Comparison of epidural morphine soaked in hemostatic sponge with patient controlled morphine pump in postoperative pain control after lumbar spine decompressive surgery硬腦膜上嗎啡止血棉與病患控制嗎啡幫浦於腰椎 減壓手術術後疼痛控制之比較 吳孟晃, 牛自健, 陳力輝, 陳文哲 林口長庚紀念醫院脊椎科 Pain control in major spinal decompression and fusion surgeryo Severe postoperative pain, which persists for at least 3 days o Bianconi et al. n Mean maximal pain score: o 73 +/- 9 (visual analog scale, VAS score 0 100) 4 h after posterior fusion surgery o 35 on the third postoperative dayBianconi, M., et al., The pharmacokinetics and efficacy of ropivacaine continuous wound instillation after spine fusion surgery. Anesth Analg, 2004. 98(1): p. 166-72Opioidso Excellent analgesic effect o Extensively via different administration route nI. V. (continuous/PCA)/ I. M. / Epidural/ Intrathecal o Side effects: nPostoperative nausea and vomiting (PONV) nrespiratory depression nSedation ngastrointestinal ileus Unwanted effect!Patient control analgesia(PCA)o Opioids based o Good and effective o 71% have mild to moderate side effectCohen, B. E, et al. (1997).“ Spine 22(16)Epidural opioidso Single dose: 24 hrs o Epidural catheter n Lower dose and low side effectn Potential side effects: o Epidural hematoma o Epidural abcess: 2/13000 o Masked by pain! o Cost!Lowry et al. spine 2001Kindler et al. Acta Anaesthesiol Scand, 1998Joshi, G.P., S.M. McCarroll, and K. ORourke, Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine. Anesth Analg, 1995. 80(3): p. 511-4.Ionescu, T.I., et al., A study of epidural morphine and sufentanil anesthesia for abdominal aortic surgery. Acta Anaesthesiol Belg, 1989. 40(1): p. 65-77Single extended dose epidural morphineo DepoDur, 2004 n Multivesicular liposome delivery system n Lower dose(10mg15mg)2007 FDA Warn: Respiratory Depression from DepoDurHartrick, C.T., et al., Evaluation of a single-dose, extended-release epidural morphine formulation for pain after knee arthroplasty. J Bone Joint Surg Am, 2006. 88(2): p. 273-81Viscusi, E.R., et al., Single-dose extended-release epidural morphine for pain following hip arthroplasty. Am J Ther, 2006. 13(5): p. 423-31Study aimo Early postoperative analgesia, nausea and vomiting using 2 methods of pain control in spine decompression and fusion surgery: 1. Single low dose epidural morphine on absorbable hemostatic sponge (Avitene Ultrafoam collagen hemostat Davol Inc.) 2. Patient-controlled analgesia (PCA) 3. Control group (patient demanded intramuscular bolus Demerol) Material and Methods: oProspective data collect study, retrospective o162 patients received short-segment lumbar spine decompression and fusion surgery oMay 2007July 2007 1. 40 pts: single low dose epidural morphine (10mg) soaked absorbable hemostatic sponge 2. 46 pts: patient-controlled analgesia (PCA, morphine based regimen) 3. 76 pts: intermettent intramuscular bolus Demerol(10mg, q4h) group oOral analgesics containing NSAIDEpidural groupo Low dose morphine (10mg) o Hemastatic sponge (Avitene Ultrafoam collagen hemostat, Bard) o DuraGen (Integra) patch cover within 30 minutes before wound closurePCA groupo Continuous based with patient controlled morphine pump n 0.00014% Fentanyl + 0.012% Morphine 340cc* 3days n Initial loading：Nil n Infusion rate: 25ml n PCA bolus dose: 35ml n Lockout interval: 5min n 4hr dose limit: 3050mlOutcome assessmento Patient ratings of pain intensity at rest (Visual Analog Scale: 0-10), nausea sensation(0-5), and vomiting(0-5) n postoperative 4 hours n postoperative day 1, 2, 3. o Other adverse events and vital signs were also recorded.Results- Pain rating0.0080.0050.0370.310pResults- Nausea0.0070.0090.0120.025pResults- Vomiting0.0080.0070.0110.021pOther side effectso PCA: n Hypotension 3/46: n Respiratory depression 1/46 o Epidural morphine hemostastic sponge n Hypotension 1/40 o Control n No major side effectDiscussiono Single epidural low dose morphine n Less post spine op pain within 2 days n Less nausea and vomiting n No respiratory depressionHemostastic spongeo Avitene collagen, natural clotting agent o Stop bleeding via fribrin clot formation nPrevent epidural hematoma and infection nDecrease blood loss o Prolong drug effect due to slow absorbsion nFibrin degrade 3 month nNo space occupying characteristicsde la Torre, R.A., et al., Hemostasis and hemostatic agents in minimally invasive surgery. Surgery, 2007. 142(4 Suppl): p. S39-45.Limitationo No in vivo release rate or absorption rate o Not blind due to PCA machine o No record for PCA dose and demoral frequencyConclusiono A single low dose epidural morphine-soaked sponge was an effective alternative in postoperative pain control after posterior lumbar spinal surgery with minimal PONV. Thank you for listening!