Nepal Med Coll J 2013; 15(1): 37-39
Intrathecal Morphine in combination with Bupivacaine:
A comparative study following caesarean section
NR Sharma, P Timalsena, and S DC
Department of Anesthesia and Critical Care, Lumbini Medical College, Pravash, Tansen, Palpa, Nepal
Dr. Nil Raj Sharma, Department of Anesthesia and Critical Care, Lumbini Medical College, Pravash, Tansen,
Post operative pain is very unpleasant. Adequate analgesia during post operative period gives good patient
satisfaction. To assess the adequacy of post operative analgesia in patients undergoing caesarean section. This
prospective study was carried out in Lumbini Medical College, Palpa in the year, and April 2011 to October 2011.
A total of 60 caesarean section cases of ASA grading I or II were selected for the study. All patients received
an intrathecal injection of 0.5% (2 .5ml) hyperbaric Bupivacaine with 100 μgm and 200 μgm of preservative
free morphine. Patients were monitored for 12 hours for adequacy of analgesia. Statistical analysis was done
using SPSS (21)
software. The median age of the patients was 22.75 (SD= 4.309).The duration of analgesia
was prolonged with the patients who had 200 μgm of morphine and less with the 100 μgm of morphine which
was statistically not signifi cant (p = 0.09). The incidence of pruritus ,nausea and vomiting was more with 200
μgm of morphine as compared to 100 μgm of morphine and was statically not signifi cant(p value 0.09 and
0.373 respectively). Intrathecal morphine provides satisfactory analgesia. By decreasing the dose than what is
recommended we can safely acheive adequate analgesia.
Analgesia, hyperbaric bupivacaine, intrathecal morphine, spinal.
(2.5ml) hyperbaric Bupivacaine with 200 μgm of
Cesarean delivery is a common challenge for both the
preservative free Morphine. All the patients who were
obstetricians and the anesthesiologists. The evaluation of
contraindicated to undergo regional anaesthesia were
effects of regional anesthesia on neonates has revealed that
it is associated with high APGAR score in comparison with
Patients were hydrated with 0.5 to 1.0 litre of Ringer Lactate
general anaesthesia.1 Intrathecal opoids are often used for
solution before administration of the subarachnoid block
postoperative pain control in Cesarean section.1 The use
(SB). SB was performed in the sitting position at L3 - L5
of Intrathecal morphine is associated with unpleasant side
inter space. The quince 25 gauge needle was inserted
effects such as pruritus, nausea , vomiting ,urinary retention
through the space. After free fl ow of clear cerebrospinal
and respiratory depression .2 In general, most of the side
fluid had been demonstrated, 12 .5mg hyperbaric
effects of intrathecal opioid are dose-dependent. 2 Side
Bupivacaine (0.5% ) with 100μgm or 200μgm preservative-
effects are less common in patients chronically exposed to
free morphine, mixed in the same syringe, were injected .
intrathecal, or systemic opioids.3 Higher the dose, higher the
Afterwards, patients were immediately placed in a supine
side effects have been seen.3 The use of intrathecal Morphine
position. Supplemental oxygen was delivered by face mask
is reported to have better analgesia in post operative period
@ 5 l/min till the delivery of baby. The level of sensory
after Cesarean Section which reduces the cost of analgesia
block was assessed by loss of cold sensation by spirit swab
and provides satisfaction to the patients.4
till it reached T4 ± 2 dermatomal levels bilaterally.
Patients were monitored every 2 hours for 12 hours after
This prospective study was carried out in Lumbini
surgery. The incidences of pruritus, nausea, vomiting
Medical College, Palpa in the year April 2011 to October
and pain (requiring analgesia) was documented through
2011 after Institutional Research Board approval.
direct questioning. Assessment and treatment of pruritus
Informed consent were taken from each patient. Sixty
and nausea vomiting was carried out immediately.
caesarean section cases of ASA class I or II was included
Nausea and vomiting was treated with 25 mg
in this study. They were divided into two groups
Promethazine I/V. All the other adverse effects in the
randomly. Group 1 (M ) received an intrathecal injection
perioperative period were recorded. In order to prevent
of 0.5% (2 .5ml) hyperbaric Bupivacaine with 100 μgm
breakthrough pain during the fi rst 12 hrs after surgery
of preservative free Morphine and group 2 (M ) received
injection diclofenac sodium 75mg IM was used.
Nepal Medical College Journal
Most of the patients were between age 15-24yrs (70%)
The addition of preservative-free Morphine to intrathecally
but very few were above 35(6.66%). Only 4 (23.33%)
injected local anesthetic provides effective, long-lasting
postoperative analgesia under spinal anaesthesia.5 Intrathecal Morphine inhibits pain transmission in the
substantia gelatinosa.The combination therapy with
Age range in years
Number of patients.
Bupivacaine avoids opioid administration during the
entire post-operative period.3 However, a common
side-effect of intrathecal Morphine administration is the
development of pruritus, nausea, vomiting and respiratory
depression.1,3 The duration of analgesia of intrathecal Morphine is dependent on dose of drug. Higher the
The duration of analgesia was prolonged with 200
dose longer the analgesia with higher incidence of side
μgm (M ) of preservative free morphine in comparison
effects has been seen.4-6 Many other therapies have been
with 100 μgm (M ) as shown in Table-2 and was
administered to control post operative pain in caesarean
statistically not signifi cant. The chi square value is
section cases.7 Trotter et al
failed to show a reduction in
2.4 and p value is 0.09 (which is statistically not
post-operative pain after Caesarean section using 20 ml
Bupivacaine 0.5% subcutaneously.7 In contrast, Genta et al
found that wound infi ltration with 20 ml Bupivacaine
Duration of Analgesia with 100 μgm (M )
0.5% reduced pain scores and analgesic requirements for
and 200 μgm (M ) of intrathecal Morphine in hours
up to 12 hr after surgery.8 Although the effi cacy of the
individual analgesics has been studied after Caesarean
delivery .Their relative contribution towards overall
pain relief in the multi-modal study group is unknown.9
Our study raveals that the patient who had 0.2 mg of
intrathecal Morphine had >12 hrs of analgesia in 60%
The incidence of nausea and vomiting is more with 200
0f cases. Whereas, in patients with 0.1mg Morphine had
μgm (M ) of preservative free morphine in comparison analgesia duration of >12 hrs in 40% of cases (p value
with 100 μgm (M ) although there is no statistical
0.09). Remaining (50%) who had analgesia duration of
signifi cant relation with each other. The chi square value
<12 hr had inj Diclofenac 75 mg intramuscularly as a
is 0.373 and p value is 0.381 (which is statistically not
The most feared side effect of intrathecal opioids
Incidence of nausea and vomiting with 100
is respiratory depression. Higher the dose betters
μgm (M ) and 200 μgm (M ) of intrathecal Morphine
the analgesia but worse the respiratory depression.
Respiratory depression was found signifi cantly after
0.2mg to 0.4mg of intrathecal morphine and it was
profound with 0.6 mg.10 Our study reveals that the
analgesic effects was good and prolonged with 0.2mg
of Morphine than 0.1mg of intrathecal morphine with
no cases recorded of respiratory depression. Delayed respiratory depression which develops progressively in
Pruritus is seen more with 200 μgm (M ) of preservative
12 to 24 hours after use of spinal morphine has limited
free Morphine in comparison with 100 μgm (M )
Morphine. However, there was no statistical correlation, the chi square value is 2.411 and p value is 0.09, which
Some study have reported 40% of respiratory depression
is statistically not signifi cant (Table-4).
with 0.2mg intrathecal morphine.10 Further increase to 0.4 and 0.6mg of intrathecal morphine resulted in
Incidence of pruritus with 100 μgm (M ) and
respiratory depression of 60% and 80% respectively
with desaturations (SpO2 < 85%).10 In these patients >
95% of cases had satisfactory pain control.10
Another most troublesome side efeect of intrathecal
morphine is nausea and vomiting. The incidence of
nausea and vomiting is 30% following 0 .2 mg of
NR Sharma et al
intrathecal morphine.12-15 Our study reveals 26.66%
long-term treatment with epidural and intrathecal opioids - a
incidence of nausea and vomiting following 0 .2 mg
nationwide survey. Acta Anaesthesiol Scand
1988; 32: 253-9.
of intrathecal Morphine and it was 20% with 0.1 mg
4. Abouleish E, Rawal N, Fallon K, Hernandez D. Combined
intrathecal morphine and bupivacaine for cesarean section.
of intrathecal Morphine which was statistically not
1988; 67: 370-4.
5. Nordberg G, Hedner T, Mellstrand T, Dahlström B.
Pharmacokinetic aspects of intrathecal morphine analgesia.
Pruritus is another troublesome situation in patients
1984; 60: 448-54.
receiving intrathecal morphine. It may be generalized but
6. Ballantyne JC, Loach AB, Carr DB. Itching after epidural
is more likely to be localized to the face, neck, or upper
and spinal opiates. Pain
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thorax.16 It is higher in intrathecal route than others. The
7. Trotter TN, Hayes-Gregson P, Robinson S, Cole L, Coley
incidence varies widely from 0 to 100%.17 Studies have
S, Fell D. Wound infi ltration of local anaesthetic after lower
observed that up to 80% of patients had complained of
segment Caesarean section. Anaesthesia
1991; 46: 404-7.
pruritus. Severe pruritus is rare, occurring in only about
8. Ganta R, Samra SK, Maddineni VR, Furness G. Comparison
of the effectiveness of bilateral ilioinguinal nerve block and
1% of patients.17 Pruritus induced by intrathecal and
wound infi ltration for postoperative analgesia after Caesarean
epidural opioids is likely due to cephalic migration of
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1994; 72: 229-30.
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9. Kehlet H, Dahl JB. The value of “multimodal” or “balanced
with the trigeminal nucleus located superfi cially in the
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medulla.17,18 In our study there was higher incidence
of pruritus with 0.2 mg of intrathecal Morphine than
Bailey PL, Rhondeau S, Schafer PG, Lu JK,
Foster W et al
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. Safety and effi cacy
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Another less common complication of intrathecal
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Morphine is retension of urine .Since all our patients
R, Viars P. Plasma pharmacokinetics of morphine after i.m.,
had urinary catheter in place for 12 hours they were not
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