Weigl Wojciech, Bieryło Andrzej, Wielgus Monika, Krzemień-Wiczyńska Świetlana, Kołacz Marcin, Dąbrowski Michał J
First Department of Anesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Akademiska Hospital, Uppsala, Sweden Department of Anesthesiology and Intensive Care, Centre of Postgraduate Medical Education, Gruca Orthopedic and Trauma Teaching Hospital, Otwock Institute of Computer Science, Polish Academy of Sciences, Warsaw, Poland.
Medicine (Baltimore). 2017 Dec;96(48):e8892. doi: 10.1097/MD.0000000000008892.
Intrathecal morphine is used in the postoperative management of pain after caesarean section (CS), but might not be optimal for intraoperative analgesia. We hypothesized that intrathecal fentanyl could supplement intraoperative analgesia when added to a local anesthetic and morphine without affecting management of postoperative pain.
This prospective, randomized, double-blind, parallel-group study included 60 parturients scheduled for elective CS. Spinal anesthesia consisted of bupivacaine with either morphine 100 μg (M group), or fentanyl 25 μg and morphine 100 μg (FM group). The frequency of intraoperative pain and pethidine consumption in the 24 hours postoperatively was recorded.
Fewer patients in the FM group required additional intraoperative analgesia (P < .01, relative risk 0.06, 95% confidence interval [CI] 0.004-1.04). The FM group was noninferior to the M group for 24-hour opioid consumption (95% CI -10.0 mg to 45.7 mg, which was below the prespecified boundary of 50 mg). Pethidine consumption in postoperative hours 1 to 12 was significantly higher in the FM group (P = .02). Postoperative nausea and vomiting (PONV) were more common in the FM group (P = .01). Visual analog scale scores, effective analgesia, Apgar scores, and rates of pruritus and respiratory depression were similar between the groups.
Intrathecal combination of fentanyl and morphine may provide better perioperative analgesia than morphine alone in CS and could be useful when the time from anesthesia to skin incision is short. However, an increase in PONV and possible acute spinal opioid tolerance after addition of intrathecal fentanyl warrants further investigation using lower doses of fentanyl.
鞘内注射吗啡用于剖宫产术后疼痛管理，但可能并非术中镇痛的最佳选择。我们推测，鞘内注射芬太尼在添加到局部麻醉药和吗啡中时可补充术中镇痛，且不影响术后疼痛管理。
这项前瞻性、随机、双盲、平行组研究纳入了60例计划行择期剖宫产的产妇。脊髓麻醉采用布比卡因，分别联合100μg吗啡（M组）或25μg芬太尼与100μg吗啡（FM组）。记录术中疼痛频率及术后24小时哌替啶用量。
FM组术中需要追加镇痛的患者较少（P<0.01，相对危险度0.06，95%置信区间[CI]0.004 - 1.04）。FM组24小时阿片类药物用量不劣于M组（95%CI - 10.0mg至45.7mg，低于预先设定的50mg界限）。FM组术后1至12小时哌替啶用量显著更高（P = 0.02）。FM组术后恶心呕吐（PONV）更常见（P = 0.01）。两组间视觉模拟量表评分、有效镇痛、阿普加评分以及瘙痒和呼吸抑制发生率相似。
鞘内注射芬太尼与吗啡联合应用在剖宫产中可能比单独使用吗啡提供更好的围手术期镇痛，并且在麻醉至皮肤切开时间较短时可能有用。然而，鞘内注射芬太尼后PONV增加以及可能出现的急性脊髓阿片类药物耐受性需要使用更低剂量的芬太尼进一步研究。
