Indian Journal of Anaesthesia

CLINICAL INVESTIGATION
Year
: 2007  |  Volume : 51  |  Issue : 6  |  Page : 515--518

Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine


Sunil Dixit 
 MD, Consultant, Chandrapur Multispeciality Hospital, Mul Road Chandrapur(MS) 442401, India

Correspondence Address:
Sunil Dixit
Ankur Charitable Trust«SQ»s Maternity Nursing Home Balaji Ward, Chandrapur (M.S.), Jatpura, Chandrapur-442402, (Maharashtra)
India

Abstract

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.



How to cite this article:
Dixit S. Post operative analgesia after caesarean section: an experience with intrathecal buprenorphine.Indian J Anaesth 2007;51:515-518


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 2020 Aug 5 ];51:515-518
Available from: http://www.ijaweb.org/text.asp?2007/51/6/515/61190


Full Text

 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 [1] . 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 [2],[3],[4]. An alka­loid of the brain, buprenorphine seems to be ideal drug for this purpose. [5]

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.

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 -1 if heart rate de­creased to 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 [5] .

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 [6] . 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 (P0.05) 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 [7] . 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 [8] . 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 [9] . 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 [1],[10],[11] .

As suggested by Capogna etal [10] 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 [12] , 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 [13] .

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 [11] , 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. [14]

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.

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