Low Dose Intrathecal Morphine (ITM) in Cardiac Surgery Enhances Recovery After Surgery (ERAS)

The recently developed Enhanced Recovery After Surgery (ERAS) protocol underscores the critical need for effective postoperative pain management. Preoperatively, the use of single-shot low-dose intrathecal morphine (ITM) plays a pivotal role in ensuring adequate intraoperative and postoperative analgesia, thereby promoting early recovery and reducing the incidence of postoperative pulmonary complications. Here, we present two case reports where low-dose ITM was administered before induction, maintaining stable hemodynamics without any episodes of hypotension or bradycardia. However, the use of ITM in patients undergoing imminent heparinisation carries a risk of spinal hematoma, necessitating careful patient selection and timing of administration. Close monitoring for any neurological deficits is essential in this context. Postoperatively, both patients were early extubated without respiratory depression, and their Visual Analog Scale (VAS) scores remained between 0-2 in the first 24 hours and 2-3 up to 48 hours postoperatively. We advocate for the use of low-dose ITM (5-6 µg/kg) as a crucial component of multimodal analgesia to achieve robust postoperative pain relief in cardiac surgery, as these procedures typically entail significant pain during the initial 24 hours, triggering catecholamine release and increasing myocardial oxygen demand. Keywords: Cardiac Surgery, Enhanced Recovery After Surgery (ERAS), Hemodynamic Stability, Intrathecal Morphine, Low-Dose ITM, Multimodal Analgesia, Postoperative Pain Control, Visual Analog Scale (VAS)