Subarachnoid meperidine (Pethidine) causes significant nausea and vomiting during labor. The Duke Women's Anesthesia Research Group

Preventing shivering with adjuvant low dose intrathecal meperidine: A meta-analysis of randomized controlled trials with trial sequential analysis

The aim of this systematic review and meta-analysis is to evaluate the pros and cons of adjuvant low dose intrathecal meperidine for spinal anaesthesia. We searched electronic databases for randomized controlled trials using trial sequential analysis (TSA) to evaluate the incidence of reduced rescue analgesics, shivering, pruritus, nausea and vomiting when applying adjuvant intrathecal meperidine. Twenty-eight trials with 2216 patients were included. Adjuvant intrathecal meperidine, 0.05–0.5 mg kg⁻¹, significantly reduced incidence of shivering (relative risk, RR, 0.31, 95% confidence interval, CI, 0.24 to 0.40; TSA-adjusted RR, 0.32, 95% CI, 0.25 to 0.41). Intrathecal meperidine also effectively reduced need for intraoperative rescue analgesics (RR, 0.27, 95% CI, 0.12 to 0.64; TSA-adjusted RR, 0.27, 95% CI, 0.08 to 0.91) and the incidence of pruritus was unaffected (RR, 2.31, 95% CI, 0.94 to 5.70; TSA-adjusted RR, 1.42, 95% CI, 0.87 to 2.34). However, nausea and vomiting increased (RR, 1.84, 95% CI, 1.29 to 2.64; TSA-adjusted RR, 1.72, 95% CI, 1.33 to 2.23; RR, 2.23, 95% CI, 1.23 to 4.02; TSA-adjusted RR,1.96, 95% CI, 1.20 to 3.21). Under TSA, these results provided a sufficient level of evidence. In conclusion, adjuvant low dose intrathecal meperidine effectively attenuates spinal anaesthesia-associated shivering and reduces rescue analgesics with residual concerns for the nausea and vomiting.

Spinal pethidine for elective caesarean section

Pethidine (meperidine) is a unique member of the opioid family. In addition to its analgesic activity, it also has significant local anaesthetic activity. This property enables it to be used as the sole agent for spinal anaesthesia. We describe the successful use of intrathecal pethidine 1 mg/kg for an elective lower segment caesarean section in a patient presumed to be allergic to amide local anaesthetics. There were no significant adverse effects in either the mother or the newborn.

Antishivering effects of two different doses of intrathecal meperidine in caesarean section: a prospective randomised blinded study. Eur J Anaesthesiol. 2011;28:202-206. [PMID: 21325901 DOI: 10.1097/eja.0b013e3283430802]

BACKGROUND AND OBJECTIVE

Shivering causes various adverse disturbances and interferes with monitoring. The optimal dose of intrathecal meperidine to prevent shivering without producing other side-effects remains unknown. This prospective randomised double-blinded study was conducted to compare the antishivering effects of two different doses of intrathecal meperidine.

METHODS

Seventy two parturients, scheduled for elective caesarean section under spinal anaesthesia, were enrolled in three different groups. Spinal anaesthesia consisted of bupivacaine 0.5% (10 mg) for the control group (M0), and the same dose of bupivacaine with meperidine 12.5 or 25 mg for the experimental groups (M1, M2). Blood pressure, heart rate, skin and core temperatures, sensory level, capnometry, pulse oximetry, Apgar scores, shivering intensity and intrathecal opioid-related side-effects were evaluated and recorded by a blinded observer. Data were analysed using analysis of variance, χ² test, Kruskal-Wallis H-test and Mann-Whitney U-test. A P value less than 0.05 was considered to be significant.

RESULTS

Shivering was more intense in group M0 than in groups M1 and M2 with P values of 0.003 and less than 0.001, respectively. The intensity of shivering was comparable in groups M1 and M2. As regards the incidence of significant shivering, it was found to be highest in M0 (4/24 ≈16.7%) in comparison with M1 (0/24) and M2 (0/24) (P = 0.03). Nausea and vomiting occurred more frequently with higher doses of meperidine (P < 0.001 and P = 0.003, respectively). Other complications were comparable.

CONCLUSION

The use of intrathecal meperidine for caesarean section during spinal anaesthesia for the prevention of shivering cannot be recommended as its use is associated with increased incidence of nausea and vomiting.

Intrathecal meperidine reduces intraoperative shivering during transurethral prostatectomy in elderly patients

Background

Shivering is a frequent event during the perioperative period. We performed a prospective, randomized, double-blind study to determine whether intrathecal meperidine (0.2 mg/kg) decreases the incidence and intensity of shivering after spinal anesthesia for transurethral operations.

Methods

Fifty patients scheduled for elective transurethral resection operations under spinal anesthesia were randomly allocated to two groups. Spinal anesthesia consisted of 0.5% hyperbaric bupivacaine 8 mg and, mperidine (0.2 mg/kg) (meperidine group) or, normal saline (saline group). Data collection, including sensory block level (by pinprick), blood pressure, heart rate, sublingual temperature, incidence and intensity of shivering, pruritus, nausea, and vomiting was performed at 10 minute intervals.

Results

The incidence and intensity of shivering was significantly less in the meperidine group than saline group (P = 0.012 and P = 0.008, for incidence and intensity, respectively). However, pruritus was more common in the meperidine group compared with the saline group (16% vs. 0%, P < 0.05).

Conclusions

The addition of meperidine 0.2 mg/kg to intrathecal bupivacaine lowers the incidence and severity of shivering during transurethral prostatectomy in elderly patients.

The Effect of Intravenous Administration of Dexamethasone on Postoperative Pain, Nausea, and Vomiting After Intrathecal Injection of Meperidine

BACKGROUND

Different drugs have been used to enhance postoperative neuraxial opioid analgesia and reduce adverse effects.

METHODS

We randomized 60 patients into 2 groups to receive either 2 mL saline or 0.1 mg/kg dexamethasone IV before the administration of intrathecal anesthesia (15 mg and meperidine 15 mg). After surgery, patients were asked to score their pain at 6, 12, 18, and 24 h. The presence of postoperative nausea and vomiting (PONV), pruritus and respiratory depression were recorded.

RESULTS

The total dose of diclofenac (P < 0.05), visual analog scale pain score at 6-h intervals (P < 0.001), and the incidence of PONV (P < 0.05) were significantly lower in the dexamethasone group.

CONCLUSIONS

Administration of IV dexamethasone prior to intrathecal meperidine injection enhances analgesia and reduces PONV.

The role of intrathecal drugs in the treatment of acute pain

Intrathecal opioids are widely used as useful adjuncts in the treatment of acute and chronic pain, and a number of non-opioid drugs show promise as analgesic drugs with spinal selectivity. In this review we examine the historical development and current use of intrathecal opioids and other drugs that show promise for treating pain in the perioperative period. The pharmacology and clinical use of intrathecal morphine and other opioids is reviewed in detail, including dosing guidelines for specific surgical procedures and the incidence and treatment of side effects associated with these drugs. Available data on the use of non-opioid drugs that have been tested intrathecally for use as analgesics are also reviewed. Evidence-based guidelines for dosing of intrathecal drugs for specific surgical procedures and for the treatment of the most common side effects associated with these drugs are presented.

Continuous Intrathecal Meperidine for Severe Refractory Cancer Pain

The control of severe cancer pain may be problematic despite advances in pain management. Patients with severe intractable pain and/or intractable side effects may require aggressive interventional pain management strategies including the administration of medications by the continuous intrathecal route and/or neurosurgical procedures. Various medications, including opioids, local anesthetics, and alpha-2 agonists may be used intrathecally for the control of cancer pain. Failure of the intrathecal route may require the additional use of neurosurgical procedures such as cordotomy for pain control. We describe a case of severe cancer pain refractory to conventional intrathecal medications and cordotomy that was successfully managed by the addition of meperidine to the intrathecal regimen.

Intrathecal opioids for combined spinal-epidural analgesia during labour

In <25 years, intrathecal administration of opioids (i.e. spinal analgesia) has evolved from an experimental model into an important therapy for obstetric analgesia and anaesthesia. A small dose of opioid delivered into the CSF provides almost immediate relief from labour pain with minimal risks to the mother and fetus. Careful attention, and prompt treatment when needed, can ameliorate the adverse effects of fetal bradycardia, respiratory depression and pruritus. The major limitation of intrathecal opioids for labour analgesia is the short duration of effect: 90-180 minutes under ideal circumstances. To address this problem, and to increase flexibility for anaesthesia as well as analgesia, the combined spinal-epidural (CSE) technique was developed. The CSE technique involves injection of drugs into the CSF and placement of an epidural catheter. An intrathecally administered opioid provides a rapid onset of labour analgesia without motor block or significant haemodynamic perturbation. The epidural catheter allows ongoing administration of medications to maintain labour analgesia and provides a means of delivering anaesthesia for operative delivery. This review will focus on intrathecally administered opioids as used as part of CSE analgesia. Considerable research has focused on the optimum dose of opioids when delivered intrathecally, with or without adjuncts, in the CSE technique. Fentanyl and sufentanil, two of the lipophilic synthetic opioids, have emerged as the most useful. Bupivacaine, a long-acting local anaesthetic, is often added to prolong the duration of analgesia, although this tends to increase the likelihood of motor blockade of the lower extremities. Comparisons of the CSE technique with standard epidural practices have shown that both are effective means of providing analgesia during labour. Controversy revolves around the incidence of fetal bradycardia following CSE and whether this phenomenon increases the rate of operative deliveries. The rapid onset of analgesia with intrathecally administered opioids must be balanced against the added risks of dural puncture and considered in the context of the whole duration of labour. Ultimately, the decision to choose a CSE technique depends on the experience of the anaesthesia provider and the local availability of drugs, equipment and monitoring capabilities.

Validation of oxygen saturation measurements in a canine model of hemoglobin-based oxygen carrier infusion

This study was designed to validate oxygen saturation measurements from the NOVA CO-Oximeter (NOVA Biomedical Corporation, Waltham, MA), the i-STAT System (Sensor Devices, Waukesha, WI), and the Corning 170 blood gas analyzer (Bayer Corporation, East Walpole, MA) under conditions similar to the clinical application of a hemoglobin-based oxygen carrier (HBOC, hemoglobin glutamer-200 [bovine]; Oxyglobin, Biopure Corporation, Cambridge, MA). A canine model was used for both in vitro and in vivo experiments. In vivo experiments were conducted in a canine laboratory, and in vitro experiments were conducted in a tonometry laboratory. Study subjects were six mixed-breed dogs, each weighing approximately 30 kg. In the first set of experiments, the target blood po(2) levels were reached by tonometry. In the second set of experiments, quantitative measurements of total oxygen content with the LEXO2CON-K (HOSPEX Fiberoptics, Chestnut Hill, MA) were performed, immediately followed by measurements with the NOVA CO-Oximeter and the i-STAT system. HBOC was added in concentrations of 16.2, 32.5, 65, and 97.5 g/L. To analyze the clinical significance of the differences in the results obtained with the each investigated instrument, blood samples from dogs treated with HBOC after acute hemorrhagic shock were used. Oxygen saturation, oxygen content, and po(2) were measured. There was a strong correlation between the oxygen saturation values measured with the investigated instruments in samples after tonometry and known po(2). The total calculated oxygen content varied by 5% based on results generated by calculations using the investigated instruments. The results did not change with different oxygenation of the sample. The differences among methods were not significant when the HBOC concentration was 16.2 g/L. Higher concentrations of HBOC increased the difference between calculated and measured oxygen content; the i-STAT system demonstrated a greater deviation compared with the results of the other two instruments. Systemic oxygen uptake using the investigated instruments showed a high correlation with values based on LEXO2CON-K measurements (R = 0.97 for CO-Oximeter, R = 0.96 for Corning 170 blood gas analyzer, and R = 0.79 for i-STAT system). Systemic oxygen uptake values based on CO-Oximeter and Corning 170 blood gas analyzer data showed 75% accuracy; i-STAT system accuracy was 63% for control samples and 50% for samples after HBOC infusion.

Intrathecal fentanyl/meperidine combined with low-dose epidural bupivacaine for Cesarean section in a patient with advanced Krukenberg tumors

This case report demonstrates the anesthetic management of a 41-year-old primiparous parturient with massive ascites due to advanced Krukenberg tumors, undergoing Cesarean section. We chose a combined intrathecal-epidural technique, using intrathecal hypobaric fentanyl and hyperbaric meperidine, and a low dose of epidural bupivacaine in order to avoid hemodynamic instability in this critically ill patient. Surgery was carried out without difficulty under adequate regional anesthesia. The blood pressure was maintained with low doses of phenylephrine and dopamine. Opioid-related complications such as nausea-vomiting, pruritus, drowsiness, and respiratory depression were not observed in this patient. Therefore, intrathecal opioids combined with a low dose of epidural local anesthetics for Cesarean section is suitable for critically ill patients with malignant abdominal tumors, such as a Krukenberg tumor, complicated by massive ascites.

Postoperative nausea and vomiting: comparison of the effect of postoperative meperidine or morphine in gynecologic surgery patients

STUDY OBJECTIVE

To evaluate the incidence and severity of postoperative nausea and vomiting in women receiving postoperative intravenous morphine or meperidine following gynecologic surgery.

DESIGN

Prospective, double-blind, randomized study.

SETTING

Tertiary-care academic medical center.

PATIENTS

200 ASA physical status I, II, and III patients scheduled for elective gynecologic surgery.

INTERVENTIONS

Patients received either postoperative IV morphine (n = 100) or meperidine (n = 100) following gynecologic surgery.

MEASUREMENTS

We compared pain scores, sedation scores, nausea scores, well-being scores, vomiting rate, and patient satisfaction in both groups 15, 30, 60, and 120 minutes after arrival in the postoperative anesthesia care unit.

MAIN RESULTS

The vomiting rate was 8/100 versus 7/100 (at 15 min), 4/100 versus 26/100 (at 30 min) (p < 0.05), 3/100 versus 23/100 (at 60 min) (p < 0.05), and 0/100 versus 0/100 (at 120 min) in the morphine or meperidine groups, respectively. The pain and sedation scores were similar in both groups. No major complications were noted in either group.

CONCLUSION

Our study demonstrates an advantage of the use of morphine rather than meperidine for pain control in the immediate postoperative period following gynecologic surgery.

Transient neurological symptoms after subarachnoid meperidine

IMPLICATIONS

The syndrome of transient neurological symptoms (TNS) after subarachnoid use of local anesthetics, particularly lidocaine, has been well described. This syndrome has not been reported with the subarachnoid use of opioids. This case report describes TNS that occurred after administration of subarachnoid meperidine, an opioid with local anesthetic properties.