Intrathecal clonidine as an adjuvant for neuraxial anaesthesia during caesarean delivery: a systematic review and meta-analysis of randomised trials

Crespo, S; Dangelser, Gaétan; Haller, Guy

doi:10.1016/j.ijoa.2017.06.009

Cited by 25 publications

(17 citation statements)

References 39 publications

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“…Meta-analyses show neuraxial clonidine prolongs motor and sensory blockade, reduces 24-hour opioid consumption, and prolongs time to first analgesic request after cesarean delivery compared to control patients, but whether these effects hold true in OUD patients has not been studied. 21,22 Clonidine may be particularly beneficial in patients with OUD as it is a non-opioid analgesic. Clonidine's analgesia is multifactorial, it works in part via stimulation of post-synaptic α 2 -adrenergic receptors in the spinal cord at the dorsal horn and substantia gelatinosa, and by reducing afferent norepinephrine-mediated transmission of painful stimuli.…”

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confidence: 99%

“…Clonidine's analgesia is multifactorial, it works in part via stimulation of post-synaptic α 2 -adrenergic receptors in the spinal cord at the dorsal horn and substantia gelatinosa, and by reducing afferent norepinephrine-mediated transmission of painful stimuli. [21][22][23] Care of OUD parturients has several overlapping features with enhanced recovery after cesarean (ERAC). Both ERAC and OUD deliveries highlight a multi-modal, multitiered, and multi-disciplinary analgesic strategy.…”

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confidence: 99%

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Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation

Reno

Kushelev

Coffman

et al. 2020

JPR

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Background: Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD). Methods: Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery. Results: A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 µg) and morphine (median 100 µg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 µg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p<0.001) compared to neuraxial anesthesia. Conclusion:Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.

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confidence: 99%

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confidence: 99%

Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation

Reno

Kushelev

Coffman

et al. 2020

JPR

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“…Crespo et al suggested that intrathecal clonidine is a safe adjuvant to neuraxial anesthesia in prolonging sensory block and motor block without increasing hypotension, pruritus, or PONV. Other drugs, including ketamine and steroids, have been used with mixed results [24]. However, these regimens require further research in regards to the safety profile.…”

Section: Discussionmentioning

confidence: 99%

Analgesic Effect of Intrathecal Morphine Combined with Low-Dose Bupivacaine on Postoperative Analgesia after Liver Resection: A Randomized Controlled Study

Ban

Choi

Koo

2022

JPM

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Although intrathecal morphine and bupivacaine are increasingly implemented in effective postoperative pain control, there is a lack of consensus on the dosage as high doses of bupivacaine may inadvertently cause unwanted side effects. The purpose of this study was to compare the effects of intrathecal morphine injection and low-dose bupivacaine with morphine injection. In total, 90 patients were divided into 3 groups: (1) sham injection for the control group; (2) morphine 400 mcg for the morphine group (M); and (3) morphine 400 mcg and bupivacaine 5 mg for the morphine and bupivacaine group (M + B). Our primary outcome was time to first rescue analgesic. The VAS (visual analogue scale) pain score was compared until POD (postoperative day)1. Total fentanyl dose was compared until POD2. Side effects were monitored until POD3. Although time to first rescue was significantly shorter in the control group compared to group M and group M + B (p < 0.001), both groups (M and M + B) were comparable to each other. There was a significant decrease in the VAS score and total fentanyl administration in group M and group M + B compared to the control group. Pruritus and tingling were more prevalent in the M + B group (p = 0.023; p = 0.010). The addition of 5 mg bupivacaine may be insufficient in providing further analgesic benefits; however, higher doses may aggravate side effects.

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“…The use of neuraxial clonidine has demonstrated prolonged sensory and motor blockade, reduced 24-hour opioid consumption, and longer time to first analgesic request after cesarean delivery compared to control patients not receiving clonidine. 16 , 17 However, the effects of intrathecal (IT) clonidine have not been specifically studied in obstetric patients with OUD. Neuraxial clonidine may be of particular benefit in patients with OUD given that it is a non-opioid medication and these patients can be resistant to the effects of opioids.…”

Section: Introductionmentioning

confidence: 99%

“… 4 , 14 Clonidine also has analgesic properties, working in part by stimulating post-synaptic alpha 2 adrenergic receptors in the dorsal horn of the spinal cord and reducing afferent transmission of painful stimuli. 16–18 Given the potential analgesic benefits of IT clonidine coupled with the lack of published material on the use of this medication in obstetric patients with OUD, we were compelled to complete a retrospective investigation among patients that delivered at our institution. In this retrospective study we sought to compare OUD patients undergoing cesarean delivery that received IT clonidine to a control group that did not receive IT clonidine and observe potential differences in analgesic outcomes (24-hour opioid requirements, pain scores, time to first post-operative pain medication, IV patient-controlled analgesia (PCA) use and regional nerve blocks) or side-effects (hypotension, vasopressor dosing and bradycardia).…”

Section: Introductionmentioning

confidence: 99%

Analgesic Outcomes in Opioid Use Disorder Patients Receiving Spinal Anesthesia with or without Intrathecal Clonidine for Cesarean Delivery: A Retrospective Investigation

Cook¹,

Kushelev²,

Coffman³

et al. 2022

JPR

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Background Intrathecal (IT) clonidine has been observed to reduce 24-hour opioid requirements and time to first analgesic request after cesarean delivery, but has not been specifically studied in patients with opioid use disorder (OUD). Methods Patients with OUD undergoing cesarean delivery under spinal or combined spinal-epidural (CSE) anesthesia at our institution from 2011 to 2020 were identified, and only patients with OUD were included in this study. Subjects that received IT clonidine were compared to a control group that did not receive IT clonidine to observe potential differences in analgesic outcomes (24-hour opioid requirements, pain scores and time to first post-operative pain medication) or side-effects (hypotension, vasopressor dosing and bradycardia). Results A total of 160 patients were included (clonidine n = 22, controls n = 138). For the clonidine group, the median IT clonidine dose was 30µg. Clonidine group patients were observed to have greater dose of IT bupivacaine (12 vs 12.75mg; p = 0.01) and IT morphine (100 vs 200µg; p < 0.001). The clonidine group was also observed to have greater incidence of intraoperative hypotension (20% vs 45%; p = 0.01) and maximum phenylephrine dose (50 vs 57.5 µg/min; p < 0.001). The time to first analgesic request (minutes) after surgery was significantly longer for the clonidine group (153.5 vs 207 min; p < 0.001). The average oral oxycodone equivalents taken per 24 hours of hospital admission were significantly less in the clonidine group (82.36 vs 41.67mg; p < 0.001), and the clonidine group also had significantly less oxycodone equivalents taken for each post-operative day. Conclusion IT clonidine was observed to result in reduced 24-hour opioid consumption in patients with OUD and may be useful as part of a multimodal analgesic regimen. The incidence of hypotension and vasopressor doses were greater in patients receiving IT clonidine, and this should be anticipated if IT clonidine is being administered.

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Intrathecal clonidine as an adjuvant for neuraxial anaesthesia during caesarean delivery: a systematic review and meta-analysis of randomised trials

Cited by 25 publications

References 39 publications

Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation

Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation

Analgesic Effect of Intrathecal Morphine Combined with Low-Dose Bupivacaine on Postoperative Analgesia after Liver Resection: A Randomized Controlled Study

Analgesic Outcomes in Opioid Use Disorder Patients Receiving Spinal Anesthesia with or without Intrathecal Clonidine for Cesarean Delivery: A Retrospective Investigation

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