The use of epidural morphine in patients with severe traumatic injury

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Abstract

Objective. Assessment of the efficacy and safety of epidural morphine in patients with severe concomitant injury.

Material and methods. 70 patients with severe combined injury (17–45 points for ISS) were divided into two groups: in group 1 (n = 37), 2 mg of morphine was administered epidurally followed by morphine infusion 0.4 mg / h, in the 2nd group (n = 33), intravenous administration of fentanyl was used at a rate of 50–100 μg / h. The level of pain syndrome was assessed by a 10-point visual analogue scale (VAS). The mean arterial pressure (MAP) and heart rate (HR) at rest and with activation were recorded, the gas composition of the blood (pH, SaO2, PaCO2) was measured, and the vital capacity (VC) was measured. The evaluation of delirium was carried out according to the RASS and CAM-ICU scales. In addition, they recorded the frequency of itching.

Results. The intensity of a pain syndrome at rest was more expressed at patients of the 2nd group (p < 0.05). Against the background of activation of 10,8% of patients of the 1st group and 36,4% of patients of the 2nd group experienced a pain syndrome intensity of 4–7 points on VAS. In patients of the 2nd group, with activation, there was an increase (p < 0.05) in the indices of MAP and HR. VC in patients of the 1st group was 45.4 ± 5.8%, in the 2nd – 41.3 ± 4.7% (p < 0.005). Patients of the 1st group had a lower level of PaCO2 (p < 0.05) compared with the 2nd group. Postoperative delirium developed in the 1st group in 16.2%, in the 2nd – in 30.3% of patients (p < 0.05). Pruritus occurred in the 1st group at 21.6% and was absent in the group with systemic administration of opioids. Opioid-induced ileus, nausea and vomiting in the 1st group were not recorded, in the 2nd group were noted in 18.2% and in 9.1% of cases (p < 0.05), respectively.

Conclusion. The use of epidural morphine in patients with severe traumatic injury effective pain relief was observed, not accompanied by of the respiratory depression and changes in blood gas composition. Epidural administration of morphine in patients undergoing massive blood loss and hemorrhagic shock was not accompanied by arterial hypotension. Effective anesthesia contributed to reducing the incidence of postoperative complications.

About the authors

Ivan Y. Sholin

Research Institute-Regional clinical hospital N1 named after Professor S.V. Ochapovsky

Author for correspondence.
Email: scholin.i@mail.ru

the Head of the Department of Anesthesiology and Intensive Care № 6

Russian Federation, Krasnodar

B. S. Ezugbaia

Research Institute-Regional clinical hospital N1 named after Professor S.V. Ochapovsky

Email: scholin.i@mail.ru
Russian Federation, Krasnodar

V. A. Avetisyan

Research Institute-Regional clinical hospital N1 named after Professor S.V. Ochapovsky

Email: scholin.i@mail.ru
Russian Federation, Krasnodar

V. A. Koriachkin

Research Institute-Regional clinical hospital N1 named after Professor S.V. Ochapovsky

Email: scholin.i@mail.ru
Russian Federation, Krasnodar

V. A. Zhikharev

Research Institute-Regional clinical hospital N1 named after Professor S.V. Ochapovsky

Email: scholin.i@mail.ru
Russian Federation, Krasnodar

References

  1. Gan T.J., Habib A.S., Miller T.E., White W., Apfelbaum J.L. Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey. Curr. Med. Res. Opin. 2014 Jan; 30 (1): 149–60.
  2. Gadsden J., Warlick A. Regional anesthesia for the trauma patient: improving patient outcomes. Local and Regional Anesthesia. 2015; 8: 45–55.
  3. Eisenach J.C. Brennan T.J. Pain after surgery. Pain. 2018; 159 (6): 1010–11.
  4. Ashton-James C. E., Tybur J. M. Tymour Forouzanfar Interpersonal behavior in anticipation of pain: naturalistic study of behavioral mimicry prior to surgery. Pain Rep. 2017; 2 (4): e605.
  5. Ivanova M.P., Konkayev A.K., Koryachkin V.A. Klinicheskaya otsenka metodov analgezii pri vnutribol’nichnoy transportirovke patsiyentov s sochetannoy travmoy. Vrach-aspirant. 2013; 4 (59): 100–4.
  6. Pogatzki-Zahn E.M, Segelcke D., Schug S.A. Postoperative pain–from mechanisms to treatment. Pain Rep. 2017; 2:e588.
  7. Rozenko D.A., Ushakova N.D., Dimitriadi S.N. Anesteziologicheskoye obespecheniye sochetaniyem mnogokomponentnoy obshchey anestezii i epidural’noy analgezii v onkologicheskoy praktike. Sovremennyye problemy nauki i obrazovaniya. 2016; 6: 150–3.
  8. Koryachkin V.A., Strashnov V.I., Pryazhentsev V.V. Dvukhurovnevaya epidural’naya analgeziya u postradavshikh s tyazhelymi mekhanicheskimi povrezhdeniyami. Consilium medicum: Khirurgiya. 2008; 2: 20–1. (In Russian)
  9. Dzyadz’ko A.M., Santotskiy Ye.O., Zlatogure A.V. Neyroaksial’naya anal’geziya v intensivnoy terapii politravmy. Regionarnaya anesteziya i lecheniye ostroy boli. 2013; 4: 54–9. (In Russian)
  10. Wu J.J., Lollo L., Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol. Res. Pract., 2011;2011:Article ID 713281, p. 1–7.
  11. Carroll K.C., Atkins P.J., Herold G.R., Mlcek C.A., Shively M., Clopton P., Glaser D.N. Pain assessment and management in critically ill postoperative and trauma patients: a multisite study. Am. J. Crit. Care. 1999; 8 (2): 105–17.
  12. Ahmadi A., Bazargan-Hejazi S., Heidari Zadie Z. et al. Pain management in trauma: A review study. Journal of Injury and Violence Research. 2016; 8 (2): 89–98.
  13. Flisberg P, Rudin, å, Linner, R, Lundberg, CJF. Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients. Acta Anaesthesiol. Scand. 2003; 47: 457–65.
  14. Carver T.W., Milia D.J., Somberg C., Brasel K., Paul J. Vital capacity helps predict pulmonary complications after rib fractures. J. Trauma Acute Care Surg. 2015; 79 (3): 413–6.
  15. McKendy K.M., Lee L.F., Boulva K., Deckelbaum D.L., Mulder D.S., Razek T.S., Grushka J.R. Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis. J. Surg. Res. 2017; 214: 117–23.
  16. Cashman J.N., Dolin, S.J. Respiratory and haemodynamic effects of acute postoperative pain management: Evidence from published data. Br. J. Anaesth. 2004; 93: 212–23.
  17. Duarte L.T.D., Fernandes M.C., Costa V.V., Saraiva R.A. The incidence of postoperative respiratory depression in patients undergoing intravenous or epidural analgesia with opioids. Rev. Bras. Anestesiol. 2009; 59 (4): 409–20.
  18. Sultan P., Gutierrez M.C., Carvalho B. Neuraxial morphine and respiratory depression: finding the right balance. Drugs. 2011; 71 (14): 1807–19.
  19. Lee L.A., Caplan R.A., Stephens L.S., Posner K.L. et al. Postoperative Opioid-induced Respiratory Depression: A Closed Claims Analysis. Anesthesiology. 2015; 122: 659–65.
  20. Bruce A.J., Ritchie C.W., Blizard R., Lai R., Raven P. The incidence of delirium associated with orthopedic surgery: a meta-analytic review. Int. Psychogeriatr. 2007; 19 (2): 197–214.
  21. Koryachkin V.A. Posleoperatsionnyy deliriy: faktory riska i profilaktika v ortopedotravmatologicheskoy praktike. Travmatologiya i ortopediya Rossii. 2013; 2 (68): 128–35. (In Russian)
  22. Witlox J., Eurelings L.S., de Jonghe J.F., Kalisvaart K.J., Eikelenboom P., van Gool W.A. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010; 304 (4): 443–51.
  23. Gruber-Baldini A.L., Zimmerman S., Morrison R.S., Grattan L.M., Hebel J.R., Dolan M.M., Hawkes W., Magaziner J. Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up. J. Am. Geriatr. Soc. 2003; 51 (9): 1227–36.
  24. Bershadskiy F.F., Ulitkina O.N., Skripkin YU.V., Likhvantsev V.V. Sedatsiya deksmedetomidinom sokrashchayet sroki lecheniya deliriya u postradavshikh s tyazheloy sochetannoy travmoy. Al’manakh klinicheskoy meditsiny. 2017; 45 (8): 652– 7. (In Russian)
  25. Sokolov C.V., Zabolotskiy D.V., Koryachkin V.A. Profilaktika posleoperatsionnogo deliriya u bol’nykh pozhilogo i starcheskogo vozrasta v ortopedicheskoy praktike. Regionarnaya anesteziya i lecheniye ostroy boli. 2018; 12 (1): 41–6. (In Russian)
  26. Reich A., Szepietowski J.C. Opioid-induced pruritus: An update. Clin. Exp. Dermatol. 2010; 35: 2–6.
  27. Rafmell D.P., Nil D.M., Viskoumi K.M. Regionarnaya anesteziya. Samoye neobkhodimoye v anesteziologii. 4th ed. Moscow: MEDpress-inform; 2015; 276 p.

Supplementary files

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2. Figure: 1. Intensity of pain syndrome at rest (M ± σ). * p <0.05 compared with group 1

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3. Figure: 2. Intensity of pain syndrome during activation (M ± σ). * p <0.05 compared with group 1

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4. Figure: 3. The value of the vital capacity of the lungs (M ± σ). * p <0.05 compared with group 1

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5. Figure: 4. Arousal level on the RASS scale

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6. Figure: 5. The incidence of postoperative delirium. * p <0.05 compared with group 1

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