Spinal (Subarachnoid) Morphine for Off-Pump Coronary Artery Bypass Surgery
Objective: To study the effects of 8 mg/kg preoperatively administered intrathecal morphine sulfate on extubation time, postoperative pulmonary function, and postoperative analgesia after off-pump coronary artery bypass grafting (OPCAB).
Design: A prospective, randomized, double-blind, placebo-controlled study.
Participants: One hundred adult patients scheduled for elective primary OPCAB.
Interventions: Patients were randomized to preoperative administration of 8 m g/kg intrathecal morphine sulfate (group 1) with a 25-gauge spinal needle or to receive sterile normal saline placebo subcutaneously (group 2). Anesthetic induction and maintenance were standardized to allow planning for facilitating early tracheal extubation. Multivessel OPCAB was performed with an Octopus stabilizer. Patients were extubated in the intensive care unit by a blinded observer using predefined extubation criteria.
Measurements and Main Results: Postoperative times to extubation were 9.47 ± 3.83 hours in group 1 versus 11.25 ± 3.94 hours in group 2 (P = .025). Postextubation bedside spirometric lung volumes in percentage of preoperative lung volume showed significant differences in group 1 versus group 2 in forced vital capacity, 39.66% ± 15.42% versus 31.85% ± 11.65% (P = .016); forced expiratory volume in the first second, 44.8% ± 16.18% versus 35.97% ± 13.32% (P = .013); maximum voluntary ventilation, 39.40% ± 13.57% ver-
Chaney MA, Smith KR, Barcky JC, Slogoff S. 1996. Large dose intrathecal morphine for coronary artery bypass grafting. Anesth Analg 83:215-22.nCremer J, Martin M, Redl H, et al. 1996. Systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg 61:1714-20.nFitzpatrick GJ, Moriarty DC. 1988. Intrathecal morphine in the management of pain following cardiac surgery: a comparison with morphine i.v. Br J Anaesth 60:639-44.nGiroir BP. 1993. Mediators of septic shock: new approaches for interrupting the endogenous inflammatory cascade. Crit Care Med 21:780-9.nHall RI, Smith MS, Rocker G. 1997. The systemic inflammatory response to cardiopulmonary bypass: pathophysiological, therapeutic and pharmacological considerations. Anesth Analg 85:766-82.nJacobson L, Chabal C, Brody MC. 1988. A dose response study of intrathecal morphine: efficacy, duration, optimal dose and side effects. Anesth Analg 67:1082-8.nLoick HM, Schmidt C, Van Aken H, et al. 1999. High thoracic epidural anesthesia, but not clonidine, attenuates the perioperative stress response via sympatholysis and reduces the release of troponin T in patients undergoing coronary artery bypass grafting. Anesth Analg 88:701-9.nMangano DT, Siciliano D, Hollenberg M, et al. 1992. Postoperative myocardial ischemia: therapeutic trials using intense analgesia following surgery. Anesthesiology 76:342-53.nVandermeulen EP, Van Aken H, Vermylen J. 1994. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 79:1165-77.nVanstrum GS, Bjornson KM, Ilko R. 1998. Postoperative effects of intrathecal morphine in coronary artery bypass surgery. Anesth Analg 67:261-7.nWang JK, Nauss LA, Thomas JE. 1979. Pain relief by intrathecally applied morphine in man. Anesthesiology 50:149-51.nYaksh TL. 1981. Spinal opiate analgesia: characteristics and principles of action. Pain 11:293-346.nZarate E, Latham P, White PF, et al. 2000. Fast-track cardiac anesthesia: use of remifentanil combined with intrathecal morphine as an alternative to sufentanil during desflurane anesthesia. Anesth Analg 91:283-7.nMathews ET, Abrams LD. 1980. Intrathecal morphine in open heart surgery [letter]. Lancet 2:543. Moen V, Irestedt L, Raf L. 1996. Review of claims from the patient insurance: spinal anesthesia is not completely without risks [in Swedish]. Lakartidningen 97:5769-24.nNader ND, Peppriell JE, Panos AL, Bawn DR. 2000. Potential beneficial effects of intrathecal opioids in cardiac surgical patients. Internet J Anesthesiol 4:N2.nOwens EL, Kasten GW, Hessel EA. 1986. Spinal subarachnoid hematoma after lumbar puncture and heparinization: a case report, review of literature and discussion of anesthetic implications. Anesth Analg 65:1201-7.nRao TLK, El-Etr AA. 1981. Anticoagulation following placement of epidural and subarachnoid catheters: an evaluation of neurologic sequelae. Anesthesiology 55:618-20.nShroff AB, Bishop MJ. 1994. Intrathecal morphine analgesia speeds extubation and shortens ICU stay following coronary artery bypass grafting [abstract]. Anesthesiology 81:A129.nTaylor A, Healy M, McCarroll M, Moriarty DC. 1996. Intrathecal morphine: one year's experience in cardiac surgical patients. J Cardiothorac Vasc Anesth 10:225-8.nAlashemi JA, Sharpe MD, Harris CL, Sherman V, Boyd D. 2000. Effect of subarachnoid morphine administration on extubation time for coronary artery bypass surgery. J Cardiothorac Vasc Anesth 14:639-44.nAnand KJS, Hickey PR. 1992. Halothane-morphine combined with high dose sufentanil for anesthesia postoperative analgesia in neonatal cardiac surgery. N Engl J Med 326:1-9.nBettex DA, Schmidlin D, Chassot PG, Schmid ER. 2002. Intrathecal sufentanil-morphine shortens the duration of intubation and improvesanalgesia in fast-track cardiac surgery. Can J Anesth 49:711-7.nChaney MA. Side effects of intrathecal and epidural opioids. 1995. Can J Anesth 42:891-903.nChaney MA. 1997. Intrathecal and epidural anesthesia and analgesia for cardiac surgery. Anesth Analg 84:1211-21.nChaney MA, Furry PA, Fluder EM, Slogoff S. 1997. Intrathecal morphine for coronary artery bypass grafting and early extubation. Anesth Analg 84:241-8.n
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