title: Preincisional and postoperative epidural morphine, ropivacaine, ketamine, and naloxone treatment for postoperative pain management in upper abdominal surgery.
abstract: OBJECTIVE
  Previous studies have shown that preincisional epidural morphine, bupivacaine, and ketamine combined with epidural anesthesia (EA) and general anesthesia (GA) provided pre-emptive analgesia for upper abdominal surgery. Recent studies reported that ultralow-dose naloxone enhanced the antinociceptive effect of morphine in rats. This study investigated the benefits of preincisional and postoperative epidural morphine + ropivacaine + ketamine + naloxone (M + R + K + N) treatment for achieving postoperative pain relief in upper abdominal surgery.
  
  
  METHODS
  Eighty American Society of Anesthesiology I-II patients scheduled for major upper abdominal surgery were allocated to four groups in a randomized, single-blinded study. All patients received combined GA and EA with a continuous epidural infusion of 2% lidocaine (6-8 mL/h) 30 minutes after pain regimen. After GA induction, in Group I, an epidural pain control regimen (total 10 mL) was administered using 1% lidocaine (8 mL) + morphine (2 mg) + ropivacaine (20 mg; M + R); in Group II, 1% lidocaine 8 (mL) + morphine (2 mg) + ropivacaine (20 mg) + ketamine (20 mg; M + R + K); in Group III, 1% lidocaine (8 mL) + morphine (2 mg) + ropivacaine (20 mg) + naloxone (2 μg; M + R + N); and in Group IV, 1% lidocaine (8 mL) + morphine (2 mg) + ropivacaine (20 mg) + ketamine (20 mg) + naloxone (2 μg; M + R + K + N), respectively. All patients received patient-controlled epidural analgesia (PCEA) with different pain regimens to control subsequent postoperative pain for 3 days following surgery. During the 3-day period following surgery, PCEA consumption (mL), numerical rating scale (NRS) score while cough/moving, and analgesic-related adverse effects were recorded.
  
  
  RESULTS
  Total PCEA consumption for the 3-day observation period was 161.5±17.8 mL, 103.2±21.7 mL, 152.4±25.6 mL, and 74.1±16.9 mL for Groups I, II, III, and IV, respectively. (p < 0.05). The cough/moving NRS scores were significantly lower in Group IV patients than Groups I and III patients at 4 hours, 12 hours, and on Days 1 and 2 following surgery except for Group II (p < 0.05).
  
  
  CONCLUSIONS
  Preincisional and postoperative epidural M + R + K + N treatment provides an ideal postoperative pain management than preincisional and postoperative epidural M + R, M + R + K, and M + R + N treatments in upper abdominal surgery.
authors.affiliation: Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC.
authors.forename: Hou-Chuan
authors.initials: HC
authors.lastname: Lai
authors.affiliation: Division of General Surgery, Department of Surgery, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC.
authors.forename: Chung-Bao
authors.initials: CB
authors.lastname: Hsieh
authors.affiliation: Division of Anesthesiology, Cathay General Hospital, Taipei, Taiwan, ROC.
authors.forename: Chih-Shung
authors.initials: CS
authors.lastname: Wong
authors.affiliation: Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC.
authors.forename: Chun-Chang
authors.initials: CC
authors.lastname: Yeh
authors.affiliation: Division of Anesthesiology, Keelung Branch, Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, ROC. Electronic address: aneswu@gmail.com.
authors.forename: Zhi-Fu
authors.initials: ZF
authors.lastname: Wu
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D000368:Aged; D000577:Amides / Q000008:administration & dosage; D015360:Analgesia, Epidural; D016058:Analgesia, Patient-Controlled; D005260:Female; D006801:Humans; D007649:Ketamine / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage; D009270:Naloxone / Q000008:administration & dosage; D010149:Postoperative Pain / Q000188:drug therapy*; D000077212:Ropivacaine; D016037:Single-Blind Method
chemical_list: D000577:Amides; D009270:Naloxone; D007649:Ketamine; D009020:Morphine; D000077212:Ropivacaine
keywords: epidural analgesia; ketamine; naloxone; postoperative pain; upper abdominal surgery