Comparison among subarachnoid opioid mix for cesarean section – An observational study
Introduction: Classically, the local anesthetic (LA) has been combined with one lipophilic and another hydrophilic opioid for neuraxial anesthesia in cesarean section. In Colombia, the practice has been the use of morphine hydrochloride with fentanyl, but the occasional shortage of the former triggered an interest in new options. In response to the shortage of morphine in 2017-2018, a contingency plan was developed at the SES Hospital in Caldas, prefilling syringes at the hospital compounding central, with: bupivacaine, morphine y fentanyl (BMF); bupivacaine, fentanyl and hydromorphone (BHF); and bupivacaine and hydromorphone (BH). Hydromorphone has a rapid onset of action, long-lasting effect and is indicated for spinal administration in the safety data sheet; therefore, the advantages of adding fentanyl to this mix are questionable.
Objective: To compare the clinical analgesic efficacy at the time of the incision and during the first 12 hours after surgery.
Methods: An observational, analytical study was conducted, using the mixtures BMF, BHF and BH in patients receiving subarachnoid anesthesia for cesarean section. Pain was assessed at the time of the incision, as well as any adverse effects and the pain visual analogue scale over the following 12 hours.
Results: Of the 71 patients participating in the study, 40.9 % received BMF; 22.5 %, BHF; and 36.6 %, BH. None of the patients experienced pain at the time of the incision. There was no difference in terms of adverse effects among the three groups. The mean difference in the visual analogue scale (VAS) for postoperative pain at 3, 6 and 12 hours was lower in the groups in which hydromorphone was used.
Conclusions: BHF and BH combinations are comparable to the original preparation in terms of adverse effects, with the advantage of being more effective in controlling postoperative pain.
Chou R, Gordon DB, De Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: A clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists’ committee on regional anesthesia, executive commi. J Pain. 2016;17(2):131–57. Available from: http://dx.doi.org/10.1016/j.jpain.2015.12.008
Bonnet MP, Mignon A, Mazoit JX, Ozier Y, Marret E. Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review. Eur J Pain. 2010;14(9):894.e1-894.e9. Available from: http://dx.doi.org/10.1016/j.ejpain.2010.03.003
Sutton CD, Carvalho B. Optimal Pain Management After Cesarean Delivery. Anesthesiol Clin. 2017;35(1):107–24.
Marroquin B, Feng C, Balofsky A, Edwards K, Iqbal A, Kanel J, et al. Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study. Int J Obstet Anesth. 2016;0(0):1–68. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0959289X16302199
Sviggum HP, Arendt KW, Jacob AK, Niesen AD, Johnson RL, Schroeder DR, et al. Intrathecal Hydromorphone and Morphine for Postcesarean Delivery Analgesia: Determination of the ED 90 Using a Sequential Allocation Biased-Coin Method. Anesth Analg. 2016;123(3):691–7.
Hindle A. Intrathecal opioids in the management of acute postoperative pain. Contin Educ Anaesthesia, Crit Care Pain. 2008;8(3):81–5. Available from: https://academic.oup.com/bjaed/article-lookup/doi/10.1093/bjaceaccp/mkn016
Mugabure Bujedo B, González Santos S, Uría Azpiazu A, Torán García L. Up to date in clinical management of neuraxial opioids for the treatment of postoperative pain | Actualizaciones en el manejo clínico de los opioides espinales en el dolor agudo postoperatorio. Rev la Soc Esp del Dolor [Internet]. 2012;19(2):72–94. Available from: http://www.scopus.com/inward/record.url?eid=2-s2.0-84877744553&partnerID=MN8TOARS
Mugabure B, Echaniz E, Marín M. Fisiología y farmacología clínica de los opioides epidurales e intratecales. Rev la Soc Esp del Dolor. 2005;12(1):33–45.
Hanna MN, Ouanes JPP, Tomas VG. Postoperative Pain and Other Acute Pain Syndromes. In: Honorio T. Benzon, James P. Rathmell, Christopher L. Wu, Dennis C. Turk, Charles E. Argoff and RWH, editor. Practical Management of Pain: Fifth Edition. 5th editio. Elsevier; 2013. p. 271–97.
Beatty NC, Arendt KW, Niesen AD, Wittwer ED, Jacob AK. Analgesia after Cesarean delivery: A retrospective comparison of intrathecal hydromorphone and morphine. J Clin Anesth. 2013;25(5):379–83. Available from: http://dx.doi.org/10.1016/j.jclinane.2013.01.014
Rauch E. Intrathecal hydromorphone for postoperative analgesia after cesarean delivery: A retrospective study. AANA J. 2012;80(SUPPL.4):25–32.
Bujedo BM. Spinal opioid bioavailability in postoperative pain. Pain Pract. 2014;14(4):350–64.
Roy SD, Flynn GL. Solubility and Related Physicochemical Properties of Narcotic Analgesics. Pharm Res An Off J Am Assoc Pharm Sci. 1988;5(9):580–6.
Bucklin B, Santos A. Local anesthetics and opioids [Internet]. Sixth Edit. Chestnut’s Obstetric Anesthesia Principles and Practice. Elsevier Inc.; 2014. 261–99 p. Available from: http://dx.doi.org/10.1016/B978-1-4557-4866-2.00013-4
Johansen MJ, Satterfield WC, Baze WB, Hildebrand KR, Gradert TL, Hassenbusch SJ. Continuous Intrathecal Infusion of Hydromorphone: Safety in the Sheep Model and Clinical Implicactions. Pain Med. 2004;5(1):14–25.
MOON RE, CLEMENTS FM. Accidental Epidural Overdose of Hydromorphone. Anesthesiology [Internet]. 1985;63(2):238. Available from: https://insights.ovid.com/crossref?an=00000542-198508000-00042
Chaplan SR, Duncan SR, Brodsky JB, Brose WG. Morphine and Hydromorphone Epidural Analgesia. Anesthesiology [Internet]. 1992 Dec;77(6):1090–4. Available from: http://journals.lww.com/anesthesiology/Abstract/1992/12000/Morphine_and_Hydromorphone_Epidural_Analgesia__A.8.aspx
Fukuda K. Analgésicos opioides. In: Miller Anestesia [Internet]. Elsevier España, S.L.U.; 2016. p. 864–914. Available from: http://dx.doi.org/10.1016/B978-84-9022-927-9/00031-7
Brown DL, Wedel DJ, Miller RD. Anestesia intradural, epidural y caudal. In: Miller RD Anestesia Barcelona: Ediciones Doyma [Internet]. 2016. p. 1269–74. Available from: http://dx.doi.org/10.1016/B978-84-9022-927-9/00056-1
Vassiliadis RM, Taylor PG. Spinal pethidine for elective caesarean section. Anaesth Intensive Care. 2013;41(1):113–5.
Nathan N, Wong C. Spinal, epidural, and caudal anesthesia: Anatomy, physiology, and technique. [Internet]. Fifth Edit. Chestnut’s Obstetric Anesthesia Principles and Practice. Elsevier Inc.; 2014. 229–60 p. Available from: http://dx.doi.org/10.1016/B978-1-4557-4866-2.00012-2
Cooper DW. Can epidural fentanyl induce selective spinal hyperalgesia? Anesthesiology [Internet]. 2000;93(4):1153–4. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=11020777
Karaman S, Günüsen I, Uyar M, Biricik E, Firat V. The effects of morphine and fentanyl alone or in combination added to intrathecal bupivacaine in spinal anesthesia for cesarean section. Agri. 2011;23(2):57–63.
Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology [Internet]. 2016;124(2):270–300. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26580836.
Copyright (c) 2020 Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.