Chon, Chong Kuan
(2006)
Perioperative analgesia in decreasing the incidence and or severity of phantom pain-non-randomised observational study between intravenous morphine versus intramuscular diclofenate.
Masters thesis, Universiti Sains Malaysia.
Abstract
PURPOSEOFTHESTUDY
To evaluate the perioperative intravenous morphine and intramuscular diclofenate in
reducing the incidence of phantom limb pain as well as the severity of phantom pain
following lower limb amputation. In addition, to evaluate the association between phantom
limb pain and the pain suffered before the amputation, the duration of diabetic mellitus and
the duration of various feet or legs problems prior to amputation.
METHOD
This was a non-randomsed observational study involving a total 55 patients. 27 patients
were selected for intravenous morphine infusion. The patients' blood pressure, heart rate,
respiratory rate, sedation score, blood oxygen saturation were monitored closely. The other
28 patients were selected for intramuscular diclofenate. The drug was given to those patient
who had pain score at 2 or more before operation and at regular dose after amputation. The
rescue intramuscular tramadol was added if the pain was not adequately controlled in
diclofenate group. Both medications were continued till day-3 post-amputation.
The characteristic, intensity and location of pain encountered before analgesia, after
analgesia and after amputation was documented. The modified numerical pain score wasused to quantify the intensity of pain. The phantom sensation, phantom pain and stump pain
following lower limb amputation was identified in both groups. The patients were followed
up at one week, 1, 3 and 6 months after amputation via phone.
RESULTS
Patients in both groups experienced comparable pain intensity before and after the
operation (p > 0.05). However, two patients in diclofenate group required rescue i/m
tramadol 50 mg for post-amputation pain control.
Overall, 50 out of 55 patients (90%) experienced phantom limb sensation and 33 patients
(60%) encountered phantom pain after amputation. Twenty one patients (75%) out of 28 in
diclofenate group had phantom limb pain compared with 12 patients ( 44%) out of 27 in
morphine group. The phantom sensation in diclofenate and morphine group was 89% and
92% respectively. In 16 patients with phantom limb pain (48%), the symptom subsided
within 6 months. Most of the phantom pain encountered was low pain score and only 2
patients required medical treatment.
Patients in morphine group was 0.176 time (odd-ratio) less likely to develop phantom limb
pain as compared to diclofenate group (p < 0.05). Intravenous morphine significantly
reduced the severity of phantom limb pain after adjusting possible confounding factors like
sex, age, race and presence or absence of diabetic mellitus (p < 0.05). The maximal
phantom pain score in morphine and diclofenate groups was 1.57 and 2.37 respectively.
The severity of pre-analgesic prun and the duration of various leg and foot problem
encountered prior to amputation did not significantly relate to phantom pain. However, the
the longer history of diabetic mellitus had less risk or incidence of phantom pain (p =0.03).
CONCLUSION
This study showed perioperative intravenous morphine infusion reduced the incidence and
severity of phantom limb pain as compared to intramuscular diclofenate.
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