Intrathecal morphine for postoperative analgesia: Current trends

The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal(IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, costeffective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.

Intrathecal morphine vs femoral nerve block for postoperative-analgesia after total knee arthroplasty:A two-year retrospective analysis

AIM To compare the efficacy of intrathecal morphine and single shot femoral nerve block for patients undergoing primary total knee arthroplasty.METHODS Data was extracted from electronic medical records and case-paper record files of patients who underwent unilateral primary total knee arthroplasty under spinal anesthesia using bupivacaine 12.5 mg with intrathecal morphine(ITM) 0.2 mg and under general anesthesia(GA) with single shot femoral nerve block(FNB) using 20 m L 0.5% bupivacaine at our hospital in 2013 and 2014.All patients had received peri-articular infiltration as per the hospital protocol.Data for gender,age,weight,American Society of Anesthesiologists status,total surgical time,postoperative pain score using visual analogue scale(VAS) from 1 to 10 at 6 h,12 h and 24 h postoperatively,24 h opioid consumption,use of oral multimodal analgesia,postoperative high dependency unit(HDU) admission and the time to discharge from the hospital was collected.The data was analyzed using Mann-Whitney U test for continuous variables and Fischer's exact-t-test for categorical variables.RESULTS Twenty-two patients in ITM group and 32 patients in FNB group were analyzed.Median pain scores using VAS in ITM group were significantly lower at 6 h(0.0 vs 2.0,P<0.001),12 h(0.0 vs 2.0,P<0.001) and 24 h(0.0 vs 2.0,P<0.001) postoperatively.Also,postoperative morphine consumption in ITM group was significantly lower(P<0.001).However,median of nonsteroid anti-inflammatory drug unit requirement in 24 h postoperatively was statistically significant higher in ITM compared to FNB group(2.0 vs 1.0,P=0.025).The difference in postoperative paracetamol consumption in 24 h was not statistically significant(P=0.147).There was no significant difference in the postoperative HDU admission or time to discharge from the hospital.No respiratory depression in either group was noticed.CONCLUSION The ITM group patients had much lower pain scores and morphine requirement in the first 24 hour postoperatively compared to FNB group.

The Influence of Emotions and Behavioral Theories behind Hand Hygiene in COVID-19 Pandemic

Background: Hand hygiene (HH) is essential in preventing healthcare-associated infections, especially during the COVID-19 pandemic, where SARS-CoV2 has shown the ability to survive on surfaces for days. In this study, we explore HH compliance rate and the factors associated with its increase during COVID-19 pandemic. Methods: HH compliance was assessed amongst doctors in Anesthesia and Surgical Intensive Care Unit by direct observation between 2018 and 2021. An anonymous survey was then sent to the doctors to understand factors influencing the observed improvement in HH compliance during the pandemic. Results: Compliance towards the five moments of HH has shown a statistically significant rising trend from a median HH compliance of 60% in 2018, to 70% in 2019 to 94% in 2020. However, HH compliance subsequently declined in the first quarter of 2021 to median of 87%. The follow-up survey had a response rate of 96% (n = 53). 90% of survey participants responded that their HH frequency had increased during the COVID-19 pandemic with 47% stating they were performing HH 11 - 20 times/day. 64% responded that this increased frequency had affected their skin condition. 62% responded that this increased frequency was sustainable even after the pandemic ends. Participants ranked considerations influencing HH compliance. “Prevent transmitting the infection to vulnerable patients” was ranked highest followed by “High infection rate”, “Fear of contracting COVID-19” and lastly, “Public health guidelines”. Conclusions: Despite the absence of new campaigns, HH compliance reached an all-time high. The pandemic has provided opportunity for behavioral change through “reflective” drivers of behavior such as emotions (“Fear”) and knowledge (“High infection rate”). Understanding the motivations behind current increased HH compliance and riding on the increased initial uptake of behavior may help convert HH into a habitual action and not just a reaction to the pandemic.

Simulation of Bleeding Airways in Cadavers: New Models for Experiential Learning

Background: Healthcare education models have recently shifted from the traditional reliance on the apprenticeship model, where trainees learn on real patients in actual clinical settings, to one based on simulation models. Education in airway management is a fundamental component of anesthetic training programs, and airway modification to simulate difficult airways increases the fidelity of airway management training. Objective: The study goal was to determine the feasibility of simulating difficult airways such as mandibular fracture and post-tonsillectomy bleed in cadaver models by surgical modification for the use in enhanced experiential learning of difficult airway management. Methods: Two cadaver heads were modified surgically to simulate a mandibular fracture and post-tonsillectomy bleed. Workshop facilitators conducted directed one-to-one learning and provided feedback to participants. A paper-based feedback was obtained from the participants on their confidence level, and the realism, attractiveness, beneficial levels, and difficulty levels of the simulation models used. Results: The modified cadavers were reliable in simulating difficult airways. The majority of participants (83.3% for fractured mandible and 87.1% for post-tonsillectomy bleed) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers, and found both models realistic, attractive, and beneficial for difficult airway training. Conclusions: Surgical modifications of cadavers to simulate difficult airways such as fractured mandible and post-tonsillectomy bleed may be incorporated into advanced airway management courses to enhance experiential learning.

Human factors in anaesthetic crisis

This paper discusses some of the key aspects of human factors in anaesthesia for the improvement of patient safety. Medical errors have emerged as a serious issue in healthcare delivery. There has been new interest in human factors as a means of reducing these errors. Human factors are important contributors to critical incidents and crises in anaesthesia. It has been shown that the prevalence of human factors in anaesthesia can be as high as 83%. Cognitive thinking process and biases involved are important in understanding human factors. Errors of cognition linked with human factors lead to anaesthetic errors and crisis. Multiple errors in the cognitive thinking process, known as "Cognitive dispositions to respond" have been identified leading to errors. These errors classified into latent or active can be easily identified in the clinical vignettes of serious medical errors. Application of the knowledge on human factors and use of cognitive de-biasing strategies can avoid human errors. These strategies could involve use of checklists, strategies to cope with stress and fatigue and the use of standard operating procedures. A safety culture and health care model designed to promote patient safety can compliment this further. Incorporation of these strategies strengthens the defence layers against the "Swiss Cheese" models, which exist in the health care industry.