Does the Use of Intrathecal Morphine Increase the Length of Hospital Stay in Fast Track Orthopedic Procedures?
Condition: Arthropathy of Knee; Arthropathy of Hip
MeSH terms: Joint Diseases
Study type: Interventional

Summary: 
      This is a clinical trial of intrathecal morphine for patients Patient with primary as well as
      revision knee and hip arthroplasty under regional anesthesia. This study would include a
      total of 134 patients. It is the intention to randomize these patients postoperatively into 2
      groups of patients:

      Group 1 - Patients will receive intrathecal morphine 100 mcg in addition to the standard dose
      of bupivacaine and 15 mcg of fentanyl for spinal anesthesia.

      Group 2 - Patients will not receive intrathecal morphine. Patients will receive only
      bupivacaine and 15 mcg of fentanyl for spinal anesthesia.

      It is postulated that the use of intrathecal morphine may be associated with an increase
      length of stay in the hospital.
    

Detailed description: 
      Procedures:

      Preoperative phase- The patients will receive the consent form together with the standard
      sheet in the pre-admission unit or remotely via telephone or email, usually one week before
      surgery, explaining intrathecal morphine and its benefits and drawbacks. These patients will
      receive an educational booklet regarding the "fast track protocol" which includes clear
      instruction related to their upcoming surgery. The material covers a wide range of topics
      such as instructions related to fasting for solids and liquids before coming for surgery, the
      expectation of pain relief and physiotherapy, types of anesthesia and expected length of
      hospital stay. Upon hospital admission, one hour before the procedure, patients will receive
      gabapentin 300mg, celecoxib 400mg (will be reduced to celecoxib 200mg in patients ≥ 65 years
      old) and acetaminophen 1000mg orally.

      Intraoperative phase- Surgical procedures to be included in the study are elective primary as
      well as revision arthroplasty of knee and hip joints under spinal anesthesia with or without
      sedation. Patient will be randomized to one of two groups. One group will receive intrathecal
      morphine 100 mcg in addition to the standard dose of bupivacaine and fentanyl 15 mcg for
      spinal anesthesia and another group will not receive intrathecal morphine. Upon prosthesis
      implant, the surgeon will infiltrate periarticular 100 ml (40 ml bupivacaine 0.5% + 60 ml of
      normal saline) as per the orthopedic protocol. Sedation will be titrated to keeping modified
      Ramsay sedations score (RSS) between 3 and 5.

      Postoperative phase- upon emergence from anesthesia patients will be taken to the recovery
      room. As per our hospital protocol, the patient will be catheterized if the bladder residual
      volume by ultrasound is 500ml or more. Post-operative pain score and opioid requirements and
      complications including urinary retention, vomiting and respiratory depression will be
      recorded. Overall duration of stay in the hospital will be noted. If any patient requires
      catheterization of bladder, the duration of catheter requirement and frequency of
      catheterization will be monitored and recorded.
    

Intervention name(s): Intrathecal Morphine; Placebo
Intervention type(s): Drug; Drug
Intervention description(s): Group 1 - Patients will receive intrathecal morphine 100 mcg in addition to the standard dose of bupivacaine and 15 mcg of fentanyl for spinal anesthesia.; Group 2 - Patients will not receive intrathecal morphine. Patients will receive only bupivacaine and 15 mcg of fentanyl for spinal anesthesia.
Intervention MeSH terms: Morphine
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Supportive Care
Keywords: Arthroplasty; Knee; Hip; Intrathecal Morphine; Urinary retention; Opioid