Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials

Seki, Hiroyuki; Shiga, Toshiya; Mihara, Takahiro; Hoshijima, Hiroshi; Hosokawa, Yuki; Hyuga, Shunsuke; Fujita, Tomoe; Koshika, Kyotaro; Okada, Reina; Kurose, Hitomi; Ideno, Satoshi; Ouchi, Takashi

doi:10.1007/s00540-021-02980-2

Cited by 18 publications

(27 citation statements)

References 80 publications

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“…The Journal of Anesthesia has recently published several NMAs [ 32 – 36 ]. We illustrate the interpretation of NMA results through published studies in the journal.…”

Section: Illustration Of Interpretation Of Nma Results Through a Rece...mentioning

confidence: 99%

Interpreting and assessing confidence in network meta-analysis results: an introduction for clinicians

2022

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Purpose We aimed to provide clinicians with introductory guidance for interpreting and assessing confidence in on Network meta-analysis (NMA) results. Methods We reviewed current literature on NMA and summarized key points. Results Network meta-analysis (NMA) is a statistical method for comparing the efficacy of three or more interventions simultaneously in a single analysis by synthesizing both direct and indirect evidence across a network of randomized clinical trials. It has become increasingly popular in healthcare, since direct evidence (head-to-head randomized clinical trials) are not always available. NMA methods are categorized as either Bayesian or frequentist, and while the two mostly provide similar results, the two approaches are theoretically different and require different interpretations of the results. Conclusions We recommend a careful approach to interpreting NMA results and the validity of an NMA depends on its underlying statistical assumptions and the quality of the evidence used in the NMA.

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“…The Journal of Anesthesia has recently published several NMAs [ 32 – 36 ]. We illustrate the interpretation of NMA results through published studies in the journal.…”

Section: Illustration Of Interpretation Of Nma Results Through a Rece...mentioning

confidence: 99%

Interpreting and assessing confidence in network meta-analysis results: an introduction for clinicians

2022

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“…However, these intrathecal, additive drugs have a short duration as well as inferior analgesic effects compared to ITM. 23 In addition, those drugs added to spinal bupivacaine also produce neuraxial opioid-induced pruritus and PONV, which does not differ from ITM. 23 Hence, morphine is recommended, rather than short-acting opioids, to be added to spinal bupivacaine for providing postoperative analgesia after Cesarean section.…”

Section: Discussionmentioning

confidence: 99%

“…23 In addition, those drugs added to spinal bupivacaine also produce neuraxial opioid-induced pruritus and PONV, which does not differ from ITM. 23 Hence, morphine is recommended, rather than short-acting opioids, to be added to spinal bupivacaine for providing postoperative analgesia after Cesarean section. Although, the quadratus lumborum block might be a technique to replace, and avoid ITM-induced side effects in Cesarean delivery, evidence showed that it did not have additive analgesic effects when combined with ITM; additionally, it was inferior to ITM when used alone in patients undergoing Cesarean section [24][25] Although, we could not eliminate intrathecal morphine-induced side effects to zero, we could reduce them as much as possible by reducing the dose of ITM.…”

Section: Discussionmentioning

confidence: 99%

Different Doses of Intrathecal Morphine on Postoperative Analgesia and Pruritus after Cesarean Section: a Prospective Randomized Triple-Blinded Trial

et al. 2022

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Objective: Intrathecal morphine (ITM) is an effective postoperative analgesia provided after Cesarean section. However, pruritus is an undesirable side effect that disrupts maternal breast feeding. This study aimed to evaluate the effects of three different doses of ITM added to spinal bupivacaine on postoperative analgesia and opioid-related side effects in Cesarean section. Material and Methods: This prospective randomized, triple-blinded trial was conducted in 321 patients undergoing Cesarean section. They were allocated to receive either; one intervention group; intrathecal morphine 50 mcg (IT50 group, N=98), 100 mcg (IT100 group, N=100), or 200 mcg (IT200 group, N=101), added to spinal bupivacaine for Cesarean section. The primary outcome was the incidence of pruritus in the recovery room, and then every 4 hours for 24 hours. The secondary outcomes were the pain scores at rest and during activities, time to the first analgesia, 24 hours of morphine consumption and the incidence of postoperative nausea and vomiting (PONV). Results: Patient characteristics between the three groups were comparable. Both of the IT50 and IT100 groups had a lower incidence of pruritus, when compared with the IT200 group at all-time points, with the exception of at 24 hours; wherein, there were no differences between the three groups. Pain scores during activities were not different between the three groups. However, at rest the IT50 group had a higher pain score than those in the IT100 and IT200 groups; at 4, 8, and 16 hours. Time to the first analgesic requirement was shorter in the IT50 group (2 hours) than in the IT100 (2.4 hours) and IT200 (2.6 hours) groups (p-value=0.03). Moreover, the median [IQR] of morphine consumption in 24 hours was higher in the IT50 group [17 mg (9, 29.8)] than those in the IT100 [13 mg (5, 23.2)] and IT200 [12 mg (4, 17)] groups (p-value<0.001). However, the incidence of PONV was lower in the IT50 group compared to other groups. Conclusion: This study demonstrates that reducing the dose of ITM to 100 mcg added to spinal bupivacaine is effective to maintain postoperative analgesic effects. Additionally, it reduces the incidence of postoperative pruritus compared to ITM at 200 mcg.

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“…Seki et al [15] in 66 RCTs comprising 4400 patients undergoing caesarean section, compared with placebo, IT opioids (fentanyl, sufentanil and morphine) significantly prolonged the analgesia duration by 96, 96 and 190 minutes, respectively (mean difference). Although morphine ranked first, the efficacy of opioids was similar.…”

Section: Neuraxial Analgesiamentioning

confidence: 99%

Perioperative Analgesia in Caesarean Section: What’s New?

Saucillo-Osuna¹,

Wilson-Manríquez²,

López-Hernández³

et al. 2023

Topics in Postoperative Pain

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Caesarean section is associated with moderate to severe postoperative pain during the first 24 hours after surgery. Inadequate pain management can influence recovery, maternal psychological well-being and breastfeeding. In the search of alternatives to minimize the use of systemic opioids, new recommendations have been made to implement protocols to improve recovery after caesarean section, with multimodal analgesia, new suggestions for neuraxial techniques, regional analgesia with ultrasound-guided fascial plane blocks and non-pharmacological approaches. Some of the interventions, such as epidural or spinal blocks, although effective, carry a significant risk of complications (for example post-puncture headache). In their place, newer alternatives such as interventions guided by ultrasound are safe and effective for relieving pain in this common clinical context. The goal of this chapter is to provide clinicians with up-to-date evidence for optimal pain management after elective caesarean section.

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Effects of intrathecal opioids on cesarean section: a systematic review and Bayesian network meta-analysis of randomized controlled trials

Cited by 18 publications

References 80 publications

Interpreting and assessing confidence in network meta-analysis results: an introduction for clinicians

Interpreting and assessing confidence in network meta-analysis results: an introduction for clinicians

Different Doses of Intrathecal Morphine on Postoperative Analgesia and Pruritus after Cesarean Section: a Prospective Randomized Triple-Blinded Trial

Perioperative Analgesia in Caesarean Section: What’s New?

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