heroin and Postoperative-Complications

The prevalence of neuraxial opioid-induced clinically significant respiratory depression (CSRD) after cesarean delivery is unknown. We sought to review reported cases of author-reported respiratory depression (ARD) to calculate CSRD prevalence. A 6-database literature search was performed to identify ARD secondary to neuraxial morphine or diamorphine, in parturients undergoing cesarean delivery. "Highest" (definite and probable/possible) and "lowest" (definite) prevalences of CSRD were calculated. Secondary outcomes included: (1) prevalence of CSRD associated with contemporary doses of neuraxial opioid, (2) prevalence of ARD as defined by each study's own criteria, (3) case reports of ARD, and (4) reports of ARD reported by the Anesthesia Closed Claims Project database between 1990 and 2016. We identified 78 articles with 18,455 parturients receiving neuraxial morphine or diamorphine for cesarean delivery. The highest and lowest prevalences of CSRD with all doses of neuraxial opioids were 8.67 per 10,000 (95% CI, 4.20-15.16) and 5.96 per 10,000 (95% CI, 2.23-11.28), respectively. The highest and lowest prevalences of CSRD with the use of clinically relevant doses of neuraxial morphine ranged between 1.63 per 10,000 (95% CI, 0.62-8.77) and 1.08 per 10,000 (95% CI, 0.24-7.22), respectively. The prevalence of ARD as defined by each individual paper was 61 per 10,000 (95% CI, 51-74). One published case report of ARD met our inclusion criteria, and there were no cases of ARD from the Closed Claims database analysis. These results indicate that the prevalence of CSRD due to neuraxial morphine or diamorphine in the obstetric population is low.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Analgesics, Opioid; Anesthesia; Cesarean Section; Female; Heroin; Humans; Morphine; Observational Studies as Topic; Pain, Postoperative; Postoperative Complications; Pregnancy; Prevalence; Respiratory Insufficiency; Treatment Outcome

Intraoperative discomfort during spinal anaesthesia for Caesarean section is the commonest cited anaesthetic cause of litigation in obstetric practice. Intrathecal opioids are used to improve intraoperative comfort and postoperative analgesia for these operations. The minimum intrathecal diamorphine dose that prevents intraoperative supplementation requires determination.. After ethics committee approval, 200 ASA I, II women with > or = 37 weeks gestation and planned for elective Caesarean section under combined spinal-epidural anaesthesia were recruited. They were randomized into four groups to receive hyperbaric bupivacaine 0.5% 12.5 mg with diamorphine 0.2, 0.3, 0.4 or 0.5 mg by intrathecal injection. The need for intraoperative i.v. supplementation with alfentanil, time to first requests for postoperative analgesia, incidence of nausea and vomiting and requirement for antiemetic and antipruritic were noted.. Intraoperative supplementation was inversely proportional to the dose of diamorphine used (P=0.004). The ED(95) value for intrathecal diamorphine to prevent intraoperative supplementation was 0.39 mg. Mean time interval for request for postoperative analgesia was 446 min in the 0.2 mg group, 489 min in the 0.3 mg group, 601 min in the 0.4 mg group and 687 min in the 0.5 mg group (P=0.003 for trend). Incidence of nausea, vomiting and pruritus increased with dose of diamorphine used (P values for trend: nausea, 0.04; vomiting, 0.008; pruritus, 0.004). Requests for antiemetic increased with dose but achieved significance only for requirement for second antiemetic (P=0.03). Request for antipruritic did not achieve significance.. The ED(95) for the amount of intrathecal diamorphine required to prevent intraoperative supplementation during spinal anaesthesia for Caesarean section is 0.4 mg in clinical terms. Times to first requests for analgesia, incidence of nausea, vomiting and pruritus increase with dose.

Topics: Adult; Alfentanil; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Double-Blind Method; Drug Administration Schedule; Female; Heroin; Humans; Pain, Postoperative; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Prospective Studies; Pruritus

Co-administration of small doses of opioids and bupivacaine for spinal anaesthesia reduces intraoperative discomfort and may reduce postoperative analgesic requirements in patients undergoing Caesarean section. Fentanyl and diamorphine are the two most frequently used agents in UK obstetric anaesthetic practice.. Seventy-five healthy parturients scheduled for elective Caesarean section under spinal anaesthesia using hyperbaric 0.5% bupivacaine, were randomly allocated to additionally receive intrathecal fentanyl 20 micrograms, diamorphine 300 micrograms or 0.9% saline. Patients also received i.v. cyclizine and rectal diclofenac.. Less supplementary intraoperative analgesia was required by patients in either opioid group (4%) compared with the control (32%) (P < 0.05). Twenty four hours after spinal injection, total mean (SD) postoperative morphine requirement was significantly lower if diamorphine was administered (31 (21) mg), in comparison with the other two groups (control 68 (26) mg; fentanyl 62 (26) mg) (P < 0.05). Reduced visual analogue pain scores were evident 12 h following diamorphine, but observed only for 1 h after fentanyl when compared with the control (P < 0.05). Mild pruritus was more common for 2 h after either spinal opioid (P < 0.05), but no inter-group differences were observed for the remainder of the first 24 h. Patients displayed deeper levels of sedation both acutely and 12 h after administration of intrathecal fentanyl (P < 0.05).. Both intrathecal opioids reduce intraoperative discomfort, but only diamorphine reduced postoperative analgesic requirement beyond the immediate postoperative period.

Topics: Adult; Anesthesia, Obstetrical; Anesthesia, Spinal; Anesthetics, Combined; Bupivacaine; Cesarean Section; Female; Fentanyl; Heroin; Humans; Injections, Spinal; Pain Measurement; Postoperative Care; Postoperative Complications; Pregnancy

In a randomised, double-blind study, the effect of addition of 1 mg of diamorphine to 4 ml of 0.5% bupivacaine for spinal anaesthesia was studied in two groups each of 30 patients presenting for either transurethral genito-urinary surgery, or for lower limb arterial surgery or inguinal herniorrhaphy. Addition of 1 mg diamorphine to intrathecal 0.5% bupivacaine produced a prolonged and satisfactory analgesia in more than half the patients undergoing lower limb arterial or inguinal surgery, and the analgesic requirements of the remainder during the first postoperative 24 h were much less than those who received bupivacaine alone. In the urological surgery set there were no significant differences between the group who received bupivacaine and diamorphine, and the group who received bupivacaine alone. The mixture of diamorphine 1 mg in 4 ml 0.5% bupivacaine was slightly less hypobaric (0.9981 at 37 degrees C) than bupivacaine alone.

Topics: Aged; Anesthesia, Spinal; Bupivacaine; Double-Blind Method; Female; Heroin; Humans; Male; Pain, Postoperative; Postoperative Complications; Specific Gravity; Time Factors

Arterial oxygen saturation (SaO2) was analysed continuously before and for 24 h after lower abdominal surgery in 30 patients breathing air using one of three postoperative analgesic regimens: i.v. diamorphine using a patient-controlled analgesia system (PCAS), extradural diamorphine or i.m. morphine. Hypoxaemia was defined as SaO2 less than 94% for more than 6 min h-1. Before operation there was no difference between the three analgesia groups assessed by the duration when SaO2 was less than 94%. After operation the pattern of SaO2 vs time distribution was either stable, with little variation from hour to hour with no hypoxaemia, or unstable with large variation with 30% of patients hypoxaemic. Thus three patterns of SaO2 distribution were seen in the postoperative period: stable without hypoxaemia (4/10 PCAS, 0/10 extradural, and 1/10 i.m. patients), unstable without hypoxaemia (4/10 PCAS, 5/10 extradural and 7/10 i.m. patients) and unstable with prolonged nocturnal periods with SaO2 less than 94% for a mean of 17.7 min h-1, 95% confidence limits (CL) 10-25 min h-1, (2/10 PCAS, 2/10 i.m. and 5/10 extradural patients). Before operation, the unstable group with hypoxaemia spent longer at less than 94% SaO2 (mean 4.8 min h-1, 95% CL 1.0-8.6 min h-1) than the stable group (mean 0.4 min h-1, 95% CL 0.17-0.61 min h-1) and this was a predictor of postoperative hypoxaemia. Hypoxaemia occurred in all analgesia groups, but extradural diamorphine tended to cause longer periods. Some patients at risk of postoperative hypoxaemia may be predicted by preoperative monitoring of SaO2 although extradural diamorphine boluses were associated with hypoxaemia in patients with normal preoperative values.

Topics: Abdomen; Adolescent; Adult; Female; Heroin; Humans; Hypoxia; Infusions, Intravenous; Injections, Epidural; Injections, Intramuscular; Male; Middle Aged; Morphine; Oximetry; Oxygen; Pain, Postoperative; Postoperative Complications; Self Administration

The analgesic effects of systemically administered diamorphine, caudal analgesia with 0.5% bupivacaine plain and caudal analgesia with 0.5% bupivacaine plain to which morphine sulphate had been added were studied in boys undergoing circumcision. Postoperative analgesia was assessed using a linear analogue scale. The time interval between operation and subsequent analgesic administration and the number of analgesic doses in 24 h were compared. The frequency of vomiting was noted. All three methods provided satisfactory results. The only detectable difference between the groups was a more rapid, but transient, recovery in the group receiving plain bupivacaine only. The frequency of vomiting was high in all groups. Caudal analgesia, with or without the addition of morphine, did not confer any advantage over injected diamorphine, and did not justify the extra time, risk and expense required to carry it out.

Topics: Anesthesia, Caudal; Anesthesia, Epidural; Bupivacaine; Child; Child, Preschool; Circumcision, Male; Heroin; Humans; Male; Morphine; Pain, Postoperative; Postoperative Complications; Time Factors; Vomiting

Topics: Adult; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Spinal; Female; Heroin; Humans; Placenta, Retained; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy

Topics: Adult; Analgesics, Opioid; Anesthesia, Obstetrical; Antiemetics; Cesarean Section; Female; Heroin; Humans; Injections, Spinal; Length of Stay; Ondansetron; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

Topics: Analgesics, Opioid; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Female; Heroin; Humans; Medical Audit; Post-Dural Puncture Headache; Postoperative Complications; Pregnancy

"Body packing" of illegal drugs has increased in the last decades, and with it our experience in treating these patients, yet no clear guidelines for surgical treatment are available. We examined the characteristics and outcomes of patients who required surgical intervention.. Charts of all patients who underwent surgery at our institution for ingested drug packets between January 1990 and January 2005 were reviewed. Patients were identified by a pre-existing list of names collected prospectively and by admission codes. Reviewed parameters included presentation, method of diagnosis, indication for surgery, procedure, and patient outcome.. Twenty-five patients were identified, for whom charts were available for review. Main indications for surgery were drug toxicity and small bowel obstruction. Most packets were retrieved using a combination of milking and multiple enterotomies. A high rate (40%) of postoperative wound infection was found. The incidence of wound infection correlated significantly with the number of enterotomies.. Surgical intervention for body packing remains the treatment for a minority of these patients. Patients should be placed in lithotomy to facilitate the exposure of the entire gastrointestinal tract, and to allow milking of the packets and their possible retrieval through the anus. The number of enterotomies should be minimized in order to reduce the risk of wound infection. If multiple enterotomies are used, the surgeon should consider leaving the wound open for delayed closure.

Topics: Adolescent; Adult; Cocaine; Cross-Sectional Studies; Deglutition; Enterostomy; Female; Foreign Bodies; Foreign-Body Migration; Gastrostomy; Heroin; Humans; Illicit Drugs; Intestinal Obstruction; Length of Stay; Male; Middle Aged; New York; Postoperative Complications; Reoperation; Retrospective Studies; Surgical Wound Infection; Tomography, X-Ray Computed

The benefits, risks and resource implications of providing an Acute Pain Service were assessed during the first year of the service. Six hundred and sixty patients recovering from major surgery were treated with patient-controlled analgesia (510 patients) or extradural infusion analgesia (150 patients). The results of a prospective outcome study showed that pain control was good: more than 60% of patients scored their pain as mild during the first 24 h. Only 10% of patients complained of severe postoperative pain. Eight patients developed potentially serious complications including respiratory depression and hypotension; the diagnosis and management of these problems on general wards is discussed. Retrospective analysis of the incidence of postoperative chest infection in surgical patients showed a marked reduction during the first year of the service (1.3% in 1988, 0.4% in 1989-90 (P less than 0.01].

Topics: Acute Disease; Adolescent; Adult; Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Bupivacaine; Evaluation Studies as Topic; Female; Heroin; Humans; Male; Middle Aged; Morphine; Pain Measurement; Pain, Postoperative; Patient Care Team; Patient Satisfaction; Postoperative Complications; Prospective Studies; Retrospective Studies

Topics: Heroin; Humans; Injections, Spinal; Postoperative Complications; Urination Disorders

Topics: Aged; Female; Heroin; Humans; Morphinans; Nalbuphine; Postoperative Complications; Respiratory Insufficiency; Time Factors

Heroin hydrochloride is approximately twice as potent as morphine sulfate, and acts slightly faster but for a shorter duration than morphine. Although patients with chronic pain due to advanced cancer differ from cancer patients with postoperative pain in terms of their degree of tolerance to the analgesic effects of morphine and heroin and their reports of various elements of mood, there is, thus far, no indication that heroin has any unique advantage over morphine in terms of side effect occurrence or effects on mood at equianalgesic doses. Both drugs improve mood provided they are administered in doses which result in analgesia. While there appears to be some slight difference in the spectrum of side effects observed after heroin as compared to morphine, heroin and morphine share the most common side effects. The incidence of side effects following both drugs appear to be highest among those effects which are primarily somatic and undesirable. The use of visual analog scales concurrent with categorical pain and pain relief scores provides a means for the finer estimation of relative analgesic potency and time action. The results of these studies are in general agreement with those of other investigators. Where apparent differences exist they can usually be explained on the bases of differences in methods and subject populations.

Topics: Adult; Aged; Analgesics; Chronic Disease; Female; Heroin; Humans; Injections, Intramuscular; Levorphanol; Male; Meperidine; Middle Aged; Morphine; Neoplasms; Pain; Postoperative Complications

Topics: Animals; Cardiac Catheterization; Digoxin; Dogs; Heart Failure; Heart Valve Diseases; Heart Valve Prosthesis; Heroin; Humans; Injections, Intravenous; Male; Postoperative Complications; Pseudomonas Infections; Self Medication; Staphylococcal Infections; Substance-Related Disorders; Tricuspid Valve; Tricuspid Valve Insufficiency; Venous Pressure

Topics: Analgesics; Heroin; Humans; Morphine; Narcotic Antagonists; Pain; Phenothiazines; Postoperative Care; Postoperative Complications