Neuraxial Morphine Administration Research Articles

Respiratory depression after administration of single-dose neuraxial morphine for post-cesarean delivery analgesia: a retrospective cohort study

BackgroundNeuraxial administration of long-acting opioid is the “gold standard” for the management of postoperative pain following cesarean delivery. Respiratory depression, however, remains a concerning complication. MethodsThis retrospective single-center study of 4963 patients evaluated the frequency of respiratory depression after neuraxial morphine administration in a post-cesarean delivery population. The spinal dose of morphine varied from 100 to 450 µg intrathecally, and from 3 to 5 mg epidurally. The primary outcome was the initiation of a Rapid Response Team (RRT) event for respiratory failure due to neuraxial opioid in the 24 h following morphine administration. Secondary outcomes studied included oxygen desaturation events (SpO2 <90%), initiation of oxygen therapy and naloxone administration. ResultsThere were no respiratory RRT events within the study period (95% confidence interval [CI] 0 to 7 per 10 000). There were no desaturation events recorded and no patients received supplemental oxygen therapy or naloxone (95% CI 0 to 7 per 10 000). ConclusionClinically significant respiratory depression is rare among patients receiving neuraxial morphine for post-cesarean delivery analgesia.

P.69 Evaluating the introduction of intrathecal morphine for caesarean section

Introduction: Due to ongoing supply issues with diamorphine,and, given the demonstrated safety profile of using central neuraxial morphine in obstetric patients, [1] Crowgey TR, Dominguez JE, Peterson-Layne C, et al. A retrospective assessment of the incidence of respiratory depression after neuraxial morphine administration for postcesarean delivery analgesia. Anesth Analg. 2013; 117:1368-70. Google Scholar it was decided to replace diamorphine with preservative free morphine for procedures in labour theatre. We evaluated whether this change had impacted on patients undergoing caesarean section, particularly with respect to analgesia requirements and occurrence of side effects.

Enhanced recovery after cesarean delivery: a challenge for anesthesiologists.

Enhanced recovery after cesarean (ERAC) delivery is an evidence-based, multi-disciplinary approach throughout pre-, intra-, post-operative period. The ultimate goal of ERAC is to enhance recovery and improve the maternal and neonatal outcomes. This review highlights the role of anesthesiologist in ERAC protocols. This review provided a general introduction of ERAC including the purposes and the essential elements of ERAC protocols. The tool used for evaluating the quality of ERAC (ObsQoR-11) was discussed. The role of anesthesiologist in ERAC should cover the areas including management of peri-operative hypotension, prevention and treatment of intra- and post-operative nausea and vomiting, prevention of hypothermia and multi-modal peri-operative pain management, and active pre-operative management of unplanned conversion of labor analgesia to cesarean delivery anesthesia. Although some concerns still remain, ERAC implementation should not be delayed. Regular assessment and process improvement should be imbedded into the protocol. Further high-quality studies are warranted to demonstrate the effectiveness and efficacy of the ERAC protocol.

Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia.

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

558: Predictors of excess postoperative opioid consumption after cesarean delivery among opioid naive women

To determine clinical and sociodemographic factors influencing inpatient opioid consumption after cesarean delivery (CD) among opioid-naïve women. We performed a retrospective cohort study of all opioid-naïve women who underwent CDs at one tertiary institution in 2015, abstracting sociodemographics, clinical characteristics, CD characteristics and inpatient postoperative consumption of all opioids. We restricted analysis to women receiving neuraxial anesthesia and neuraxial morphine. Opioid consumption was converted to oral morphine milligram equivalents (MME). Based on ACOG recommendations, we defined excess daily opioid use as >45 MME per 24 hours, excluding the first 24 postoperative hours to account for neuraxial morphine administration. We performed multivariable logistic regression to identify predictors of excess inpatient opioid use. 977 opioid-naïve women underwent CD in 2015 and met inclusion criteria. Mean and median opioid consumption were 47.3 (+22.5) and 44.0 (IQR 35.1-64.1) MME, respectively, per 24 post-operative hours. 47% exceeded the ACOG recommended post-cesarean opioid daily use. Excess opioid use was only predicted by a history of marijuana use pre-pregnancy (OR 2.86, 95% CI 1.19-6.87) (Table). Excess inpatient opioid use after cesarean delivery is common. The primary risk factor identified is the self-reported use of marijuana pre-pregnancy. Marijuana is legalized in several states, and the full gamut of unintended consequences has yet to be described. Moreover, as increased inpatient opioid use is associated with increased outpatient use, identification of patients at risk and optimization of post cesarean pain management strategies are critical.

A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious Issues Collections Obstetric Airway ManagementMaternal EmbolismRegional Anesthesia for Cesarean SectionGeneral Anesthesia for Cesarean SectionAnalgesia for LaborObstetric HemorrhagePre-Eclampsia/EclampsiaPharmacologyTraumaInfection and SepsisMaternal ObesityMaternl Morbidity and MortalityNeonatal Morbidity and MortalityObstetric ComplicationsAnesthetic ComplicationsNon-Obstetric Maternal DiseaseCritical CareDrug Abuse in PregnancyEthicsSystems Based Practice For Authors Information for AuthorsLanguage Editing Services Journal Info About the JournalEditorial BoardAdvertisingOpen AccessSubscription ServicesReprintsRights and Permissions All Articles Images Videos Podcasts Blogs Advanced Search

A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

Crowgey, Theresa R.; Dominguez, Jennifer E.; Peterson-Layne, Cathleen; Allen, Terrence K.; Muir, Holly A.; Habib, Ashraf S. Author Information

A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

Respiratory depression can occur after neuraxial morphine administration. In the obstetric population, there are little data on respiratory depression after neuraxial morphine administration in women undergoing cesarean delivery. In this single-center, retrospective study in 5036 obstetric patients (mean body mass index = 34 kg/m) who underwent cesarean delivery and received neuraxial morphine, we did not identify any instances of respiratory depression requiring naloxone administration or rapid response team involvement. Therefore, the upper 95% confidence limit for respiratory depression in our study is 0.07% (1 event per 1429 cases).

Dexamethasone for the Prophylaxis of Postoperative Nausea and Vomiting Associated With Neuraxial Morphine Administration

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious Issues Collections Obstetric Airway ManagementMaternal EmbolismRegional Anesthesia for Cesarean SectionGeneral Anesthesia for Cesarean SectionAnalgesia for LaborObstetric HemorrhagePre-Eclampsia/EclampsiaPharmacologyTraumaInfection and SepsisMaternal ObesityMaternl Morbidity and MortalityNeonatal Morbidity and MortalityObstetric ComplicationsAnesthetic ComplicationsNon-Obstetric Maternal DiseaseCritical CareDrug Abuse in PregnancyEthicsSystems Based Practice For Authors Information for AuthorsLanguage Editing Services Journal Info About the JournalEditorial BoardAdvertisingOpen AccessSubscription ServicesReprintsRights and Permissions All Articles Images Videos Podcasts Blogs Advanced Search

Dexamethasone for the Prophylaxis of Postoperative Nausea and Vomiting Associated With Neuraxial Morphine Administration

Dexamethasone for the Prophylaxis of Postoperative Nausea and Vomiting Associated With Neuraxial Morphine Administration

Dexamethasone for the Prophylaxis of Postoperative Nausea and Vomiting Associated with Neuraxial Morphine Administration

We performed a systematic review to assess the efficacy of dexamethasone in reducing postoperative nausea, vomiting (PONV), pruritus, and enhancing postoperative analgesia in patients receiving neuraxial anesthesia with neuraxial morphine. We searched Medline (1966-2011), the Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science for all randomized controlled trials comparing dexamethasone with placebo for the prevention of PONV and/or pruritus in patients receiving neuraxial morphine as part of a neuraxial anesthetic technique. Data were extracted independently by the authors on the incidence of PONV, pruritus, pain scores at 4 and 24 hours, and use of rescue antiemetics, antipruritics, and analgesics. Eight randomized controlled trials (4 cesarean deliveries, 4 total abdominal hysterectomies) were included. From these trials, 768 patients were analyzed with 473 receiving dexamethasone and 295 receiving placebo. The doses of dexamethasone investigated ranged from 2.5 to 10 mg. Dexamethasone reduced the incidence of postoperative nausea (relative risk, RR [95% confidence interval, CI] = 0.57 [0.45, 0.72]), vomiting (RR [95% CI] = 0.56 [0.43, 0.72]), and the use of rescue antiemetic therapy (RR [95% CI] = 0.47 [0.36, 0.61]) compared with placebo. There was no evidence of dose responsiveness with respect to its antiemetic effect. Dexamethasone also reduced 24-hour visual analog pain scores (measured on an 11-point scale [0-10]) (mean difference [95% CI] = -0.30 [-0.46, -0.13]) and the use of rescue analgesics (RR [95% CI] = 0.72 [0.52, 0.98]). Dexamethasone did not reduce the incidence of pruritus (RR [95% CI] = 0.98 [0.84, 1.15]). Examination of the funnel plots and Egger's test revealed evidence of publication bias in the primary outcomes. Dexamethasone is an effective antiemetic for patients receiving neuraxial morphine for cesarean delivery and abdominal hysterectomy. In addition, the doses used for antiemetic prophylaxis enhanced postoperative analgesia compared with placebo. However, dexamethasone was not effective for the prophylaxis against neuraxial morphine-induced pruritus.

Neuraxial Morphine and Oral Herpes Reactivation in the Obstetric Population

Neuraxial morphine administration is a common strategy for providing postcesarean delivery analgesia. Morphine delivered via this route increases the risk of herpes labialis (oral herpes) reactivation, a disease common in women of childbearing age. A primary concern is risk of transmission to the neonate from maternal reactivation. The benefits to the mother of this form of analgesia outweigh the risk of neonatal herpes acquired postpartum from maternal recurrence because serious neonatal morbidity from recurrent herpes has not been described.

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine

Study Objective To describe the frequency and timing of intravenous patient-controlled analgesia (IV-PCA) or neuraxial morphine–induced postoperative respiratory depression. Design Audit of data captured by routine quality assurance of the acute pain protocols that were implemented by nurses performing routine postoperative care. Setting The surgical wards of a university-affiliated, 700-bed, tertiary hospital. Patients and Interventions In real time, the data of all patients enrolled into our Acute Pain Service (APS) were entered and stored in the APS database. Thereafter, patients who had received IV morphine via a PCA device or neuraxial morphine between January 1999 and December 2002 were isolated. From this subset, all patients in whom a respiratory rate (RR) less than 10 breaths per minute was recorded were retrieved. Measurements and Main Results From a total of 4500 patients, IV or neuraxial morphine was administered to 1524 patients. Eighteen (1.2%) cases of an RR less than 10 breaths per minute were recorded (13 patients, 4 patients, and 1 patient in the IV-PCA, daily epidural morphine, and single-dose intrathecal morphine groups, respectively). A direct correlation between intraoperative fentanyl administration and postoperative respiratory depression was demonstrated between the IV-PCA ( P = 0.03) and epidural groups ( P = 0.05). The time from IV-PCA initiation or last neuraxial morphine administration until the diagnosis of respiratory depression ranged between 2 hours and 31.26 hours and 2 hours and 12.15 hours, respectively. Ten (55.6%) patients received naloxone. Conclusion Morphine-induced respiratory depression may occur at any time during the APS admission. However, the optimal frequency of intermittent RR monitoring is unknown. Furthermore, because multiple variables (age, sex, prior opioid administration, site of operation) may affect morphine-induced respiratory depression, further investigation must be performed to determine the ideal monitoring protocol.