Comparison Between Intravenous Patient Controlled Analgesia And Subcutaneous Morphine In Patients After Gastrectomy

摘要

The Aim of this study was to evaluate the effectiveness on postoperative pain, by intravenous patient-controlled analgesia (PCA) using morphine compared with subcutaneous (s.c.) injections of morphine on demand in patients undergoing gastrectomy, so that subcutaneous morphine if found to have comparable efficacy and safety could be used in the setting of developing nations with less manpower and insufficient monitoring equipments. Fifty patients of either sex weighing b/w (56-80) kg & age b/w (60- 80) were randomly assigned to two different postoperative analgesic techniques for 24 hrs: i.v. PCA morphine (dose, 1 mg; lockout interval, 10 min; PCA group) or regular s.c. morphine injections (SC group) on demand. Postoperative pain was assessed using a visual analogue scale (VAS).Side-effects were also recorded systematically during the first 24 h after surgery The PCA group showed lower pain scores than the SC group. However the clinical significance of pain scores was weak. The incidence of side effects was similar in both the group We conclude that in healthy subjects with ASA I and ASA II status for gastrectomy, the postoperative pain can be managed effectively and safely using subcutaneous route for administration of morphine. This is true especially in a set up where level of nursing care is limited and high dependency units are not available to monitor patients with epidural or intravenous opioids. Abbreviations : PCA (patient controlled analgesia), s.c (subcutaneous), i.m (intramuscular), PACU (postanaesthesia care unit), Introduction Postoperative pain is one of the most feared and probably the most prevalent of all pain conditions, yet in many cases it continues to be inadequately treated. Physicians, nurses, and patients alike fear opioids, even though they remain the mainstay of acute pain treatment1. Furthermore, because of the acute and finite nature of postoperative pain, a degree of complacency in treating it sometimes prevails. In 1990, The Royal College of Surgeons (RCS) report ‘pain after surgery’ found 30–70% patients with moderate or worse pain after surgery. A recent review finds that although the incidence of post-operative pain has reduced by ≈2%/year for the last 30 years, 30% of patients still complain of moderate pain and 11% severe pain 2. Patient-controlled analgesia (PCA) has emerged as a standard technique for management of acute postoperative pain1. In addition to being an efficacious analgesia, several advantages such as high patient acceptability, faster postoperative recovery, earlier hospital discharge and reduced nursing time have been ascribed to PCA (reviewed by Macintyre3). However, some of the more recent studies comparing the efficacy of PCA with that of conventional methods of opioid analgesia have produced conflicting results.4, 5 Choiniere and colleagues4 have demonstrated that PCA is more expensive and does not offer clinical advantages over regular i.m. dosing for pain management after hysterectomy. We performed a prospective randomized study in patients undergoing gastrectomy, to evaluate the effectiveness on postoperative pain, by intravenous patient-controlled analgesia (PCA) using morphine compared with subcutaneous (s.c.) injections of morphine on demand in patients undergoing gastrectomy, so that subcutaneous morphine if found to have comparable efficacy and safety could be used in the setting of developing nations with less manpower and insufficient monitoring equipments. Methods After informed consent a total 0f 50 patients of either sex weighing between 56-80 kg and age between 60- 80 years belonging to ASA-I and ASA-II presenting for elective gastrectomy were included in the study. Patients with history of moderate to severe vomiting in previous operation as a result of opioid use and Patients with developmental disability or cognitive impairment which limit understanding of PCA therapy or limits successful interface with the pump were excluded from the study.Patients were