Original Article
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 Corresponding author: 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.
Keywords: 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 Table-1: Demography
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 Table-2: 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 <12 hour
>12 hour
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 Table-3: 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 Table-4: 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 Anesth Analg 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 Anesthesiol 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 1988; 33: 149-60.
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 section. Br J Anaesth 1994; 72: 229-30.
the drug in cerebrospinal fl uid and subsequent interaction 9. Kehlet H, Dahl JB. The value of “multimodal” or “balanced with the trigeminal nucleus located superfi cially in the analgesia” in postoperative pain treatment. Anesth Analg 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. Dose response pharmacology of intrathecal 0.1 mg of intrathecal morphine. (56.66 % and 36.66 morphine in human volunteers. Anesthesiol 1993; 79: 49- % respectively), but was not statistically signifi cant (p value 0.09).Higher the dose, higher the incidence of 11. Burrows WR, Gingo AJ Jr, Rose SM et al. Safety and effi cacy of early postoperative solid food consumption after cesarean section. J Reprod Med 1995; 40: 463-7.
Another less common complication of intrathecal Chauvin M, Samii K, Schermann M, Sandouk P 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 extradural and intrathecal administration. Brit J Anaesth 200 μgm of intrathecal Morphine is adequate to provide extradural and intrathecal opiates: report of a nationwide satisfactory analgesia. However, low incidences of survey in Sweden. Brit J Anaesth 1982; 54: 479-86.
Morphine related side effects is seen with 100μgm Tamsen A, Persson MP, Hartvig P. Pharmacokinetics of intrathecal morphine and meperidine in humans. of morphine when used in combination with 0.5% Anesthesiol 1987; 67: 889-95.
hyperbaric Bupivacaine intrathecally.
g G, Hedner T, Mellstrand T, Dahlström B. Pharmacokinetic aspects of intrathecal morphine analgesia. REFERENCES
1. Chadwick HS, Ready LB. Intrathecal and epidural morphine sulfate for postcesarean analgesia - a clinical comparison. Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiol 1984; 61: 276-310.
2. Abboud TK, Dror A, Zhu J et al. Mini-dose intrathecal gan M. The rational use of intrathecal and extradural morphine for the relief of post-cesarean section pain: safety, opioids. Brit J Anaesth 1989; 63: 165-88.
effi cacy and ventilatory responses to carbon dioxide. Anesth McClain E. The incidence of adynamic ileus in postcesarean 3. Arnér S, Rawal N, Gustafsson LL. Clinical experience of patients. Patient-controlled analgesia versus intramuscular analgesia. J Reprod Med 1993; 38: 293-300.


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