Services Information for About Us Contact Us
Volume 58, Number 12, 2006
Comparison of Intravenous vs. Intramuscular Morphine for Postoperative Pain Relief on the Multidisciplinary Care Path Implemented Ward
Vimolluck Sanansilp, M.D.,Varit Rasmidatta, M.D.,Peerapatr Tangkitngamwong, M.D.,Santi Pongphantarak, M.D.
Department of Anesthesiology, Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
Download:

Abstract
Objective:? To compare the efficacy and side effects of intravenous and intramuscular morphine injection for postoperative pain relief on the multidisciplinary care path implemented ward and to study the attitude of nurses and doctors in using these two routes of analgesia.
Methods:? We performed a prospective, single-blind, randomized controlled trial in 80 patients undergoing elective gynecologic surgery.? They were randomly allocated into two groups.? Group IM received 10 mg morphine intramuscular (IM) injection for pain prn every 4 hours.? Group IV received intravenous (IV) morphine for pain prn every 2 hours.? The dose of morphine was given based on pain score: <7 gave 1 mg, >7 gave 2 mg.? In the recovery room (RR) both groups received IV morphine until they felt enough pain relief.? We recorded patients’ pain scores at the time discharged from RR, at the time arrival to the ward, 24 and 48 hours postoperation, and the amount of morphine received.? We interviewed the patients on their satisfaction for pain relief.? The questionnaire was sent to nurses and doctors working in the ward.
Results:? The numbers of patients having pain scores? >? 4 and > 7 within 48 hours in the IV group and the IM group were not different (95% and 42.5% vs. 97.5% and 45%, respectively).? More than half of them felt no need to ask for analgesic very often and they received analgesic quite soon.? Patients in the IM group had more pain on injection than the IV group (p<0.001).?? The time they started to experience pain relief after each dose of analgesic was not different in both groups, but more patients in the IV group felt much overall pain relief (p=0.005).? The IV group had less nausea, vomiting and dizziness than in the IM group (p=0.002, p<0.001 and p=0.003, respectively).? No respiratory depression found in this study.? Both groups were satisfied with the treatments.? Nurses found no difference in their convenience for administration of morphine between the 2 routes but doctors felt that they were called by nurse for the same patient because of inadequate pain relief more often after the IM route than after the IV route (p=0.007).
Conclusion:? There is no difference in postoperative pain relief in 48 hours between giving 2 mg morphine IV prn? every 2 hours and 10 mg morphine IM prn? every 4 hours in patients undergoing major gynecological operations on the multidisciplinary-care-path-implemented ward.? However, patients in the IV group feel less pain on injection, and less nausea and vomiting, although both groups give similar satisfaction scores.? Nurses give their opinion of no differences in their convenience for administration of morphine between these two routes.? Doctors, however, feel that they are called because of inadequate pain relief more often in the IM group than in the IV group.
Keywords: Intramuscular; Intravenous; Multidisciplinary care path; Postoperative pain
Page: 1216 - 1221


??????????????????????????????????????????? ???????????? 3,000 ??????????? ????????????????? 50 ???????????????????????????????????????????????? ???????????????????????????????????? ?????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????? ??? numerical rating scale (NRS) 6.1 + 2.8 ??? 10 ????? ?????? 85 ?????????? ?? verbal rating scale (VRS) ?????????????

???????????????????????????????????????????????????????????????????????????????????????????????????????????? (intramuscular, IM) ????? ????????????????????????????????? (intravenous, IV) ????????????????????????????1 ????????? ??????????????????? ???????????????????????????????????????????? ??????????????????????????????????????? (peak plasma concentration) ????????? ??????????????????????????????? ?????????????????? (plasma concentration) ?????????????????????????????????????????????????????????? ????????????????????????????????????????????????????? ??????????????????????????????????????? ????????????????????????????????????? ???????????????????????????????????????????????? ?????????????????????????????????????? ???????????????????????????????????? ???????????????????????????????????????????????????1

???????????????????????? ????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????????? ??????????????????? ?????????????????????????? ?????????? ?????????????????????????? ?????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????? ?????????????????????????????????????????????????? 7? ????????????????????????????????????????????????????? 5 ??????? 2 ?????????????????????? 4 ????????????? 24 ????????????????????2

????????????????????????????? (p.r.n.) ??? 6 ?????????????????????? ??????????????????????????? ????????????????????????????????????????????? ??????????????????????????????????????????????????????????? ?????????????????????????? ??? 6 ?????????????????? ??????????????????????????????????????????????????????????????????????????????3 ??????????????????????????????????????????????????????????? ???????????????? 4 ????????????????? ?????????????????????????????????? 2 ?????????????????

?????????????????????????????????? ?????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????? ???????????? ??? 2 ??????? ??????????????????????? ???????????? ??? 4 ?????????????? ?????????????????????????????????????????????? 3 ?????????????? ???????????????????????????????????????????????????????????? ??????????????????????????????????????????????????????????????
???????????????
????????????????????????????????????????????????????????????????????????? ?????????????????????????? ????????????????????????????????????????????????? ??????????????????????????????????????? ?????????????? ????????????????????????????????????????? ??????????????????????????????? (prospective, single-blind, randomized controlled trial) ?????????????? 80 ?????????????????????????????????????????? ?????????????????????? ?????????????????????????????????????????????? ??????????? ASA class 1-2? ???????????????????????????????????? ?????????????????????????????????????????? ????????????????????????????????????? ??????????????????????? ??????????????????????????? ?????????????????????????????????????????? ???? ???????????????????????????????????? ??????????????????????? ???????????????? ?????????????????????????????????? ?????????????????????

??????????????????? ???????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????????????????????? (multidisciplinary care path) ????????????????????????????????????? ?????????????????????????????????????? ???????? ???????????????????? ?????????????????????????4,5

???????????? ??????????????????????????????????????????????????? ??????????????????????????????????????????????????????? ?????????????????????????????????????? ???????????????????????????????? ??????????????????????????????????? ????????????????????????????????????????????????????????????????????????? numerical rating scale, 0-10: 0 = ?????????, 10 = ???????????????????????????

???????????????? ?????????????? ?????????????????????????????????????????? 3 ??? 10 ????? ?????????????? ???????????????????? ??????????????????????? ??????????????????????????????????????????????????????????? ????????????????????????????????? 4 ???????? ????????? ?????????????????????????????????????????????? (sedation score) ?????????? ?????????????????????????????????????????????????? ??????????????????????????? sedation score < 2 (sedation score, 0-3, S: 0 = ??????????, ????????????, 1 = ???????????????, ?????????????????, 2 = ??????????????, ???????????????????????????????????, 3 = ??????????????????, ???????, ???????????, S = ????????)?

???????????????????????? ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????

????????????????????????????????????? ??????? 40 ?????????? ??????????? ??? Random number table ???????????????? ????? IM ????????????????????????????????????????????????????????? ???????????? (p.r.n.) ??? 4 ??????? ???????? IV ??????????????????????????????????? ???????????? ??? 2 ??????? ??????????????????????????????????????????????????????????????????????? ??????????????????? 3 ???????????????????????????????? ???????????????????????????????????????????????????????????????????? ???????????????????????????????????? 2 ??????? ?????????????????????????????????????????

??????????????????????????? ????????????????6? ????? IM ????????????????????????????????????? 4 ?????????????????????? 60 ????? 10 ??. 60 ??????????? 5 ??. ????????? IV ??????????????????????????????????????????? 2 ??????? ??????????????? 70 ?? ???????? >7 ??? 2 ??., <7 ??? 1 ??., ???? 70 ???????? ???????? >7 ??? 1 ??., <7 ??? 0.5 ??. ??????????? 5 ???? ???????????????????????? ?????????????????????????????????????? ????????????????? (?? sedation score = 0, 1) ????? >10 ?????/???? ?????????????????? ????????????????????????????? 2 ????? ???????????????????????????????????????????6? ?????????????? ??? 1 ??????? 4 ????? ??? 2 ??????? 4 ????? ?????? 4 ???????????? 48 ??????? ????????????????????????????????????? ???? numerical rating scale, 0-10? ???? 48 ?????????????????? ?????????????????????????????????????? ??????????????????? 24 ??? 48 ??????? ??????????????????????????????????????????????????? (??????? 1) ????????????????????????? ????????????????????????????????? ?????????????? ?????? ???????????????????????? 0-24 ??????? ??????? 24-48 ??????? ????????????????????????? ??? ???????? ??????? ?????????? ????????????? ???????? 48 ????????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????? ?????????????????????????????? ? – 1 ??????? ??????????????????????????????? anesthetic record ?????? ???????????? ???? ???????????????? opioid ?????????????????????? ???????????????

???????????????????????????????????????????????????????????????????????????????????? 17 ?????????????????????????????????????? 2 ??? (IM p.r.n. ??? 4 ??????? ??? IV p.r.n. ??? 2 ???????) ???????????????????????????????? 3 ?????? ????? 42 ?? ???????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????????????? 2 ??? ???????????????????????????????????????????????? 6 ?????????????????????????????????

???????????? ?????????????????? SAM ????????????????? (????? IM) ????????????????????????????? >3 ?????? 48 ????????????????? 70 ????????????????????? (????? IV) ?????????????????????????? 35 (type I error = 0.05, power = 0.8) ??????????????????? 36.3 ?? ?????????????????????? 10 ??????????????? 40 ??????????

????????????????
????????????????????????????? Chi-square test ??? Fisher’s exact test ?????? nominal data? ??? Student’s t-test ?????? continuous data ???????????????????????????????????????? Kolmogorov-Smirnov Goodness of fit test ?????? Mann-Whitney U test ?????? nonparametric data? ?????? p ??? <0.05 ????????????????????????
??????????
?????????????????????????????????????????????? ??????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????? ??????????????????????????????????????????????????????????????? (???????? 1) ??????????????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????????????????????????????

????????????????????????? 4 ?????? ??? 7 ??????????????????? 48 ????????????????? ???????? Chi-square for trend ????????? ??????????????????? ?????????????????? ???????????????????? IV ??? IM ????????????? 4 ?????? ????????? 0, 1-5, 6-10, >11 ????? ?? 2 (5%), 18 (45%), 16 (40%), 4 (10%) ?? ??? 1 (2.5%), 16 (40%), 14 (35%), 9 (22.5%) ?? ???????? (p=0.21) ???????????????? 7 ????????????? IV ??? IM ????????? 0, 1-5,? >6 ????? ?? 23 (57.5%), 17 (42.5%), 0 (0%) ?? ??? 22 (55%), 17 (42.5%), 1 (2.5%) ?? ???????? (p=0.67)? ???????? IM 1 ????????????? 7 ????????? 9 ????? ??????????????????????????????????? 7 ?????? > 2 ???????????? IV ??? IM ?? 9 (22.5%) ??? 11 (27.5%) ?? ???????? (95% CI ????????????????????? 2 ????? = -23.4%, 13.8%)

???????? 2 ????????????? (mean) ????????????????????????????????????????????? 3–12, 13–24, 25–36 ??? 37–48 ??????? (???? 0–2 ??????? ?????????????????????????) ????????????????????????????????????????? ??? 25–36 ??? 37–48 ??????? ??????????????????????????????????? ????????????????????????? 24–48 ????????????????????????? IV ????????????? IM ??????????????????????? (???????? 2) ???????????????????????????????????????????? (???????? 3)? ??????? ???????????????????????? 24 ?????????? ???????? IV ????????????? IM ??????????????????????? (???????? 4) ????????????????????????????????? IV (2.6+1.0 [1-4] ?????) ????????????????????????????? IM (2.2+0.9 [1-5] ?????) (p=0.11)

???????? 5 ???????????????????????? ??????????????????? IV ???????? (52.5%) ??????????????????????????????????? ????????????? IM ???????? (55%) ?????????????????? ??????????????????????????????????????????? ????????????????????????????????????????????????????????????????????? ???????????????????????? IV ???????????????? ?????? 65 ????????????????????????????????????? ????????????? IM ????????????? 37.5 ??????????? 10 ???????????????????????????????????????????????? ????????????????????????????????????? (p=0.005)? ????????????? 50 ????????????????????????????????????????????????????????????????????????????????????????????? ?????????????? IV ?????? 87.5 ?????????????????????? ????????????? IM ?????? 12.8 ?????????????? ?????? 59 ???????????? ????????? 28.2 ??????????????????????? ????????????????????????????????????? (p<0.001)?

???????????????????????????????????????????????????? ???????????????????????????????????????? ???????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????????????????????????????????????

???????????????????????????????????????????????????????????????????????????????????? ?????????? IV ????????????????????????????????? ????????????? IM ???????????????????????????? ????????????????????????????????????? (p=0.016) (???????? 5)

???????????????????????????????????????????????????????????????????????????????????????????????????????? (???????? 6)? ???????????? IV ??????????????? ??????? ????????????? ????????????? IM ??????????????? (p<0.05) ?????????????????????????????????

??????????????????????????????????????????????????????? 2 ???? ???????????????????? 17 ?????? ?????????????????????????????????????????? 2 ???? ???????????????????????????????? ?????????????????? ?????????????? ??????????????????????????? ??????????????????????????????????????????????????????

????????????????????????????????????????????????? ??????????????????????????????????????? 2 ???? ????????????????? 3 ?????? ?????????????????????????????????????????? 6 ???????????????????????????? 34 ?? ?????????????????????????????????????????????????????????????????????????????? IM ??????????????????? IV ??????????????????????? (p=0.007)
???????
??????????????????????????????????????? 2 ????????????????? IV ????????????? IM ??????????????????????? ????????????????????????????????????????????????????? ????????? ???????? 7 ?????? ?????????????????? ??????????????????? 3 ?????????????????? ?????????????????????????? 43-45 ?????????? 7 ?????? ???????? 1-4 ???????????? IV ??? 1-9 ???????????? IM? ??????????????????????? 1-2 ??????????????????? 48 ??????????????????? ????????????????????????????????? ???????????????????????????????????????????????????? 7 ???????????????????? 3? ????????????????????????? >3 ???????????????????? ????????????????????????? ?????????????????? 40 ?? ?????????????????????????????????????????????? IM ????????????? 7 ?????? > 2 ????? ????????????? 27.5 95%CI (16.1, 42.8%) ????????????????????? ?????????????????????????????????????????????????????????????????????????????????????????????????????? 85 ??????????????????????????????????????????????????????????????? 6 ??????????????????? ??????????????????????????????????????????????????????????????????????? (multidisciplinary care path) ???????????????

??????????? IM ???????????????????????????????????????????????????????? ?????????????????????? IM ???????????????????????????????????????????????????????????????????????????????? 6? ????????????????????????????????????? ???????????????????????????????????????????????????????? ???????????????????????????????? ???????? ????????????????????????????????????????????????????????????????????????????????????????????

???????????????????? ??????????????????????????????????????????????????????? (multidisciplinary care path) ??????????????????????????? ????????????????????? ???????????????????????????????????????? ???????????????????????????? ???????????????????????? ????????????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????? ??????? ????????????????????????????????????????? 3 ?????????????????????????????????? 4 ??????? ???????????? ???????? sedation score < 2 ?????????????????????????????????????????? ?????????????????????????????????????? 5 ??????????????????????????????????????????????? ???????????? ???????????????????????????????????????????? ??????????????????????????? ????????????????????????????????????????????????????????????? ???????????????????????????????????????????? ?????????????????????????????????? 3 ?????????????????????? ??????? ?????????????? ??????????????????????????????????????????????? ???????????????? IM ???????????? ??? 4 ??????? ??????????????????? IV ???????????? ??? 2 ??????? ?????????????????????????????????? ???????????????????????????????? IV ??????????????? ??????????????????? ?????????????????????? ???????????????????????????????????????????????????????????????????? IM ????

?????????????????????????????????????????????? ????????????????????????????????????????????????? ???????????????????? IV ????????????????????????????????????????? IM ?????????????????????????????????????????? IV ????????????? IM ???????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????????????????????????? ???????????????????????? IV ?????????? IM? ?????????????????????????? IM ????????????????????????????????? ?????????????? (peak effect) ?????????????? IM ??????????????????????????? ?????????????????????????????????????????????????????????? IV?? ?????????????????????????????? ???????????? IM ??????????????????????? IV? ?????????????? 2 ????????????????????????????????????? ????????????????????????????? IM ???????????? ??????????????????????????? IV?

??????????????????????????????????????????????????? ?????????????????????? ??????????????????????????????? ???????????????????????????????????????????? ??????????????????????????????????????? ????????????????????????? ???????????????????????????????????????????? ???????????????????????????

??????????????????????????????????????????????????????? ????? IV ???????????????????????????????????????????????????????????? ????????????? IM ??????????????????????????? ???????????????????????????????????? IV ?????????????????????????????????????????? IM ???????

???????????????????????????? ??????????????????????????????????????????????????????????????????????????? ??????????????????????????????????? IV ?????????? ???????????? ??? 2 ???????

????????? ??????????????????????????????????????????????????? ???????????????????????????????????????????????????????????? ?????????????????????????????????????????? ?????????????????????????????????? ????????????????????????????????? 17 ??? ?????????????????????????????????????????????? power ?????????? ??????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????? ??????????????????????????

???????????????????????????????????????????????????????????? ???????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????????? ????????????????????????????????????????? ?????????????????????????????????????????????????????????? ?????????????? ????????????????? ????????????????? 24 ??? 48 ??????????? ????????????????????????????????????????????????????????????????????? ???????????????????????????????????????????????????? 2 ??????????? 24-48 ??????????????????????????????????????? ??????????????????????????????????????????? 4 ??? 7 ?????? ?????????????????? ??????????????????????????????????????????????? 3? ???????????????????? ???????????????????????????????????????????? 4 ???? 7 ???????????? 2 ????? ????????????????????? 1-2 ??????? ??????????????????????????????????????????????? ??????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????? 5 ??????? 2 ?????????????????????? 4 ????????????? 24 ????????????????????2 ?????????????????????????????????????????????????

Table 1. Demographic data (values are mean ± SD or n (%))

Table 2. The mean recorded pain scores on the ward during 3-12, 13-24, 25-36, and 37-48 hours postoperatively, the interviewed maximum (max), minimum (min) and average pain scores during 0-24 and 24-48 hours postoperatively (values are mean ± SD).

Table 3. The mean recorded pain scores on the ward before and after each injection (values are mean ± SD).

Table 4. The total amount of morphine used on the ward (values are mean ± SD).

Table 5. Results of patientsû interview (values are n (%)). Rating score 0-3; 0 = no, 1 = little/less, 2 = moderate/equal, much/ more.

Table 6. Side effects after analgesics (values are n (%)).
????
?????????????????????????????????????????????????????????????????????????????????? ?????????????????????????? IM ??? IV ???????????????????????????????????????????????? ?????????? ?????????????????????? IV ??????????????? ??????????????????? ?????????????????????????????????????????????????????????? IM? ????????????????????????????????????
???????????????
???????????????? ?????????????????????????? ???????????????? ???????????????????? ?????????????????????????????????? ??????????????? ?????????????? ?????? ???????????????????????????????????? ?????????????????-??????????? ??????????????????????????????????????????????? ???????????????????????? ????????????? 5 ????????????????????????? 11/1 ?????????????????????????????????????????????????????? ??????????? ?????????? ???????????? ??????????????????????????????????????
References
1. Rutter PC, Murphy F, Dudley HAF. Morphine: controlled trial of different methods of administration for postoperative pain relief. Br Med J 1980; 280: 12-3.
2. Counsell D. Acute pain services. In: Lack JA, White LA, Thoms GM, Rollin A-M, eds. Raising the standard. A compendium of audit recipes for continuous quality improvement in anaesthesia. London: The Royal College of Anaesthetists, 2000: 11.5.
3. Austrup ML, Korean G. Analgesic agents for the postoperative period. Opioids. Surg Clin North Am 1999; 79: 253-73.
4. Carpenter RL. Optimizing postoperative pain management. Am Fam Physician 1997; 56: 835-50.
5. Werner MU, Soholm L, Rotboll-Nielsen P, Kehlet H. Does an acute pain service improve postoperative outcome? Anesth Analg 2002; 95: 1361-72.
6. Macintyre PE, Ready LB. Routes of opioid administration. In: Macintyre PE, Ready LB. Acute pain management: a practical guide. 2nd ed. London: W.B. Saunders; 2001: 61-84.

Print this page

 
Copyright © 2005-2008 Siriraj Medical Journal