Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study

Marroquin, Bridget M.; Feng, Changyong; Balofsky, A.; Edwards, Katherine M.; Iqbal, Asif; Kanel, Jeffrey S.; Jackson, Meghan Drayton; Newton, Micah; Rothstein, David H.; Wong, Elissa L.; Wissler, Richard N.

doi:10.1016/j.ijoa.2016.12.008

Cited by 22 publications

(21 citation statements)

References 12 publications

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“…Shulman et al reported pruritus in one of the 21 patients who received single bolus of epidural hydromorphone (1.25–1.5 mg) [20]. Marroquin et al found that pruritus occurred in 25% patients while adding 0.6 mg hydromorphone to epidural space [15]. In our present study, the occurrence of pruritus was low in all groups.…”

Section: Discussionsupporting

confidence: 47%

“…To limit major and minor opioid side effects, the use of low-dose epidural opioids has been advocated. In a recent study, Marroquin et al found that epidural injection of 0.6 mg hydromorphone provided good postoperative analgesia and only 25% of patients requested antipruritic medication [15]. In Chestnut's research, using epidural hydromorphone 1 mg, the rate of pruritus was up to 58% [16].…”

Section: Discussionmentioning

confidence: 99%

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Postoperative Analgesic Effects of Different Doses of Epidural Hydromorphone Coadministered with Ropivacaine after Cesarean Section: A Randomized Controlled Trial

Yang

Wang

Chen

et al. 2019

Pain Research and Management

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Purpose. Single dose of epidural hydromorphone has been introduced to serve as an alternative method for postcesarean section analgesia. However, optimal dose of epidural hydromorphone remains unknown. Hence, we evaluated and compared the analgesic and adverse effects of postoperative different doses of epidural hydromorphone coadministered with ropivacaine after cesarean section. Methods. Eighty term parturients with elective cesarean section under epidural anesthesia were allocated into four groups. Epidural analgesia was administered with an epidural bolus of either 0 mg (group H0), or 0.2 mg (group H1), or 0.4 mg (group H2), or 0.6 mg (group H3) hydromorphone coadministered with ropivacaine. The primary outcome was the visual analogue pain scores (VAPSs) and rescue opioid consumption (PCIA with sulfentanil) in 24 hours. Adverse effects such as respiratory depression, pruritus, nausea, and vomiting were recorded. Results. The VAPSs of group H1 at 2, 4, 6, 12 h and 24 h after surgery was similar to group H0. The VAPSs of group H2 at 4 and 6 h postoperatively were significantly decreased when compared to group H0. But, the VAPSs of group H2 at 2, 12, and 24 h postoperatively were similar to those of group H0. The VAPSs of group H3 at 4, 6, 12 h, and 24 h after surgery were significantly decreased when compared to those of group H0. The total sulfentanil consumption in 24 hours was 90 ± 26 μg in group H0, 75 ± 29 μg in group H1, 54 ± 32 μg in group H2, and 15 ± 16 μg in group H0. Adverse effects were comparable in the four groups. Conclusions. Epidural administration of 0.6 mg hydromorphone coadministered with ropivacaine after cesarean section provided satisfactory pain relief with less sulfentanil consumption. This trial is registered with ChiCTR-IPR-16010026.

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Section: Discussionsupporting

confidence: 47%

Section: Discussionmentioning

confidence: 99%

Postoperative Analgesic Effects of Different Doses of Epidural Hydromorphone Coadministered with Ropivacaine after Cesarean Section: A Randomized Controlled Trial

Yang

Wang

Chen

et al. 2019

Pain Research and Management

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“…This was because the low-dose epidural morphine was still working during that period, thus relieving pain more effectively in the epidural morphine group. Studies showed that the duration of a single low-dose epidural morphine may last for more than 20 hours [17,18]. From 24 to 36 hours after surgery, more patients suffered from moderate to severe pain than before and bolus injections were required frequently.…”

Section: Discussionmentioning

confidence: 99%

“…Low-dose epidural morphine is commonly used for analgesia after cesarean section. The effect of single dose morphine lasts more than 20 hours, with low incidences of itching, nausea, vomiting, and respiratory depression [17,18]. We hypothesized that, for patients undergoing TKA, combined use of low-dose epidural morphine and single-injection femoral nerve block could improve the effect of postoperative analgesia, reduce the consumption of intravenous opioids and decrease opioid-associated side effects.…”

Section: Introductionmentioning

confidence: 99%

Epidural morphine improves postoperative analgesia in patients after total knee arthroplasty: A randomized controlled trial

Meng¹,

Cui²,

Li³

et al. 2019

PLoS ONE

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Background Patients after total knee arthroplasty (TKA) often develop moderate to severe pain. This study compared the analgesic effect of low-dose epidural morphine vs. a comparable saline injection in patients following TKA surgery. Methods This randomized, double-blinded, and placebo-controlled trial was conducted in a tertiary hospital in Beijing between July 1, 2017 and May 30, 2018. One hundred and ten patients following TKA under combined spinal-epidural anesthesia were randomized to receive either epidural morphine (2 mg diluted to 5 ml normal saline, the epidural morphine group) or placebo (5 ml normal saline, the placebo group). For all patients, single-injection femoral nerve block was performed, and a supplementary patient-controlled intravenous analgesia pump was provided. The severity of pain was assessed with the numerical rating scale (NRS, an 11-point scale where 0 = no pain and 10 = the worst pain) at 6, 12, 24, 36, and 48 hours after surgery. The primary endpoint was moderate to severe pain (NRS pain score ≥4) within 48 hours after surgery. Results The percentage with moderate to severe pain within 48 hours was lower in the epidural morphine group than in the placebo group (58.2% [32/55] with epidural morphine vs. 76.4% [42/55] with placebo; OR 0.43, 95% CI 0.19–0.98; p = 0.042). Furthermore, the cumulative morphine consumption within 48 hours was lower (18.4±6.1 mg vs. 22.4±7.3 mg; p = 0.002) whereas the mental component summary score of 30-day quality of life was higher (63.8±2.9 vs. 61.9±4.2; p = 0.008) in the epidural morphine group than in the placebo group. Conclusions For patients following TKA, the addition of epidural morphine to single-injection femoral nerve block improves the quality of analgesia within 48 hours, without increasing adverse events. Trial registration ClinicalTrials.gov NCT03203967 .

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“…Neuraxial opioids in combination with local anesthetics are routinely used for analgesia during CD 27 . One limitation of our study is that we left the choice of neuraxial anesthetic agents to the discretion of the anesthesiologist; however, similar policies were in place at our institution prior to implementation of the MAP.…”

Section: Discussionmentioning

confidence: 99%

Opioid‐free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

Mehraban

Suddle

Mehraban

et al. 2020

J of Obstet and Gynaecol

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Aim To evaluate an opioid‐free multimodal analgesic pathway (MAP) to decrease opioid utilization after cesarean delivery (CD) compared to historic data of our institution prior to using MAP for pain management (pre‐MAP). Methods The MAP was implemented in three phases from September 2018 to August 2019. Patients received 1000 mg intravenous (IV) acetaminophen with 30 mg IV ketorolac at 0 (arrival time at recovery room), 6, 12 and 18 h of postoperative course. On the 2nd and the 3rd postoperative days, patients were monitored for pain every 6 h by Numeric Pain Intensity Scale (0 = no pain to 10 = severe pain) and administered 600 mg oral ibuprofen for a pain score between 0 and 4, 600 mg oral ibuprofen and/or 650 mg oral acetaminophen for a pain score between 5–6, 1000 mg IV acetaminophen and/or 30 mg of IV or intramuscular ketorolac for a pain score between 7 and 10. Five milligrams of oral oxycodone was reserved for rescue if all protocol options were exhausted. Patients were discharged with 600 mg oral ibuprofen without opioid prescription. Likert surveys measuring patient satisfaction of pain control were administered during phase 3. Results Inpatient and outpatient opioid consumption rates were significantly decreased from 45%, 18% to 23.8%, 8.5% after MAP implementation (P‐value <0.001). More than 90% of patients reported that their pain was well controlled and willing to request the same regimen for a future CD. Conclusion MAP Implementation after CD significantly reduced inpatient and outpatient opioid consumption compared to pre‐MAP results while maintaining high patients' satisfaction with pain control.

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Neuraxial opioids for post-cesarean delivery analgesia: can hydromorphone replace morphine? A retrospective study

Cited by 22 publications

References 12 publications

Postoperative Analgesic Effects of Different Doses of Epidural Hydromorphone Coadministered with Ropivacaine after Cesarean Section: A Randomized Controlled Trial

Postoperative Analgesic Effects of Different Doses of Epidural Hydromorphone Coadministered with Ropivacaine after Cesarean Section: A Randomized Controlled Trial

Epidural morphine improves postoperative analgesia in patients after total knee arthroplasty: A randomized controlled trial

Opioid‐free multimodal analgesia pathway to decrease opioid utilization after cesarean delivery

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