Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia

Hess, Philip E.; Snowman, C.E.; Hahn, Caroline J.; Kunze, Lisa; Ingold, Venesa J.; Pratt, Stephen D.

doi:10.1016/j.jclinane.2005.05.003

Cited by 16 publications

(8 citation statements)

References 18 publications

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“…One parameter that varies from one study to another was the nature of local anaesthetic. Local anaesthetic solutions may change the quality and duration of the block during surgery, but do not seem to play a significant role in postoperative analgesia (Hess et al, 2006). To limit clinical heterogeneity between the selected trials for the current meta‐analysis, one study including CS in emergency was not taken into account.…”

Section: Discussionmentioning

confidence: 99%

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

Bonnet

Mignon

Mazoit

et al. 2010

European Journal of Pain

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Section: Discussionmentioning

confidence: 99%

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

Bonnet

Mignon

Mazoit

et al. 2010

European Journal of Pain

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“…Hess suggested that these medications may potentially be masking any CP antagonism; however, if supplemental acetaminophen and nonsteroidal anti-inflammatory drugs were effective in doing so, any antagonism of epidural morphine is of less clinical significance. 9 Studies investigating pain can be challenging due to wide interindividual variations in pain perception and tolerance. Our primary end point was total opioid consumption for the first 24 hours after epidural morphine administration; however, opioid use does not necessarily reflect pain intensity and can be affected by multiple factors.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, we used the typical size in previous studies that also investigated CP in the setting of cesarean delivery. 9 Our study was designed to be exploratory, and the new findings should be used to design larger confirmatory studies to further elucidate this topic.…”

Section: Discussionmentioning

confidence: 99%

“…The belief that epidural CP before epidural morphine results in decreased analgesic efficacy of epidural morphine is controversial and may be secondary to a window period between the regression of surgical anesthesia and the peak analgesic effect of epidural morphine. 9 Previous investigations have not been conducted with study designs utilizing CP as the primary anesthetic for cesarean delivery and have not suggested solutions to mitigate the window period.…”

mentioning

confidence: 99%

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Postcesarean Analgesia With Epidural Morphine After Epidural 2-Chloroprocaine: A Randomized Noninferiority Trial

Lee¹,

Ramirez-Chapman²,

White³

et al. 2022

Anesthesia &Amp; Analgesia

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BACKGROUND: Previous studies have suggested that administration of epidural 3% 2-chloroprocaine (CP) before epidural morphine results in decreased analgesic efficacy of epidural morphine. We sought to determine whether these observations were a result of antagonism or a window period between the conclusion of surgical anesthesia for cesarean delivery and the peak onset time of epidural morphine, and whether a method to preserve the analgesic efficacy of epidural morphine exists. METHODS: Term parturients scheduled for nonemergent, unscheduled cesarean delivery with preexisting labor epidural catheters were recruited for this exploratory, randomized, single-blinded, noninferiority trial. Subjects were randomized to initial dosing to a T4 dermatome surgical anesthetic level with either 3% CP or 2% lidocaine with 1:200,000 epinephrine and sodium bicarbonate (LEB). Subsequent redosing for both groups was performed with LEB at regular intervals. Epidural morphine 3 mg was administered to both groups after delivery. Assessing the difference between the 2 groups in total opioid use for the first 24 hours after epidural morphine administration was the primary objective. The noninferiority margin of 10 oral milligram morphine equivalents was prespecified based on previous noninferiority studies. Secondary end points included time from epidural morphine administration to first rescue opioid request, numerical pain scores, nausea/vomiting, and pruritus. RESULTS: Data were analyzed for 40 parturients, 20 in each group. The median 24-hour opioid consumption for the CP group was 0 (Q 1 = 0 and Q 3 = 15.6) oral milligram morphine equivalents compared to 15 (6.3-22.5) for the LEB group. The median difference was −7.5, with a 95% confidence interval −15 to 0. Noninferiority was concluded, as the confidence interval was less than the predetermined noninferiority margin of 10 oral milligram morphine equivalents. There was no treatment effect on time to first opioid request and no statistically significant differences in pain scores or nausea, vomiting, or pruritus at all time points (4, 8, 12, and 24 hours after epidural morphine administration). CONCLUSION: While designed as an exploratory study, initial epidural dosing with 3% CP and beginning subsequent redosing with LEB within 30 minutes of the initial CP bolus provided noninferior postcesarean analgesia with epidural morphine compared to initial epidural dosing and redosing with LEB. Previous observations of decreased analgesic efficacy of epidural morphine after epidural CP were likely due to a window period that may be mitigated by redosing with lidocaine; however, larger studies are necessary to confirm these findings.

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“…Caesarean Pain: Oral morphine was better than intravenous morphine PCA in controlling pain after cesarean delivery (264). Chloroprocaine failed to affect epidural morphine for post cesarean delivery analgesia (468). Droperidol, allzapride and propofol, but not promethazine had prophylactic effects on spinal morphine-induced pruritus following caesarean section (480).…”

Section: Surgical Painmentioning

confidence: 99%

Endogenous opiates and behavior: 2009

Bodnar

2010

Peptides

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Chloroprocaine may not affect epidural morphine for postcesarean delivery analgesia

Cited by 16 publications

References 18 publications

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

Analgesic efficacy and adverse effects of epidural morphine compared to parenteral opioids after elective caesarean section: A systematic review

Postcesarean Analgesia With Epidural Morphine After Epidural 2-Chloroprocaine: A Randomized Noninferiority Trial

Endogenous opiates and behavior: 2009

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