Intrathecal Morphine Administration in Fast-Track Cardiac Anesthesia

Abstract

Background: We aimed to investigate the effect of 10 µg/kg intrathecal morphine administration in the fast-track cardiac anesthesia protocol on postoperative analgesia and fast-tracking.
Materials and Methods: 42 patients from ASA I-III group undergoing elective coronary bypass grafting (CABG) were divided into two groups as intrathecal morphine (ITM) and control (K) groups by closed envelope method. Morphine at a dose of 10 µg/kg was intrathecally administered to the ITM group before induction. The same method of anesthesia induction and maintenance was used in both groups. Patient controlled analgesia (PCA) and tramadol were started in both groups in the intensive care unit. Intraoperative hemodynamic parameters, extubation time, sedation score, VAS score, capacity of lung, analgesia, time of intensive care and hospital stay were recorded.
Results: There was no difference between demographic data and intraoperative data of both groups (p> 005). The extubation time was 192 ± 42.4 minutes in the ITM group and 254.3 ± 88.4 minutes in the control group (p <0.05). Postoperative pain scores, tramadol consumption, lung volumes and length of stay in intensive care were better in the ITM group (p<0.05). Length of stay in the hospital was similar.
Conclusion: Intrathecal morphine administration at a dose of 10 µg/kg provided very good analgesia after cardiac surgery, earlier recovery in lung volumes and shorter intensive care stay.

Key Words: Cardiac anesthesia, Fast-track, Intrathecal morphine, Desflurane, Remifentanil

Fast-Track Kardiyak Anestezide İntratekal Morfin Uygulaması

Abstract

Amaç: Fast-track (Erken derlenme) kardiyak anestezi protokolünde 10 µgkg-1 dozunda intratekal morfin uygulamasının postoperatif analjezi ve erken derlenme üzerine etkisini araştırmayı planladık. Materyal ve Metod: Elektif koroner bypass greftleme (KABG) operasyonu planlanan ASA I-III grubundan 42 hasta, kapalı zarf usulü ile intratekal morfin (İTM) ve kontrol (K) grubu olarak iki gruba ayrıldı. İTM grubuna indüksiyondan önce 10 µgkg-1 dozundan morfin intratekal olarak uygulandı. Her iki gruba aynı anestezi indüksiyon ve idame yöntemi kullanıldı. Yoğun bakımda her iki gruba hasta kontrollü analjezi (HKA) ile tramadol başlandı. İntraoperatif hemodinamik parametreler, ekstübasyon süresi, sedasyon skoru, VAS skoru, postoperatif akciğer kapasitesi, VAS skoru, yoğun bakım ve hastanede kalış süresi kaydedildi. Bulgular: Her iki grubun demografik verileri ve intraoperatif verileri arasında fark yoktu (p>005). Ekstübasyon zamanı İTM grubunda 192±42.4 dakika, kontrol grubunda 254.3±88.4 dakika bulundu (p<0.05). Postoperatif ağrı skorları, tramadol tüketimi, akciğer volümleri ve yoğun bakımda kalış süresi ITM grubunda daha iyi bulundu (p<0.05). Hastanede kalış süreleri benzerdi. Sonuç: 10 µgkg-1 dozunda intratekal morfin uygulaması, kardiyak cerrahi sonrası çok iyi analjezi, akciğer volümlerinde daha erken derlenme ve daha kısa yoğun bakım kalış süresi sağladı.

Keywords

• Kardiyak anestezi
• Fast-track
• İntratekal morfin
• Desfluran
• Remifentanil

References

1. Alhashemi JA, Sharpe MD, Harris CL, Sherman V, Boyd D. Effects of subarachnoid morphine administration on extubation time after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2000;14:639-44.
2. Engoren M, Luther G, Fenn-Buderer N. A comparison of fentanil, sufentanil and remifentanil for fast-track cardiac anesthesia. Anesth Analg 2001;93:859-64.
3. Zaugg M, Lucchinetti E, Garcia C, Pasch T, Spahn DR, Schaub MC. Anaesthetics and cardiac preconditioning. Part II. Clinical implications. Br J Anaesth 2003; 91: 566-76.
4. Aşkın T, Karadeniz Ü, Ünver S, Boran E, Erdemli Ö. An efficacy comparison of fentanyl and remifentanil during off-pump coronary artery bypass graft surgery. Türk Göğüs Kalp Damar Cerrahisi Dergisi 2013;21:683-90.
5. Bauer M, Wilhelm W, Kraemer T, Kreuer S, Brandt A, Adams HA, et al. Impact of bispectral index monitoring on stress response and propofol consumption in patients undergoing coronary artery bypass surgery. Anesthesiology 2004;101:1096-104.
6. Chaney MA, Smith KR, Barclay JC, Slogoff S. Large-dose intrathecal morphine for coronary artery bypass grafting. Anesth Analg 1996;83:215- 22.
7. Silbert BS, Myles PS. Is fast-track cardiac anesthesia now the global standard of care? Anesth Analg 2009;108:689-91.
8. Hawkes CA, Dhileepan S, Foxcroft D. Early extubation for adult cardiac surgical patients. Cochrane Database Syst Rev 2003(4);CD003587.

9. Zarate E, Latham P, White PF. Fast-track cardiac anesthesia: Use of remifentanil combined with intrathecal morphine as an alternative to sufentanil during desflurane anesthesia. Anesth Analg 2000;91:283-7.
10. Tuman KJ, McCarthy RJ, March RJ. Effects of epidural anesthesia and analgesia on coagulation and outcome after ma¬jör vascular surgery. Anesth Analg 1991;73:696-704.
11. Chaney MA, Furry PA, Fluder EM, Slogoff S. Intrathecal morphine for coronary artery bypass grafting and early extubation. Anesth Analg 1997;84:241-8.
12. Latham P, Zarate E, White PF, Bossard R. Fast-track cardiac anesthesia: A comparison of remifentanil plus intrathecal morphine with sufentanil in a desflurane-based anesthetic. J Cardiothorac Vasc Anesth 2000;14:645-51.
13. Vanstrum GS, Bjornson KM, Ilko R. Postoperative effects of intrathecal morfine in coronary artery bypass surgery. Anesth Analg 1988;67:261-7.
14. Gray JR, Fromme GA, Nauss LA. Intrathecal morphin for post-thoracotomy pain. Anesth Analg 1986;65:873-6.
15. Turan S, Ayık İ, Öztürk D, Karadeniz Ü, Soyal Ö, Coşar A, et al. Effects of Remifentanil and Fentanyl on Postoperative Pain and Recovery in Fast-Tract Cardiac Surgery. GKDA Derg 2012;18(4):80-7.
16. Ahonen J, Olkkola KT, Verkkala K. A comparison of remifentanil alfentanil for use with propofol in patientts undergoing minimally invasive coronary artey bypass surgery. Anesth Analg 2000;90:1269-74.
17. Lenan P, Balarac N, Arnulf JJ, Teboul J, Bonnet F. Intrathecal morphin and clonidine for coronary artery bypass grafting. Br J Anaesth 2003;90(3):300-3.
18. Bowler I, Djaiani G, Abel R, Pugh S. A combination of intrathecal morphine and remifentanil anesthesia for fast-track cardiac anesthesia and surgery. J Cardiothorac Vasc Anesth 2002;16:709-14.
19. Turker G, Goren S, Sahin S, Korfali G, Sayan E. Combination of Intrathecal Morphine and Remifentanil Infusion for Fast-Track Anesthesia in Off-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2005;19(6):708-13.