Spinal Morphine vs. Hydromorphone for Pain Control After Cesarean Delivery

Overview

About this study

Intrathecal (IT) opioids are commonly administered with local anesthetic during spinal anesthesia for post-Cesarean delivery analgesia. Traditionally, IT morphine has been used but the use of IT hydromorphone is growing. Our group recently found the effective dose for postoperative analgesia in 90% patients (ED90) for both IT hydromorphone and IT morphine (IRB # 13-008490). These doses that we found were 75 mcg for hydromorphone and 150 mcg for morphine. Our current proposed study would compare the duration of analgesia of IT morphine vs IT hydromorphone after elective cesarean delivery. Additionally, we will compare each drug on the incidence of nausea and pruritus.

Participation eligibility

Participant eligibility includes age, gender, type and stage of disease, and previous treatments or health concerns. Guidelines differ from study to study, and identify who can or cannot participate. There is no guarantee that every individual who qualifies and wants to participate in a trial will be enrolled. Contact the study team to discuss study eligibility and potential participation.

Inclusion:

  1. ASA physical status II-III women presenting for elective cesarean delivery
  2. Term gestation (37-42 weeks)
  3. Desire to have a spinal anesthesia technique for cesarean delivery

Exclusion:

  1. Any contraindication to the administration of a spinal technique for anesthesia
  2. History of intolerance or adverse reaction to opioid medications
  3. Chronic pain syndrome or current opioid use >30 oral morphine equivalents/day
  4. Allergy or intolerance to acetaminophen, ketorolac, ibuprofen, or oxycodone
  5. Current BMI > 50

Participating Mayo Clinic locations

Study statuses change often. Please contact the study team for the most up-to-date information regarding possible participation.

Mayo Clinic Location Status

Rochester, Minn.

Mayo Clinic principal investigator

Hans Sviggum, M.D.

Closed for enrollment

More information

Publications

  • Intrathecal (IT) morphine is considered the "gold standard" for analgesia after cesarean delivery under spinal anesthesia, most commonly administered at a dose of 100 to 200 μg. There is less experience with IT hydromorphone for postcesarean analgesia and limited information on its optimal analgesic dose. We conducted this study to determine the effective analgesic dose for 90% patients (ED90) of IT hydromorphone that provides effective analgesia for women undergoing elective cesarean delivery and its potency ratio to IT morphine. Read More on PubMed
  • To compare analgesia and opioid-related side effects of intrathecal morphine and intrathecal hydromorphone after elective Cesarean delivery. Read More on PubMed
  • Despite compelling evidence for the safety and efficacy of intrathecal hydromorphone, the use of this opioid intrathecally for the pain management of patients undergoing cesarean delivery has not been widely accepted. The purpose of this retrospective study was to compare the reported efficacy and safety of pain management in women who received intrathecal hydromorphone (100 microg) vs in women who received intrathecal fentanyl (25 microg) or a local anesthetic for their cesarean delivery. The author hypothesized that intrathecal hydromorphone because of its known pharmacodynamics would provide better postoperative analgesia within the first 24 hours after cesarean delivery. The results of this retrospective chart review confirmed the hypothesis that intrathecal hydromorphone possesses the appropriate pharmacodynamics to facilitate optimal pain relief in patients undergoing cesarean delivery. It provided a comparable onset of effective pain relief, as well as a significantly prolonged duration of pain relief (P < .001) compared with intrathecal fentanyl or local anesthetic. Traditionally, intrathecal morphine was the opioid of choice for prolonged pain management during cesarean deliveries in which spinal anesthesia was selected. However, intrathecal hydromorphone was shown to be an effective and possibly even better substitute. Further research on intrathecal hydromorphone is needed. Read More on PubMed
  • Currently, morphine and fentanyl are the most commonly used intrathecal opioids for the postoperative pain management of patients who underwent cesarean delivery. Unfortunately, the analgesic benefits of these 2 drugs tend to fall into different extremes based on lipid solubility. Intrathecal hydromorphone may provide more consistent analgesia because its lipid solubility falls between that of the other 2 opioids. A 22-year-old woman with a 39-week intrauterine pregnancy, gravida 2, para 1, came in for a scheduled second-time cesarean delivery. Her preoperative history included a morphine allergy discovered when administered intrathecally during her first cesarean delivery. Thus, in this case, preservative-free hydromorphone, 100 microg, was administered intrathecally as the opioid replacement for the spinal anesthetic. Intrathecal hydromorphone was found to have provided superior pain relief with fewer side effects in this patient, who received intrathecal morphine for the same surgery 2 years earlier. This case report supports an emerging hypothesis that intrathecal hydromorphone is not only safe but possibly more effective than other intrathecal opioids for pain management after cesarean delivery. The purpose of this case report is to encourage the development of more research regarding this use of intrathecal hydromorphone. Read More on PubMed
  • Intrathecal morphine is often used for postoperative analgesia after surgery. We performed a meta-analysis to obtain more detailed information on the frequency of side-effects in patients receiving intrathecal morphine in combination with spinal anaesthesia compared with placebo treated patients. We clustered the analysis to patients receiving placebo, less than morphine 0.3 mg (M < 0.3), or equal to or more than morphine 0.3 mg (M > or = 0.3) and calculated the risk ratios of morphine vs placebo. Twenty-eight studies investigating 46 morphine groups vs placebo were included. A total of 790 patients with intrathecal morphine and 524 patients who received placebo were analysed. Compared with placebo the lower dose of morphine resulted in an increase of nausea (RR 1.4, 95% CI 1.1-1.7), vomiting (RR 3.1, 95% CI 1.5-6.4) and pruritus (RR 1.8, 95% CI 1.4-2.2). The higher dose resulted in an increased risk ratio for pruritus (RR 5.0, 95% CI 2.9-8.6), but not nausea (RR 1.2, 95% CI 0.9-1.6) or vomiting (RR 1.3, 95% CI 0.9-1.9). Overall, intrathecal morphine did not increase respiratory depression. However, the higher dose of intrathecal morphine was associated with more episodes of respiratory depression (7/80) compared with the lower dose (2/247). Intrathecal morphine is associated with a mild increase in side-effects. With a dose < 0.3 mg we found there were no more episodes of respiratory depression than in placebo patients who received systemic opioid analgesia. Read More on PubMed
  • To determine the effect of intrathecal injection of morphine 0.2 mg on postoperative analgesia, activity and satisfaction after elective cesarean section. Read More on PubMed
  • Low-dose intrathecal (spinal) morphine (0.1-0.2 mg) for Caesarean section delivers excellent postoperative analgesia but is associated with significant nausea and vomiting. We compared the antiemetic efficacy of cyclizine, dexamethasone, and placebo in this clinical setting. Read More on PubMed
  • This series investigated the quality of analgesia and the incidence and severity of side effects of intrathecal morphine for post-cesarean analgesia administered over a dose range of 0.0-0.5 mg. Read More on PubMed

Study Results Summary

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Supplemental Study Information

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CLS-20267881

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