From the Departments of Anesthesiology and Peri-operative Medicine (E.E.S., R.J.M., K.W.A., D.A.O., R.L.J., A.K.J., A.D.N., H.P.S.) Obstetrics and Gynecology (V.E.T.) Health Sciences Research (D.R.S.), Mayo Clinic, Rochester, Minnesota.
Anesthesiology. 2020 Jun;132(6):1382-1391. doi: 10.1097/ALN.0000000000003283.
BACKGROUND: Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. METHODS: In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. RESULTS: There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). CONCLUSIONS: Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.
背景：鞘内阿片类药物在脊髓麻醉中常规用于剖宫产术后镇痛。鞘内吗啡用于剖宫产术后镇痛的效果已得到充分证实，鞘内氢吗啡酮的应用也在不断增加。尚无前瞻性研究比较鞘内等剂量吗啡与鞘内氢吗啡酮作为剖宫产术后多模式镇痛方案的一部分的有效性。作者假设鞘内吗啡与鞘内氢吗啡酮相比，在分娩后 24 小时内会产生更好的镇痛效果。
方法：在这项单中心、双盲、随机试验中，138 名接受择期剖宫产的产妇被随机分为接受鞘内注射 150μg 吗啡或 75μg 鞘内氢吗啡酮作为主要脊髓麻醉和多模式镇痛方案的一部分；134 名产妇纳入分析。主要结局是分娩后 24 小时时运动时疼痛的数字评分量表评分。在产后 36 小时内，每 6 小时评估一次静态和动态疼痛评分、恶心、瘙痒、镇静程度和患者满意度。记录总阿片类药物消耗量。
结果：分娩后 24 小时运动时疼痛评分（鞘内氢吗啡酮中位数[25%，75%]为 4[3,5]，鞘内吗啡为 3[2,4.5]）或任何时间点均无显著差异（估计差值，0.5；95%CI，0 至 1；P=0.139）。两组在 24 小时内接受的阿片类药物无差异（鞘内氢吗啡酮的口服吗啡毫克当量中位数[25%，75%]为 30[7.5,45.06]，而鞘内吗啡为 22.5[14.0,37.5]，P=0.769）。从 Kaplan-Meier 分析来看，氢吗啡酮首次需要阿片类药物的中位时间为 5.4 小时，吗啡为 12.1 小时（对数秩检验 P=0.200）。
结论：尽管假设鞘内吗啡的镇痛效果优于鞘内氢吗啡酮，但结果并未证实这一点。在研究剂量下，鞘内吗啡和鞘内氢吗啡酮联合多模式镇痛方案均可有效用于剖宫产术后镇痛。
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