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Intrathecal morphine for analgesia in children undergoing selective dorsal rhizotomy
T E Dews1, A Schubert, A Fried
1Department of General Anesthesiology, Cleveland Clinic Foundation, OH 44195, USA.
Insights
This study found that a 30 micrograms/kg dose of intrathecal morphine provided the best pain relief 6 hours after selective dorsal root rhizotomy in children with cerebral palsy. However, other doses were comparable over 24 hours.
Area of Science:
- Pediatric Anesthesiology
- Neurosurgery
- Pain Management
Background:
- Selective dorsal root rhizotomy (SDRR) is a surgical procedure to alleviate spasticity in children with cerebral palsy.
- Intrathecal morphine is effective for postoperative pain management following SDRR.
- Optimal dosing of intrathecal morphine in this pediatric population requires further definition.
Purpose of the Study:
- To determine the optimal dose of intrathecal morphine for postoperative pain relief in children undergoing SDRR.
- To compare the efficacy and safety of 10, 20, and 30 micrograms/kg doses of intrathecal morphine.
Main Methods:
- A randomized, double-blinded prospective trial involving 27 pediatric patients (ages 3-10 years).
- Patients were randomized to receive 10, 20, or 30 micrograms/kg of preservative-free morphine intrathecally.
- Postoperative pain scores, vital signs, and supplemental morphine requirements were monitored for 24 hours.
Main Results:
- The 30 micrograms/kg dose (Group C) showed significantly lower cumulative supplemental morphine use at 6 hours compared to lower doses.
- Group B (20 micrograms/kg) consistently required higher supplemental doses at 6, 12, and 18 hours.
- Pain scores and adverse events (respiratory events, nausea, vomiting, pruritus) were similar across all groups by 24 hours.
Conclusions:
- Intrathecal morphine at 30 micrograms/kg offers the most potent analgesia in the early postoperative period (6 hours) after SDRR in children.
- While 30 micrograms/kg provides superior initial pain control, its overall benefit compared to 10 micrograms/kg is comparable over 24 hours.
- Further research may refine optimal dosing strategies based on individual patient needs and procedural specifics.
Abstract:
Selective dorsal root rhizotomy is performed for relief of spasticity in children with cerebral palsy. Postoperative pain relief can be provided by intrathecal morphine administered at the time of the procedure. We sought to define an optimal dose of intrathecal morphine in children undergoing selective rhizotomy, through a randomized, double-blinded prospective trial. After institutional approval and parental written informed consent, 27 patients, ages 3-10 years, were randomized to receive 10, 20, or 30 micrograms.kg-1 (Groups A, B, and C, respectively) of preservative-free morphine administered intrathecally by the surgeon after dural closure. Postoperatively, vital signs, pulse oximetry, and pain intensity scores were recorded hourly for 24 hr. Supplemental intravenous morphine was administered postoperatively according to a predetermined schedule based on pain scores. There was considerable individual variability in the time to initial morphine dosing and cumulative supplemental morphine dose. Time to first supplemental morphine dose was not different between groups. When compared to Groups A and B, cumulative 6-hr supplemental morphine dose was significantly lower in Group C (38.6 +/- 47 micrograms versus 79.1 +/- 74 and 189.6 +/- 126 for Groups A and B, respectively). By 12 hr, cumulative supplemental morphine dose was similar in Groups A and C. Group B consistently had a higher supplemental dose requirement than Groups A and C at 6, 12, and 18 hr. By 24 hr, there was no difference in cumulative dose among groups. Postoperative pain scores and the incidence of respiratory events, nausea, vomiting and pruritus were comparable among groups. These data suggest that intrathecal morphine at 30 micrograms.kg-1 provides the most intense analgesia at 6 hr following selective dorsal root rhizotomy, but was otherwise comparable to the 10 micrograms.kg-1 dose.