Hypothermia and excessive sweating following intrathecal morphine in a parturient undergoing cesarean delivery

Hypothermia With Paradoxical Symptoms: A Case Series of Cesarean Deliveries With Intrathecal Morphine

Women receiving intrathecal morphine for cesarean delivery may experience hypothermia with paradoxical symptoms of sweating, nausea, and shivering. Despite being relatively rare in comparison to commonly experienced symptoms of perioperative hypothermia, hypothermia with paradoxical symptoms affects early maternal recovery and comfort. The cause is undetermined, and treatment approaches vary. Regular active-warming strategies may not be tolerated because of the paradoxical symptoms of sweating and feeling overheated. This case series aims to explore the phenomenon through the evaluation of health care records of women receiving intrathecal morphine for cesarean delivery at a single, tertiary health care institution in Australia from 2015 to 2018. We also summarize published literature to review treatment approaches used in the care of women experiencing profound heat loss while feeling overheated.

Midazolam for the Successful Treatment of Refractory Spinal-Anesthesia-Associated Hypothermia After Cesarean Delivery

Cesarean deliveries receiving spinal anesthesia with intrathecal morphine are associated with post-operative hypothermia. Lorazepam has been proposed as a reversal agent for treating intrathecal morphine-associated post-cesarean hypothermia. Midazolam is a benzodiazepine familiar to most anesthesia providers and is frequently administered in the perioperative period. We present a post-cesarean delivery spinal anesthesia-associated hypothermia patient successfully treated with intravenous midazolam.

Neuraxial Morphine-Induced Hypothermia After Cesarean Delivery Managed With Nalbuphine: A Case Report

Neuraxial morphine-induced hypothermia has been reported as a relatively rare complication, with the successful use of naloxone and lorazepam to reverse symptoms. We report a case of intrathecal morphine-induced hypothermia with profuse sweating, intractable nausea, and vomiting in a primigravid woman undergoing cesarean delivery in the setting of preeclampsia. All symptoms rapidly resolved after a single dose of intravenous nalbuphine. Because nalbuphine has a long track record of safe use on labor and delivery units, it is an attractive and novel choice for treatment of neuraxial morphine-induced hypothermia.

Altered Thermoregulatory Responses Following Spinal Morphine for Caesarean Delivery: a Case Report

OBJECTIVE

Spinal anaesthesia interferes with physiological thermoregulatory responses, potentially leading to peri-operative hypothermia. Spinal morphine can further compound this by a paradoxical clinical presentation leading to poor patient outcome.

CASE REPORT

Following an uneventful caesarean delivery (CD) under spinal anaesthesia with intrathecal morphine for post-operative analgesia, a parturient presented in the recovery room with increasing somnolence, excessive sweating and a sensation of feeling hot. She was haemodynamically stable, but her temperature was 34.5°C. Active warming measures were implemented, and normothermia was achieved in 3 hours.

CONCLUSION

Spinal morphine can alter the clinical presentation of hypothermia by manifesting as excessive sweating and subjective sensation of warmth. Teams involved in the perioperative care of parturients should be aware of (a) the possibility of spinal anaesthesia causing perioperative hypothermia, (b) intrathecal morphine masking the clinical presentation of hypothermia and (c) the importance of monitoring temperature of patients who have received spinal anaesthesia with added morphine.

Pain Management in the Emergency Department: a Review Article on Options and Methods

CONTEXT

The aim of this review is to recognizing different methods of analgesia for emergency medicine physicians (EMPs) allows them to have various pain relief methods to reduce pain and to be able to use it according to the patient's condition and to improve the quality of their services.

EVIDENCE ACQUISITION

In this review article, the search engines and scientific databases of Google Scholar, Science Direct, PubMed, Medline, Scopus, and Cochrane for emergency pain management methods were reviewed. Among the findings, high quality articles were eventually selected from 2000 to 2018, and after reviewing them, we have conducted a comprehensive comparison of the usual methods of pain control in the emergency department (ED).

RESULTS

For better understanding, the results are reported in to separate subheadings including "Parenteral agents" and "Regional blocks". Non-opioids analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen are commonly used in the treatment of acute pain. However, the relief of acute moderate to severe pain usually requires opioid agents. Considering the side effects of systemic drugs and the restrictions on the use of analgesics, especially opioids, regional blocks of pain as part of a multimodal analgesic strategy can be helpful.

CONCLUSION

This study was designed to investigate and identify the disadvantages and advantages of using each drug to be able to make the right choices in different clinical situations for patients while paying attention to the limitations of the use of these analgesic drugs.

Persistent Hypothermia and Excessive Sweating Following Intrathecal Morphine Administration in a Teenage Boy: A Case Report

Introduction

Opioids are used intrathecally to manage surgical pain. There are few reports of hypothermia after spinal morphine injection, none in the pediatric population. We present a teenager's case of mild hypothermia.

Case Presentation

A 15-year-old boy was scheduled for elective abdominal laparotomy. General anesthesia was combined with spinal anesthesia, using levobupivacaine and morphine. In the recovery room, he presented a decreased tympanic temperature (34.4°C) associated with excessive sweating, hyperglycemia, and complained of feeling hot. All other vital signs were normal. It was decided to maintain clinical vigilance and hourly monitoring of temperature and glycaemia values. Despite active warming, he remained hypothermic for 16 hours, with gradual remission of symptoms and normalization of glycemic values. It is unknown how intrathecal morphine causes hypothermia. The most viable hypothesis is its effect on the hypothalamus. In our case the most probable causes of post anesthesia hypothermia were excluded; therefore, we can admit that the cause of hypothermia was the spinal administration of morphine. Some reports used naloxone and lorazepam successfully. In our report, they disappeared spontaneously 16 hours later, which corroborates our diagnosis.

Conclusions

Children undergoing subarachnoid block with with intrathecal morphine may develop a disruption on thermoregulation, leading to a resistant postoperative hypothermia associated with excessive sweating.

Influence of hydatidiform mole follow-up setting on postmolar gestational trophoblastic neoplasia outcomes: a cohort study

OBJECTIVE

To assess the influence of hydatidiform mole (HM) management setting (reference center versus other institutions) on gestational trophoblastic neoplasia (GTN) outcomes.

METHODS

This cohort study included 270 HM patients attending Botucatu Trophoblastic Diseases Center (BTDC, São Paulo State University, Brazil) between January 1990 and December 2009 (204 undergoing evacuation and entire postmolar follow-up at BTDC and 66 from other institutions [OIs]). GTN characteristics and outcomes were analyzed and compared according to HM management setting. The confounding variables assessed included age, gravidity, parity, number of abortions and HM type (complete or partial). Postmolar GTN outcomes were compared using Mann-Whitney's test, chi2 test or Fisher's exact test.

RESULTS

Postmolar GTN occurred in 34 (34/204 = 16.7%) BTDC patients and in 27 (27/66 = 40.9%) of those initially treated in other institutions. BTDC patients showed lower metastasis rate (5.8% vs. 48%, p = 0.003) and lower median FIGO (2002) score (2.00 [1.00, 3.00] vs. 4.00 [2.00, 7.00], p = 0.003]. Multiagent chemotherapy to treat postmolar GTN was required in 2 BTDC cases (5.9%) and in 8 OI cases (29.6%) (p = 0.017). Median time interval between molar evacuation and chemotherapy onset was shorter among BTDC patients (7.0 [6.0, 10.0] vs. 10.0 [7.0, 16.0], p = 0.040).

CONCLUSION

BTDC patients showed GTN characteristics indicative of better prognosis. This underscores the importance of GTD specialist centers.

A randomised double-blind controlled study evaluating the hypothermic effect of 150 mug morphine during spinal anaesthesia for Caesarean section

We studied the hypothermic effect of adding 150 microg morphine during spinal anaesthesia in 60 parturients scheduled for elective caesarean section. All the parturients received intrathecal injection of a solution containing 150 mug morphine or normal saline in addition to 10-12 mg hyperbaric bupivacaine 0.5%. In both groups, a significant decrease in body temperature was noted. There was no difference in the area under the curve for temperature against time for the two groups; however, the maximum decrease in temperature from baseline was significantly larger after morphine than after saline injection (mean (SD) 1.11 (0.61) degrees C vs 0.76 (0.39) degrees C, respectively; p = 0.01) and the time to nadir temperature was significantly longer (59.5 (17.6) min vs 50.4 (15.9) min, respectively; p = 0.047). The lowest temperature observed in the morphine group was 34.3 degrees C. We conclude that intrathecal injection of 150 microg morphine intensified the intra-operative hypothermic effect of bupivacaine spinal anaesthesia for caesarean section.