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REGIONAL ANESTHESIA AND PAIN MEDICINE

The Efficacy of Intravenous 0.15 Versus 0.25 mg/kg Intraoperative Morphine for Immediate Postoperative Analgesia After Remifentanil-Based Anesthesia for Major Surgery

D. Fletcher, MD^*, M. Pinaud, MD, P. Scherpereel, MD, N. Clyti^§, and M. Chauvin, MD^*

*Département d’Anesthésie Réanimation, Hôpital Ambroise Paré, Boulogne; Département d’Anesthésie Réanimation, Hôpital Hotel-Dieu, Nantes; Département d’Anesthésie Réanimation, Hôpital Claude Huriez, Lille; and §Glaxo Wellcome Laboratory, Marly-le-Roi, France

Address correspondence and reprints to Fletcher Dominique, Département d’Anesthésie Réanimation, 9 ave. Charles de Gaulle 92104 Boulogne, Cedex, France.

We evaluated the effect of perioperative administration of two doses of morphine for postoperative analgesia after remifentanil-based anesthesia. The prospective, randomized study included 245 patients from 33 centers. All patients were scheduled for abdominal or urological surgery lasting more than 1 h. General anesthesia used remifentanil as the perioperative opioid (1 µg/kg as a bolus then, 0.5 µg/kg as a continuous infusion). A morphine bolus of 0.15 mg/kg (0.15-mg group) or 0.25 mg/kg (0.25-mg group) was administered 30 min before the end of surgery. In the postanesthesia care unit, pain scores for patients were evaluated by using behavioral pain scores of 1–3, verbal pain scores of 0–3, and visual analog scale scores of 0–10). Postoperative analgesia was obtained by a morphine titration (3 mg every 5 min). Demographic and surgery characteristics were similar in both groups. The delay for first demand of morphine was similar in the 0.15-mg and the 0.25-mg groups (26 [9–60] and 30 [10–60] min, respectively). The frequency of morphine titration was similar in both groups (75% and 66%, respectively). The amount of morphine used in the postanesthesia care unit was smaller in the 0.25-mg group (0.16 [0.0–1.25] vs 0.10 [0.0–0.56] mg/kg; P = 0.008). In the 0.25-mg group, the behavioral pain score was lower at 15 min, the verbal pain score was lower at 60 min (P < 0.001), and similar at 30 min. The visual analog scale pain score at 30 min and 60 min was similar in both groups. The incidence of minor side effects was similar in both groups. However, three cases of postoperative respiratory depression occurred in the 0.25-mg group compared with no cases in the 0.15-mg group. In conclusion, perioperative administration of morphine alone does not provide entirely adequate immediate postoperative pain control after remifentanil-based anesthesia in major surgery.

Implications: The administration of 0.15 or 0.25 mg/kg perioperative morphine during remifentanil-based anesthesia for major surgery does not preclude additional morphine administration in the postanesthesia care unit. The larger dose of 0.25 mg/kg slightly improves postoperative analgesia; however, it may be responsible for postoperative respiratory depression.

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