Comparison of Postoperative Analgesia Quality of Single Dose Spinal and Combined Spinal Epidural Anesthesia in Cesarean Deliveries

Öz

Objective: It is aimed to compare the analgesic effects of intrathecal morphine and epidural morphine, which are frequently used in cesarean delivery analgesia.
Materials and Methods: Patients were divided into single-dose spinal (SDS) and combined spinal epidural (CSE) anesthesia groups. While 10mg 0.5% hyperbaric bupivacaine, 10µg fentanyl, 100µg morphine were administered to SDS anesthesia group as standard, the aforementioned drugs without morphine were injected into the subarachnoid space in CSE group. The patients in CSE group, 3mg morphine in a volume of 10mL was administered through the epidural catheter at the 2nd and 24th hour. Visual analog scale (VAS) was used to calculate pain intensity.
Results: Total of 144 patients were included in the study. It was observed that 71 patients were applied SDS anesthesia and 73 patients were applied CSE anesthesia. In the comparison of VAS scores, significant difference was found in the scores at 2nd, 12th and 48th hours. While the 2nd hour VAS score was lower in SDS anesthesia group, 12th, 24th, and 48th hour VAS scores were lower in CSE anesthesia group. The highest difference was found in the 48th hour VAS scores.
Conclusion: Both treatments provided good analgesia. Especially after mobilization, application of epidural analgesia gives better results than intrathecal opioid use.

Anahtar Kelimeler

• Cesarean Delivery
• Combined spinal epidural anesthesia
• Morphine
• Spinal anesthesia

Sezaryen Doğumlarda Tek Doz Spinal ve Kombine Spinal Epidural Anestezinin Postoperatif Analjezi Kalitesinin Karşılaştırılması

Öz

Amaç: Sezaryen doğum analjezisinde sıkça kullanılan intratekal morfin ve epidural morfinin analjezik etkilerinin karşılaştırılması amaçlanmıştır.
Materyal ve Metot: Hastalar tek doz spinal (TDS) ve kombine spinal epidural (KSE) anestezi grubuna ayrıldı. TDS anestezide standart olarak 10 mg %0,5 hiperbarik bupivakain, 10 µg fentanyl, 100 µg morfin, KSE’de ise morfin eklenmeden subaraknoid aralığa enjekte edildi. KSE grubundaki hastalara 2. saat ve 24. saatte epidural kateterden 3 mg morfin 10 mL hacimde uygulandı. Ağrı şiddetinin hesaplanması için visual analog skala (VAS) kullanıldı.
Bulgular: Çalışmaya toplam 144 hasta dahil edildi. 71 hastaya TDS, 73 hastaya ise KSE anestezi uygulandı. VAS skorlarının karşılaştırılmasında 2., 12. ve 48. saat skorlarında anlamlı fark bulundu. 2.saat VAS skorunda TDS anestezi grubunda daha düşük VAS skoru mevcutken 12., 24., ve 48. saat VAS skorlarında KSE anestezi grubunda daha düşük VAS skoru bulundu.
Sonuç: Her iki tedavide iyi analjezi sağladı. Özellikle mobilizasyon sonrasında epidural analjezi uygulaması intratekal opioid kullanımına göre daha iyi sonuçlar vermektedir.  

Anahtar Kelimeler

• kombine spinal epidural anestezi
• morfin
• sezeryan doğum
• spinal anestezi

Kaynakça

1. 1- Filiz M. Investigation of study on the cesarean operation carried out in Turkey. ACU International Journal of Social Sciences 2020;6(1):74-83. doi: 10.22466/acusbd.736529.
2. 2- Kaufner L, Heimann S, Zander D, et al. Neuraxial anesthesia for pain control after cesarean section: A prospective randomized trial comparing three different neuraxial techniques in clinical practice. Minerva Anestesiol. 2016;82(5):514-524.
3. 3- Practice guidelines for obstetric anesthesia: An updated report by the American society of anesthesiologists task force on obstetric anesthesia and the society for obstetric anesthesia and aerinatology. Anesthesiology. 2016;124:270-300. doi: 10.1097/ALN.0000000000000935.
4. 4- Dichtwald S, Ben-Haim M, Papismedov L, Hazan S, Cattan A, Matot I. Intrathecal morphine versus intravenous opioid administration to impact postoperative analgesia in hepato-pancreatic surgery: a randomized controlled trial. J Anesth. 2017;31(2):237-245. doi: 10.1007/s00540-016-2286-y.
5. 5- Sato I, Iwasaki H, Luthe SK, Iida T, Kanda H. Comparison of intrathecal morphine with continuous patient-controlled epidural anesthesia versus intrathecal morphine alone for post-cesarean section analgesia: a randomized controlled trial. BMC Anesthesiology 2020;20(1):138. doi: 10.1186/s12871-020-01050-6.
6. 6- Otao G, Maruta T, Tsuneyoshi I. Comparison of opioid local anesthetic combination regimens using the number of self-administrated boluses in patient-controlled epidural analgesia after cesarean section: A retrospective single-center study. Medicine (Baltimore). 2021;100(17):e25560. doi: 10.1097/MD.0000000000025560.
7. 7- Choi DH, Ahn HJ, Kim JA. Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery. Int J Obstet Anesth. 2006;15(1):13-17. doi: 10.1016/j.ijoa.2005.05.009.
8. 8- The National Institute for Health and Clinical Excellence (NICE). Guidelines for cesarean section, 2011 update: Implications for the anaesthetist. Int J Obstet Anesth. 2012;21(3):264-272. doi: 10.1016/j.ijoa.2012.03.004.

9. 9- Wee MYK, Brown H, Reynolds F. The National Institute of Clinical Excellence (NICE) guidelines for cesarean sections: Implications for the anaesthetist. Int J Obstet Anesth. 2005;14(2):147-158. doi: 10.1016/j.ijoa.2004.09.008.
10. 10- Sarvela J, Halonen P, Soikkeli A, Korttila K. A double-blinded, randomized comparison of intrathecal and epidural morphine for elective cesarean delivery. Anesth Analg. 2002;95(2):436-440. doi: 10.1097/00000539-200208000-00037.
11. 11- Chen SY, Liu FL, Cherng YG, et al. Patient-controlled epidural levobupivacaine with or without fentanyl for post-cesarean section pain relief. Biomed Res Int. 2014;2014:965152. doi:10.1155/2014/965152.
12. 12- 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(2):137-143.
13. 13- Pöpping DM, Elia N, Marret E, Wenk M, Tramer MR. Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: A meta-analysis of randomized trials. Pain. 2012;153(4):784-793. doi: 10.1016/j.pain.2011.11.028.
14. 14- Shaikh JM, Memon A, Memon MA, Khan M. Post dural puncture headache after spinal anaesthesia for caesarean section: a comparison of 25 g Quincke, 27 g Quincke and 27 g Whitacre spinal needles. J Ayub Med Coll Abbottabad. 2008;20(3):10-13.
15. 15- Binici O, Kuyrukluyildiz U. Epidural blood patch for the treatment of post dural puncture headache in pregnant women. Medical Science and Discovery. 2018;5(11):357-360. doi: 10.17546/msd.476791.
16. 16- Meylan N, Elia N, Lysakowski C, Tramèr MR. Benefit and risk of intrathecal morphine without local anaesthetic in patients undergoing major surgery: meta-analysis of randomized trials. Br J Anaesth 2009;102:156-67. doi: 10.1093/bja/aen368.
17. 17- Cift T, Ustunyurt E, Yilmaz C, Olmez F, Basar B. Shoulder tip pain after cesarean section. J Clin Diagn Res. 2015;9(8):QC04-6. doi: 10.7860/JCDR/2015/13841.6314.