Cohen Mindy, Zuk Jeannie, McKay Nancy, Erickson Mark, Pan Zhaoxing, Galinkin Jeffrey
From the Departments of *Anesthesiology and Surgery, †Orthopedic Surgery, and ‡Statistics Pediatric Research Institute, Children's Hospital Colorado, University of Colorado, Aurora, Colorado.
Anesth Analg. 2017 Jun;124(6):2030-2037. doi: 10.1213/ANE.0000000000002061.
Posterior spinal fusion for scoliosis is one of the most painful elective pediatric surgeries. Good postoperative pain control allows early ambulation and return of ability to tolerate oral intake. Options for analgesia in this patient population are suboptimal. We hypothesized that extended-release epidural morphine (EREM) would provide better pain control and less adverse effects compared to intrathecal (IT) morphine.
The primary outcome was total IV morphine consumption during 0-48 hours postoperatively. Secondary outcomes included time until first patient-controlled analgesia (PCA) demand, pain scores, and adverse opioid effects. After institutional review board approval, 71 subjects undergoing posterior spinal fusion for idiopathic scoliosis completed the study. The subjects were randomly allocated to 7.5 μg/kg IT morphine or 150 μg/kg EREM. The final IT morphine and EREM groups contained 37 and 34 subjects, respectively. Postoperative pain was treated with morphine PCA, ketorolac, oral oxycodone, and acetaminophen. Morphine consumption, pain scores, nausea and vomiting, pruritus, and respiratory depression were measured every 4 hours. Parents completed a caregiver questionnaire about their child's pain control regimen after the first postoperative day.
There was no difference in total morphine consumption over the first 48 hours between subjects in the EREM and IT morphine groups: median (range) 42.2 (5.5-123.0) and 34.0 (4.5-128.8) mg, respectively (P = .27). EREM and IT morphine groups had no difference in time until first PCA demand. Pain scores were no different between the groups from 8 to 24 hours after surgery. Compared to IT morphine, EREM subjects had lower pain scores from 28 to 36 hours after surgery. The reported incidence of pruritus was lower in the EREM subjects.
There was no difference in total morphine consumption or time until first PCA demand between the EREM and IT morphine groups. EREM provides a longer duration of analgesia after posterior spinal fusion for scoliosis and may be associated with less opioid-induced pruritus.
脊柱后路融合术治疗脊柱侧弯是小儿择期手术中最疼痛的手术之一。良好的术后疼痛控制可使患者早期下床活动并恢复经口进食的能力。该患者群体的镇痛选择并不理想。我们假设与鞘内注射吗啡相比，缓释硬膜外吗啡（EREM）能提供更好的疼痛控制且不良反应更少。
主要结局指标为术后0至48小时内静脉注射吗啡的总量。次要结局指标包括首次患者自控镇痛（PCA）需求的时间、疼痛评分及阿片类药物的不良反应。经机构审查委员会批准后，71例接受特发性脊柱侧弯后路融合术的受试者完成了该研究。受试者被随机分为7.5μg/kg鞘内注射吗啡组或150μg/kg缓释硬膜外吗啡组。最终，鞘内注射吗啡组和缓释硬膜外吗啡组分别包含37例和34例受试者。术后疼痛采用吗啡PCA、酮咯酸、口服羟考酮和对乙酰氨基酚进行治疗。每4小时测量吗啡用量、疼痛评分、恶心呕吐、瘙痒及呼吸抑制情况。术后第一天后，家长完成一份关于其孩子疼痛控制方案的照顾者问卷。
缓释硬膜外吗啡组和鞘内注射吗啡组受试者在术后最初48小时内吗啡总用量无差异：中位数（范围）分别为42.2（5.5 - 123.0）mg和34.0（4.5 - 128.8）mg（P = 0.27）。缓释硬膜外吗啡组和鞘内注射吗啡组在首次PCA需求时间上无差异。术后8至24小时两组疼痛评分无差异。与鞘内注射吗啡相比，缓释硬膜外吗啡组受试者在术后28至36小时疼痛评分更低。缓释硬膜外吗啡组报告的瘙痒发生率更低。
缓释硬膜外吗啡组和鞘内注射吗啡组在吗啡总用量或首次PCA需求时间上无差异。脊柱侧弯后路融合术后，缓释硬膜外吗啡提供的镇痛持续时间更长，且可能与阿片类药物引起的瘙痒较少有关。
