A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

Crowgey, Theresa; Dominguez, Jennifer E.; Peterson-Layne, Cathleen; Allen, Terrence K.; Muir, Holly A.; Habib, Ashraf S.

doi:10.1213/ane.0b013e3182a9b042

Cited by 70 publications

(39 citation statements)

References 11 publications

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“…While neuraxial morphine may be associated with early onset and delayed respiratory depression and an increase in hypercapnia events, recent evidence suggests that the risk of clinically significant respiratory depression is extremely low in women receiving neuraxial morphine for post-caesarean analgesia. 47,48 It is also currently unclear whether clonidine would enhance the respiratory depression observed following neuraxial morphine administration. However, the increased sedation observed with neuraxial clonidine administration suggests that it could also enhance opioid-induced maternal respiratory depression and compromise maternal safety in the postoperative period.…”

Section: Discussionmentioning

confidence: 99%

The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects in women having elective Caesarean section–a systematic review and meta-analysis

Allen¹,

Mishriky²,

Klinger³

et al. 2018

British Journal of Anaesthesia

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Neuraxial clonidine improves postoperative analgesia in the general surgical population. The efficacy and safety of neuraxial clonidine as a postoperative analgesic adjunct in the Caesarean section population still remains unclear. This systematic review and meta-analysis aims to evaluate the effect of perioperative neuraxial clonidine on postoperative analgesia in women having Caesarean section under neuraxial anaesthesia. We included randomized controlled trials comparing the analgesic efficacy of the perioperative administration of neuraxial clonidine alone or in combination with a local anaesthetic and/or opioids in women having elective Caesarean section under neuraxial anaesthesia when compared with placebo. PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE were searched until February 2017. Eighteen studies were included in the meta-analysis. Neuraxial clonidine reduced 24 h morphine consumption [mean difference (MD): -7.2 mg; 95% confidence interval (CI): -11.4, -3.0 mg; seven studies] and prolonged time to first analgesic request (MD: 135 min; 95% CI: 102, 168 min; 16 studies) when compared with the control group. Neuraxial clonidine increased intraoperative hypotension [odds ratio (OR): 2.849; 95% CI: 1.363, 5.957], intraoperative sedation (OR: 2.355; 95% CI: 1.016, 5.459), but reduced the need for intraoperative analgesic supplementation (OR: 0.224; 95% CI: 0.076, 0.663). The effect of clonidine on intraoperative bradycardia, intraoperative and postoperative nausea and vomiting, postoperative sedation, and pruritus were inconclusive. Neuraxial clonidine did not negatively impact neonatal umbilical artery pH or Apgar scores. This review demonstrates that neuraxial clonidine enhances postoperative analgesia in women having Caesarean section with neuraxial anaesthesia, but this has to be balanced against increased maternal adverse effects.

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Section: Discussionmentioning

confidence: 99%

The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects in women having elective Caesarean section–a systematic review and meta-analysis

Allen¹,

Mishriky²,

Klinger³

et al. 2018

British Journal of Anaesthesia

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“…In our study, the incidence of desaturation episodes was greater than the number of bradypnea episodes previously described after ITM. 3–5 We attribute this to the enhanced detection of episodes due to continuous pulse oximetry, with respiratory rate being a less sensitive measure of respiratory depression than hypoxia and hypercarbia. Our findings are consistent with the 32% incidence of hypercapnic events (transcutaneous CO 2 >50 mmHg for ≥2 min) in post-cesarean delivery patients who had received ITM 150 μg.…”

Section: Discussionmentioning

confidence: 99%

“…2 The incidence of bradypnea associated with ITM for post-cesarean analgesia is reported to be as low as 0–0.26%. 3–5 However, the rate estimations provided in these studies may not fully account for the extent of opioid-induced respiratory depression, because respiratory rate was not monitored continuously. In addition, patients may be hypoxic and hypercarbic without exhibiting bradypnea.…”

Section: Introductionmentioning

confidence: 99%

A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150 μg

Ladha

Kato

Tsen

et al. 2017

International Journal of Obstetric Anesthesia

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Introduction Delayed respiratory depression is a feared complication of intrathecal morphine in patients undergoing cesarean delivery. The incidence, timing and risk factors for hypoxia in this population are not known. Methods Patients undergoing cesarean delivery under spinal anesthesia at a tertiary care center from October 2012 to March 2016 were included in the study. The Berlin sleep apnea Questionnaire was completed before surgery. Oxygen saturation was recorded every second for 24 hours after the initiation of spinal anesthesia. Desaturation events were defined as a median saturation of <90% (mild) or <85% (severe) across a 30 second period. Multivariable logistic regression was used to determine predictors of a desaturation event. Results A total of 721 patients were included in the analysis. Within this cohort, 169 women (23%) experienced at least one mild desaturation event, 91 (13%) experienced two or more mild desaturations, and 26 (4%) suffered a severe desaturation event. After the administration of intrathecal morphine, the median times to first mild or first severe desaturation were 7.4 (IQR 4.1–13.5) h and 12.0 (IQR 5.4–19.6) h, respectively. Patients who screened positive for sleep apnea had increased odds of having a mild desaturation event (OR 2.31, 95% CI: 1.40 to 3.79, P=0.001), as did patients who were obese (OR 1.80, 95% CI 1.05 to 3.09, P=0.033). Conclusions Mild hypoxemia occurred frequently in women receiving intrathecal morphine 150 μg for post-cesarean analgesia. Desaturations were observed most frequently 4–8 hours after administration of intrathecal morphine. Obesity and a positive Berlin questionnaire were risk factors for hypoxemic events.

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“…In der Literatur finden sich einige Fälle von Bradypnoe innerhalb von 24 Stunden und eine Kasuistik eines Atemstillstands, allerdings nach epiduraler Morphininjektion im Rahmen einer kombinierten Spinal-/Epiduralanästhesie (CSE) [25,26]. Obwohl in der angloamerikanischen Literatur meistens 150 µg Morphin s. a. gegeben werden, sollte eine Dosis von 100 µg aus Sicherheitsgründen nicht überschritten werden [27].…”

Section: Morphinunclassified

Geburtshilfliche Anästhesie Teil 2: Etablierte Standards und neue Perspektiven

Kranke¹,

Annecke²,

Bremerich³

et al. 2018

Frauenheilkunde up2date

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A Retrospective Assessment of the Incidence of Respiratory Depression After Neuraxial Morphine Administration for Postcesarean Delivery Analgesia

Cited by 70 publications

References 11 publications

The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects in women having elective Caesarean section–a systematic review and meta-analysis

The impact of neuraxial clonidine on postoperative analgesia and perioperative adverse effects in women having elective Caesarean section–a systematic review and meta-analysis

A prospective study of post-cesarean delivery hypoxia after spinal anesthesia with intrathecal morphine 150 μg

Geburtshilfliche Anästhesie Teil 2: Etablierte Standards und neue Perspektiven

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