Analgesia for major abdominal surgery: A feasibility study using a combination of intrathecal and epidural morphine

1. Epidural Morphine Group o Combined spinal epidural prior to induction of anaesthesia Single lumbar intrathecal injection of preservative-free morphine • 300 mcg in 2 - 4 ml 0.5% bupivacaine Lumbar epidural catheter inserted, labelled and capped o Intravenous fentanyl PCA (fPCA) post op with 10 – 20 mcg bolus / 5 - 10 minute lockout o After 24 hours Acute Pain Service (APS) to test the epidural with 4 ml 2% lignocaine with 1 in 200000 Adrenaline to ensure correct placement with onset of a sensory block, and exclusion of spinal block o APS to administer 3 mg of epidural morphine with 3 ml normal saline 0.9% flush. o APS to repeat epidural bolus 12 – 24 hourly up until 5 days post procedure if required as long as pain NRS is 3 or greater at the time of review • Intravenous fentanyl PCA to continue whilst epidural in-situ • Rescue analgesia for NRS pain score > 4 o Contact APS, to consider clinical situation, no restrictions as per protocol o APS to consider the clinical situation and the following options first, prior to following local protocols to control pain - Recommencing IV fPCA if ceased - Epidural bolus fentanyl 50 mcg - Oral analgesic including opioids o Following rescue analgesia, respiratory observations every 30 minutes for the two hours after administration, then back to hourly PCA observations • If sedation score > 2 or RR < 8, remove intravenous fentanyl PCA, alert medical team and consider naloxone administration. • Epidural site must be checked twice daily. Should fever, or signs of local site infection occur, the epidural catheter must be removed following timing of anticoagulation confirmed, and consultation with APS Protocol adherence will be determined following completion of patient follow up at 30 days upon review of the electronic medical record