Post Cesarean Section Pain
Conditions
Keywords
Analgesia, Cesarean section, Intrathecal Morphine, Postoperative pain
Brief summary
Central neuraxial blocks (CNBs) remain the preferred anesthetic technique for cesarean section, with single shot spinal anesthesia (SSSA) being the standard practice at investigator's institute unless contraindicated. SSSA offers reliable intraoperative anesthesia and provides a few hours of postoperative analgesia. Enhanced recovery after cesarean section protocol has recommended the addition of intrathecal (IT) morphine to improve the postoperative quality of the recovery profile. Fentanyl improves the quality of intraoperative analgesia, while morphine significantly prolongs the postoperative pain relief, often lasting up to 24 hours. Routine uterine exteriorization, practiced in all cases at investigator's institute, often results in peritoneal stretching pain during surgery. This visceral pain is managed with 10 mcg intrathecal fentanyl added to hyperbaric bupivacaine. For postoperative pain management, the intrathecal morphine is recommended by many guidelines and studies. Intrathecal morphine dose typically ranges from 50 to 300 mcg. The dose of morphine exceeding 150 mcg are usually associated with prolongation of analgesia with higher incidence of side effects like nausea, vomiting and pruritus. In selected cases, investigator had administered morphine 100-150 mcg and the clinical experience has shown reduced postoperative analgesic requirements and favorable recovery profile, with minimal adverse effects. Despite these promising experiences and extensive literature on IT morphine, their is still lack formal data on the efficacy and safety profile of IT morphine in cesarean section patient. This comparative study will help institute to find the optimum dose of IT morphine with better postoperative analgesia quality with low side effects profile. The finding could serve as a foundation to promote routine use of intrathecal morphine in cesarean section anesthesia at investigator's institute.
Interventions
Spinal anesthesia with 0.5% bupivacaine heavy with fentanyl at L3-L4 intervertebral space using Quincke's spinal needle in sitting position in patients undergoing cesarean section to study the dose with better analgesia profile and lower side effect profile.
DRUG0.5% bupivacaine heavy with fentanyl plus morphine 50 mcg
Spinal anesthesia with 0.5% bupivacaine heavy with fentanyl with morphine 50mcg at L3-L4 intervertebral space using Quincke's spinal needle in sitting position in patients undergoing cesarean section to study the dose with better analgesia profile and lower side effect profile.
DRUG0.5% bupivacaine heavy with fentanyl plus morphine100 mcg
Spinal anesthesia with 0.5% bupivacaine heavy with fentanyl with morphine 100mcg at L3-L4 intervertebral space using Quincke's spinal needle in sitting position in patients undergoing cesarean section to study the dose with better analgesia profile and lower side effect profile.
DRUG0.5% bupivacaine heavy with fentanyl plus morphine 150mcg
Spinal anesthesia with 0.5% bupivacaine heavy with fentanyl with morphine 150mcg at L3-L4 intervertebral space using Quincke's spinal needle in sitting position in patients undergoing cesarean section to study the dose with better analgesia profile and lower side effect profile.
Sponsors
Tribhuvan University Teaching Hospital, Institute Of Medicine.
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Investigator, Outcomes Assessor)
Intervention model description
Prospective double blinded, randomized controlled trial
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 45 Years
Healthy volunteers
No
Inclusion criteria
* Pregnant lady \> 36 weeks of gestation presenting for cesarean section under spinal anesthesia * ASA II/ III * Maternal Height \> 150 cm * BMI\< 40 Kg/m2 * Elective Indication
Exclusion criteria
* Patient unwilling to take part in the study * Patient with known allergy to the study medications * Contraindication to Spinal Anesthesia
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| To compare the incidence of postoperative pain after cesarean section with different doses of intrathecal morphine with bupivacaine among the four groups. | NRS score is measured in recovery room for postoperative pain assessment. This time will be recorded as "time zero". Then in postoperative ward, NRS score is measured at 2 hours, 4 hours, 6 hours, 12 hours and 24 hours from 'time zero". | The parturient among study groups receiving different dose of intrathecal morphine with bupivacaine were compared for incidence of postoperative cesarean section pain. The pain is assessed by using Numerical Pain Rating Scale(NRS) ,a 11-point, standardized tool (0-10) in which 0 means "no pain" and 10 means "the worst pain imaginable". The number of parturient with NRS more than 3 will be compared for postoperative pain among the 4 groups. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| To compare the first rescue analgesia demand time among the four groups | Postoperative period after cesarean delivery till 24 hour | Rescue analgesia demand is defined as the first time after the cesarean section when the NRS score \> 3, and analgesic will be needed. The time period after cesarean section when first rescue analgesic is needed will be compared among the four group. Inj.Ketorolac 30 mg iv will be supplemented first as rescue analgesic and recorded. |
| To compare the total analgesic consumption in first 24 hours among the parturient of four group | Postoperative total analgesia consumption for first 24 hour | Total analgesia consumption is defined as the total amount of paracetamol, ketorolac and tramadol received in the first 24 hours. From the time of first dose of ketorolac, regular analgesia will be prescribed as inj. ketorolac 30mg iv 8 hourly and inj. paracetamol 1gm iv 6 hourly for 24 hour. If the NRS score \>3 at any point of time apart from the regular above medication, then Inj. tramadol 50 mg iv SOS will be provided and recorded. The number pf parturient with total analgesics consumption in 24 hour will be compared among the four groups. |
| To compare the frequency of rescue analgesia demanded by parturient in first 24 hours among the groups | Postoperative period for first 24 hour | Frequency of rescue analgesia demand is measured by number of time patient with NRS \>3 who demand for iv ketorolac, paracetamol and tramadol despite providing regular analgesia (inj ketorolac 30mg iv 8 hourly and inj.paracetamol 1gm iv 6 hourly) for 24 hour. |
| To compare the incidence of side effects like nausea, vomiting, respiratory depression, level of sedation and pruritus in first 24 hours among the groups | Postoperative period for first 24 hour | Number of parturient with treatment related side effects like nausea, vomiting, pruritus, respiratory depression and level of sedation are assessed and compared among the groups. Level of sedation is assessed by Pasero Opioid - Induced Sedation Scale (POSS) This score consist: of : S Sleepy, easy to arouse 1. Awake and alert 2. Slightly drowsy, easily arousable 3. Frequently drowsy, arousable, drift off to sleep during conversation 4. Somnolent, minimal or no response to verbal or physical stimulation A POSS score of S, 1, or 2 indicates an acceptable level of sedation, whereas a score of 3 or 4 indicates over-sedation. |
Contacts
CONTACTBashu Dev Parajuli, MD Anaesthesiology
CONTACTPooja Poudyal, MD Obstetric and Gynaecology
Outcome results
None listed