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Intrathecal hydromorphone for post-cesarean delivery pain—a dose finding study
Abstract Number: T-42
Abstract Type: Original Research
Introduction: Postoperative analgesia with intrathecal (IT) morphine 100 or 200 mcg is well established for cesarean delivery (CD). A national shortage of morphine prompted substitution of morphine with hydromorphone at our institution. A dose of 100mcg of hydromorphone has been advocated, but has yet to be validated. We have performed a randomized, blinded dose-finding study for IT hydromorphone for post-CD analgesia.
Methods: After informed consent, healthy ASA 1 or 2 women undergoing elective singleton CD were randomized to three groups: IT hydromorphone 25mcg (n=6), 50mcg (n=6), or 100mcg (n=5). Spinal anesthesia was achieved with hyperbaric bupivacaine 12mg, fentanyl 10mcg, and a blinded hydromorphone study dose. Postoperative pain was managed with intravenous (IV) hydromorphone administered via a patient-controlled analgesia (PCA) pump. Hydromorphone PCA use, Visual Analogue Scale (VAS) scores, incidence of nausea, vomiting, pruritus, hypothermia, respiratory depression, and all required interventions were recorded for 24 hours.
Results: Seventeen of 90 patients have been enrolled to date. There were no cases of postoperative hypothermia or respiratory depression. The postoperative pain assessed by the VAS was not different among the three groups 24 hours after surgery (25mcg: 2 [0-3], 50mcg: 1 [0-4], 100mcg: 0 [0-4]), nor was the cumulative VAS score (measured in the PACU, then every 4 hours until 24 hours) (25mcg: 8 [4-12], 50mcg: 9.5 [4-16], 100mcg: 10 [8-15]). Total IV hydromorphone PCA use was similar among groups (25mcg: 1.8 +/- 1.5mg, 50mcg: 3.5 +/- 2.5mg, 100mcg: 2.6 +/-1.5mg, p = ns). The incidence of nausea, vomiting, and pruritus was not different between the groups, but there was a trend for more interventions to treat nausea, vomiting, and/or pruritus in the 100mcg group (25mcg: reference group, 50mcg: .5 [-1.22 – 2.22], 100mcg: 1.8 [0 – 3.6], 95% CI, p=0.07).
Conclusion: Our goal was to determine the optimal dose of IT hydromorphone for post-CD analgesia and minimal side effects. Our preliminary data suggest no difference in postoperative analgesia requirement for elective CD after IT hydromorphone at 25, 50, or 100mcg doses. Further data collection will determine whether our observed trend for more nausea, vomiting, and pruritis intervention among the 100mcg hydromorphone group is a significant finding.
Girgin NK J Clin Anesth., 2008 May
Rauch E AANA J., 2012 Aug