MOrphine intermittent bolus versus Ropivacaine-Fentanyl INfusion through epidural route after gastrointestinal oncosurgery: a randomized clinical trial
Authors: Nandi Rudranil , Haldar Srimanta Kumar , Mitra Suparna , More Shikhar , Sarkar Anshuman , Goswami Jyotsna 
Published: May 2024

Abstract

Background: Epidural local anesthetic infusion is the gold standard analgesia technique after open major abdominal surgery for gastrointestinal cancers. However, hypotension associated with it often leads to administration of large amounts of fluid, increased vasopressor requirement, reduction of epidural drug dose and thus increased consumption of intravenous opioid as rescue analgesia. Epidural morphine can be an alternative in this regard. This study was designed to compare the efficacy of intermittent bolus of epidural morphine with the epidural infusion of ropivacaine-fentanyl.
Methods: Total 86 patients, scheduled for open elective gastrointestinal oncosurgery were enrolled in the study. They were randomized to either group ROP or group MOR. In group ROP, analgesia was provided with 6 ml bolus of epidural ropivacaine (0.2%)-fentanyl (2mcg/ml) followed by an infusion at 3-10 ml/hr. during perioperative period. In group MOR, bolus of epidural morphine 0.05 mg/kg in 10 ml bupivacaine 0.1% was administered every 8-24 hr. In both the groups, rescue analgesia was provided with intravenous 25 mcg fentanyl bolus. If fentanyl consumption increased above 100 mcg in 4 hr., fentanyl infusion was started at 20 mcg/hr. Primary objective of the study was to compare postoperative fentanyl consumption between the two groups.
Results: Demographic parameters and types of procedure were similar in both groups. Fentanyl consumption (mcg) was significantly lower in group MOR in the first 24 hr. [92 (33-151) in group MOR vs 255 (173-338) in group ROP; P<0.01], 24-48 hr. [71 (9-134) in group MOR vs 261 (150-372) in group ROP; P<0.01] and 48-72 hr. [51(0-103) in group MOR vs 240 (140-339) in group ROP; P<0.01] in the postoperative period. Pain scores at rest [2.1(1.4-2.8) in group MOR vs 3.6 (2.7-4.5) in group ROP, P<0.01)] as well as during movement [3.1(2.4- 3.9) in group MOR vs 5.0 (4.0-6.0) in group ROP] were significantly lower in group MOR during the immediate postoperative period. Postoperative fluid requirement (ml) in the first 24 hr. was significantly lower in group MOR [3051(2863-3238) ml in group MOR vs 3485(3290-3679) ml in group ROP]. Intraoperative fentanyl requirement, pain scores in all other postoperative timepoints were comparable in both groups. Perioperative noradrenaline requirement and intraoperative fluid requirement were apparently lower in group MOR; however, the result did not achieve statistical significance.
Conclusion: Intermittent boluses of epidural morphine with low dose bupivacaine is associated with lesser postoperative fentanyl consumption and fluid administration compared to epidural ropivacaine-fentanyl infusion after gastrointestinal oncosurgery.
Trial registration number- CTRI/2020/12/030076, Date of registration: 28/12/2020 @ ctri.nic.in
URL- https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NTAyNDQ=&Enc=&userName=
Registered- 28/12/2020.
First enrolment- 1/1/2021