Arul Prahash, A (2009) Evaluation of the efficacy of 150 Micrograms of Intrathecal Morphine with Bupivacaine compared to 250 Micrograms for Post Operative Analgesia following Abdominal Hysterectomy: A Double Blinded Randomized Control study. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Spinal anesthesia continues to be one of the commonest regional anesthetic techniques because of its rapid onset, safety and simplicity. Ignored until the late twentieth century as a substrate for analgesia, the spinal cord has now emerged as one –if not the key target for pain control in clinical anesthesiology. More and more anesthesiologists now give drugs spinally to provide intraoperative anesthesia and post operative analgesia in various surgical procedures. The use of neuraxial opioids has increased dramatically in recent years, augmenting the analgesia produced by local anesthetics by binding directly to opiate receptors. Animal and human studies have indicated that opioids and local anesthetics administered spinally have a synergistic analgesic effect. The synergistic action of local anesthetics and morphine is well known, morphine probably more superior for post operative analgesia, when compared to other opioids. Preservative-free morphine is now available in India making intrathecal administration possible. The present randomized double blind study was designed to evaluate the effect of adding preservative free morphine to hyperbaric bupivacaine given intrathecally for abdominal hysterectomy. In India, most of the abdominal hysterectomies are done under regional anesthesia. By adding morphine along with local anesthetic, the duration of analgesia can be increased with minimum side effects and this is also cost- effective. AIM OF THE STUDY: The present randomized double blind study was designed to evaluate the effects of addition of morphine to hyperbaric bupivacaine given intrathecally to patients undergoing elective abdominal hysterectomy. 1. To compare the efficacy of two different doses i.e, 150mcg and 250 mcg of intrathecal morphine with bupivacaine in terms of duration of analgesia, time to first dose of rescue analgesia, total dose of rescue analgesic medication required for the first 24 hours. 2. To compare the incidence and severity of side effects after administration of 150 mcg and 250 mcg intrathecal morphine. MATERIAL AND METHODS: Following approval by the institutional review board and institutional research grant committee, eighty patients presenting for elective abdominal hysterectomy were included in this randomized, double blind study. A pilot study was initially conducted on 20 patients to obtain the sample size required for statistical estimation. Inclusion Criteria: 1. Patients of ASA 1 & ASA 2 physical status. 2. Uterus < 24 weeks size. 3. Patient willing to participate in the study. 4. Age 30-60 years. Exclusion Criteria: 1. Patients of ASA 3 & ASA 4 physical status. 2. Large uterus > 24 weeks size. 3. Age>60 years. 4. Known allergy to the study drug. 5. Morbid obesity. 6. Previous complicated abdominal surgeries. Patient not willing for spinal Anesthesia and study Other contraindication for spinal Anesthesia such as coagulopathy, systemic or local infection. Preoperative Preparation: All the patients were seen by the anesthetist on the day prior to surgery. The procedure was explained and informed consent obtained. The visual analogue scale (VAS) and post operative nausea and vomiting (PONV) score was explained to the patients. All patients received tablet ondansetron 8 mg orally along with benzodiazepine one hour prior to surgery as premedication. Method of randomization: The patients were randomised to one of the 2 groups by a computer generated random assignment. Method of allocation concealment: The investigator who was giving the drug was given a sealed envelop mentioning the group and method of preparation of the drug. After the drug was administered it was recorded as bupivacaine with study drug 1 or 2. The envelop and the allocation sheet were destroyed. Blinding and masking: This is a double blind study as the participant and outcome assesors were blinded to treatment allocation. STATISTICAL METHEODS: The data collected from the patients were entered in EXCEL sheet and statistical analysis was done using SPSS 11 software. Comparison of the mean between the two groups was done by Pierson chi-square test. RESULTS: The results for the 80 patients allocated to the two groups were analysed. Group A received – 3.5 ml of 0.5% hyperbaric bupivacaine with 250 micro gms of morphine. Group B received – 3.5 ml of 0.5% hyperbaric bupivacaine with 150 micro gms of morphine. The data for all the 80 patients are shown in the master chart. CONCLUSION: Our study showed that addition of 150μgms and 250μgms of preservative free morphine as adjuncts to bupivacaine local anesthetic for subarachnoid block prolonged the duration of analgesia after transabdominal hysterectomy. 250μgms morphine with local anesthetic resulted in a statistically significant longer duration of analgesia compared to 150μgms. However, there was no statistically significant increase in side-effects in this group either. Urinary retention was not a problem as these patients are routinely catheterized as part of surgery. There was no evidence of life-threatening problems like delayed respiratory depression, the dreaded PDPH or any other complication that increased morbidity. Adverse effects were similar in both groups. All the patients in both groups reported good surgical analgesia for the first 16-18 hours. Thereafter all patients in both the groups required only one or two doses of Ketorolac as rescue analgesic for the first 24 hours. Incidence of PDPH was nil despite the spinal Anesthesia, probably due to the intrathecal analgesia and this is definitely an advantage as far as the patient and costs are concerned. Morphine being less expensive compared to other analgesics and since very minimal doses are required via the intrathecal route, this is also a less costlier method of postoperative analgesia compared to continuous analgesic infusions and PCA while involving only the same amount of monitoring too. The incidence of pruritus in our study was found to be significantly lesser than in other studies. This may have been due to the administration of ondansetron prophylactically before the onset of action of intrathecal morphine which is thought to reduce the incidence and intensity of PONV and pruritis in patients receiving intrathecal opioids. Nearly one-fourth of the patients in both groups still had PONV despite injection ondansetron prophylactically and 8th hourly. Since our group of patients are high risk for PONV, addition of steroids like injection dexamethasone along with ondansetron with the first dose may probably help. We conclude that 250μgms of preservative-free intrathecal morphine provides longer duration of analgesia when compared to 150μgms morphine, with hardly any additional adverse effects. Since preservative free morphine is now freely available in India, 250μgms intrathecal morphine pre-emptively along with local anesthetics and oral NSAIDs thereafter round the clock as required, is a good cost-effective option for complete postoperative analgesia in patients undergoing Transabdominal hysterectomy under subarachnoid block.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | 150 Micrograms Intrathecal Morphine ; Bupivacaine ; 250 Micrograms ; Post Operative Analgesia ; Abdominal Hysterectomy ; Double Blinded Randomized Control study. |
| Subjects: | MEDICAL > Anaesthesiology |
| Depositing User: | Subramani R |
| Date Deposited: | 30 Apr 2018 02:53 |
| Last Modified: | 30 Apr 2018 02:53 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7315 |
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