Faculty Collaboration Database

The effect of caudal vs intravenous morphine on early extubation and postoperative analgesic requirements for stage 2 and 3 single-ventricle palliation: a double blind randomized trial. Paediatr Anaesth 2011 Apr;21(4):441-53

Date

02/11/2011

Pubmed ID

21306473

DOI

10.1111/j.1460-9592.2011.03527.x

Scopus ID

2-s2.0-79952471592 (requires institutional sign-in at Scopus site)   20 Citations

Abstract

BACKGROUND: High-dose single-shot caudal morphine has been postulated to facilitate early extubation and to lower initial analgesic requirements after staged single-ventricle (SV) palliation.

METHODS: With Institutional Review Board approval and written informed parental consent, 64 SV children aged 75-1667 days were randomized to pre-incisional caudal morphine-bupivacaine (100 μg·kg(-1) morphine (concentration 0.1%), mixed with 0.25% bupivacaine with 1 : 200,000 epinephrine, total 1 ml·kg(-1)) and postcardiopulmonary bypass (CPB) intravenous (IV) droperidol (75 μg·kg(-1)) ('active caudal group') or pre-incisional caudal saline (1 ml·kg(-1)) and post-CPB IV morphine (150 μg·kg(-1)) with droperidol (75 μg·kg(-1)) ('active IV group'). Assignment remained concealed from families and the care teams throughout the trial. Early extubation failure rates (primary or reintubation within 24 h), time to first postoperative rescue morphine analgesia, and 12-h postoperative morphine requirements were assessed for extubated patients.

RESULTS: Thirty-one (12 stage 2) SV patients received caudal morphine and 32 (15 stage 2) received IV morphine. Extubation failure rates were 6/31 (19%) for caudal and 5/32 (16%) for IV morphine. For successfully extubated patients (n = 54), active caudal treatment significantly delayed the need for postoperative rescue morphine in stage 3 patients (P = 0.02) but not in stage 2 patients (P = 0.189) (Kaplan-Meier survival analysis with LogRank test). The reduction in 12-h postoperative morphine requirements with active caudal treatment did not reach significance (P = 0.085) but morphine requirements were significantly higher for stage 2 compared with stage 3 patients (P < 0.001) (two-way anova in n = 50 extubated patients).

CONCLUSIONS: High-dose caudal morphine with bupivacaine delayed the need for rescue morphine analgesia in stage 3 patients. All stage 2 patients required early rescue morphine and had significantly higher postoperative 12-h morphine requirements than stage 3 patients. Early extubation is feasible for the majority of stage 2 and 3 SV patients regardless of analgesic regimen. The study was underpowered to assess differences in extubation failure rates.

Author List

Stuth EA, Berens RJ, Staudt SR, Robertson FA, Scott JP, Stucke AG, Hoffman GM, Troshynski TJ, Tweddell JS, Zuperku EJ

Authors

Richard J. Berens MD Professor in the Anesthesiology department at Medical College of Wisconsin
George M. Hoffman MD Chief, Professor in the Anesthesiology department at Medical College of Wisconsin
John P. Scott MD Professor in the Anesthesiology department at Medical College of Wisconsin
Astrid G. Stucke MD Professor in the Anesthesiology department at Medical College of Wisconsin
Eckehard A. Stuth MD Professor in the Anesthesiology department at Medical College of Wisconsin
Todd J. Troshynski MD Associate Professor in the Anesthesiology department at Medical College of Wisconsin
Edward J. Zuperku PhD Professor in the Anesthesiology department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Airway Management
Analgesics, Opioid
Anesthetics, Local
Bupivacaine
Cardiopulmonary Bypass
Child, Preschool
Double-Blind Method
Droperidol
Female
Heart Septal Defects, Ventricular
Humans
Hypnotics and Sedatives
Infant
Injections, Intravenous
Injections, Spinal
Intubation, Intratracheal
Kaplan-Meier Estimate
Male
Morphine
Pain Measurement
Pain, Postoperative
Survival Analysis