HAMAD Medical Corporation, Doha, Qatar; 2Anesthesia Dept. Assiut University Hospitals, Egypt.
Cardiology Dept. Assiut University Hospitals, Egypt.
Pain Physician. 2017 Jul;20(5):405-412.
Intrathecal morphine (ITM) has been used in hopes of providing good postoperative analgesia in cardiac surgery. Little is known about its use in isolated aortic valve replacement surgery.
To evaluate the effects of 7 µ/kg ITM administration in aortic valve replacement in regards to hemodynamics, pain score, and postoperative complications when compared to general anesthesia alone.
A randomized, double-blind trial.
Academic medical center.
Forty-four patients, who underwent aortic valve replacement, were randomly assigned to receive ITM, before the induction of general anesthesia (ITM group, n = 22) or no intrathecal injection i.e., general anesthesia alone (control group, n = 22). Induction of anesthesia was done with fentanyl, propofol, and isoflurane. Pain scores, determined by visual analog scale (VAS), were recorded immediately after extubation, at the first, sixth, twelfth, eighteenth, and twenty-fourth hour after extubation. Hemodynamics, heart rate, mean arterial pressure, central venous pressure, pulmonary capillary wedge pressure, and cardiac index were recorded intra-operatively and up to 24 hours post-operatively.
VAS scores were lower in the ITM group at each measured time than control group (P < 0.01). The cumulative fentanyl consumption during the first 24 hours after extubation was significantly reduced by 35% in the ITM group (951 µg /first 24 hours) as compared to the control group (1463.6 µg /first 24 hours), (P < 0.001). The mean time to first request for rescue analgesia was significantly prolonged in the ITM group (20.11 ± 4.24 hours, P < 0.001) compared with the control group (0.60 ± 0.44 hours). The mean tramadol consumption dose was significantly reduced in the ITM group (279.33 ± 61.35 mg), compared with the control group (895 ± 106.42 mg), (P < 0.001). Hemodynamic parameters exhibited a significant decrease in HR and MAP in the ITM group, but no significant difference was found in regards to CVP, PCWP, and CI. Glyceryl trinitrate consumption in the first 24 hours was significantly reduced by 43% in the ITM group (28.3 mg /first 24 hours) when compared to the control group (145.5 mg /first 24 hours), (P < 0.001). Extubation time (4.5 ± 7.5 vs. 5.3 ± 1.0 hours, P < 0.05) and intensive care unit length of stay (3.7 ± 1.0 vs. 5.6 ± 1.6 days, P < 0.01) were shorter in the ITM group.
Small sample size.
In valvular heart disease patients undergoing aortic replacement surgery, ITM is a good adjunct to general anesthesia as a safe and effective analgesic alternative. It provides better hemodynamic control, earlier tracheal extubation, and shorter ICU stay.
Intrathecal, morphine, fentanyl, analgesia, aortic, cardiac, surgery.
鞘内注射吗啡（ITM）被用于希望在心脏手术中提供良好的术后镇痛。关于其在单纯主动脉瓣置换手术中的应用，知之甚少。
评估 7 µ/kg ITM 在主动脉瓣置换术中与单纯全身麻醉相比对血流动力学、疼痛评分和术后并发症的影响。
随机、双盲试验。
学术医疗中心。
44 名接受主动脉瓣置换术的患者被随机分为接受 ITM 组（n = 22）或不接受鞘内注射（即单纯全身麻醉）组（n = 22）。麻醉诱导采用芬太尼、丙泊酚和异氟醚。疼痛评分采用视觉模拟评分（VAS），在拔管后即刻、拔管后第 1、6、12、18 和 24 小时进行记录。术中及术后 24 小时内记录血流动力学、心率、平均动脉压、中心静脉压、肺毛细血管楔压和心指数。
与对照组相比，ITM 组在每个测量时间的 VAS 评分均较低（P < 0.01）。ITM 组在拔管后 24 小时内芬太尼累积消耗量减少 35%（951 µg/首 24 小时），而对照组减少 1463.6 µg/首 24 小时（P < 0.001）。ITM 组首次要求解救镇痛的平均时间明显延长（20.11 ± 4.24 小时，P < 0.001），与对照组（0.60 ± 0.44 小时）相比。ITM 组曲马多的平均剂量明显减少（279.33 ± 61.35 mg），而对照组（895 ± 106.42 mg）（P < 0.001）。ITM 组的心率和平均动脉压明显下降，但中心静脉压、肺毛细血管楔压和心指数无显著差异。与对照组相比，ITM 组在 24 小时内使用硝酸甘油的量减少了 43%（28.3 mg/首 24 小时）（P < 0.001）。与对照组（5.3 ± 1.0 小时）相比，ITM 组拔管时间（4.5 ± 7.5 小时）和重症监护病房住院时间（3.7 ± 1.0 天）更短（P < 0.05）。
样本量小。
在接受主动脉瓣置换术的瓣膜性心脏病患者中，ITM 是全身麻醉的良好辅助手段，是一种安全有效的镇痛替代方法。它提供了更好的血流动力学控制、更早的气管拔管和更短的 ICU 住院时间。
鞘内、吗啡、芬太尼、镇痛、主动脉、心脏、手术。
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