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Greig P, Sotiriou A, Kailainathan P, Carvalho CYM, Onwochei DN, Thurley N, Desai N. Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery. J Clin Anesth 2024; 95:111468. [PMID: 38599160 DOI: 10.1016/j.jclinane.2024.111468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/07/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery. DESIGN Systematic review. SETTINGS Robot assisted abdominal surgery. PATIENTS Adults. INTERVENTIONS Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials. MAIN RESULTS We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent. CONCLUSIONS Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.
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Affiliation(s)
- P Greig
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - A Sotiriou
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - P Kailainathan
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - C Y M Carvalho
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - D N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
| | - N Thurley
- Bodleian Health Care Libraries, University of Oxford, United Kingdom
| | - N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom.
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Kukreja P, O'keefe K, Peabody Lever JE, Hussey H, Piennette PD, Vining B, Nagi P, Short RT, Mabry S, Kalagara H. Effects of Intrathecal Morphine Administration in Patients Undergoing Primary Total Hip Arthroplasty Under Spinal Anesthesia With Quadratus Lumborum Block for Postoperative Analgesia. Cureus 2024; 16:e57346. [PMID: 38690501 PMCID: PMC11060833 DOI: 10.7759/cureus.57346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Quadratus lumborum (QL) block has previously been shown to provide improved analgesia in patients undergoing primary total hip arthroplasty (THA) under spinal anesthesia when compared to spinal anesthesia alone. Additionally, recent studies have shown the addition of intrathecal morphine (ITM) to provide superior postoperative analgesia in patients undergoing various surgical interventions including total knee arthroplasty under spinal anesthesia with peripheral nerve blockade. At this time, however, there has not been a study evaluating the effects of intrathecal morphine in patients undergoing THA under spinal anesthesia with QL block. This study aims to assess if the addition of intrathecal morphine can provide adequate or even superior postoperative analgesia in patients undergoing primary THA. Methods This retrospective study included 26 patients in the spinal/QL block/intrathecal morphine (SA+QLB+ITM) group, 31 patients in the spinal/QL block group (SA+QLB), and 28 patients in the spinal only (SA or control) group. Twenty-six patients undergoing primary THA under a combination of spinal anesthesia and peripheral nerve blockade (quadratus lumborum block) were given a dose of 100 mcg of intrathecal morphine. Various parameters were evaluated including Post-Anesthesia Care Unit (PACU) and 24-hour visual analog scale (VAS) scores, time to first opioid use, 24- and 48-hour total opioid use as oral morphine equivalents (OME), 24-hour ambulation distance, and time from block placement to hospital discharge. The results were analyzed and compared to patients undergoing primary THA under spinal anesthesia with QL block (no intrathecal morphine) and compared to a control group of patients undergoing primary THA under spinal anesthesia only. Results The study analysis included 26 patients in the SA+QLB+ITM group, 31 patients in the SA+QLB group, and 28 patients in the SA (control) group. When compared with the control group, the SA+QLB+ITM had lower 24-hour total opioid usage (mean difference 20.80 OME, CI 6.454 to 35.15, p-value 0.0025), longer time to 1st opioid use (mean difference -20.51 hours later, p-value .0052), lower 24-hr VAS (difference 2.421, p-value 0.0012, CI 0.8559 to 3.987), and faster time to discharge (16.00 hr earlier, p-value 0.0459). When compared to the SA+QLB group, the SA+QLB+ITM group only showed a statistically significant difference in faster time to discharge (19.46 hr earlier, p-value 0.0068). However, while there was no statistically significant difference in time to 1st opioid use between the control and SA+QLB group, the difference did become significant when comparing the control to the SA+QLB+ITM group (mean difference -20.51 hours later (p-value .0052). There was no significant difference in either of the three groups in ambulation distance at 24 hours, PACU VAS, or 48-hour total opioid use. Conclusion Our study concludes that the addition of 100 mcg ITM for total hip arthroplasty under spinal anesthesia improved postoperative analgesia compared to the control group. Also, the ITM group did better with respect to delay in first opioid use and decreased hospital stay compared to the control and block-only groups. Our study warrants no more concerns of PONV, pruritus, or respiratory depression with this dose of ITM and requires standard postoperative care.
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Affiliation(s)
- Promil Kukreja
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Kevin O'keefe
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Jacelyn E Peabody Lever
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB) School of Medicine, Birmingham, USA
| | - Hanna Hussey
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB) School of Medicine, Birmingham, USA
| | - Paul D Piennette
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Brooke Vining
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Peter Nagi
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Roland T Short
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Scott Mabry
- Orthopaedics, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
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3
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Cadd M, Jackson P, Ewnetu B. Ondansetron for the Prevention of Pruritus in Women Undergoing Cesarean Delivery With Intrathecal Opioid: A Systematic Review and Meta-Analysis. Anesth Analg 2024; 138:70-84. [PMID: 37167702 DOI: 10.1213/ane.0000000000006526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Pruritus is a frequently reported and unpleasant side effect following intrathecal opioid use with frequency further increased among parturients. We have performed a systematic review to assess the overall efficacy of ondansetron for the prevention of pruritus in patients receiving intrathecal opioid as part of spinal anesthesia for cesarean delivery. METHODS A literature search of MEDLINE, Embase, Cochrane, and Web of Science databases was conducted from date of inception to September 2022. Studies that included patients undergoing cesarean delivery with spinal anesthesia using intrathecal opioid were included. The primary outcome was the presence of pruritus, and the secondary outcome was time to onset of pruritus. Data from included studies were pooled for analysis using an appropriately determined random-effects model. Outcomes were presented using forest plots and 95% confidence intervals. Additional sensitivity and subgroup analysis were performed. Trial sequential analysis was conducted for the primary outcome. RESULTS Twenty-three randomized controlled trials with a total of 2586 patients were included: 1219 received ondansetron, 1030 received a placebo, and a further 337 received a different study drug and were excluded from analysis. Opioids used in the included studies were morphine, fentanyl, and sufentanil. Patients who received ondansetron showed a significant reduction in the incidence of pruritus compared to the control group (RR, 0.81; 95% confidence interval [CI], 0.71-0.92; I 2 = 64%). There was no significant difference in pruritus onset between the groups (mean difference [MD], 17.54 minutes; 95% CI, -2.18 to 37.26; I 2 = 83%). The overall Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of quality of evidence was low. CONCLUSIONS This systematic review has demonstrated a significant reduction in the incidence of pruritus following the use of ondansetron. This is in contrast to previously published meta-analyses. Studies included were of varying quality and some at high risk of bias with a high degree of statistical heterogeneity. Furthermore, high-quality and well-powered studies are required to confirm these findings.
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Affiliation(s)
- Matthew Cadd
- From the Anaesthetics Department, Conquest Hospital, East Sussex Healthcare Trust, United Kingdom
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Bapodra A, Moy K, Nekola D, Schwartz GS. Neuraxial analgesia, nerve blocks, and special considerations for the parturient. Int Anesthesiol Clin 2024; 62:62-68. [PMID: 38063038 DOI: 10.1097/aia.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Anuj Bapodra
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York
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Cerasuolo J. Re: Impact of Intrathecal Fentanyl on Hospital Outcomes for Patients Undergoing Primary Total Hip Arthroplasty With Neuraxial Anesthesia. Arthroplast Today 2023; 24:101266. [PMID: 38023656 PMCID: PMC10679763 DOI: 10.1016/j.artd.2023.101266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Joseph Cerasuolo
- Department of Anesthesia and Perioperative Medicine, Emerson Hospital, Concord, MA, USA
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Gautier N, Lejeune D, Al Zein L, Kesteloot C, Ciccarella Y, Brichant JF, Bouvet L, Cops J, Hadzic A, Gautier PE. The effects of intrathecal morphine on urinary bladder function and recovery in patients having a cesarean delivery - A randomized clinical trial. Anaesth Crit Care Pain Med 2023; 42:101269. [PMID: 37364852 DOI: 10.1016/j.accpm.2023.101269] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Spinal anesthesia with intrathecal morphine (ITM) is a common anesthesia technique for cesarean delivery. The hypothesis was that the addition of ITM will delay micturition in women undergoing cesarean delivery. METHODS Fifty-six ASA physical status I and II women scheduled to undergo elective cesarean delivery under spinal anesthesia were randomized to the PSM group (50 mg prilocaine + 2.5 mcg sufentanil + 100 mcg morphine; n = 30) or PS group (50 mg prilocaine + 2.5 mcg sufentanil; n = 24). The patients in the PS group received a bilateral transverse abdominal plane (TAP) block. The primary outcome was the effect of ITM on the time to micturition and the secondary outcome was the need for bladder re-catheterization. RESULTS The time to first urge to urinate (8 [6-10] hours in the PSM group versus 6 [4-6] hours in the PS group) and the time to first micturition (10 [8-12] hours in the PSM group versus 6 [6-8] hours in the PS group) were significantly (p < 0.001) prolonged in the PSM group. Two patients in the PSM group met the 800 mL criterium for urinary catheterization after 6 and 8 h respectively. CONCLUSION This study is the first randomized trial to demonstrate that the addition of ITM to the standardized mixture of prilocaine and sufentanil significantly delayed micturition.
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Affiliation(s)
- Nicolas Gautier
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
| | - Delphine Lejeune
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
| | - Lilas Al Zein
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
| | - Cédric Kesteloot
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
| | - Yannick Ciccarella
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
| | - Jean-François Brichant
- Department of Anesthesiology and Resuscitation, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Lionel Bouvet
- Department of Anesthesia and Critical Care, Hospices Civils de Lyon, Lyon, France
| | | | - Admir Hadzic
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Department of Anesthesiology & Algology, Faculty of Medicine, KULeuven, Leuven, Belgium
| | - Philippe E Gautier
- Department of Anesthesiology, Clinique Sainte-Anne Saint-Rémi - CHIREC, Anderlecht, Belgium
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Sorabella LL, Ende HB, Bellenger SR, Stewart MF, French B, McIlroy DR, Raymond BL. Neuraxial buprenorphine for post-cesarean delivery analgesia: a case series. Int J Obstet Anesth 2023; 56:103906. [PMID: 37364348 DOI: 10.1016/j.ijoa.2023.103906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/12/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Affiliation(s)
- L L Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - H B Ende
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - B French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - D R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - B L Raymond
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Kukreja P, Peabody Lever JE, Hussey H, Piennette P, Nagi P, Mabry S, Feinstein J, Vining B, Gerlak J, Paul CA, Kalagara H. The Dose Comparison of Intrathecal Morphine for Postoperative Analgesia in Total Knee Arthroplasty Under Spinal Anesthesia: A Single Institute Retrospective Study. Cureus 2023; 15:e49350. [PMID: 38143599 PMCID: PMC10749179 DOI: 10.7759/cureus.49350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Background and purpose of the study Intrathecal morphine (ITM) provides effective postoperative analgesia in patients undergoing total knee arthroplasty (TKA) under spinal anesthesia. However, the ideal dose at which maximal analgesic effects can be delivered with minimal side effects is not clearly known. This retrospective study is aimed to compare two different doses of ITM with respect to analgesia benefits and side effects. Methods This is a retrospective, descriptive, single-center study approved by the Institutional Review Board (IRB) at the University of Alabama at Birmingham. Three patient groups were selected: a control group receiving continuous adductor canal block (CCACB) under spinal anesthesia, and two experimental groups receiving single-dose adductor canal block (SSACB) under spinal anesthesia with either 100 mcg or 150 mcg of ITM. The sample size included 75 patients (25 per group) who were 18 years and older, American Society of Anesthesiology (ASA) class 1-3 who were undergoing primary TKA. Patients with chronic pain or opioid use exceeding 30 days and those undergoing surgeries other than primary TKA were excluded. Outcome data, including opioid use (from which post-operative oral morphine equivalents (OME) were calculated), antiemetic use, visual analog pain scale (VAS) scores, distance ambulated at 24 hours, and length of hospital stay, were extracted by chart review. Results In the post-anesthesia care unit (PACU), patients in both ITM groups experienced significantly lower opioid consumption and pain scores compared to the control group (p<.001). Furthermore, cumulative OME at 24 hours was significantly less in the ITM groups compared to the control, but there was no difference between ITM doses (p=0.004; mean cumulative OME for control was 77.2 OME vs 43.4 OME for 100 mcg ITM vs 42.6 OME for 150 mcg ITM). Antiemetic usage did not increase in the ITM groups. Although there was no statistically significant difference in ambulation at 24 hours, both ITM groups exhibited a trend toward greater average ambulation distance compared to the control group (p=0.095; mean distance walked for control was 67.6 feet, 76.6 feet for 100 mcg ITM vs 98.8 feet for 150 mcg ITM). Hospital length of stay did not significantly differ between the groups. Conclusion ITM doses of 100 mcg and 150 mcg provide effective analgesia for patients undergoing lower extremity total knee arthroplasty under spinal anesthesia. Patients receiving ITM had better pain scores in the immediate post-operative period and had overall less oral morphine equivalent consumption when compared to control. In addition, the safety and side effect profile for ITM is similar for both doses as there was no incidence of respiratory depression and antiemetic usage did not differ between all study arms. Future studies should explore the use of higher ITM doses and consider a broader patient population to further understand the advantages and potential drawbacks of ITM in TKA surgery.
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Affiliation(s)
- Promil Kukreja
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Jacelyn E Peabody Lever
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Hanna Hussey
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Paul Piennette
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Peter Nagi
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Scott Mabry
- Orthopaedics, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Joel Feinstein
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Brooke Vining
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Jason Gerlak
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Christopher A Paul
- Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham (UAB), Birmingham, USA
| | - Hari Kalagara
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA
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Botea MO, Lungeanu D, Petrica A, Sandor MI, Huniadi AC, Barsac C, Marza AM, Moisa RC, Maghiar L, Botea RM, Macovei CI, Bimbo-Szuhai E. Perioperative Analgesia and Patients' Satisfaction in Spinal Anesthesia for Cesarean Section: Fentanyl Versus Morphine. J Clin Med 2023; 12:6346. [PMID: 37834990 PMCID: PMC10573232 DOI: 10.3390/jcm12196346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/17/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
Perioperative analgesia for cesarean section aims to ensure the mother's comfort, facilitate a smooth surgical experience, and promote a successful recovery. One-hundred-ninety patients were enrolled in a randomized double-blind study designed to assess the quality of perioperative analgesia, level of satisfaction, and incidence of adverse reactions in elective cesarean section under spinal anesthesia when fentanyl or morphine was added to bupivacaine. Two treatment groups comprising 173 subjects were compared in the per-protocol analysis: F (fentanyl, standard dose 25 μg) and M (morphine, standard dose 100 μg). Numerical pain scores were recorded perioperatively for 72 h (both at rest and on mobilization), with overall postoperative satisfaction and analgesic-related side effects. The patients in the morphine group had significantly better pain management (Mann-Whitney U test, p < 0.001) and higher level of satisfaction (Mann-Whitney U test, p < 0.001). The latter was related to the greater need for rescue medication in the fentanyl group (OR = 4.396; p = 0.019). On the other hand, fentanyl had significantly fewer non-life-threatening side effects, such as high-intensity pruritus (Mann-Whitney U test, p < 0.001), nausea (OR = 0.324; p = 0.019), vomiting and dizziness upon first mobilization (OR = 0.256; p < 0.001). It remains for future clinical trials to help establish doses that will tilt the scale to one side or the other.
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Affiliation(s)
- Mihai O. Botea
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
- Pelican Clinic, Medicover Hospital, 4104869 Oradea, Romania
| | - Diana Lungeanu
- Center for Modeling Biological Systems and Data Analysis, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania;
- Department of Functional Sciences, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alina Petrica
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.B.); (A.M.M.)
- Emergency Department, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania
| | - Mircea I. Sandor
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
| | - Anca C. Huniadi
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
- Pelican Clinic, Medicover Hospital, 4104869 Oradea, Romania
| | - Claudiu Barsac
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.B.); (A.M.M.)
- Clinic of Anaesthesia and Intensive Care, “Pius Brinzeu” Emergency Clinical County Hospital, 300736 Timisoara, Romania
| | - Adina M. Marza
- Department of Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (C.B.); (A.M.M.)
- Emergency Department, Emergency Clinical Municipal Hospital, 300079 Timisoara, Romania
| | - Ramona C. Moisa
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
| | - Laura Maghiar
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
| | - Raluca M. Botea
- Oradea County Clinical Emergency Hospital, 410169 Oradea, Romania
| | - Codruta I. Macovei
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
- Pelican Clinic, Medicover Hospital, 4104869 Oradea, Romania
| | - Erika Bimbo-Szuhai
- Department of Surgery, Faculty of Medicine and Pharmacy, University of Oradea, 410087 Oradea, Romania; (M.O.B.); (M.I.S.)
- Pelican Clinic, Medicover Hospital, 4104869 Oradea, Romania
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Tamdoğan İ, Turunç E, Kocamanoğlu İS. Comparison of the Efficacies of Three Different Intrathecal Doses of Morphine in Achieving Postcesarean Delivery Analgesia. J Perianesth Nurs 2023; 38:717-723. [PMID: 36997388 DOI: 10.1016/j.jopan.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/01/2022] [Accepted: 11/20/2022] [Indexed: 03/30/2023]
Abstract
PURPOSE The objective of this study is to compare the efficacies of 3 different intrathecal doses (80, 120, and 160 mcg) of morphine in achieving postcesarean delivery analgesia and the severity of the side effects thereof. DESIGN A prospective, randomized, double-blind study. METHODS A total of 150 pregnant women between the ages of 18 and 40, with a gestational week >36, who were planned to have elective cesarean section were included in the study. Patients were randomized into 3 groups based on the dosages of intrathecal doses of morphine (80, 120, and 160 mcg) they will receive in addition to 10 mg 0.5% hyperbaric bupivacaine and 20 mcg fentanyl. Intravenous (IV) patient-controlled analgesia (PCA) prepared with fentanyl was administered to each patient after the surgery. Postoperative 24-hour total IV PCA-fentanyl consumption was recorded. The patients were evaluated for side effects such as pain, nausea-vomiting, pruritus, sedation score, and respiratory depression after the surgery. FINDINGS PCA-fentanyl consumption was significantly higher in Group 1 compared to Group 2 and 3 (P = .047). There was no significant differences between the groups in terms of nausea-vomiting scores. The pruritus scores were significantly higher in Group 3 compared to Group 1 (P = .020). The pruritus scores were significantly higher in all groups at the postoperative 8th-hour (P = .013). Respiratory depression, which would require treatment, was not observed in any patient. CONCLUSIONS Based on the study findings, it was concluded that 120 mcg intrathecal morphine provides adequate analgesia with minimal side effects in cesarean sections.
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Affiliation(s)
- İlke Tamdoğan
- Department of Anaesthesiology and Reanimation, Obstetrics and Pediatrics Training and Research Hospital, The Ministry of Health and Giresun University, Giresun, Turkey
| | - Esra Turunç
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
| | - İsmail Serhat Kocamanoğlu
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Yue L, Zhang F, Mu G, Shang M, Lin Z, Sun H. Effectiveness and safety of intrathecal morphine for percutaneous endoscopic lumbar discectomy under low-dose ropivacaine: a prospective, randomized, double-blind clinical trial. Spine J 2023; 23:954-961. [PMID: 36931566 DOI: 10.1016/j.spinee.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/06/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND CONTEXT Percutaneous endoscopic lumbar discectomy (PELD) is a surgical setting that requires minimal motor impairment. Low-dose spinal ropivacaine induces little motor blockade and could be ideal for maintaining safety of PELD, but its analgesic efficacy is questionable. An adjunct analgesic approach is needed to maximize the benefits of low-dose spinal ropivacaine for PELD. PURPOSE This study aimed to explore the effectiveness and safety of 100 µg intrathecal morphine (ITM) as an adjuvant analgesic method for PELD under low-dose spinal ropivacaine. STUDY DESIGN A double-blind, randomized, placebo-controlled trial. TRIAL REGISTRATION ChiCTR2000039842 (www.chictr.org.cn). SAMPLE Ninety patients scheduled for elective single-level PELD under low-dose spinal ropivacaine. OUTCOME MEASURES The primary outcome was the overall intraoperative visual analogue scale (VAS) score for pain. Secondary outcomes were intraoperative VAS scores assessed at multiple timepoints; intraoperative rescue analgesic requirement; postoperative VAS scores; disability scale; patients' satisfaction with anesthesia; adverse events; and radiographic outcomes. METHODS Patients were randomized to receive low-dose ropivacaine spinal anesthesia with (ITM group, n=45) or without (control group, n=45) 100 µg ITM. RESULTS The overall intraoperative VAS score in the ITM group was significantly lower than that in the control group (0 [0, 1] vs 2 [1, 3], p<.001). During operation, the VAS scores at cannula insertion, 30 minutes after insertion, 60 minutes after insertion, and 120 minutes after insertion were all significantly lower in the ITM group (all p<.05). Less patients in the ITM group required rescue analgesia during operation compared with those in the control group (14% vs 42%, p= .003). The VAS score for back pain in the ITM group was lower than that in the control group at 1 hour, 12 hours, and 24 hours postoperatively. Besides, the satisfaction score in the ITM group was significantly higher than that in the control group (p=.017). For adverse events, 8/43 of ITM and 1/44 of control participants experienced pruritus (p=.014), with a relative risk (95% confidence interval) of 8.37 (1.09-64.16). The incidence of other adverse events was similar between the two groups. Of note, respiratory depression occurred in one ITM-treated patient. CONCLUSION The addition of 100 µg ITM to low-dose ropivacaine appears to be effective in analgesia without compromised motor function for PELD; however, ITM increased the risk of pruritus and clinicians should be vigilant about its potential risk of respiratory depression.
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Affiliation(s)
- Lei Yue
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Feng Zhang
- Department of Anesthesiology, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Guanzhang Mu
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China
| | - Meixia Shang
- Department of Medical Statistics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing,100034, China
| | - Zengmao Lin
- Department of Anesthesiology, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China.
| | - Haolin Sun
- Department of Orthopedics, Peking University First Hospital, 8th Xishuku Ave, Xicheng District, Beijing, 100034, China.
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12
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Belin O, Casteres C, Alouini S, Le Pape M, Dupont A, Boulain T. Manually Controlled, Continuous Infusion of Phenylephrine or Norepinephrine for Maintenance of Blood Pressure and Cardiac Output During Spinal Anesthesia for Cesarean Delivery: A Double-Blinded Randomized Study. Anesth Analg 2023; 136:540-550. [PMID: 36279409 DOI: 10.1213/ane.0000000000006244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND To counteract the vasoplegia induced by spinal anesthesia (SA) and maintain blood pressure (BP) during cesarean delivery, phenylephrine is currently recommended, but norepinephrine might offer superior preservation of cardiac output. We aimed to compare the hemodynamic effects of phenylephrine and norepinephrine administered by manually adjusted continuous infusion during elective cesarean delivery. METHODS In this pragmatic, parallel-group, double-blind randomized controlled trial, 124 parturients scheduled for elective cesarean delivery under SA in a tertiary maternity in France, between February 2019 and December 2020, were randomized to receive norepinephrine at a starting rate of 0.05 μg·kg -1 ·min -1 (n = 62) or phenylephrine at a starting rate of 0.5 μg·kg -1 ·min -1 (n = 62). In both groups, the vasopressor infusion rate was then manually adjusted to maintain maternal systolic BP above 90% of the baseline value. The primary outcome, the change in cardiac index (CI) measured by thoracic bioreactance from SA to umbilical cord clamping, was analyzed through repeated measures analysis of variance and post hoc t tests. Secondary outcomes included maternal BP and neonatal outcomes. RESULTS In the norepinephrine group, cardiac index was maintained between 90% and 100% of baseline from SA to umbilical cord clamping, whereas it was maintained at significantly lower values (81%-88%) in the phenylephrine group ( P = .001). The percentage of elapsed time with a mean maternal BP <65 mm Hg and with systolic BP <80% of the baseline value was higher in the phenylephrine group: 2.9% (7.3) vs 0.5% (1.8) (absolute risk difference [ARD], -2.4%; 95% confidence interval, -4.4 to -0.5; P = .012) and 8.5% (16.6) vs 2.3% (5.2) (ARD, -6.2%; 95% confidence interval, -10.6 to -1.8; P = .006). Excluding parturients with gestational diabetes, severe neonatal hypoglycemia was more common in the phenylephrine group at 19.6% (9/46) vs 4.1% (2/49) ( P = .02). The other neonatal outcomes did not differ significantly between the groups. CONCLUSIONS When administered by manually adjusted infusion during SA for cesarean delivery, norepinephrine was associated with a higher CI; both infusions were effective for maintaining BP.
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Affiliation(s)
| | | | | | | | | | - Thierry Boulain
- Medical Intensive Care Unit, Centre Hospitalier Régional d'Orléans, Orléans, France
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13
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Zaslansky R, Baumbach P, Edry R, Chetty S, Min LS, Schaub I, Cruz JJ, Meissner W, Stamer UM. Following Evidence-Based Recommendations for Perioperative Pain Management after Cesarean Section Is Associated with Better Pain-Related Outcomes: Analysis of Registry Data. J Clin Med 2023; 12:jcm12020676. [PMID: 36675605 PMCID: PMC9864952 DOI: 10.3390/jcm12020676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/23/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Women who have had a Cesarean Section (CS) frequently report severe pain and pain-related interference. One reason for insufficient pain treatment might be inconsistent implementation of evidence-based guidelines. We assessed the association between implementing three elements of care recommended by guidelines for postoperative pain management and pain-related patient-reported outcomes (PROs) in women after CS. The analysis relied on an anonymized dataset of women undergoing CS, retrieved from PAIN OUT. PAIN OUT, an international perioperative pain registry, provides clinicians with treatment assessment methodology and tools for patients to assess multi-dimensional pain-related PROs on the first postoperative day. We examined whether the care included [i] regional anesthesia with a neuraxial opioid OR general anesthesia with wound infiltration or a Transvesus Abdominis Plane block; [ii] at least one non-opioid analgesic at the full daily dose; and [iii] pain assessment and recording. Credit for care was given only if all three elements were administered (= “full”); otherwise, it was “incomplete”. A “Pain Composite Score-total” (PCStotal), evaluating outcomes of pain intensity, pain-related interference with function, and side-effects, was the primary endpoint in the total cohort (women receiving GA and/or RA) or a sub-group of women with RA only. Data from 5182 women was analyzed. “Full” care was administered to 20% of women in the total cohort and to 21% in the RA sub-group. In both groups, the PCStotal was significantly lower compared to “incomplete” care (p < 0.001); this was a small-to-moderate effect size. Administering all three elements of care was associated with better pain-related outcomes after CS. These should be straightforward and inexpensive for integration into routine care after CS. However, even in this group, a high proportion of women reported poor outcomes, indicating that additional work needs to be carried out to close the evidence-practice gap so that women who have undergone CS can be comfortable when caring for themselves and their newborn.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
- Correspondence: (R.Z.); (U.M.S.)
| | - Philipp Baumbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ruth Edry
- Acute Pain Service, Department of Anesthesiology, Rambam Health Care Campus, Haifa 3109601, Israel
| | - Sean Chetty
- Department of Anaesthesiology& Critical Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7500, South Africa
| | - Lim Siu Min
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Isabelle Schaub
- Department of Anesthesiology and Pain Clinic, Clinique St Jean, 1000 Brussels, Belgium
| | - Jorge Jimenez Cruz
- Department of Obstetrics and Gynecology, Bonn University Hospital, 53127 Bonn, Germany
| | - Winfried Meissner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Jena, 07747 Jena, Germany
| | - Ulrike M. Stamer
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence: (R.Z.); (U.M.S.)
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14
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Dagasan Cetin G, Dostbil A, Aksoy M, Kasali K, Ince R, Kahramanlar AA, Atalay C, Topdagi Yilmaz EP, Ince I, Ozkal MS. Intraperitoneal instillation versus wound infiltration for postoperative pain relief after cesarean delivery: A prospective, randomized, double-blind, placebo-controlled trial. J Obstet Gynaecol Res 2023; 49:209-219. [PMID: 36270632 DOI: 10.1111/jog.15469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 01/19/2023]
Abstract
AIM To compare local anesthetic wound infiltration with intraperitoneal instillation of local anesthetic for analgesia after cesarean section under spinal anesthesia. METHODS This study was conducted on 150 pregnant women undergoing elective cesarean section under spinal anesthesia. Spinal anesthesia was performed with 7 mg isobaric bupivacaine and 15 μcg fentanyl. The patients were randomized into three groups of 50 patients each: Group local anesthetic wound infiltration (LWI): 20 ml local anesthetic solution (10 ml 0.5% bupivacaine and 10 ml 2% lidocaine mixture) was administered subcutaneous wound infiltration at the end of surgery prior to skin closure and 20 ml saline was instilled into the uterine peritoneal area before fascia closure. Group intraperitoneal local anesthetic (IPLA): 20 ml local anesthetic solution (10 ml 0.5% bupivacaine and 10 ml 2% lidocaine mixture) was instilled into the uterine peritoneal area and 20 ml saline was administered subcutaneous wound infiltration. Group Placebo: 20 ml saline was instilled into the uterine peritoneal area and 20 ml saline was administered local subcutaneous wound infiltration. Pain scores at rest and on movement, total fentanyl consumption at 24 h, maternal satisfaction, and the time to first analgesic request were recorded. RESULTS No statistically significant difference was observed in the postoperative pain scores at rest at 2, 12, and 24 h (p = 0.314, 0.343, and 0.735, respectively) and on movement at 12 and 24 h (p = 0.318 and 0.642, respectively) between the groups. The pain scores on movement at 2 h were significantly lower in Group IPLA compared with Group Placebo (p = 0.047). There were no significant differences between the groups in terms of total fentanyl consumption and the time to first analgesic request. CONCLUSION The use of intraperitoneal instillation of bupivacaine and lidocaine reduces early the pain score on movement in women undergoing cesarean section under spinal anesthesia.
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Affiliation(s)
- Gozdenur Dagasan Cetin
- Department of Anesthesiology and Reanimation, University of Health Sciences, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Aysenur Dostbil
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey.,Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Mehmet Aksoy
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey.,Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Kamber Kasali
- Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey.,Department of Biostatistics, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ramazan Ince
- Department of Anesthesiology and Reanimation, University of Health Sciences, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Agah Abdullah Kahramanlar
- Department of Anesthesiology and Reanimation, University of Health Sciences, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Canan Atalay
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey.,Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey
| | - Emsal Pınar Topdagi Yilmaz
- Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey.,Department of Obstetrics and Gynecology, Faculty of Medicine, Ataturk University, Erzurum, Turkey
| | - Ilker Ince
- Anesthesiology Clinical Research Office, Ataturk University, Erzurum, Turkey.,Department of Anesthesiology and Reanimation, Altınbas University, İstanbul, Turkey
| | - Mırac Selcen Ozkal
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Ataturk University, Erzurum, Turkey
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15
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Zhai W, Liu H, Yu Z, Jiang Y, Yang J, Li M. Bibliometric Analysis of Research Studies on Postoperative Pain Management of Cesarean Section. J Pain Res 2023; 16:1345-1353. [PMID: 37113260 PMCID: PMC10128081 DOI: 10.2147/jpr.s404659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Purpose Cesarean section (C-section) is associated with moderate-to-severe postoperative pain. Many studies on pain management after C-section have been published in recent decades, many of which focused on new regional techniques. The purpose of this study is to outline the connections within the dynamic evolution of postcesarean delivery analgesia research publications using retrospective bibliometric analysis. Patients and Methods Published studies on postoperative pain management of C-section were retrieved from the Science Citation Index Expanded (SCI-E) of Web of Science (WOS) Core collection database. All papers published from 1978 to October 22, 2022 were searched. The research progress and growing trend were quantitatively analyzed by total publications, research institutions, journal impact factors, and author's contribution. Total citations frequency, average citations per item and h-index were used for evaluating literature quantity. Top 20 journals with the highest number of publications were charted. The keywords co-occurrence overlay map was visualized by the VOSviewer software. Results From 1978 to 2022, a total of 1032 articles in postcesarean delivery analgesia research field were published, with 23,813 times cited, average citations of 23.07 per item, and an h-index of 68. The most high-yield publication year, countries, journals, authors, institutions were 2020 (n=79), the United States (n=288), Anesthesia and Analgesia (n=108), Carvalho B (n=25), and Stanford University (n=33), respectively. The United States had the most cited papers. The future research interest might be "prescription", "quadratus lumborum block", "postnatal depression", "persistent pain", "dexmedetomidine", "enhanced recovery", and "multimodal analgesia". Conclusion By employing the online bibliometric tool and VOSviewer software, we found that studies on postcesarean analgesia had grown markedly. The focus had evolved to nerve block, postnatal depression, persistent pain, and enhanced recovery.
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Affiliation(s)
- Wenwen Zhai
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Huili Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Zhuoying Yu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ye Jiang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Jing Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Min Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, People’s Republic of China
- Correspondence: Min Li, Department of Anesthesiology, Peking University Third Hospital, No. 49 North Garden Road, Haidian District, Beijing, 100191, People’s Republic of China, Tel +86 13522757239, Email
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16
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Abbas MS, Hassan SA, Abbas AM, Thabet AM, Thabet AM, Mahdy MM. Hemodynamic and antiemetic effects of prophylactic hyoscine butyl-bromide during cesarean section under spinal anesthesia: a randomized controlled trial. BMC Anesthesiol 2022; 22:112. [PMID: 35448942 PMCID: PMC9027476 DOI: 10.1186/s12871-022-01659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 02/10/2022] [Indexed: 12/03/2022] Open
Abstract
Background Abrupt bradycardia and hemodynamic instability during spinal anesthesia for cesarean section are not uncommon and are considered as one of the primary causes of intraoperative nausea and vomiting (IONV). We hypothesized that prophylactic use of hyoscine butyl-bromide (HBB) could improve hemodynamics and reduce IONV in parturients undergoing cesarean section. Methods A randomized, double-blind placebo-controlled trial was carried out in a tertiary university hospital, patients scheduled for elective cesarean section were equally randomized to receive either IV HBB 20 mg in 1 ml (Hyoscine group) or the same volume of 0.9% saline (Control group), one minute after spinal anesthesia. The primary endpoint was the incidence of intraoperative bradycardia (HR < 50 beats min−1). Secondary endpoints included changes in mean arterial blood pressure (MAP), the incidence of Intraoperative and Postoperative nausea or vomiting (IONV & PONV), the fetal heart rate and, Apgar score. Results Of the 160 subjects randomized, 80 received HBB and 80 received placebo. There was a significant reduction in the incidence of the primary endpoint of intraoperative bradycardia (HR < 50 beats min−1) in the Hyoscine group (0% vs 10%; OR = 0.05, 95% CI = [0.003, 0.93]; P = 0.004) compared with placebo. MAP showed an insignificant difference between groups over time. HBB significantly decreased incidences of IONV and PONV (p = 0.002 & 0.004) respectively. Conclusions In parturients undergoing cesarean section under spinal anesthesia, pretreatment with intravenous HBB was a safe measure for both the mother and the baby to reduce the risk of severe intraoperative bradycardia, but not hypotension. Furthermore, it was associated with less incidence of both IONV and PONV. Trial registration https://clinicaltrials.gov/ct2/show/NCT04069078
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Affiliation(s)
- Mostafa Samy Abbas
- Anesthesia and Intensive Care department, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Shimaa Abbas Hassan
- Anesthesia and Intensive Care department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Mohamed Abbas
- Obstetrics and Gynaecology department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Amr Mohamed Thabet
- Anesthesia and Intensive Care department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed Mostafa Thabet
- Anesthesia and Intensive Care department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Magdy Mohammed Mahdy
- Anesthesia and Intensive Care department, Faculty of Medicine, Assiut University, Assiut, Egypt
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17
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Ryu C, Choi GJ, Jung YH, Baek CW, Cho CK, Kang H. Postoperative Analgesic Effectiveness of Peripheral Nerve Blocks in Cesarean Delivery: A Systematic Review and Network Meta-Analysis. J Pers Med 2022; 12:jpm12040634. [PMID: 35455750 PMCID: PMC9033028 DOI: 10.3390/jpm12040634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/05/2022] [Accepted: 04/10/2022] [Indexed: 02/01/2023] Open
Abstract
The purpose of this systematic review and network meta-analysis was to determine the analgesic effectiveness of peripheral nerve blocks (PNBs), including each anatomical approach, with or without intrathecal morphine (ITMP) in cesarean delivery (CD). All relevant randomized controlled trials comparing the analgesic effectiveness of PNBs with or without ITMP after CD until July 2021. The two co-primary outcomes were designated as (1) pain at rest 6 h after surgery and (2) postoperative cumulative 24-h morphine equivalent consumption. Secondary outcomes were the time to first analgesic request, pain at rest 24 h, and dynamic pain 6 and 24 h after surgery. Seventy-six studies (6278 women) were analyzed. The combined ilioinguinal nerve and anterior transversus abdominis plane (II-aTAP) block in conjunction with ITMP had the highest SUCRA (surface under the cumulative ranking curve) values for postoperative rest pain at 6 h (88.4%) and 24-h morphine consumption (99.4%). Additionally, ITMP, ilioinguinal-iliohypogastric nerve block in conjunction with ITMP, lateral TAP block, and wound infiltration (WI) or continuous infusion (WC) below the fascia also showed a significant reduction in two co-primary outcomes. Only the II-aTAP block had a statistically significant additional analgesic effect compared to ITMP alone on rest pain at 6 h after surgery (−7.60 (−12.49, −2.70)). In conclusion, combined II-aTAP block in conjunction with ITMP is the most effective post-cesarean analgesic strategy with lower rest pain at 6 h and cumulative 24-h morphine consumption. Using the six described analgesic strategies for postoperative pain management after CD is considered reasonable. Lateral TAP block, WI, and WC below the fascia may be useful alternatives in patients with a history of sensitivity or severe adverse effects to opioids or when the CD is conducted under general anesthesia.
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Affiliation(s)
- Choongun Ryu
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06911, Korea; (C.R.); (G.J.C.); (Y.H.J.); (C.W.B.)
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06911, Korea; (C.R.); (G.J.C.); (Y.H.J.); (C.W.B.)
| | - Yong Hun Jung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06911, Korea; (C.R.); (G.J.C.); (Y.H.J.); (C.W.B.)
| | - Chong Wha Baek
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06911, Korea; (C.R.); (G.J.C.); (Y.H.J.); (C.W.B.)
| | - Choon Kyu Cho
- Department of Anesthesiology and Pain Medicine, College of Medicine, Konyang University, Daejeon 35365, Korea;
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06911, Korea; (C.R.); (G.J.C.); (Y.H.J.); (C.W.B.)
- Correspondence: ; Tel.: +82-2-6299-2586
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18
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Singh N, Makkar J, Jafra A, Verma P, Singh PM. The effect of two groups of intrathecal fentanyl doses on analgesic outcomes and adverse effects in parturients undergoing cesarean delivery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis. Int J Obstet Anesth 2022; 50:103270. [DOI: 10.1016/j.ijoa.2022.103270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/20/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
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19
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Nayak NS, Kalpana K, Dhanpal R, Tudu LC, Prakash J. Comparative Study of the Analgesic Efficacy of Intrathecal Fentanyl with Ultrasound-Guided Transversus Abdominis Plane Block after Lower Segment Cesarean Section. Anesth Essays Res 2021; 15:101-106. [PMID: 34667355 PMCID: PMC8462421 DOI: 10.4103/aer.aer_80_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/04/2021] [Accepted: 07/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background: This study was conducted to compare the analgesic efficacy of intrathecal fentanyl with ultrasound-guided transversus abdominis plane (TAP) block after lower segment cesarean section. The objectives of the study were to compare the effects of subarachnoid fentanyl versus TAP block with respect to duration of postoperative analgesia, time for first analgesic request, total analgesic consumption in 24 h, time to first breastfeed and Apgar score at 1 and 5 min. Materials and Methods: Sixty-two patients undergoing elective or emergency cesarean delivery were recruited for the study in a prospective, randomized, single-blind manner. The patients were randomly allocated to either intrathecal fentanyl group (Group F) or TAP block group (Group T) after determining the eligibility criteria. Group F patients received subarachnoid block with 10 mg of 0.5% bupivacaine heavy with 25 mcg of fentanyl. Group T patients received subarachnoid block with 10 mg of 0.5% bupivacaine heavy prior to surgery and at the end of surgery, they received TAP block with 0.25% bupivacaine 20 mL on each side. Results: Group T had significantly longer time for the first analgesic request (7.65 ± 1.23 h) than group F (4.10 ± 0.32 h). The total analgesic consumption in 24 h was significantly less in Group T (1.0 ± 0) than Group F (2.13 ± 0.34). The Visual Analogue Scale scores at rest and on movement were significantly less in Group T than Group F at all-time points. The Apgar score at 1 and 5 min and time to first breast feed were comparable between the two groups. The incidence of side effects was less in Group T. Conclusion: This study indicated that ultrasound-guided TAP block has a better analgesic as well as safety profile compared to intrathecal fentanyl for cesarean delivery.
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Affiliation(s)
- Nagalakshmi S Nayak
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - K Kalpana
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Radhika Dhanpal
- Department of Anaesthesia, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - Lal Chand Tudu
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Jay Prakash
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
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20
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The Current Consideration, Approach, and Management in Postcesarean Delivery Pain Control: A Narrative Review. Anesthesiol Res Pract 2021; 2021:2156918. [PMID: 34589125 PMCID: PMC8476264 DOI: 10.1155/2021/2156918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/04/2021] [Indexed: 12/25/2022] Open
Abstract
Optimal postoperative analgesia has a significant impact on patient recovery and outcomes after cesarean delivery. Multimodal analgesia is the core principle for cesarean delivery and pain management. For a standard analgesic regimen, the use of long-acting neuraxial opioids (e.g., morphine) and adjunct drugs, such as scheduled acetaminophen and nonsteroidal anti-inflammatory drugs, is recommended unless contraindicated. Oral or intravenous opioids should be reserved for breakthrough pain. In addition to the aforementioned use of multimodal analgesia, preoperative evaluation is critical to individualize the analgesic regimen according to the patient requirements. Risk factors for severe postoperative pain or analgesia-related adverse effects will require modifications to the standard analgesic regimen (e.g., the use of ketamine, gabapentinoids, or regional anesthetic techniques). Further investigation is required to determine analgesic drugs or dose alterations based on preoperative predictions for patients at risk of severe pain. Outcomes beyond pain and analgesic use, such as functional recovery, should be determined to evaluate analgesic treatment protocols.
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Ferrarezi WPP, Braga ADFDA, Ferreira VB, Mendes SQ, Brandão MJN, Braga FSDS, Carvalho VH. Spinal anesthesia for elective cesarean section. Bupivacaine associated with different doses of fentanyl: randomized clinical trial. Braz J Anesthesiol 2021; 71:642-648. [PMID: 34411627 PMCID: PMC9373100 DOI: 10.1016/j.bjane.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/28/2021] [Accepted: 03/13/2021] [Indexed: 11/17/2022] Open
Abstract
Objective Assess patients submitted to elective cesarean section under spinal anesthesia, and the efficacy of different doses of fentanyl associated with bupivacaine. Methods The study included 124 pregnant women randomly distributed into 4 groups (n = 31) according to different doses of fentanyl (15 μg, 10 μg, 7.5 μg), Groups I, II, and III, respectively, and control group IV, associated with 0.5% hyperbaric bupivacaine (10 mg). An epidural catheter was inserted in case epidural top-up was required. We assessed the anesthetic blockage characteristics, negative maternal and neonatal outcomes, and maternal side effects. Statistical analysis was performed using Kruskal-Wallis, Fisher’s exact and chi-square tests. The level of significance was 5% (p < 0.05). Results The quality of analgesia, time for the first complaint of pain and motor block recovery time were significantly better for groups that received fentanyl in comparison to controls (p < 0.001). None of the groups had negative maternal-fetal outcomes. Nausea was significantly more frequent in patients in Groups II (10 µg) and III (7.5 µg) when compared to Groups I (15 µg) and IV (no fentanyl). Vomiting was more frequent in Group III than in Group I (p = 0.006). The incidence of pruritus was significantly higher in the groups receiving fentanyl (p = 0.012). Conclusions Among the solutions studied, the spinal anesthesia technique using 15 µg of fentanyl associated with 10 mg of hyperbaric bupivacaine provided satisfactory analgesia and very low incidence of adverse effects for patients submitted to cesarean section. Trial Registration Number UTN U1111-1199-0285. REBEC RBR-5XWT6T.
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Affiliation(s)
- Wesla Packer Pfeifer Ferrarezi
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Farmacologia, Campinas, SP, Brazil
| | | | - Valdir Batista Ferreira
- Universidade Estadual de Campinas (UNICAMP), Centro de Atenção Integrada à Saúde Mental (CAISM), Campinas, SP, Brazil
| | - Sara Quinta Mendes
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brazil
| | - Maria José Nascimento Brandão
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brazil
| | - Franklin Sarmento da Silva Braga
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brazil
| | - Vanessa Henriques Carvalho
- Universidade Estadual de Campinas (UNICAMP), Faculdade de Ciências Médicas, Departamento de Anestesiologia, Campinas, SP, Brazil.
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Seki H, Shiga T, Mihara T, Hoshijima H, Hosokawa Y, Hyuga S, Fujita T, Koshika K, Okada R, Kurose H, Ideno S, Ouchi T. Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials. J Anesth 2021; 35:911-927. [PMID: 34338864 DOI: 10.1007/s00540-021-02980-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/23/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to compare the beneficial and harmful effects of opioids used as adjuncts to local anesthetics in patients undergoing cesarean section under spinal anesthesia. METHODS We searched electronic databases and ClinicalTrials.gov from their inception until March, 2021 without language restrictions. The primary outcome was the complete analgesia duration (Time to VAS > 0). Data were synthesized using the Bayesian random-effects model. Evidence confidence was evaluated using the Confidence In Network Meta-Analysis. RESULTS We identified 66 placebo-controlled randomized controlled trials (RCTs) comprising 4400 patients undergoing elective cesarean section. Compared with the placebo, intrathecal opioids (fentanyl, sufentanil, and morphine) significantly prolonged the analgesia duration by 96, 96, and 190 min, respectively (mean difference). Despite morphine ranking first, opioid efficacy was similar; the results were inconsistent with respect to other analgesic outcomes. Except for diamorphine, all opioids were associated with significant increases in the pruritus incidence. Sufentanil and morphine were associated with increases in the respiratory depression incidence. CONCLUSIONS We confirmed that intrathecal opioids benefit postoperative analgesia. Although morphine seems to be the most appropriate agent, some results were inconsistent, and the evidence confidence was often moderate or low, especially for adverse outcomes. Well-designed RCTs with an evidence-based approach are imperative for determining the most appropriate opioid for cesarean sections.
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Affiliation(s)
- Hiroyuki Seki
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan. .,Department of Anesthesiology, Kyorin University School of Medicine, 6-20-2, ShinkawaTokyo, Mitaka, 181-8611, Japan.
| | - Toshiya Shiga
- Department of Anesthesiology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Takahiro Mihara
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Graduate School of Medicine, Kanagawa, Japan.,Department of Health Data Science, Yokohama City University Graduate School of Data Science, Kanagawa, Japan
| | - Hiroshi Hoshijima
- Division of Dento-Oral Anesthesiology, Tohoku University Graduate School of Dentistry, Miyagi, Japan
| | - Yuki Hosokawa
- Department of Anesthesiology, Showa University School of Medicine, Tokyo, Japan
| | - Shunsuke Hyuga
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Tomoe Fujita
- Department of Anesthesiology, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kyotaro Koshika
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Reina Okada
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Hitomi Kurose
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Ideno
- Department of Anesthesiology, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Takashi Ouchi
- Department of Anesthesiology, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Oji-Zurmeyer J, Ortner C, Klein KU, Putz G, Jochberger S. [Neuraxial Morphine for Postoperative Analgesia after Caesarean Deliveries]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:439-447. [PMID: 34187076 DOI: 10.1055/a-1204-5169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The use of neuraxial morphine, in combination with nonopioid analgesic regimens for postoperative analgesia after Caesarean deliveries is common practice, especially in the Anglo-American world. Neuraxial morphine offers a longer-lasting superior analgesia than intravenous opioids or patient-controlled analgesia. If neuraxial anaesthesia is being used for a caesarean delivery, it may be recommended to concomitantly administer neuraxial morphine for the postoperative analgesia.A low dose of neuraxial morphine in a healthy parturient bears a low morbidity and mortality risk. The optimal frequency, duration and modality of respiratory monitoring for patients at low risk for respiratory depression is dependent on the dose of morphine administered and the patient-specific and obstetric risk profile.
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Mohd Daut FN, Seevaunnamtum SP, Nik Mohamad NA, Che Omar S, Wan Hassan WMN. Granisetron vs. Granisetron and Dexamethasone on The Reduction of Postoperative Nausea and Vomiting (PONV) After Caesarean Section With Intrathecal Morphine: A Randomised Controlled Trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1916860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- FN Mohd Daut
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - SP Seevaunnamtum
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - NA Nik Mohamad
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - S Che Omar
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - WMN Wan Hassan
- Department of Anesthesiology & Intensive Care, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia. Anesthesiology 2021; 134:72-87. [PMID: 33206131 DOI: 10.1097/aln.0000000000003611] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine. METHODS Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects. RESULTS Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (-2 to 1) and -0.1 cm (-0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (-2 to 15) and 0.6 cm (-0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of -18 mg (-28 to -7) and -1.5 cm (-2.4 to -0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by -4.4 cm · h (-5.0 to -3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons. CONCLUSIONS Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spinal morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used. EDITOR’S PERSPECTIVE
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Evaluation of inpatient postpartum recovery using the Obstetric Quality of Recovery-10 patient-reported outcome measure: a single-center observational study. Am J Obstet Gynecol MFM 2020; 2:100202. [DOI: 10.1016/j.ajogmf.2020.100202] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/13/2020] [Accepted: 08/02/2020] [Indexed: 12/20/2022]
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Khosravi F, Sharifi M, Jarineshin H. Comparative Study of Fentanyl vs Dexmedetomidine as Adjuvants to Intrathecal Bupivacaine in Cesarean Section: A Randomized, Double-Blind Clinical Trial. J Pain Res 2020; 13:2475-2482. [PMID: 33116789 PMCID: PMC7548853 DOI: 10.2147/jpr.s265161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 09/03/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Effective postoperative analgesia is essential in cesarean section. This study aimed to compare postoperative analgesia and hemodynamic changes after intrathecal use of fentanyl or dexmedetomidine combined with bupivacaine. Patients and Methods This study involved 110 pregnant women with ASA I and II and gestational age ≥37 weeks who were candidates for elective cesarean section. They were randomly divided into two groups of 55; Group B-D received 10 mg bupivacaine (0.5%) + 5 μg dexmedetomidine and Group B-F received 10 mg bupivacaine (0.5%) + 25 μg fentanyl, intrathecally. The onset of block, duration of analgesia, the score of pain intensity, hemodynamic changes, Apgar scores, and any adverse events were evaluated. P-value <0.05 was considered statistically significant. Results Patients in two groups were similar in terms of demographic characteristics and ASA classification. Duration of analgesia in the B-D group was significantly longer than B-F group (428.64±73.39 vs 273.18±61.91 min; P<0.001). The score of pain intensity during recovery time in the B-D group was significantly lower than that of B-F group (0.33±0.84 vs 0.51±0.57 min; P=0.004). The onset of block was also faster in the B-D group than B-F group (98.27±35.95 vs 110.45±37.69 seconds; P=0.036). The two groups did not show significant differences in hemodynamic changes and other variables (P>0.05). Conclusion Compared with fentanyl, it seems that adding 5 μg dexmedetomidine to bupivacaine has a better effect on postoperative pain management in cesarean section under spinal anesthesia.
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Affiliation(s)
- Fatemeh Khosravi
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.,Department of Physiology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mehdi Sharifi
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Hashem Jarineshin
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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Moraitis A, Hultin M, Walldén J. Risk of postoperative nausea and vomiting in hip and knee arthroplasty: a prospective cohort study after spinal anaesthesia including intrathecal morphine. BMC Anesthesiol 2020; 20:242. [PMID: 32972366 PMCID: PMC7517815 DOI: 10.1186/s12871-020-01154-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/09/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The overall risk of postoperative nausea and vomiting after general anaesthesia is approximately 30% even with prophylactic medications. Studies exploring the risk after regional anaesthesia including intrathecal morphine are limited but indicate that intrathecal morphine is highly emetogenic and is additive to the PONV risk associated with other forms of anaesthesia. The aim of this observational study was to investigate the risk of PONV after spinal blockade combined with intrathecal morphine and to explore associations with patient and perioperative factors, including given PONV-prophylaxis. We hypothesized that a large number of patients in a clinical setting receive less prophylaxis than the recommendations in guidelines (suboptimal prophylaxis), leading to a higher risk for PONV compared to those receiving adequate PONV prophylaxis. METHODS The study was conducted as a prospective observational cohort study regarding PONV in patients undergoing hip/knee replacement under spinal anaesthesia including intrathecal morphine. Patients were included at a county hospital in Sweden during April-November 2013 (n = 59) and September 2014-June 2015 (n = 40). One hundred eight patients entered the study with 99 patients analysed in the final cohort. Patients were followed the first three postoperative days with a questionnaire regarding PONV and peri- and postoperative data was collected. PONV risk is presented as the proportion of patients (%) with PONV and was related to the level of perioperative PONV-prophylaxis (suboptimal/optimal). Univariate analysis was used to analyse factors associated with PONV. RESULTS Forty-six patients (46%) experienced PONV during the 3-day study period whereof 36 patients (36%) until noon the first day after the procedure. 19/27 patients (70%) that received suboptimal PONV-prophylaxis experienced PONV compared to 27/72 (38%) that received optimal PONV-prophylaxis (p = 0.015). Further, female gender and/or a history of motion sickness were associated with an increased PONV-risk. CONCLUSIONS There was a high risk for PONV after spinal anaesthesia including morphine. PONV risk was associated with the level of prophylaxis and with known risk factors for PONV. Our findings suggest that a more liberal use of PONV prophylaxis might be motivated.
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Affiliation(s)
- Antonio Moraitis
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Sundsvall, Sweden.
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Umeå), Umeå University, Umeå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine (Sundsvall), Umeå University, Sundsvall, Sweden
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Subramani Y, Nagappa M, Kumar K, Fochesato LA, Chohan MBY, Zhu YF, Armstrong K, Singh SI. Effect of intrathecal lipophilic opioids on the incidence of shivering in women undergoing cesarean delivery after spinal anesthesia: a systematic review and bayesian network meta- analysis of randomized controlled trials. BMC Anesthesiol 2020; 20:214. [PMID: 32847522 PMCID: PMC7448354 DOI: 10.1186/s12871-020-01116-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/04/2020] [Indexed: 01/17/2023] Open
Abstract
Background Shivering is a common side effect in women having cesarean delivery (CD) under spinal anesthesia, which can be bothersome to the patient, and it can also interfere with perioperative monitoring. In several studies, the intrathecal (IT) addition of a lipophilic opioid to local anesthetics has been shown to decrease the incidence of shivering. Objective We performed this network meta-analysis to evaluate the effects of intrathecal lipophilic opioids in preventing the incidence of shivering in patients undergoing CD. Methods This review was planned according to the PRISMA for Network Meta-Analysis (PRISMA-NMA) guidelines. An English literature search of multiple electronic databases was conducted. We included randomized controlled trials (RCTs) that reported on the incidence of shivering, with study groups receiving either IT fentanyl, sufentanil, or meperidine in women undergoing CD under spinal anesthesia. Quality of the studies was assessed using the modified Oxford scoring system. Using random-effects modeling, dichotomous data were extracted and summarized using odds ratio (OR) with a 95% credible interval (CrI). Statistical analysis was conducted using R studio version 1.0.153 - Inc. Results Twenty-one studies consisting of 1433 patients (Control group: 590 patients in twenty-one studies; Fentanyl group:199 patients in seven studies; Sufentanil group: 156 patients in five studies; Meperidine group: 488 patients in ten studies) met the inclusion criteria for this systematic review investigating the effect of intrathecal lipophilic opioids in preventing the incidence of shivering in women undergoing cesarean delivery under spinal anesthesia. Methodological validity scores ranged from 3 to 7. The Bayesian mixed network estimate showed the incidence of shivering was significantly lower with IT fentanyl (pooled odds ratio (OR): 0.13; 95% credible interval (CrI): 0.04 to 0.35; P = 0.0004) and IT meperidine (OR: 0.12; 95% CrI: 0.05 to 0.29; P < 0.00001), but not with IT sufentanil (OR: 0.37; 95% CrI: 0.11 to 1.22; P = 0.23). The IT fentanyl group had a significantly lower incidence of intraoperative discomfort [Risk Ratio (RR): 0.19; 95% CI: 0.10–0.35; P < 0.00001], the IT sufentanil group had a significantly higher incidence of pruritus (RR: 6.18; 95% CI: 1.18–32.46; P = 0.03) The IT meperidine group had a significantly lower incidence of intraoperative discomfort (2.7% vs. 13.6%; RR: 0.22; 95% CI: 0.09–0.55; P = 0.001), but there was a significant increase in nausea and vomiting (IT meperidine group vs. Control group: 42.7% vs. 19.4%; RR: 2.56; 95% CI: 1.14–5.75; P = 0.02). Meta-regression analysis based on the opioid dose and quality of the study did not impact the final inference of our result. Conclusion IT fentanyl significantly decreased the incidence of shivering in women undergoing CD under spinal anesthesia without increasing maternal adverse events, confirming that routine use in this patient population is a good choice. IT sufentanil did not decrease the incidence of shivering. IT meperidine decreased the incidence and severity of shivering, but its use was also associated with significant nausea and vomiting.
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Affiliation(s)
- Yamini Subramani
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, & Dentistry, Western University, London Health Sciences Centre- University Hospital, (LHSC-UH) , London, Ontario, Canada.
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, & Dentistry, Western University, London Health Sciences Centre- University Hospital, (LHSC-UH) , London, Ontario, Canada
| | - Kamal Kumar
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, & Dentistry, Western University, London Health Sciences Centre- Victoria Hospital, (LHSC-VH) , London, Ontario, Canada
| | - Lee-Anne Fochesato
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph's Health Care, Western University, London, Ontario, Canada
| | - Moaz Bin Yunus Chohan
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph's Health Care, Western University, London, Ontario, Canada
| | - Yun Fei Zhu
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, & Dentistry, Western University, London Health Sciences Centre- University Hospital, (LHSC-UH) , London, Ontario, Canada
| | - Kevin Armstrong
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph's Health Care, Western University, London, Ontario, Canada
| | - Sudha Indu Singh
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine, & Dentistry, Western University, London Health Sciences Centre- University Hospital, (LHSC-UH) , London, Ontario, Canada
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Wilson SH, Wolf BJ, Robinson SM, Nelson C, Hebbar L. Intravenous vs Oral Acetaminophen for Analgesia After Cesarean Delivery: A Randomized Trial. PAIN MEDICINE 2020; 20:1584-1591. [PMID: 30561704 DOI: 10.1093/pm/pny253] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Examination of postoperative analgesia with intravenous and oral acetaminophen. DESIGN Prospective, three-arm, nonblinded, randomized clinical trial. SETTING A single academic medical center. SUBJECTS Parturients scheduled for elective cesarean delivery. METHODS This trial randomized 141 parturients to receive intravenous acetaminophen (1 g every eight hours, three doses), oral acetaminophen (1 g every eight hours, three doses), or no acetaminophen. All patients received a standardized neuraxial anesthetic with intrathecal opioids and scheduled postoperative ketorolac. The primary outcome, 24-hour opioid consumption, was evaluated using the Kruskal-Wallace test and Tukey-Kramer adjustment for multiple comparisons. Secondary outcomes included 48-hour opioid consumption, first opioid rescue, pain scores, patient satisfaction, times to ambulation and discharge, and side effects. RESULTS Over 18 months, 141 parturients with similar demographic variables completed the study. Median (interquartile range) opioid consumption in intravenous morphine milligram equivalents at 24 hours was 0 (5), 0 (7), and 5 (7) for the intravenous, oral, and no groups, respectively, and differed between groups (global P = 0.017). Opioid consumption and other secondary outcomes did not differ between the intravenous vs oral or oral vs no groups. Opioid consumption was reduced at 24 hours with intravenous vs no acetaminophen (P = 0.015). Patients receiving no acetaminophen had 5.8 times the odds of consuming opioids (P = 0.036), consumed 40% more opioids controlling for time (P = 0.041), and had higher pain scores with ambulation (P = 0.004) compared with the intravenous group. CONCLUSIONS Intravenous acetaminophen did not reduce 24-hour opioid consumption or other outcomes compared with oral acetaminophen. Intravenous acetaminophen did decrease opioid consumption and pain scores compared with no acetaminophen.
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Affiliation(s)
| | | | - Stefanie M Robinson
- Departments of Anesthesia and Perioperative Medicine.,East Carolina Anesthesia Associates, Greenville, North Carolina, USA
| | - Cecil Nelson
- Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA.,Regional Obstetrical Consultants, Chattanooga, Tennessee, USA
| | - Latha Hebbar
- Departments of Anesthesia and Perioperative Medicine
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Abstract
Enhanced recovery after surgery (ERAS) is a multimodal perioperative strategy originally developed to attenuate the postsurgical stress response in patients after colorectal surgery. Patients undergoing gynecologic surgery who had ERAS had significantly shorter hospital length of stay, reduced hospital-related costs, and acceptable pain management with reduced opioid use, without compromising patient satisfaction. Intrathecal hydromorphone is an effective alternative ERAS protocol analgesia for these patients and will not compromise patient outcomes or healthcare costs.
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The impact of a transversus abdominis plane block including clonidine vs. intrathecal morphine on nausea and vomiting after caesarean section: A randomised controlled trial. Eur J Anaesthesiol 2020; 36:575-582. [PMID: 31274545 DOI: 10.1097/eja.0000000000001013] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intrathecal morphine (ITM) is a widely used technique for postcaesarean section analgesia but entails a high risk of postoperative nausea and vomiting (PONV). The transversus abdominis plane (TAP) block is an alternative. OBJECTIVE We tested the hypothesis that a TAP block including clonidine reduces the incidence of PONV after caesarean section when compared with ITM. DESIGN A randomised, controlled, double-blinded study. SETTING Geneva University Hospitals, Switzerland, from October 2013 to February 2017. PATIENTS A total of 182 patients undergoing elective caesarean section were studied. Reasons for noninclusion were complicated pregnancy, contraindication to spinal anaesthesia or TAP block, extreme weight or height, allergy to any medication or previous median abdominal incision. INTERVENTIONS Patients were allocated randomly to one of two groups (quadruple blinded): 100 μg of morphine added to the spinal local anaesthetic or a bilateral TAP block with 20 ml of ropivacaine 0.375% + 75 μg of clonidine on each side. MAIN OUTCOME MEASURES The primary outcome measure was the total number of patients presenting with PONV at 24 h. Secondary aims were to compare other adverse effects (pruritus, respiratory depression, hypotension, bradycardia, sedation), analgesic efficacy and the quality of postoperative recovery. RESULTS At 24 h, there was no significant difference between ITM and TAP groups in the total number of patients presenting with PONV: 17/92 patients (18.5%, 95% confidence interval 11.1 to 27.9) and 27/88 patients (30.7%, 95% confidence interval 21.3 to 41.4) in TAP and ITM groups, respectively (P = 0.065). Pain scores at 6 h and cumulative morphine consumption at 24 h were lower in the ITM group (P < 0.0001 for morphine consumption at 24 h). The incidence of hypotension was higher in the TAP group (54.3 vs. 29.2%, P = 0.0006). Maternal satisfaction was high and not different between groups. CONCLUSION A TAP block with clonidine and local anaesthetic does not reduce significantly the incidence of PONV compared with ITM. We confirm the superiority of ITM on acute postcaesarean section analgesia compared with a TAP block, even with clonidine as an adjunct. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01931215.
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The Quality of Recovery after Dexamethasone, Ondansetron, or Placebo Administration in Patients Undergoing Lower Limbs Orthopedic Surgery under Spinal Anesthesia Using Intrathecal Morphine. A Randomized Controlled Trial. Anesthesiol Res Pract 2020; 2020:9265698. [PMID: 32518560 PMCID: PMC7256731 DOI: 10.1155/2020/9265698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/02/2023] Open
Abstract
Intrathecal morphine is widely and successfully used to prevent postoperative pain after orthopedic surgery, but it is frequently associated with side effects. The aim of this study was to evaluate the effect of dexamethasone or ondansetron when compared to placebo to reduce the occurrence of these undesirable effects and, consequently, to improve the quality of recovery based on patient's perspective. Methods. One hundred and thirty-five patients undergoing lower extremity orthopedic surgery under spinal anesthesia using bupivacaine and morphine were randomly assigned to receive IV dexamethasone, ondansetron, or saline. On the morning following surgery, a quality of recovery questionnaire (QoR-40) was completed. Results. No differences were detected in the global and dimensional QoR-40 scores following surgery; however, following postanesthesia care unit (PACU) discharge, pain scores were higher in patients receiving ondansetron compared with patients who received dexamethasone. Conclusion. Neither ondansetron nor dexamethasone improves the quality of recovery after lower limbs orthopedic surgery under spinal anesthesia using intrathecal morphine.
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Tan HS, Habib AS. The optimum management of nausea and vomiting during and after cesarean delivery. Best Pract Res Clin Anaesthesiol 2020; 34:735-747. [PMID: 33288123 DOI: 10.1016/j.bpa.2020.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/17/2020] [Indexed: 12/28/2022]
Abstract
Intraoperative and postoperative nausea and vomiting (IONV and PONV) afflict up to 80% of parturients undergoing cesarean delivery with neuraxial anesthesia. Preventing nausea and emesis is a top priority for women undergoing cesarean delivery and is included in the quality of recovery measures and enhanced recovery after cesarean delivery protocols. The majority of known perioperative emetic triggers can be avoided or mitigated by optimizing anesthetic and surgical management. IONV may arise from spinal anesthesia-induced hypotension, intraoperative pain, and medications such as uterotonics and antibiotics. Furthermore, uterine exteriorization and peritoneal irrigation increase IONV risk. Conversely, preventing PONV mainly focuses on optimizing analgesia through an opioid-sparing, multimodal strategy. In addition, combination prophylactic antiemetic therapy should be instituted in this high-risk population to further reduce the risk of IONV and PONV.
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Affiliation(s)
- Hon Sen Tan
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University Medical Center, Box 3094, Durham, NC, 27710, USA.
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Gomez NAG, Warren N, Labko Y, Sinclair DR. Intrathecal Opioid Dosing During Spinal Anesthesia for Cesarean Section: An Integrative Review. J Dr Nurs Pract 2020; 13:108-119. [DOI: 10.1891/jdnp-d-19-00025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Approximately one in three women in the United States deliver via Cesarean section (CS), making it one of the most common surgical procedures in the country. Neuraxial (spinal or epidural) anesthesia is the most effective and common anesthetic approach for pain relief during a CS in the United States and often associated with adverse effects such as nausea, vomiting, and pruritus. While recommended dose ranges exist to protect patient safety, there are a lack of guidelines for opioid doses that both optimize postoperative pain management and minimize side effects. This integrative review synthesizes the evidence regarding best practice of opioid dosing in neuraxial anesthesia for planned CS. Evidence supports the use of lower doses of intrathecal (IT) opioids, specifically 0.1 morphine, to achieve optimal pain management with minimal nausea, vomiting, and pruritus. Lower IT doses have potential to achieve pain management and to alleviate preventable side effects in women delivering via CS.
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Hamed MA, Yassin HM, Botros JM, Abdelhady MA. Analgesic Efficacy of Erector Spinae Plane Block Compared with Intrathecal Morphine After Elective Cesarean Section: A Prospective Randomized Controlled Study. J Pain Res 2020; 13:597-604. [PMID: 32273748 PMCID: PMC7102879 DOI: 10.2147/jpr.s242568] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia. Methods In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan–Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups. Results No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0–24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly. Conclusion ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.
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Affiliation(s)
- Mohamed Ahmed Hamed
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum 63511, Egypt
| | - Hany Mahmoud Yassin
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum 63511, Egypt
| | - Joseph Makram Botros
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum 63511, Egypt
| | - Mahdy Ahmed Abdelhady
- Department of Anesthesiology, Faculty of Medicine, Fayoum University, Fayoum 63511, Egypt
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Arroyo-Fernández FJ, Calderón Seoane JE, Torres Morera LM. Strategies of analgesic treatment after cesarean delivery. Current state and new alternatives. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2020; 67:167-175. [PMID: 32085919 DOI: 10.1016/j.redar.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 06/10/2023]
Abstract
The number of caesarean sections performed worldwide is increasing, and with it, the need for the optimal analgesia strategies. Deficient postoperative analgesia increases the need for opioids, delays recovery, and is associated with chronic pain and postpartum depression. It is essential to find good postoperative pain control strategies that facilitate early mobility, early recovery, and early hospital discharge with minimal side effects on the mother and infant. Multimodal analgesia based on neuroaxial anaesthesia with morphine in combination with non-opioids such as non-steroidal anti-inflammatory drugs and paracetamol, gives the best post-caesarean analgesia outcome, and allows anaesthesiologists to reserve opioids, corticoids, gabapentin, magnesium or ketamine for situations where neuroaxial anaesthesia cannot be performed, for high-risk patients, or when pain is difficult to control. Peripheral nerve block techniques can also be added, such as transverse abdominis plane block, erector spinae block, or continuous wound infiltration.
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Selzer A, Pryor KO, Tangel V, O’Connell K, Kjaer K. The effect of intravenous dexamethasone on postoperative nausea and vomiting after Cesarean delivery with intrathecal morphine: a randomized-controlled trial. Can J Anaesth 2020; 67:817-826. [DOI: 10.1007/s12630-020-01582-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 12/26/2019] [Accepted: 12/28/2019] [Indexed: 01/02/2023] Open
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Uppal V, Retter S, Casey M, Sancheti S, Matheson K, McKeen DM. Efficacy of Intrathecal Fentanyl for Cesarean Delivery. Anesth Analg 2020; 130:111-125. [DOI: 10.1213/ane.0000000000003975] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Macones GA, Caughey AB, Wood SL, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol 2019; 221:247.e1-247.e9. [PMID: 30995461 DOI: 10.1016/j.ajog.2019.04.012] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/02/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND This Enhanced Recovery After Surgery Guideline for postoperative care in cesarean delivery will provide best practice, evidenced-based recommendations for postoperative care with primarily a maternal focus. OBJECTIVE The pathway process for scheduled and unscheduled cesarean delivery for this Enhanced Recovery After Surgery cesarean delivery guideline will consider time from completion of cesarean delivery until maternal hospital discharge. STUDY DESIGN The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Delivery," "Cesarean Section Delivery," and all postoperative Enhanced Recovery After Surgery items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses evaluated the quality of evidence, and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system as used and described in previous Enhanced Recovery After Surgery Guidelines. RESULTS The Enhanced Recovery After Surgery cesarean delivery guideline/pathway has created a pathway for postoperative care. Specifics include sham feeding, nausea and vomiting prevention, postoperative analgesia, nutritional care, glucose control, thromboembolism prophylaxis, early mobilization, urinary drainage, and discharge counseling. A number of elements of postoperative care of women who undergo cesarean delivery are recommended, based on the evidence. CONCLUSION As the Enhanced Recovery After Surgery cesarean delivery pathway (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, there will be an opportunity for focused and optimized areas of care and recommendations to be further enhanced.
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Affiliation(s)
- George A Macones
- Department of Obstetrics & Gynecology, Washington University in St Louis, St. Louis, MO.
| | - Aaron B Caughey
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - Stephen L Wood
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ian J Wrench
- Sheffield Teaching Hospitals Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield, United Kingdom
| | | | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karin Pettersson
- Division of Obstetrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford, United Kingdom
| | - Medhat M Shalabi
- Departments of Anesthesiology and Intensive Care, Alzahra Hospital, Dubai, United Arab Emirates
| | - Amy Metcalfe
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - R Douglas Wilson
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
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Shin DW, Kim Y, Hong B, Yoon SH, Lim CS, Youn S. Effect of fentanyl on nausea and vomiting in cesarean section under spinal anesthesia: a randomized controlled study. J Int Med Res 2019; 47:4798-4807. [PMID: 31452417 PMCID: PMC6833428 DOI: 10.1177/0300060519869515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Objective Although opioids may induce nausea and vomiting, they possess sedative effects and can reduce intraoperative nausea and vomiting (IONV). This study assessed the effect of adding fentanyl to midazolam on sedation levels and IONV during cesarean section under spinal anesthesia. Methods Eighty parturients scheduled for elective cesarean section were enrolled in the study. Following fetal delivery, patients were administered 0.05 mg/kg of midazolam plus 0.03 mL/kg of normal saline (M group) or 0.05 mg/kg of midazolam plus 1.5 μg/kg of fentanyl (MF group). The primary outcome was the incidence of IONV. The secondary outcomes were incidence of postoperative nausea and vomiting (PONV), intraoperative sedation level, and five-point patient satisfaction score (PSS). Results The IONV incidence was significantly lower in the MF group compared with the M group (5% [2/40] vs. 25% [10/40]). The PONV incidence did not differ significantly between the groups. The intraoperative sedation level tended to be deeper in the MF group. The 5-point PSS was significantly higher in the MF group. There was a strong correlation between the sedation level and IONV incidence. Conclusions Adding fentanyl to midazolam is effective for sedation and to prevent IONV in women who are undergoing cesarean section under spinal anesthesia.
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Affiliation(s)
- Dong Wook Shin
- Department of Anesthesiology and Pain Medicine CHA Gumi Medical Center, CHA University Gumi, Gumi, Republic of Korea
| | - Yeojung Kim
- Department of Anesthesiology and Pain Medicine College of Medicine Chungnam National University, Daejeon, Republic of Korea
| | - Boohwi Hong
- Department of Anesthesiology and Pain Medicine College of Medicine Chungnam National University, Daejeon, Republic of Korea
| | - Seok-Hwa Yoon
- Department of Anesthesiology and Pain Medicine College of Medicine Chungnam National University, Daejeon, Republic of Korea
| | - Chae Seong Lim
- Department of Anesthesiology and Pain Medicine College of Medicine Chungnam National University, Daejeon, Republic of Korea
| | - Sookyoung Youn
- Department of Anesthesiology and Pain Medicine College of Medicine Chungnam National University, Daejeon, Republic of Korea
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Yamada LAP, Guimarães GMN, Silva MAS, Sousa AM, Ashmawi HA. [Development of a multivariable predictive model for postoperative nausea and vomiting after cancer surgery in adults]. Rev Bras Anestesiol 2019; 69:342-349. [PMID: 31378385 DOI: 10.1016/j.bjan.2019.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/22/2019] [Accepted: 03/03/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Predicting postoperative nausea and vomiting risk is the cornerstone for deciding prophylaxis. Apfel's score does not define how long a person must be abstinent from smoking to be considered a non-smoker, and the use of intraoperative spinal opioids as a risk factor for predicting postoperative nausea and vomiting is also not addressed. The aim of this study was to quantify predicting postoperative nausea and vomiting risk by an ordinal smoking status and the use of intraoperative opioids (systemic or neuraxial), and to develop a new predictive model. METHODS Patients scheduled for cancer surgery were prospectively evaluated for predicting postoperative nausea and vomiting in the first 24h after surgery. RESULTS Of 2014 initially included patients, 185 participants were excluded. Smoking status classification was associated with predicting postoperative nausea and vomiting incidence rates of 14.1%, 18.1%, 24.7%, 29.4% and 33.9% for smokers, patients who stopped smoking up to 1 month prior to surgery, one to 6 months prior, more than 6 months prior or patients who never smoked, respectively, which was significant in the multiple comparisons analysis (adjusted p=0.015). The multiple comparisons-adjusted hypothesis tests for association with predicting postoperative nausea and vomiting for sex, age, previous predicting postoperative nausea and vomiting, chemotherapy-induced nausea, and ordinal smoking status had p-values of <0.001. The type of surgery (p=0.04), total fentanyl consumption (p=0.04), both intraoperative and postoperative, were significant predictors. A new model was developed and showed higher discriminative power than Apfel's score (AUC 67.9% vs. 63.7%, p<0.001). CONCLUSION Smoking status showed a significant and linear impact on predicting postoperative nausea and vomiting incidence, and we developed a new model that uses unambiguous smoking and opioid predictors.
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Affiliation(s)
| | | | | | - Angela Maria Sousa
- Instituto do Câncer do Estado de São Paulo, Centro Integrado de Tratamento da Dor, São Paulo, SP, Brasil
| | - Hazem Adel Ashmawi
- Universidade de São Paulo, Faculdade de Medicina, Disciplina de Anestesiologia, São Paulo, SP, Brasil
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Kang W, Lu D, Yang X, Zhou Z, Chen X, Chen K, Zhou X, Feng X. Postoperative analgesic effects of various quadratus lumborum block approaches following cesarean section: a randomized controlled trial. J Pain Res 2019; 12:2305-2312. [PMID: 31413627 PMCID: PMC6663075 DOI: 10.2147/jpr.s202772] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 06/24/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose Quadratus lumborum block (QLB) is shown to be effective on analgesia following cesarean section. This study aimed to compare the effects of three practical QLB approaches and classic epidural analgesia (EA) for cesarean section under spinal anesthesia. Patients and methods Parturients undergoing elective cesarean section were randomized as group 1 (QLB type 2), group 2 (QLB type 3), group 3 (QLB type 2+3) and group 4 (EA). The block was performed at the end of the operation, and the epidural group was given a single epidural bolus. All subjects were provided with intravenous patient-controlled analgesia under identical settings. In addition, the postoperative pain severity was assessed by the VAS, which together with the morphine consumption at specific time intervals, was recorded within 48 hrs after surgery. Data were collected from December 2017 to June 2018. Results A total of 94 parturients had completed the study. At almost all postoperative time points, the VAS scores at rest and with movement in QLB type 2+3 group were lower than those in QLB type 2 or 3 group. The mean additional morphine consumption in QLB type 2+3 group (2.7 mg) was lower than that in QLB type 2 or 3 group (6.1 mg and 5.7 mg, respectively) within 48 h after surgery (P<0.001). Besides, the total morphine consumption in EA group (1.3 mg) was lower than that in any other QLB group (P<0.001). Conclusions The analgesic effect of QLB is highly dependent on the injection position of local anesthetic. Besides, the ultrasound-guided QLB type 2+3 can provide superior analgesic effect following cesarean section to that of QLB type 2 or 3 block. However, it remains to be further validated about whether the combination of QLB type 2 and 3 is the best approach.
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Affiliation(s)
- Wenbin Kang
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Dihan Lu
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Xiaoyu Yang
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Zhibin Zhou
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Xi Chen
- Department of Anesthesiology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, People's Republic of China
| | - Keyu Chen
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Xue Zhou
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
| | - Xia Feng
- Department of Anesthesiology, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People's Republic of China
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Development of a multivariable predictive model for postoperative nausea and vomiting after cancer surgery in adults. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31378385 PMCID: PMC9391896 DOI: 10.1016/j.bjane.2019.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and objectives Predicting postoperative nausea and vomiting risk is the cornerstone for deciding prophylaxis. Apfel's score does not define how long a person must be abstinent from smoking to be considered a non-smoker, and the use of intraoperative spinal opioids as a risk factor for predicting postoperative nausea and vomiting is also not addressed. The aim of this study was to quantify predicting postoperative nausea and vomiting risk by an ordinal smoking status and the use of intraoperative opioids (systemic or neuraxial), and to develop a new predictive model. Methods Patients scheduled for cancer surgery were prospectively evaluated for predicting postoperative nausea and vomiting in the first 24 h after surgery. Results Of 2014 initially included patients, 185 participants were excluded. Smoking status classification was associated with predicting postoperative nausea and vomiting incidence rates of 14.1%, 18.1%, 24.7%, 29.4% and 33.9% for smokers, patients who stopped smoking up to 1 month prior to surgery, one to 6 months prior, more than 6 months prior or patients who never smoked, respectively, which was significant in the multiple comparisons analysis (adjusted p = 0.015). The multiple comparisons-adjusted hypothesis tests for association with predicting postoperative nausea and vomiting for sex, age, previous predicting postoperative nausea and vomiting, chemotherapy-induced nausea, and ordinal smoking status had p-values of <0.001. The type of surgery (p = 0.04), total fentanyl consumption (p = 0.04), both intraoperative and postoperative, were significant predictors. A new model was developed and showed higher discriminative power than Apfel's score (AUC 67.9% vs. 63.7%, p < 0.001). Conclusion Smoking status showed a significant and linear impact on predicting postoperative nausea and vomiting incidence, and we developed a new model that uses unambiguous smoking and opioid predictors.
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Ffrench-O'Carroll R, Steinhaeuser H, Duff S, Close J, McNamara J, Ahmed N, Murray M, Rice T, Immanni S. A randomized controlled trial comparing tapentadol with oxycodone in non-breastfeeding women post elective cesarean section. Curr Med Res Opin 2019; 35:975-981. [PMID: 30444145 DOI: 10.1080/03007995.2018.1550059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Tapentadol may allow greater pain relief with reduced "opioid load" compared to oxycodone. Its use has not been studied in the obstetric population. The objective of this study was to compare the efficacy and side effect profile of tapentadol with oxycodone in patients who received spinal anesthesia for elective cesarean section. The trial was registered with EU Clinical Trials Register with CT number 2016-001621-33. METHODS This was a multicenter, randomized controlled trial. Randomized patients (n = 68) received either 50 mg tapentadol or oxycodone 10 mg 12 hourly postoperatively. The primary endpoint was the sum of pain intensity difference over the first 48 hours of treatment (SPID48). Secondary outcomes included time to rescue medications, SPID36, total pain relief (TOTPAR) scores, patient satisfaction scores, sum of total pain relief and pain intensity difference (SPRID) scores, time to rescue medications and side effects experienced. An analysis of covariance model with baseline pain intensity score as a covariate was used for statistical analysis. RESULTS There was no significant difference in the primary endpoint of SPID48 with adjusted mean difference -11.45 (95% CI -35.35, 12.45) p = .34). Oxycodone showed significantly greater SPID36 scores compared to tapentadol with increased time to rescue medication. Side effects experienced were similar between groups. CONCLUSION Tapentadol did not provide superior pain control or improved tolerability compared to oxycodone post cesarean section. Results should be interpreted however with consideration of administration of intrathecal opioids to all patients in this study and debate over the optimal dose of tapentadol for acute pain.
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Affiliation(s)
| | | | - S Duff
- a University Hospital Waterford , Waterford , Ireland
| | - J Close
- a University Hospital Waterford , Waterford , Ireland
| | - J McNamara
- a University Hospital Waterford , Waterford , Ireland
| | - N Ahmed
- b St Luke's General Hospital , Kilkenny , Ireland
| | - M Murray
- a University Hospital Waterford , Waterford , Ireland
| | - T Rice
- c South Tipperary General Hospital , Clonmel , Ireland
| | - S Immanni
- a University Hospital Waterford , Waterford , Ireland
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Sivevski A, Ivanov E, Karadjova D, Slaninka-Miceska M, Kikerkov I. Spinal-Induced Hypotension in Preeclamptic and Healthy Parturients Undergoing Cesarean Section. Open Access Maced J Med Sci 2019; 7:996-1000. [PMID: 30976348 PMCID: PMC6454163 DOI: 10.3889/oamjms.2019.230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND There is a widespread belief that spinal anaesthesia in patients with preeclampsia might cause severe hypotension and decreased uteroplacental perfusion. This study aimed to evaluate the incidence and severity of spinal induced-hypotension in preeclamptics and healthy parturients. METHODS Total of 78 patients (40 healthy and 38 preeclamptic) undergoing a C-Section with spinal anaesthesia were included. Spinal anaesthesia was performed with a mixture of 8-9 mg isobaric 0.5% bupivacaine, 20 mcg fentanyl and 100 mcg morphine (total volume 2.2-2.4 ml). Blood pressures (BP)-SBP, DBP, MAP were recorded non-invasively before performing spinal anaesthesia and at 2.5 minutes after a spinal puncture. RESULTS The BP falls (%) from baseline were significantly greater in the healthy parturients compared to those with preeclampsia (25.8% ± 10.1 vs 18.8% ± 17.0 for SBP, 28.5% ± 8.8 vs 22.5% ± 10.4 for DBP, and 31.2% ± 14.2 vs 18.2% ± 12.6% for MAP, p < 0.05). The incidence rate of hypotension in the preeclamptics was 25% compared to 53% in healthy parturients (p < 0.001). Higher doses of vasopressors both ephedrine (16.5 ± 8.6 vs 6.0 ± 2.0 mg) and phenylephrine (105 ± 25 mg) in the healthy women were required. There was no need for phenylephrine treatment in the preeclamptic group. CONCLUSION This study showed that the incidence and severity of spinal-induced hypotension in preeclamptic patients are less than in healthy women. The use of low dose spinal anaesthesia also contributed to this statement.
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Affiliation(s)
- Atanas Sivevski
- University Clinic for Gynecology & Obstetrics, Anaesthesia Department, Clinical Center Mother Teresa, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Emilija Ivanov
- University Clinic for Gynecology & Obstetrics, Anaesthesia Department, Clinical Center Mother Teresa, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Dafina Karadjova
- University Clinic for Gynecology & Obstetrics, Anaesthesia Department, Clinical Center Mother Teresa, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Maja Slaninka-Miceska
- Institute of Preclinical and Clinical Pharmacology and Toxicology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Igor Kikerkov
- Institute of Preclinical and Clinical Pharmacology and Toxicology, Faculty of Medicine, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Carvalho B, Sutton CD, Kowalczyk JJ, Flood PD. Impact of patient choice for different postcesarean delivery analgesic protocols on opioid consumption: a randomized prospective clinical trial. Reg Anesth Pain Med 2019; 44:578-585. [PMID: 30867278 DOI: 10.1136/rapm-2018-100206] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/23/2019] [Accepted: 02/01/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Choice of postcesarean delivery analgesic protocol may improve pain experience and reduce analgesic requirements. METHODS Cesarean delivery patients were randomly assigned either to choose their postcesarean delivery analgesia protocol or to have no choice and receive routine care. Choices were low (50 μg intrathecal morphine), medium (identical to routine care: 150 μg intrathecal morphine), or high (300 μg intrathecal morphine with 600 mg oral gabapentin). All groups received scheduled acetaminophen and ibuprofen. The primary outcome was oxycodone requirements 0-48 hours postdelivery in those offered versus not offered a choice. RESULTS Of 160 women enrolled, 120 were offered a choice and 40 were not offered a choice. There was no difference in oxycodone requirements or pain associated with choice, but those who had a choice expressed more satisfaction than those who did not have a choice (mean (95% CI) difference 5% (0% to 10 %), p=0.005). In the choice group, the high dose group required more oxycodone (5 (0 to 15) mg 0-24 hours after delivery and 15 (10 to 25) mg at 24-48 hours; p=0.05 and p=0.001) versus the low and medium groups. The low dose group had less pruritus (p=0.001), while the high dose group had more vomiting (p=0.01) requiring antiemetic treatment (p=0.04). CONCLUSION Having a choice compared with no choice routine care did not reduce oxycodone requirements or pain scores. However, women have insight into their analgesic needs; women offered a choice and who chose the higher dose analgesic protocol required more oxycodone, and women who chose the lower dose protocol required less oxycodone. Despite providing additional analgesic (six times more intrathecal morphine plus gabapentin in high dose vs low dose protocols), we still did not equalize postcesarean oxycodone requirement differences between groups. TRIAL REGISTRATION NUMBER NCT02605187.
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Affiliation(s)
- Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - John J Kowalczyk
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Pamela Dru Flood
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Duggan AB, Katz SG. Combined Spinal and Epidural Anaesthesia for Caesarean Section in a Parturient with Severe Primary Pulmonary Hypertension. Anaesth Intensive Care 2019; 31:565-9. [PMID: 14601281 DOI: 10.1177/0310057x0303100511] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe the management of a parturient with severe primary pulmonary hypertension who underwent caesarean section. A multi-disciplinary approach was used. She was admitted to the intensive care unit perioperatively for invasive monitoring and trial of inhaled nitric oxide. Anaesthesia was provided by combined spinal-epidural block. We discuss controversies about the management of obstetric patients with this rare and serious condition.
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MESH Headings
- Adrenergic Agonists/therapeutic use
- Adult
- Analgesics, Opioid/therapeutic use
- Anesthesia, Epidural
- Anesthesia, Obstetrical
- Anesthesia, Spinal
- Anesthetics, Combined/therapeutic use
- Anesthetics, Inhalation/therapeutic use
- Cesarean Section
- Dobutamine/therapeutic use
- Epinephrine/therapeutic use
- Female
- Fentanyl/therapeutic use
- Humans
- Hypertension, Pulmonary/drug therapy
- Hypertension, Pulmonary/physiopathology
- Morphine/therapeutic use
- Nitrous Oxide/therapeutic use
- Pregnancy
- Pregnancy Complications, Cardiovascular/drug therapy
- Pregnancy Complications, Cardiovascular/physiopathology
- Severity of Illness Index
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Affiliation(s)
- A B Duggan
- Division of Anaesthesia and Intensive Care, Prince of Wales Hospital, N.S.W
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