A comparative study on the effects of intrathecal morphine added to levobupivacaine for spinal anesthesia

Hakki Unlugenc, MD; Murat Gunduz, MD; Baris Guzel, MD; Geylan Isik, MD

doi:10.5055/jom.2012.0103

Authors

Hakki Unlugenc, MD
Murat Gunduz, MD
Baris Guzel, MD
Geylan Isik, MD

DOI:

https://doi.org/10.5055/jom.2012.0103

Keywords:

combined spinal-epidural anesthesia, cesarean section, morphine, levobupivacaine

Abstract

Objective: In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor, and analgesic block characteristics of two different doses of morphine compared with saline when added to 0.5 percent levobupivacaine.
Design: Prospective, randomized, double-blinded, controlled study.
Setting: University hospital.
Patients, Participants, Interventions: One hundred and twelve ASA I or II adult patients undergoing cesarean section with combined-spinal epidural anesthesia (CSEA) were randomly allocated to receive 0.5 mL of 0.9 percent sodium chloride in group S, 0.1 mg of morphine in group M1, or 0.2 mg of morphine in group M2 following 15 mg of isobaric spinal levobupivacaine 0.5 percent (3 mL).
Main Outcome Measure(s): We recorded the following: onset and duration of sensory and motor block, duration of spinal anesthesia, time to first request for analgesia, and side effects.
Results: The onset time of sensory block was significantly less in group M2 (3.5 ± 3 minutes) than S (4 ± 3 minutes; p < 0.003). Parturients given morphine had a significantly greater duration of analgesia (554 ± 350 minutes in group M1 and 879 ± 725 minutes in group M2) than the saline group (80 ± 70 minutes; p < 0.001). Similarly, the time to first request for analgesia was longer in groups M1 (582 ± 470 minutes) and M2 (917 ± 709 minutes) than in group S (92 ± 77 minutes; p < 0.001).
Conclusion: In patients undergoing cesarean delivery with CSEA, adding intrathecal morphine (0.1 and 0.2 mg) to 15 mg of spinal levobupivacaine prolonged the duration of spinal analgesia and provided rapid onset of action and longer time to first analgesic request without causing any significant side effect compared to saline.

Author Biographies

Hakki Unlugenc, MD

Department of Anaesthesiology, Cukurova University Faculty of Medicine, Adana, Turkey.

Murat Gunduz, MD

Department of Anaesthesiology, Cukurova University Faculty of Medicine, Adana, Turkey.

Baris Guzel, MD

Department of Obstetric & Gynecology, Cukurova University Faculty of Medicine, Adana, Turkey.

Geylan Isik, MD

Department of Anaesthesiology, Cukurova University Faculty of Medicine, Adana, Turkey.

References

Abouleish E, Rawal N, Fallon K, et al.: Combined intrathecal morphine and bupivacaine for cesarean section. Anesth Analg. 1988; 67: 370-374.

Dahl JB, Jeppesen IS, Jorgessen H, et al.: Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioid in patients undergoing cesarean section with spinal anaesthesia. Anesthesiology. 1999; 91: 1919-1927.

Karaman S, Kocabas S, Uyar M, et al.: The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for caesarean section. Eur J Anaesthesiol. 2006; 23: 285-291.

Berti M, Casati A, Fanelli G, et al.: 0.2% ropivacaine with or without fentanyl for patient-controlled epidural analgesia after major abdominal surgery: a double-blind study. J Clin Anesth. 2000; 12: 292-297.

Crews JC, Hord AH, Denson DD, et al.: A comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0.005% morphine alone for the management of postoperative pain in patients undergoing major abdominal surgery. Anesth Analg. 1999; 89: 1504-1509.

Yeh HM, Chen LK, Shyu MK, et al.: The addition of morphine prolongs fentanyl-bupivacaine spinal analgesia for the relief of labor pain. Anesth Analg. 2001; 92: 665-668.

Buttner J, Klose R. Alkalinization of mepivacaine for axillary plexus anaesthesia using a catheter. Reg Anaesth. 1991; 14: 17-24.

Camorcia M, Capogna G: Sensory assessment of epidural block for caesarean section: a systematic comparison of pinprick, cold and touch sensation. Eur J Anaesthesiol. 2006; 23: 611-617.

Ogun CO, Kirgiz EN, Duman A, et al.: Comparison of intrathecal isobaric bupivacaine-morphine and ropivacaine-morphine for caesarean delivery. Br J Anaesth. 2003; 90: 659-664.

Milner AR, Bogod DG, Harwood RJ: Intrathecal administration of morphine for elective caesarean section. A comparison between 0.1 mg and 0.2 mg. Anaesthesia. 1996; 51: 871-873.

Girgin NK, Gurbet A, Turker G, et al.: Intrathecal morphine in anaesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine. J Clin Anaesth. 2008; 20: 180-185.

Glaser C, Marhofer P, Zimpfer G, et al.: Levobupivacaine versus racemic bupivacaine for spinal anaesthesia. Anesth Analg. 2002; 94: 194-198.

Sell A, Olkkola KT, Jalonen J, et al.: Minimum effective local anaesthetic dose of isobaric levobupivacaine and ropivacaine administered via a spinal catheter for hip replacement surgery. Br J Anaesth. 2005; 94: 239-242.

Burke D, Kennedy S, Bannister J: Spinal anaesthesia with 0.5% S(-)-bupivacaine for elective lower limb surgery. Reg Anaesth Pain Med. 1999; 24: 519-523.

Uchiyama A, Ueyama H, Nakano S, et al.: Low dose intrathecal morphine and pain relief following caesarean section. Int J Obstet Anesth. 1994; 3: 87-91.

Morgan GE, Mikhail MS, Murray MJ: Local Anesthetics. Clinical Anesthesiology. The McGraw-Hill Companies, Inc, 2002: 233-240.

Ummenhofer WC, Arends RH, Shen DD, et al.: Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Anesthesiology. 2000; 92: 739-753.

Gehling M, Luesebrink T, Kulka P, et al.: The effective duration of analgesia after intrathecal morphine in patients without additional opioid analgesia: a randomized double-blind multicentre study on orthopaedic patients. Eur J Anaesthesiol. 2009; 26: 683-688.

Dualé C, Frey C, Bolandard F, et al.: Epidural versus intrathecal morphine for postoperative analgesia after caesarean section. Br J Anaesth. 2003; 91: 690-694.

Abboud TK, Dror A, Mosaad P, et al.: Mini-dose intrathecal morphine for the relief of post-cesarean section pain: safety, efficacy, and ventilatory responses to carbon dioxide. Anesth Analg. 1988; 67: 137-143.

Uchiyama A, Nakano S, Ueyama H, et al.: Low dose intrathecal morphine and pain relief following caesarean section. Int J Obstet Anesth. 1994; 3: 87-91.

Nortcliffe SA, Shah J, Buggy DJ: Prevention of postoperative nausea and vomiting after spinal morphine for caesarean section: comparison of cyclizine, dexamethasone and placebo. Br J Anaesth. 2003; 90: 665-670.

Palmer CM, Emerson S, Volgoropolous D, et al.: Doseresponse relationship of intrathecal morphine for postcesarean analgesia. Anesthesiology. 1999; 90: 437-444.