Shawqi Muhammad, Mohamed Sahar Abdel-Baky, Sharkawy Essam, Hetta Diab
Department of Anaesthesiology, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.
Department of Anaesthesiology, Faculty of Medicine, Assiut University, Assiut, Egypt.
Perioper Med (Lond). 2025 May 6;14(1):52. doi: 10.1186/s13741-025-00521-z.
Epidural morphine is considered one of the most potent drugs used for postoperative analgesia; however, its side effects are dose-related and exaggerated in elderly people. In this study, we aimed to determine which of three doses within that range (1.5 mg, 3 mg, or 4.5 mg) can provide adequate pain relief.
A total of 102 patients were assessed for allocation into one of four groups to receive either placebo (group Morphine 0, N = 22), 1.5 mg of epidural morphine (Morphine 1.5, N = 22), 3 mg of epidural morphine (Morphine 3, N = 22), or 4.5 mg of epidural morphine (Morphine 4.5, N = 22) before skin incision, 24 h after surgery and 48 h after surgery. Cumulative intravenous IV-PCA morphine consumption, VAS pain scores, modified Ramsay Sedation Scores, nausea, vomiting, and pruritus were evaluated.
The VAS pain scores at activity of patients who received epidural morphine at doses of 3 mg and 4.5 mg were significantly lower than the placebo and 1.5 mg groups, VAS Score at 72 h was (2 ± 0.8) and (1.7 ± 1) vs (4.3 ± 1.1) and (4 ± 1) respectively, p value = 0.000. The mean total IV-PCA morphine consumption (mg) was significantly higher in patients who received received epidural 0.9% sodium chloride alone compared to 1.5 mg, 3 mg and 4.5 mg epidural morphine groups (38.1 ± 4.8 mg vs 27.2 ± 5.6 mg, 9.2 ± 3.5 mg, and 6.3 ± 3.3 mg respectively), p value = 0.000). However, the difference between the 3 mg and the 4.5 mg groups was not statistically significant in both of VAS scores and IV-PCA morphine consumption (P value > 0.05 for 3 mg vs. 4.5 mg). Patients who received 4.5 mg of epidural morphine experienced a significant increase in the level of sedation, measured by the Ramsay sedation scale, in comparison with 1.5 mg, 3 mg and placebo epidural morphine groups in the first 24 h, the Scale for this group was (2.5 ± 0.5) vs (2.1 ± 0.2, 2.1 ± 0.2, and 2.2 ± 0.5 respectively); p value = 0.000. No relationship between postoperative nausea and the dosage of epidural morphine was found.
Epidural morphine 3 mg as a bolus every 24 h with add on IV patient control analgesia (PCA) morphine, set to deliver 1.5 mg boluses on demand without background infusion with a lockout period of 45 min, could achieve effective and adequate analgesia lasting up to 72 h postoperatively without increasing in the level of sedation or other side effects in older adults after a lower abdominal cancer surgery.
硬膜外吗啡被认为是用于术后镇痛的最有效药物之一；然而，其副作用与剂量相关，且在老年人中更为明显。在本研究中，我们旨在确定该剂量范围内的三种剂量（1.5毫克、3毫克或4.5毫克）中的哪一种能够提供充分的疼痛缓解。
总共评估了102例患者，将其分配到四组中的一组，在皮肤切开前、术后24小时和术后48小时接受安慰剂（吗啡0组，N = 22）、1.5毫克硬膜外吗啡（吗啡1.5组，N = 22）、3毫克硬膜外吗啡（吗啡3组，N = 22）或4.5毫克硬膜外吗啡（吗啡4.5组，N = 22）。评估累积静脉注射静脉自控镇痛（IV-PCA）吗啡消耗量、视觉模拟评分（VAS）疼痛评分、改良拉姆齐镇静评分、恶心、呕吐和瘙痒情况。
接受3毫克和4.5毫克剂量硬膜外吗啡的患者活动时的VAS疼痛评分显著低于安慰剂组和1.5毫克组，72小时时的VAS评分分别为（2±0.8）和（1.7±1），而安慰剂组和1.5毫克组分别为（4.3±1.1）和（4±1），p值 = 0.000。与仅接受硬膜外0.9%氯化钠的患者相比，接受1.5毫克、3毫克和4.5毫克硬膜外吗啡组的患者平均总IV-PCA吗啡消耗量（毫克）显著更高（分别为38.1±4.8毫克、27.2±5.6毫克、9.2±3.5毫克和6.3±3.3毫克），p值 = 0.000）。然而，3毫克组和4.5毫克组在VAS评分和IV-PCA吗啡消耗量方面的差异均无统计学意义（3毫克组与4.5毫克组相比，P值>0.05）。与1.5毫克、3毫克和安慰剂硬膜外吗啡组相比，接受4.5毫克硬膜外吗啡的患者在前24小时内，根据拉姆齐镇静量表测量的镇静水平显著升高，该组的量表评分为（2.5±0.5），而其他组分别为（2.1±0.2、2.1±0.2和2.2±0.5）；p值 = 0.000。未发现术后恶心与硬膜外吗啡剂量之间存在关联。
每24小时推注3毫克硬膜外吗啡并联合静脉患者自控镇痛（PCA）吗啡，按需给予1.5毫克推注量且无背景输注，锁定时间为45分钟，可在老年患者下腹部癌症手术后实现有效且充分持续至术后72小时的镇痛，而不会增加镇静水平或其他副作用。
