1. The use of Morphine with Bupivacaine, or Neostigmine for analgesia post-operatory in urology surgery. Haxhire Gani, Proff.M.Xhani,I.Ohri,E.Cobani.R.Domi,A.Janko, Clinic of Urology University Hospital Center “Mother Tereza”Tirana
The purpose of the study.
To compare Neostigmine and Morphine analgesic effectiveness in patients that underwent urology operation with the spinal anesthesia. After open urinary bladder surgery pain can be associated with severe reflex spasms of the uretral muscle.The addition 50ug neostimgine prolongs motor blockade via an acetylcholine Ach mediated reduction in motor neuron outflow.In addition to the direct inhibition of motor activity resulting spinal levels of Ach may augment motor blocade as result of the axonal conduction block caused by spinal marcaine .Neostimine enhanced motor block after spinal administration off local anesthetic can be a troublesome side effect postoperatively but may be useful in surgery of urinary bladder.Confirmation of this hypotesis warrants specific investigation. IT morfine is considered to be the “preferred ”route of neuroaxil opiod adminstrating owing to the ease of the technique,the simplicity of postoperative management ,and the immediate availability of opiod in the cerebrospinal fluid for biding to dorsal horn receptors.The major concern in IT morfine administration is respiratory depression
Opioides are commonly chosen for painrelief. Intrathecal[IT] and epidural administration of opioids is frecuently used to provide postoperative analgjesia without sensory or motor blockade
Unfortunatly ,neuroaxial opioids are associated with adverse side effects,in particular,delayed respiratory depression.IT neostigmine prodused analgesia in animals and humans ,but its side effects ,including nausea and vomiting ,limit its use in clinical practice.
.Nevertheless,studies have shown that small doses of neostigmine [50ug]can enhance sensory anesthesia with few side effects when combined with small dose bupivacaine spinal anesthesia .
Thus it is conceivable that the combination of IT 50ug neostigmine and local anesthetic might improve the quality of spinal anesthesia and prolong postoperative analgjesia with few adverse effects.of the addition .

2. Method:Participants were 90 patients that underwent spinal anesthesia and had an urology surgery, participant were classified in three groups. Respectively each group received 15mg Bupivacaine(sol.0.5%) and 50ug Neostignime, and the other group instand of Neostignime received Morphine 300ug. And the third group received normal saline 0.5ml. On those patients was monitored carefully maximal motor block level, the time that anesthesia lasted, the need for analgesics in 24 hours, interval analogue scale ( VAS) pain score, and the frequency of side effects in 24 hours post anesthesia.
Esclusion criteria included age<40yr or >80yr:
and ASA physical status greater than III,
allergy to local anesthetics,
contraindications to spinal anesthesia(coagulation defects, infection at puncture site,preexisting neurological deficits in the lower extremities).
a history of opioids dependence, contrindications for nonsteroid anti-inflamatory drugs (NSAID).NSAID or
aspirin allergy,
severe liver disease, or
impaired renal function,
weight >100 kg .

3. .None of the patients received any pre- medication,
Was used a 25- gauge Quinck .
The patients was administrated 3ml of 0.5% (15mg) marcaine in addition morfine or neostigmine.
The morfine group received 300ug morfine ,
while the neostigmine group received 50ug neostigmine.
Noninvasive monitoring of blood pressure .heart rate,oxygen saturation,and respiratory rate continued throughout the anesthesia and the first 24 hr following surgery in the postanesthesia.
All patients has taken 500ml of ringer lactate solution.
Blood pressure was monitored every 3min imidiatly after spinal anesthesia ,and during remove of prostate .While after blood pressure was monitored every 5 min.
Bradicardia was corrected with atropine,
vomiting and nausea were corrected with metoclopramide. Resccue antiemetik were given if vomiting occurred more than once ,for nausea lasting more than ten minutes ,or at the patiens request .The treatment was repeated if necessary .
Postoperative analgesia was provided with im diclofenac 75mg if dhe VAS score was four or greater .
If necessary diclofenac was given 12hr after the previous injection .The last of analgesia is measured from the time of drug administration to the time when the VAS became greater than zero . Was recorded the time of giving of the first dose alsothe number of diclofenac doses .
The duration of motor block was recorded from the timeof drug administration to the time when patients can move their legs in bed, The incidence of adverse effects such as nausea,
vomiting, pruritus,dizziness,and anxiety was evaluated with yes or no survey.

4. Resultats Table II frequency of side effects and satisfaction rate
Table I Demographic data
Saline
Morphine
Neostigmine
Age(yr)
68±6
65±6
6±8 NS
Sex(M/F)
10/20
9/21
8/22
Weight(kg)
72±3
73±5
71±6
Height(cm)
165±7
164±6
167±8
Surger
Duratio
(min)
123±19
126±18
128±12
Saline
Morphine
Neostigmine
Nausea/vomiting
1/30
8/30
9/30*
Pruritus
0/30
18/30
Dizziness
6/30
5/30 NS
Anxiety
3/30
Respirat.
depression
Satisfaction
19/30
Values are expresses as mean ±SEM. NS =non-significant.
NS= no significance.*P<compared with the saline group

5. For respiratory depression is seen a respiratory rate
Patients satisfaction (yes/no)with postoperative analgesia over the 24 hr is also recorded.
After open urinary bladder surgery pain can be associated with severe reflex spasms of the uretral muscle.The addition 50ug neostimgine prolongs motor blockade via an acetylcholine Ach mediated reduction in motor neuron outflow.In addition to the direct inhibition of motor activity resulting spinal levels of Ach may augment motor blocade as result of the axonal conduction block caused by spinal marcaine .Neostimine enhanced motor block after spinal administration off local anesthetic can be a troublesome side effect postoperatively but may be useful in surgery of urinary bladder.Confirmation of this hypotesis warrants specific investigation. IT morfine is considered to be the “preferred ”route of neuroaxil opiod adminstratin owing to the ease of the technique,the simplicity of postoperative management ,and the immediate availability of opiod in the cerebrospinal fluid for biding to dorsal horn receptors.The major concern in IT morfine administration is respiratory depression .
Conclusion:IT 300ug morfine prodused longer lasting analgesia with a duration of about 9hr compared to IT 50ug neostigmine wich resulted in postoperative analgesia lasting about 7hr .
The incidence of adverse effects was similar for both group,
expect for pruritus, wich occurred more frequently in the morfine group.
The patient assed rate of analgesic satisfaction was higher in the neostigmine group than in the morfine group