From the Department of Anesthesia and Critical Care, University of Chicago Medicine, Chicago, Illinois.
Department of Public Health Sciences, University of Chicago, Chicago, Illinois.
Anesthesiology. 2021 Nov 1;135(5):864-876. doi: 10.1097/ALN.0000000000003963.
Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery.
In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire.
Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004).
When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h.
鞘内注射吗啡可减轻标准心脏手术的术后疼痛。但其在微创心脏手术中的安全性和有效性尚未得到充分评估。作者假设鞘内注射吗啡可减少微创心脏手术后的术后吗啡消耗量。
在这项随机、安慰剂对照、双盲临床试验中，接受机器人全内镜冠状动脉旁路移植术的患者在手术前接受鞘内注射吗啡（5 mcg/kg）或鞘内生理盐水。主要结局是术后 24 小时内的术后吗啡等效消耗量；次要结局包括疼痛评分、副作用和患者满意度。术后在重症监护病房到达后 1、2、6、12、24 和 48 小时通过视觉模拟量表评估疼痛。每天评估阿片类药物相关副作用（恶心/呕吐、瘙痒、尿潴留、呼吸抑制）。使用修订后的美国疼痛协会结局问卷评估患者满意度。
79 名患者被随机分配接受鞘内注射吗啡（n = 37）或鞘内安慰剂（n = 42），70 名患者进行了分析（吗啡 33 名，安慰剂 37 名）。与安慰剂组相比，鞘内注射吗啡的患者在术后前 24 小时（中位数[25%至 75%分位数]吗啡等效物，28 [16 至 46] mg 比 59 [41 至 79] mg；差值，-28 [95%CI，-40 至-18]；P < 0.001）和术后第 2 个 24 小时（中位数[25%至 75%分位数]吗啡等效物，0 [0 至 2] mg 比 5 [0 至 6] mg；差值，-3.3 [95%CI，-5 至 0]；P < 0.001）需要的吗啡等效物明显更少，并且在所有术后时间点的静息和咳嗽时的视觉模拟量表疼痛评分均显著降低（总体治疗效果，-4.1 [95%CI，-4.9 至-3.3] 和-4.7 [95%CI，-5.5 至-3.9]；P < 0.001），并且在术后期间处于严重疼痛的时间百分比（10 [0 至 40] 比 40 [20 至 70]；P = 0.003）也更低。鞘内吗啡组更常见轻度恶心（36%比 8%；P = 0.004）。
在完全内镜冠状动脉旁路移植术的麻醉诱导前给予鞘内吗啡可减少术后阿片类药物的使用，并在 48 小时内产生显著的术后镇痛效果。
