Comparison between repeat bolus intrathecal morphine and an epidurally delivered bupivacaine and fentanyl combination in the management of post-thoracotomy pain with or without cyclooxygenase inhibition.
OBJECTIVE
To compare the analgesic efficacy of a traditional epidurally delivered bupivacaine/fentanyl combination with a repeat bolus intrathecal morphine technique in the management of post-thoracotomy pain and to assess further the effect of cyclooxygenase (COX) inhibition on both modalities.


METHODS
Prospective, randomized, blinded study.


METHODS
University teaching hospital.


METHODS
Patients having thoracic surgery.


METHODS
Epidural and intrathecal catheters were inserted. Blood and urine samples were collected for analysis. COX-1 and COX-2 inhibition with ibuprofen and nimesulide (COX-2 selective) was instituted.


RESULTS
Pain was assessed at rest and coughing by visual analog scale. Peak expiratory flow rate, patient satisfaction rating, sedation score, analgesic requirements, and preoperative and postoperative urinary creatinine levels were measured. The spinal and nimesulide combination showed the lowest pain scores (p < 0.001), least reduction in peak expiratory flow rate (p < 0.001), and highest patient satisfaction rating (p = 0.02). COX inhibition did not affect analgesic requirements in the epidural group or increase urinary creatinine in any group.


CONCLUSIONS
The intrathecal morphine and nimesulide combination offered significantly better analgesia than any other combination studied. The efficacious interaction between opioids and nonsteroidal anti-inflammatory drugs may be COX-2 mediated.
McCrory
Connail
C
Department of Anaesthesia, St. James Hospital, Dublin, Ireland.
Diviney
Dara
D
Moriarty
Jeanne
J
Luke
David
D
Fitzgerald
Desmond
D
D000368:Aged; D015360:Analgesia, Epidural; D000701:Analgesics, Opioid / Q000008:administration & dosage*; D002045:Bupivacaine / Q000008:administration & dosage*; D016861:Cyclooxygenase Inhibitors / Q000627:therapeutic use; D004311:Double-Blind Method; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage*; D006801:Humans; D007278:Injections, Spinal; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage*; D010149:Postoperative Pain / Q000188:drug therapy*; D011446:Prospective Studies; D013908:Thoracotomy
D000701:Analgesics, Opioid; D016861:Cyclooxygenase Inhibitors; D009020:Morphine; D005283:Fentanyl; D002045:Bupivacaine