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Stanislaus MA, Reno JL, Small RH, Coffman JH, Prasad M, Meyer AM, Carpenter KM, Coffman JC. Continuous Epidural Hydromorphone Infusion for Post-Cesarean Delivery Analgesia in a Patient on Methadone Maintenance Therapy: A Case Report. J Pain Res 2020; 13:837-842. [PMID: 32425588 PMCID: PMC7196209 DOI: 10.2147/jpr.s242271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 04/17/2020] [Indexed: 12/03/2022] Open
Abstract
The prevalence of opioid use disorder (OUD) in the United States has more than quadrupled over the past two decades. This patient population presents a number of challenges to clinicians, including difficult pain management after surgical procedures due to the development of opioid tolerance. Significantly greater opioid consumption and pain scores after cesarean delivery have been reported in patients with OUD compared to other obstetric patients. A multi-modal analgesic regimen is generally recommended, but there are few well-established pain management strategies after cesarean delivery specific to patients with OUD. We present the case of a patient with OUD maintained on daily methadone that received a continuous epidural hydromorphone infusion for post-cesarean analgesia, a technique not previously reported in obstetric patients and only rarely described for patients undergoing other surgical procedures. The patient received epidural anesthesia for cesarean delivery, and after surgery, the epidural catheter was left in place for the epidural hydromorphone infusion, initiated at 140 mcg/hr and continued for approximately 40 hrs. This strategy reduced her average daily oral opioid consumption by 97%, reduced self-reported pain scores, shortened the length of hospitalization and improved ability to ambulate compared to her previous cesarean delivery. The use of continuous epidural hydromorphone infusion was effective in this case, and this analgesic technique may also be applicable to other types of surgical procedures with the potential for significant post-operative pain, particularly in patients with OUD.
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Affiliation(s)
- Mellany A Stanislaus
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph L Reno
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Robert H Small
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Julie H Coffman
- Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA
| | - Mona Prasad
- Department of OBGYN, Riverside Methodist Hospital, Columbus, OH, USA
| | - Avery M Meyer
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kristen M Carpenter
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - John C Coffman
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Sim WS, Yeo JS. A Comparison of Hydromorphone-Bupivacaine and Fentanyl-Bupivacaine in Patient Controlled Epidural Analgesia after Thoracotomy. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.2.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Woo Seok Sim
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Yeo
- Department of Anesthesiology and Pain Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
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Zheng M, McErlane KM, Ong MC. Hydromorphone metabolites: isolation and identification from pooled urine samples of a cancer patient. Xenobiotica 2002; 32:427-39. [PMID: 12065064 DOI: 10.1080/00498250110119090] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
1. Hydromorphone-3-glucuronide, dihydromorphine, dihydroisomorphine, dihydromorphine-3-glucuronide and dihydroisomorphine-3-glucuronide were isolated from a cancer patient's urine and identified as metabolites of hydromorphone by comparison with synthetic standards using LC/MS/MS with gradient elution. 2. The relative urinary recovery of dihydroisomorphine-3-glucuronide was estimated to be 17-fold higher than previously reported. 3. Three new metabolites, including hydromorphone-3-sulphate, norhydromorphone and nordihydroisomorphine, were tentatively identified.
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Affiliation(s)
- M Zheng
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2146 East Mall, Vancouver, BC V6T 1Z3, Canada
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Sinatra RS, Levin S, Ocampo CA. Neuroaxial hydromorphone for control of postsurgical, obstetric, and chronic pain. ACTA ACUST UNITED AC 2000. [DOI: 10.1053/sa.2000.6790] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Singh H, Bossard RF, White PF, Yeatts RW. Effects of ketorolac versus bupivacaine coadministration during patient-controlled hydromorphone epidural analgesia after thoracotomy procedures. Anesth Analg 1997; 84:564-9. [PMID: 9052302 DOI: 10.1097/00000539-199703000-00018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We studied the comparative effects of ketorolac versus bupivacaine supplementation of hydromorphone (HM) patient-controlled epidural analgesia (PCEA) on the HM requirement, postoperative pain, and pulmonary function in 62 consenting patients after thoracotomy procedures. Patients were randomly assigned to receive one of three different combinations of analgesic medications after the operation according to a double-blind, placebo-controlled study. The treatment groups consisted of: Group 1 (n = 23): PCEA HM 3-mL (0.15 mg) bolus doses + saline 1 mL intravenously (IV) q6h, Group 2 (n = 20): PCEA HM (0.15 mg) in 0.125% bupivacaine 3-mL bolus doses + saline 1 mL IV q6h, and Group 3 (n = 19): PCEA HM 3-mL (0.15 mg) bolus doses + ketorolac 1 mL (30 mg) IV q6h. Epidural HM and supplemental analgesic requirements, pain visual analog scale (VAS) scores, the incidence of nonincisional pain, and side effects were recorded at 24 and 48 h after surgery. Bedside pulmonary function tests were performed using a Puritan Bennett 100TM (Puritan-Bennett Corp., Wilmington, MA) spirometer before and 24 and 48 h after surgery. IV ketorolac supplementation of HM PCEA significantly reduced the incidence of nonincisional pain and the HM requirement over 48 h compared with the HM PCEA alone group (7% vs 26%; 3 +/- 1.6 mg vs 5.3 +/- 2.8 mg). Both ketorolac and bupivacaine supplementation of HM PCEA reduced the severity of pain on coughing and on movement compared with HM PCEA alone on postoperative day (POD) 1. Significant reductions in forced vital capacity, forced expiratory volume in 1 s, forced expiratory flow 25%-75% of the vital capacity, and peak expiratory flow rate (PEFR) were noted on PODs 1 and 2 in all three treatment groups. The decrease in PEFR on PODs 1 and 2 was significantly less with ketorolac compared with bupivacaine supplementation. We conclude that ketorolac supplementation of HM PCEA reduces the incidence of nonincisional pain and HM requirement compared with HM PCEA alone and may have a beneficial effect on pulmonary function compared with bupivacaine supplementation of HM PCEA in postthoracotomy patients.
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Affiliation(s)
- H Singh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas 75235-9068, USA
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Singh H, Bossard RF, White PF, Yeatts RW. Effects of Ketorolac Versus Bupivacaine Coadministration During Patient-Controlled Hydromorphone Epidural Analgesia After Thoracotomy Procedures. Anesth Analg 1997. [DOI: 10.1213/00000539-199703000-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Halpern SH, Arellano R, Preston R, Carstoniu J, O'Leary G, Roger S, Sandler A. Epidural morphine vs hydromorphone in post-caesarean section patients. Can J Anaesth 1996; 43:595-8. [PMID: 8773867 DOI: 10.1007/bf03011773] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
PURPOSE The purpose of this randomized controlled double blind study was to compare the efficacy of pain relief and the side effects of epidural hydromorphone and morphine in post-Caesarean patients. METHODS In all patients, epidural anaesthesia was induced using carbonated lidocaine 2% with 1:200,000 epinephrine and 50 micrograms fentanyl, given in incremental doses. Patients in Group 1 (n = 24) received 0.6 mg hydromorphone and patients in Group 2 (n = 22) received 3 mg morphine after delivery of the infant. Pain, pruritus and nausea were measured using a visual analog scale (at times: baseline, on admission to the recovery room, 3, 6, 12, 18 and 24 hr postoperatively), by the number of requests for additional medications and by an overall satisfaction score. RESULTS There was no difference between the groups in pain relief of in the incidence and severity of side effects. Pruritus was more pronounced within the first six hours in Group 1 and at 18 hr in Group 2. CONCLUSION Hydromorphone provides no clinical benefit over epidural morphine for post operative analgesia following Caesarean section.
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Affiliation(s)
- S H Halpern
- Department of Anaesthesia, Women's College Hospital, Toronto, Ontario, Canada.
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Thomson CA, Becker DR, Messick JM, de Castro MA, Pairolero PC, Trastek VF, Murray MJ, Schulte NK, Offord KP, Ferguson JA. Analgesia After Thoracotomy. Anesth Analg 1995. [DOI: 10.1213/00000539-199511000-00014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Thomson CA, Becker DR, Messick JM, de Castro MA, Pairolero PC, Trastek VF, Murray MJ, Schulte NK, Offord KP, Ferguson JA. Analgesia after thoracotomy: effects of epidural fentanyl concentration/infusion rate. Anesth Analg 1995; 81:973-81. [PMID: 7486087 DOI: 10.1097/00000539-199511000-00014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
After thoracotomy some patients have discomfort, primarily in the rostral portion of their incisions. In this prospective, randomized study in 66 patients after lateral thoracotomy we evaluated whether, for equal fentanyl dosage in micrograms per kilogram, epidural infusion (lumbar catheter) of fentanyl 5 micrograms/mL provided better segmental analgesia (including the rostral portion of the incision) than a 10-micrograms/mL concentration infused at a rate half that used in the 5-micrograms/mL group. Ketorolac was used as an analgesic adjunct for nonincisional pain. Postoperative epidural fentanyl infusion included a 1-microgram/kg initial dose and an initial infusion rate of 1 microgram.kg-1.h-1 in both the 5-micrograms/mL and 10-micrograms/mL groups. Patients were evaluated for comfort level and pain relief while resting, taking a deep breath, coughing, and ambulating at eight times over 3 days using two visual analog scales for overall comfort and a verbal rating score (VRS) for segmental analgesia. There were no significant differences in demographics, surgical procedure, intraoperative fentanyl dose, side effects, rates of epidural fentanyl infusion, or total epidural fentanyl doses at 12, 24, 36, 48, and 60 h postbolus. Analgesia was effective in both groups. Although overall comfort levels were lower (i.e., indicated greater comfort) in the 5-micrograms/mL group in 6 of 8 visual analog scores (VASs) for comfort level and 20 of 24 VRSs for comfort level scores, and mean VRSs for the rostral portion of the incision were lower (i.e., indicated greater comfort) in the 5-micrograms/mL group at 21 of 24 evaluation subsets (one statistically significant), statistical significance was achieved in only six evaluation subsets.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C A Thomson
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Gaeta RR, Macario A, Brodsky JB, Brock-Utne JG, Mark JB. Pain outcomes after thoracotomy: lumbar epidural hydromorphone versus intrapleural bupivacaine. J Cardiothorac Vasc Anesth 1995; 9:534-7. [PMID: 8547554 DOI: 10.1016/s1053-0770(05)80136-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To evaluate postthoractomy analgesia in patients receiving lumbar epidural hydromorphone versus intrapleural bupivacaine. DESIGN A randomized, prospective, double-blind study. SETTING A university-affiliated medical center. PARTICIPANTS Twenty patients undergoing lateral thoracotomy for either pulmonary wedge resection, lobectomy, or pneumonectomy. INTERVENTION Nine patients received epidural hydromorphone, and 11 patients received intrapleural bupivacaine in the postoperative period. MEASUREMENTS AND MAIN RESULTS Severity of pain was assessed using a visual analog pain scale (VAPS) (0 to 100 mm) at 1, 3, and 5 hours. Patients receiving epidural hydromorphone had a statistically significant improvement in VAPS scores. Patients who received intrapleural bupivacaine did not achieve a significant reduction in pain scores. Nine of 11 patients in the intrapleural bupivacaine group had "failed" postoperative analgesia as defined by a VAPS greater than 30. Only 3 of 9 patients in the continuous epidural hydromorphone group had "failed" analgesia. CONCLUSION Epidural hydromorphone is superior to intrapleural bupivacaine in achieving satisfactory pain outcomes during the first 5 hours after thoracotomy.
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Affiliation(s)
- R R Gaeta
- Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, CA 94305-5115, USA
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Affiliation(s)
- C J O'Connor
- Department of Anesthesia, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612
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Miguel R, Hubbell D. Pain management and spirometry following thoracotomy: a prospective, randomized study of four techniques. J Cardiothorac Vasc Anesth 1993; 7:529-34. [PMID: 8268431 DOI: 10.1016/1053-0770(93)90308-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Forty-five patients who underwent anterolateral and posterolateral thoracotomy were studied to compare the relative efficacy of cryoanalgesia, epidural morphine, intrapleural analgesia, and intravenous morphine for relief of postoperative pain and prevention of deterioration in pulmonary function. Spirometry (FEV1, FVC) was performed preoperatively and postoperatively. Patients' pain was assessed using the 0 to 100 mm visual analog scale. Because intravenous morphine was used to supplement pain relief in the patients who received intrapleural analgesia and cryoanalgesia, total morphine use was compared to that administered to patients in the intravenous morphine group. Epidural morphine was found to offer better pain relief than the other treatment modalities. There were no differences in spirometric testing between the groups at any time during the study. Although the number of evaluable patients was insufficient to draw definitive conclusions, 12-week follow-up suggested a difference in the incidence of post-thoracotomy pain syndrome in patients who received cryoanalgesia. It is concluded that post-thoracotomy pain is best relieved with epidural morphine, compared to intrapleural analgesia, cryoanalgesia, and parenteral morphine. There was no change in the deterioration in spirometric tests after thoracotomy, nor was there any advantage offered by cryoanalgesia or intrapleural analgesia over intravenous morphine, with respect to pain relief.
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Affiliation(s)
- R Miguel
- Department of Anesthesiology, University of South Florida, Tampa
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