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A1703
October 22, 2008
9:00 AM - 11:00 AM
Room Hall E2-Area E,
Comparison of Side-Effects with Extended Release Epidural Morphine and Other Analgesic Modalities
Kathleen M. Colfer, M.S.N., RN-BC, Kishor Gandhi, M.D., M.P.H., Robert F. Olszewski, B.S., Deborah A. Colli, B.S.N., RN-BC, Eugene R. Viscusi, M.D.
Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
Introduction: Opioids are the mainstay of post-operative pain management and may produce side effects that impact patient recovery. Use of Extended Release Epidural Morphine (EREM) has been shown to result in significantly less average morphine usage and to have superior analgesic efficacy than other modes of post-operative pain management. The purpose of this retrospective review was to compare the incidence and onset of side effects of EREM and other post-operative analgesic regimens.

Method: This was a retrospective, IRB approved analysis of 206 randomly selected patients receiving unilateral hip (THA) or knee arthroplasty (TKA) between January 2007 and July 2007. 119 patients received lower than recommended doses of EREM. 87 received one of the following analgesic regimens: patient controlled analgesia (PCA) with fentanyl, intrathecal (IT) morphine and fentanyl PCA, indwelling epidural catheter with 0.2 % ropivacaine and fentanyl PCA, or femoral nerve block (FNB) and fentanyl PCA. The incidence of opioid side effects on post operative day (POD) 0, 1, & 2 was recorded. Nausea/vomiting and pruritus were identified by the administration of treatment medication. Time interval between spinal, CSE, or EREM administration and first dose of side effect treatment was also noted. Standard error of the mean (SEM) and two-tailed ANOVA with α=0.05 was performed on average time to first dose of treatment between groups of analgesic modalities.

Results:[figure1][figure2]Discussion: All analgesic modalities produced peak side effects on day zero which then declined over the next 24 hours. The occurrence of side-effects was reported by a request for treatment. The intensity of side effects was not graded. Hence the incidence of side effects may appear higher than expected. Although EREM caused more side effects than some other modalities it had a similar profile to the IT morphine with fentanyl PCA group. The majority of patients responded to a single rescue dose for nausea and pruritus. No patients in any group experienced respiratory depression requiring an opioid antagonist. ANOVA analysis showed no statistical significance in the time to rescue between the analgesic groups. Overall, THA had higher incidence of side-effects than TKA.

Conclusion: Analgesic efficacy must be considered when evaluating side effects. Other studies have demonstrated superior analgesic efficacy with EREM. While EREM may have a higher side effect profile than some treatments, the impact may be minimal compared to the benefits of better analgesia and a reduction in risks related to other more invasive modalities. Overall, the side-effects of EREM responded to one rescue dose, supporting minimal patient discomfort and use of healthcare resources.

Anesthesiology 2008; 109 A1703
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