Patient-controlled analgesia in the pediatric population: morphine versus hydromorphone

Journal of Pain Research Dovepress open access to scientific and medical research Original Research Open Access Full Text Article Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. Patient-controlled analgesia in the pediatric population: morphine versus hydromorphone This article was published in the following Dove Press journal: Journal of Pain Research 13 August 2014 Number of times this article has been viewed Matthew DiGiusto 2 Tarun Bhalla 1 David Martin 1 Derek Foerschler 3 Megan J Jones 2 Joseph D Tobias 1 Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital and the Ohio State University, 2The Ohio State School of Medicine, 3Department of Anesthesiology, The Ohio State University, Columbus, OH, USA 1 Objective: Patient controlled analgesia (PCA) is commonly used to provide analgesia following surgical procedures in the pediatric population. Morphine and hydromorphone remain the most commonly used opioids for PCA. Although both are effective, adverse effects may occur. When these adverse effects are unremitting or severe, opioid rotation may be required. In this study, we retrospectively evaluated PCA use, the adverse effect profile, and the frequency of opioid rotation. Methods: This retrospective study was performed at Nationwide Children’s Hospital (Columbus, OH). The hospital’s electronic registry was queried for PCA use delivering either morphine or hydromorphone from January 1, 2008 to December 31, 2010. Results: A total of 514 patients were identified, that met study entry criteria. Of the 514 cases, 298 (56.2%) were initially started on morphine and 225 (43.8%) were initially started on hydromorphone. There were a total of 26 (5.1%) opioid changes in the cohort of 514 patients. Of the 26 switches, 23 of 298 (7.7%) were from morphine to hydromorphone, and 3 of 225 (1.3%) were from hydromorphone to morphine (P=0.0008). Of the 17 morphine-to-hydromorphone switches with adverse effects, pruritus (64.7%), and inadequate pain control (47.1%) were the most common side effects. The most common side effect resulting in a hydromorphone-tomorphine switch was nausea (66.7%). Conclusion: PCA switches from morphine-to-hydromorphone (88.5%) were more common than vice-versa (11.5%). The most common reasons for morphine-to-hydromorphone switch were pruritus and inadequate pain control. These data suggest that a prospective study is necessary to determine the side effect differences between morphine and hydromorphone in pediatric PCA. Keywords: acute pain, analgesia, opioids, pediatric Introduction Correspondence: Tarun Bhalla Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA Tel +1 614 722 4200 Fax +1 614 722 4203 Email 471 submit your manuscript | www.dovepress.com Journal of Pain Research 2014:7 471–475 Dovepress © 2014 DiGiusto et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php http://dx.doi.org/10.2147/JPR.S64497 Powered by TCPDF (www.tcpdf.org) Morphine and hydromorphone, both µ-opioid receptor agonist analgesics, are associated with typical opioid side effects including nausea, vomiting, pruritus, and cognitive disturbances.1 Both opioids are commonly used in patient-controlled analgesia (PCA), a device that delivers preset amounts of intravenous medication to the patient each time a demand button on the PCA pump is depressed.1 The use of PCA is currently the mainstay of acute pain management for children over the age of 6 years, given that studies demonstrate improved analgesia, fewer adverse effects, and decreased opioid use when compared to intermittent, on-demand opioid dosing.1–6 While both morphine and hydromorphone are µ-opioid receptor agonists, more is known about morphine than any other opioids, and it is commonly referred to as the “gold standard” for pain Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 37.59.46.207 on 13-Jul-2018 For personal use only. DiGiusto et al management.1,4,7 As the “gold standard”, morphine is the first-line medication for postoperative pain control with PCA in the majority of pediatric patients.1 There is a belief among health care providers that hydromorphone offers better pain control with fewer side effects compared to morphine, a belief that Hong et al1 refer to as “clinical lore”. The reason this belief is referred to as “clinical lore” is because if either drug were consistently found to have fewer side effects with equal or greater efficacy, then it would clearly be the drug of choice; but as it stands, morphine is still considered by most to be the “gold standard”.1 There are, however, some pharmacological differences between hydromorphone and morphine that may substantiate this “clinical lore”. After the administration of either hydromorphone or morphine, the onset of the analgesic effect is rapid, but the time to maximum analgesia is delayed in patients who receive morphine.8 This delay in attaining maximum analgesia for morphine is consistent with the hypothesis that one of the metabolites of morphine, morphine-6-glucuronide, plays a role in analgesia.9 In the setting of a PCA, a more rapid onset of maximum analgesia could give the patient better pain control.9 Additionally, morphine has been shown to induce histamine release while hydromorphone has not.10 Histamine release may increase the incidence of one of the undesirable effects of opioids: pruritus. So, while it may be “clinical lore” that hydromorphone has better pain control with fewer side effects when compared to morphine, there is pharmacological evidence that this lore may be a reality. At the present time, there are limited and inconclusive data that compare the adverse effects of morphine and hydromorphone. Even less information is available on their use in PCA, and virtually no information is available in the pediatric population. We retrospectively surveyed the use of PCA in the pediatric population at our institution and investigated the adverse effect profile of morphine and hydromorphone. Methods Following approval from the Institutional Review Board of the Nationwide Children’s Hospital (Columbus, OH, USA), a systemic retrospective review of the medical records was performed to identify patients, ranging in age from 4–13 years who had received a PCA delivering either morphine or hydromorphone (...truncated)