The unwillingness to use morphine is a bit more complicated than it seems.
There is some evidence that it interferes with cerebral autoregulation in
the setting of a SAH (mainly by extrapolation of the effects of naloxone).
This is all based on animal models and has never been shown to be a problem
in practice. Personally, it's hard enough to alter my prejudices with a good
quality systematic review of RCTs, so a couple of equivocal rat studies
won't stop me using analgesia (seriously, best evidence available is a
clinical impression that patients are more comfortable and 'I've never seen
any problems with it'. This probably outweighs small animal studies showing
a theoretical problem); but the theory is out there.
Matt Dunn
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