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Patient-Controlled Analgesia After Cardiac Surgery With Median Sternotomy: No Advantages of Hydromorphone When Compared to Morphine
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Design
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Single-center, retrospective analysis
N= 41
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Objective
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To compare the efficacy, safety, and side effects of hydromorphone and morphine administered as patient-controlled analgesia (PCA) for postoperative pain therapy after cardiac surgery with median sternotomy
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Study Groups
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Hydromorphone (n= 21)
Morphine (n= 20)
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Inclusion Criteria
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Adult patients undergoing cardiac surgery with median sternotomy; aged 40 to 85 years; body mass index ≤35 kg/m2; American Society of Anesthesiologists (ASA) physical status classification 3; left ventricular ejection fraction ≥40%
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Exclusion Criteria
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Pregnancy; allergy to opioids; diabetes mellitus; renal, psychiatric, neurologic, chronic inflammatory, or chronic obstructive lung diseases; drug abuse; use of monoaminoxidase-inhibitors or nonsteroidal anti-inflammatory drugs; participation in another clinical trial, or pain therapy with opioids within 14 days before the start of the study
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Methods
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Published and unpublished data from postoperative pain therapy that were collected in 2 randomized control trials, which were performed at a single-center intensive care unit (ICU) at the University Hospital of Erlangen were pooled for retrospective analysis. In the first study, a total of 25 out of 50 patients were assigned to receive pain therapy by PCA with hydromorphone whereas 25 out of 50 patients were assigned to receive pain therapy by PCA with morphine in the second study.
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Duration
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First study: December 2013 to April 2015
Second study: April 2015 to December 2016
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Outcome Measures
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Numerical pain rating scale (NRS) at rest and under deep inspiration, hemodynamics and respiration stability, incidence of adverse effects
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Baseline Characteristics
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Hydromorphone (n= 21)
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Morphine (n= 20)
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Age, years
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61 |
68 |
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Male/Female
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17/4 |
17/3 |
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Body mass index, kg/m2
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27.5 |
27.1 |
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Type of surgery
Coronary artery bypass graft
Aortic valve replacement
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20
1
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18
2
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Duration of anesthesia, min*
Duration of surgery, min
Aortic clamping time, min*
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277
216
38
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309
201
46
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Number of bypass grafts
Number of chest tubes
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2
2
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2
2
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Medication dose
Propofol, mg/kg/h
Sufentanil, mcg/kg/h
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4.4
0.51
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4.5
0.47
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*Significant difference between the two groups (p< 0.05)
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Results
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Endpoint
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Hydromorphone (n= 21)
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Morphine (n= 20)
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p-value
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Median (range) NRS rating
At rest
Under deep inspiration
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1.5 (0 to 5)
3 (0 to 6)
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0.5 (0 to 5)
4 (0 to 7)
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0.41
0.07
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Time to extubation (interquartile range [IQR], h
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3.6 (2.9 to 4.4) |
0.42 |
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0.31 |
Opioid dose (IQR), mcg/kg/h
Dose until extubation
Dose during PCA
Total dose
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3.52 (3.22 to 3.95)
3.01 (2.09 to 4.31)
3.15 (2.32 to 4.07)
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25.6 (18.6 to 29.1)
17.2 (11.9 to 24.3)
19.1 (15.2 to 24.7)
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-
-
-
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Positive requests/h
Negative requests/h
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1.54 (0.98 to 2.06)
1.54 (0.28 to 2.26)
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0.88 (0.61 to 1.31)
0.42 (0.07 to 1.89)
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0.054
0.36
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Adverse Events
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Common Adverse Events were not significantly different between hydromorphone vs. morphine: nausea, 5 (24%) vs. 7 (35%); vomiting, 1 (5%) vs. 1 (5%); shivering, 1 (5%) vs. 4 (20%)
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Serious Adverse Events: respiratory depression, 2 (10%) vs. 2 (10%)
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Percentage that Discontinued due to Adverse Events: N/A
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Study Author Conclusions
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There were no significant differences in analgesic efficacy and safety between hydromorphone and morphine when used for post-operative pain therapy with PCA after cardiac surgery with median sternotomy.
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InpharmD Researcher Critique
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In addition to the limitations inherent to the retrospective design, this study excluded patients with severe comorbidities, potentially reducing the external validity of the results.
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