|Year : 2007 | Volume
| Issue : 6 | Page : 515-518
Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine
MD, Consultant, Chandrapur Multispeciality Hospital, Mul Road Chandrapur(MS) 442401, India
|Date of Acceptance||20-Oct-2007|
|Date of Web Publication||20-Mar-2010|
Ankur Charitable Trust's Maternity Nursing Home Balaji Ward, Chandrapur (M.S.), Jatpura, Chandrapur-442402, (Maharashtra)
Source of Support: None, Conflict of Interest: None
Buprenorphine is a mixed agonist-antagonist narcotic with high affinity at both µ and k opiate receptors. The aim of the study was to compare intrathecal bupivacaine (0.5%) and buprenorphine (60µg) with bupivacaine (0.5%) for postoperative analgesia in caesarean section. Sixty parturients undergoing elective lower segment caesarean section (LSCS) were randomly selected after dividing into two groups of 30 each. Control group (C) received 1.70ml (8.5mg) of bupivacaine (0.5%) while patients of Study group (S) received 1.70ml (8.5mg) bupivacaine 0.5% + 60µg buprenorphine. Onset of analgesia was 5.35± 1.79 min in Control group, while 1.85 ± 1.39 min in Study group (P<0.001). The total duration of analgesia was prolonged from145.16 ± 25.86 min in Control group to 491.26 ± 153.97min in Study group. We conclude that intrathecal buprenorphine is a suitable drug for postoperative analgesia after caesarean section with no effects on neonatal Apgar scores with minimal side effects.
Keywords: Buprenorphine, Intrathecal anaesthesia; Post-operative analgesia
|How to cite this article:|
Dixit S. Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine. Indian J Anaesth 2007;51:515-8
|How to cite this URL:|
Dixit S. Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine. Indian J Anaesth [serial online] 2007 [cited 2019 Dec 11];51:515-8. Available from: http://www.ijaweb.org/text.asp?2007/51/6/515/61190
| Introduction|| |
Pain relief is of utmost importance in postoperative period and it is a matter of concern in parturient. Favorable results have been observed with buprenorphine as an analgesic  . Buprenorphine is a mixed agonist - antagonist narcotic with high affinity at both µ and kappa opiate receptors. It is an effective analgesic, as morphine in nearly all-clinical situations ,,. An alkaloid of the brain, buprenorphine seems to be ideal drug for this purpose. 
Lanz et al 1 demonstrated that buprenorphine is compatible with CSF and produces no adverse reactions when administered intrathecally. Buprenorphine has high molecular weight (481), is highly lipophilic and has high affinity for opiate receptors. The aim of the study was to compare intrathecal bupivacaine (0.5%) and buprenorphine (60µg) with bupivacaine (0.5%) for postoperative analgesia in caesarean section.
| Methods|| |
Sixty patients at term (ASA-I & ASA-II) scheduled for elective caesarean section under spinal anaesthesia were randomly selected using sealed envelope technique and divided into two groups of thirty (30) each. The patients belonging to Control group received 8.5mg(1.7ml) of 0.5% bupivacaine and Study group received 8.5mg bupivacaine (0.5%) with 60µg buprenorphine(0.2ml).The injectable volume (0.2ml) did not makea significant difference to the total volume injected.
To keep dose of bupivacaine constant, only patients of height in the range of 158-165 cm were selected in both groups.Alan Santos etal 6 have described height dose correlation for bupivacaine (0.5%) in caesarean section.
<158cm---- 7.5mg (1.5ml).
158-163cm-- 8 - 8.5mg (1.6 - 1.7ml)
>165cm---- 9 - 10mg (1.8 - 2.0ml)
All patients were kept nil by mouth for six hours prior to surgery.
The height, blood pressure, pulse rate, respiratory rate and weight were noted before procedure.I.V. line was secured with 20G cannula. Premedication was given in the form of ondansetron 4mg and ranitidine 50 mg to both the groups.After preloading with 1000 ml of Ringer lactate infusion, patients were placed in left lateral position and lumbar puncture was performed in the L 3 -L 4 space using midline approach with 25 G spinal needle. As soon as free flow of C.S.F. was obtained, the solution was injected. Injections were made over 10-15 seconds. After withdrawing the needle, patient was turned supine with approximately 10-degree tilt head low with shoulder on pillowand left uterine displacement wasdone. Patients were supplemented with O 2 (6 L/min) via a facemask until delivery of baby.After subarachnoid injection,bloodpressure and pulse rate were monitored immediately & subsequently at 2 min interval for first 10 min and then every 10 min for rest of the surgical procedure.
Onset of cephalad spread of analgesia was determined as loss of sensation to pinprick. Intraoperative hypotension was considered to be present whenever systolic blood pressure decreased to less than 90mm of Hg or <20% of the baseline whichever appeared first and treated with ephedrine. Bradycardia was to be treated with atropine i.v. 0.02 mg.kg -1 if heart rate decreased to < 60/min, any fall in respiratory rate less than ten per minute was noted. The attending paediatrician assessed the neonatal Apgar scores at 1 & 5 min of delivery of the baby. Vital parameters such as pulse rate, systolic blood pressure, respiratory rate and SpO 2 were monitored half hourly for first four hours and then hourly in post operative period. Post-operative analgesia was evaluated using Magill's classification  .
Magill's classification: - 0 - no pain, 1- slight pain, 2- discomfort, 3- unbearable pain, 4- excruciating pain.
Rescue analgesia in the form of diclofenac sodium I.M. was given at the Magill's score of 3, effective analgesia time was the time taken between the injection of intrathecal drug and onset of unbearable pain. Side effects and complications like nausea, vomiting, pruritus, respiratory depression were noted and treated. . The analysis of results was done for stastical significance.
| Results|| |
Mean values of age, height and weight were comparable and difference was statistically non significant [Table 1]. Onset of analgesia was significantly earlier in Study group (1.85+ 1.39min) as compared to Control group (5.35 + 1.79min) , (P<0.001) [Table 2]. Duration of analgesia was significantly longer in Study group (491.26 + 153.97 min) than in Control group (145.16 + 25.86 min), (P<0.001) [Table 3].
Magill's classification was used to assess postoperative analgesia for the degree of pain  . Majority of patients in Study group (66.66%) had excellent analgesia (score 0) till 6 h as compared to 2 h in Control group(83.33%). At 6 hnopatients in Control group had excellent analgesia while majority of the patients (63.33%) had only fair (score 2) analgesia. As many as eight patients had excellent analgesia at 12 h and 3 patients at 24 h in Study group. The Study group required rescue analgesic as late as 8 h unlike the Control group which required it after 4 h [Table 4].
Seventeen patients in the Study group were drowsy in the intraoperative period (P<0.001). Nausea (20%) (P<0.05) and vomiting (10%) (P>0.05) were treated with I.V ondansetron 4mg in Study group. [Table 5].
In all groups the mean respiratory rate did not differ significantly during the postoperative period. SpO 2 remained in the range of 98-100% & no fall was observed in any of the patients [Table 5].
The paediatrician could find no difference in neonatal Apgar score between the Control and Study group after 1 and 5 min [Figure 1].
| Discussion|| |
The intrathecal route has advantages of greater technical ease and a single injection producing pain relief of sufficient duration is always beneficial. Since the first clinical use of intrathecal opioids was byWang etal  . Postural hypotension and exaggerated sympathetic blockade is absent with use of opioids which allows parturient to ambulate early and mother can breastfeed child effectively thereby improving interaction between mother and child  . During pregnancy risk of thromboembolic disease is increased, as good pain relief postoperatively provided by intrathecal buprenorphine improves mobility thereby reducing chances of thromboembolic phenomenon.
Buprenorphine increases sensory block without affecting motorblock and haemodynamic alterations  . In present study onset of analgesia was significantly earlier due to addition of buprenorphine. This is due to high lipid solubility and highest affinity for opiate receptors of buprenorphine ,, .
As suggested by Capogna etal  duration of analgesia is dose dependent, and buprenorphine increased the duration of analgesia in our study.
Intraoperatively quality of analgesia was excellent in Study group, visceral or traction pain, pain during exteriorization of uterus was obtunded, as observed by Shah et al  , due to favorable property of intrathecal opiates.
Thomas et al 5 assessed the efficacy of buprenorphine as postoperative analgesic using the Magill's classification. High affinityof buprenorphine for narcotic receptors produces longer duration of action  .
The major side effects of buprenorphine seen in this study was drowsiness, though sedation can be considered desirable in postoperative period. Though drowsy, all patients were easily arousable.
Incidence of nausea was significant in Study group. The concern regarding late respiratory depression from neuraxial opiates perhaps, been the main reason for reluctance in the wide spread use of these analgesic technique but this was not observed in any of the patients in our study as buprenorphine is lipid soluble drug due to rapid absorption into the spinal venous plexus there is minimal increase in spinal fluid concentration thus minimal risk of respiratory depression associated with rostral spread  , according to Stoelting the patients receiving intrathecal opioids should be under close surveillance for adequacy of breathing but suggests that low dose neuraxial administration of narcotics as in our study does not obligate observation in an intensive care environment. 
Thus it can be concluded that intrathecal buprenorphine is suitable drug for postoperative analgesia, after cesarean section, it enhances the sensory blockade of local anaesthetics without affecting the sympathetic activity. Anaesthesia was superior when buprenorphine is mixed with bupivacaine (0.5%) as compared to bupivacaine (0.5%) used alone. The benefits of neuraxial opiates are significant and far outweighs the side effects. Intrathecal procedure is easy to perform, most predictable and the drug is easily available.
| References|| |
|1.||Lanz E, Suke G, Theiss D, and Glocke MH. Epidural buprenorphine- a double blind study of postoperative analgesia and side effects. Anesth Analg 1984; 63: 593-598. |
|2.||Harcus AH, Ward AE, and Smith DW. Buprenorphine in postoperative pain: results in 7500 patients. Anaesthesia 1980; 35:382-386. |
|3.||Howell BC, WardAE. Pain relief in the postoperative period: a comparative trial of morphine and a new analgesic buprenorphine. J Int Med Res 1977;5:417-421. |
|4.||Kay BA. Double blind comparison of morphine and buprenorphine in the prevention of pain after operation. Br J Anaesth 1978;50:605-608. |
|5.||W Thomas, V Abraham, B Kaur. Intrathecal buprenorphine for postoperative analgesia. IJA 1997;41:188-194. |
|6.||Alan Santos et al, Anesth Analg 1984;63:1009-13. |
|7.||Wang JK, Nauss LA, Thomas JK. Pain relief by intrathecally applied morphine in man. Anesthesiology 1979; 50:149-51. |
|8.||Jeff Gasden, Stuart Hart and Alan C. Santos. Post-cesarean delivery analgesia.AnesthAnalg 2005; 101: 62-S 69. |
|9.||Saxena AK, Arva S. Current concepts in neuraxial administration of opioids and non- opioids: An over view and future prospective. IJA 2004; 48:13-24. |
|10.||Capogna G, Celleno D. Spinal buprenorphine for postoperative analgesia after caesarean section. Acta Anasthesiol Scand 1989; 33:236-238. |
|11.||Capogna G, Celleno D. Intrathecal buprenorphine for postoperative analgesia in the elderly patients. Anaesthesia 1988; 48: 128-30. |
|12.||Shah FR, Halbe AR, Panchal JD and Goodchild CS. Improvement in postoperative pain relief by the addition of midazolam to an intrathecal injection of buprenorphine and bupivacaine. European Journal ofAnesthesiology 2003; 20: 904-910. Cambridge University press. |
|13.||Khan FA, Hamdani GA. Comparison of intrathecal fentanyl and buprenorphine in urological surgery. JPMA 2006;56:6. |
|14.||Stoelting RK. Intrathecal morphine; An underused combination for postoperative pain management [Editorial]. Anesth Analg 1989; 68:707-9. [PUBMED] [FULLTEXT] |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]