 Intraoperative IV fentanyl requirements showed statistical signi cant di erences between the morphine groups (M4 and M5)

when compared to placebo group. However, no statistical signi cant di erences were shown between M4 group and M5 group. The rst PCA rescues were signi cantly delayed in both morphine groups without statistical signi cant di erence between them. However, statistical signi cant di erences were shown when each of the morphine groups compared with placebo.

Fig (1): Comparison between the study groups regarding numeric pain scores at rest

PATIENTS & METHODS

Fifty one adult morbidly obese patients were enrolled and randomly allocated into 3 groups using a computer-generated randomization list. M4 group (n=17) in whom patients received IT morphine in a dose of 400 g, M5 group (n=17) in whom patients received IT morphine in a dose of 500 g and MP group (n=17) (Placebo) in whom patients received IT 0.9% saline solution (dose of morphine= 0.0).

Table (1): Patients gender, age, weight, height, body mass index, ASA physical status and duration of the procedure.
Gender (M/F) Age(y) Weight(kg) Height(cm) BMI(kg/m2) ASA(II/III) Duration of the procedure(min) (9/8) 365 118 13 162 4 419 (10/7) 170 21 (11/6) 317 123 8 159 9 445 (9/8) 165 18 (7/10) 324 120 15 164 8 437 (11/6) 162 17

MP group= placebo group; M4 group=morphine group (400 g); M5 group=morphine group (500 g) P is signi cant at 0.05-P1 (*) is the signi cance di erence between MP and M4-P2 (@) is the signi cance di erence between MP and M5-P3 (#) is the signi cance di erence between M4 and M5.

Fig (2): Comparison between the study groups regarding numeric pain scores on coughing

CONCLUSIONS
IT morphine provided a signi cant reduction in postoperative fentanyl consumption during the rst 24 postoperative hours after laparoscopic bariatric surgery. Moreover, the administration of IT morphine had additional advantages without serious adverse e ects.

ASA = American society of anesthesiologists physical status; BMI = body mass index. Data are mean SD, numbers for gender and ASA- status. Combined spinal-epidural analgesia technique was performed for every patient in the three groups between L3-L4 (or adjacent) space in the sitting position, before induction of general anesthesia (GA). IT morphine injection was performed using a 26-gauge needle passed through Touhy needle. Postoperative patient controlled epidural fentanyl analgesia (PCEA) was administrated via the epidural catheter.
MP group= placebo group; M4 group=morphine group (400 g); M5 group=morphine group (500 g). P is signi cant at 0.05-P1 (*) is the signi cance di erence between MP and M4-P2 (@) is the signi cance di erence between MP and M5-P3 (#) is the signi cance di erence between M4 and M5.

REFERENCES
Original published article in Journal of Egyptian Society of Pain Management.

CORRESPONDENCE

Ahmed El Molla.

Medical Research Institute, Alexandria University- Egypt.

aelmulla@yahoo.co.uk