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CONTROLLED TRIAL OF EXTRADURAL BUPIVACAINE WITH FENTANYL, MORPHINE OR PLACEBO FOR PAIN RELIEF IN LABOUR
Br. J. Anaesth. (1989), 62, 641-644
CONTROLLED TRIAL OF EXTRADURAL BUPIVACAINE WITH FENTANYL, MORPHINE OR PLACEBO FOR PAIN RELIEF IN LABOUR J. D. LIRZIN, P. JACQUINOT, P. DAILLAND, J. C. JORROT, J. JASSON, M. L. TALAFRE AND C. CONSEILLER
PATIENTS AND METHODS
The study was approved by the Hospital Ethics Committee and informed consent was obtained from all participating patients—255 healthy pregnant women with uncomplicated full-term gestation (> 38 week) who elected to have extradural analgesia for labour and delivery. All patients J. D. LIRZIN, M . D ; P. JACQUINOT, M.D. ; P. DAILLAND, M.D. ;
J. C. JORROT, M.D.; J. JASSON, M.D.; M. L. TALAFRE, M.D.; C. CONSEILLER, M.D.; Department d'Anesthesie et de Reanimation chirurgicale, Hopital universitaire Cochin-Maternites, 123, Boulevard Port-Royal 75014, Paris, France. Accepted for Publication: December 12, 1988.
SUMMARY In a prospective, randomized double-blind study carried out on 255 parturients, fentanyl 80 ug (v\ = 81), morphine 4 mg (n = 83) or placebo (n - 85) was added to 0.25% bupivacaine administered extradurally for pain relief during labour. Fentanyl increased the mean duration of bupivacaine analgesia by 30% and did not reduce the rate of inadequate pain relief. Morphine did not increase the mean duration of bupivacaine analgesia significantly, but increased the rate of inadequate pain relief. It was concluded that morphine 4 mg added to extradural 0.25% bupivacaine was of no value.
were in labour with a healthy singleton fetus in a cephalic presentation. Previous opioid administration excluded the patient from the study. When a patient requested pain relief, an extradural catheter was inserted at the L2/3 or L3/4 space via a 17-gauge Tuohy needle. A 4-ml test dose of 0.25% plain bupivacaine was injected. Patients were allocated randomly to one of the three groups. The ampoules of extradural solution had been coded randomly and prepared by the hospital pharmacy. Each ampoule contained 8 ml of 5% dextrose alone or in combination with either fentanyl 80 ug or 4 mg of preservative-free morphine hydrochloride. The pH values of the three solutions were, respectively, 4.46 (placebo), 4.83 (fentanyl) and 4.60 (morphine). The contents of the coded ampoule were administered extradurally 7 min after the test dose. Twelve minutes after the test dose, each parturient was given 0.25% plain bupivacaine 8 ml. This timing was chosen to avoid dilution of bupivacaine. The
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
The use of extradural opioids for pain relief in labour has been shown to be inefficient and hazardous [1—9]. It has been demonstrated, however, that the combination of an opioid and a local anaesthetic may improve both the onset and the duration of analgesia produced by the latter, and provide better quality of analgesia [10-13]. Niv and co-workers concluded that the concomitant use of extradural morphine 2 mg augmented the analgesic effect of 0.25% bupivacaine [12], but Cohen and colleagues found that the addition of extradural fentanyl 50 or 100 ug to 0.25 % bupivacaine 9 ml did not result in significant improvement in analgesia compared with the local anaesthetic alone [14]. The majority of clinical trials have been limited to small numbers of parturients, and none has compared fentanyl with morphine in combination with extradural bupivacaine. This study has been carried out in a prospective, randomized double-blind manner to compare, in a large study, the efficacy of extradural combinations of fentanyl with bupivacaine, morphine with bupivacaine and placebo with bupivacaine for control of labour pain.
BRITISH JOURNAL OF ANAESTHESIA
642
TABLE I. Maternal characteristics and state of cervical dilatation at the onset of the study (mean No significant differences
Placebo group (n = 85)
Morphine group (n = 83)
29.3 (0.6)
29.7 (0.6)
28.8 (0.7)
55.9 (0.9) 69.6(1.3) 163.0 (0.7)
57.1(1.0) 69.2(1.7) 164.0(0.8)
53.7(1.7) 69.8(1.8) 157.0(6.4)
57 28
53 28
58 25
39.6(0.1)
39.7(0.1)
39.7(0.1)
3.3(0.1)
3.4(0.1)
3.3(0.1)
duration of analgesia was defined as the time RESULTS between administration of the test dose and the first request for re-injection. Two hundred and fifty-five women entered the The patients were asked to rate the efficacy of study, but six coded ampoules were opened and the extradural block. Analgesia was considered not used. Thus data were obtained in 249 successful and adequate when contractions were parturients allocated randomly to one of the three painless. Inadequate pain relief was assessed as groups: placebo (« = 85), fentanyl (n = 81) and decreased but persisting painful contractions, morphine (n = 83). The three groups were compersisting painful area or lateralized analgesia. parable with regard to age, weight, height, parity, When a further injection was needed within 35 term and cervical dilatation at the time of the test min, patients were excluded from data analysis. dose (table I). Subsequently, 0.25% bupivacaine was adminDuration of analgesia. The mean duration of istered extradurally at the patient's request. pain relief induced by bupivacaine was signifiThroughout labour, fetal status was assessed by cantly greater in the group given fentanyl 80 |ig continuous fetal heart rate monitoring. The than after placebo (table II). In addition, signifipresence of adverse side-effects was also recorded, cantly more parturients were delivered vaginally including pruritus, nausea and vomiting, drowsi- without an additional dose of bupivacaine (table ness, hypotension (decrease in systolic arterial III). The time elapsed between test dose and pressure of more than 20%), respiratory de- delivery was not significantly different in these pression (ventilatory rate less than 10 b.p.m.). two groups (115 min v. 102 min). In the group The study was terminated at the first reinjection. given morphine the mean duration of pain relief All the results are presented as mean (SEM). induced by bupivacaine was not significantly Statistical analysis was performed using one-way longer than that in the placebo group. The analysis of variance, unpaired Student's t test and number of parturients delivered vaginally without Chi-square test, as appropriate. Statistical signifi- additional bupivacaine was not different in the morphine and placebo groups (table III). For the cance was assumed when P < 0.05. TABLE II. Mean duration of analgesia assessed as the interval between the test dose and first increment (mean (SEM)). *P < 0.05 compared with placebo. No other significant differences
Placebo group (n = 85) Parturients who required an increment Duration of analgesia (min)
68(80%) 97.2 (3.7)
Fentanyl group 48(54.2%) 132.5 (5.0)*
Morphine group (n = 83) 67 (80.7%) 109.6 (6.4)
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
Age (yr) Weight (kg) Before pregnancy At term Height (cm) Parity Primiparous Multiparous Term (week) Cervical dilatation (cm)
Fentanyl group (« = 81)
(SEM)).
EXTRADURAL BUPIVACAINE WITH FENTANYL OR MORPHINE
643
TABLE I I I . Parturients delivered vaginally without a further dose of bupivacaine. The data from five parturients in the fenlanyl group who progressed to Caesarean section before an increment was needed are not included in this table. *P < 0.05 compared with placebo
Placebo group (» = 85) Number Time elapsed between test dose and delivery (min)
17(20%) 102.5(9.5)
Fentanyl group
Morphine group (n = 83)
28(34.5%) 115.7(9.5)
16(19.3%) 92.3(9.9)
TABLE IV. Frequency of inadequate pain relief. *P <0.05 compared with placebo and fentanyl groups
Persisting painful contraction Residual painful area Lateralized analgesia
Fentanyl group (n = 81)
Morphine group (« = 83)
11(13%)
5(6.2%)
23(27.7%)*
4(4.7%) 4(4.7%)
4(4.9%) 0
12 (14.4%)* 4(4.8%)
TABLE V. Frequency of side-effects. *P < 0.01 compared with placebo group
Placebo group (n = 85) Itching Nausea and vomiting Drowsiness Hypotension Urinary retention
1 (1-2%) 11(13%) 1 (1-2%) 2 (2.4%) 1 (1-2%)
Fentanyl group (« = 81)
Morphine group {n = 83)
22(27.2%)* 6(7.4%) 11(13.6%)* 4(4.9%) 2 (2.4%)
20(24%)* 27(32.5%) 12(14.4%)* 3(3.6%) 5(6%)
Mode of delivery and Apgar scores. Sixty-eight parturients who were delivered without additional bupivacaine, the time elapsed between the test percent of patients had a normal vaginal delivery, dose and delivery was not significantly different 8 % had Caesarean section and 24 % had forceps (92 min v. 102 min). There was no significant delivery; there was no significant difference difference in duration of pain relief in the between the three groups. No changes in fetal heart pattern occurred in association with the morphine and fentanyl groups (table II). Efficacy of analgesia. There was an equal rate of extradural blocks. Apgar scores > 7 at 1 min and inadequate pain relief (persisting painful con- > 9 at 5 min were achieved in 94.8% and 98.4% traction or painful area) in the fentanyl and of neonates, respectively, with no significant placebo groups (table IV). However, there was a difference between the three groups. greater rate of inadequate pain relief in the morphine group, compared with the fentanyl and DISCUSSION placebo groups (table IV). Side effects. There was a higher rate of side In non-pregnant patients, extradural fentanyl effects in the fentanyl and morphine groups than produces a short lasting analgesic effect of rapid in the placebo group (table V). In both opioid onset [15]. In pregnant patients, extradural fengroups the frequency of pruritus and drowsiness tanyl has been shown to be effective only in was greater than in the placebo group (table V). achieving pain relief in the first stage of labour One patient with drowsiness in the morphine [4, 16, 17]. Several investigators [4, 10, 11, 13] group required repeated administration of reported that the combination of fentanyl with small doses of bupivacaine increased the duration naloxone.
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
Placebo group (« = 85)
644
1. 2. 3. 4. 5.
6. 7.
8.
Lafaye P, Gandar R. Hypoalgesie obstetricale par injection peridurale de morphine. Anesthe'sie Analge'sie et Re'ani-
mation 1981; 38: 35-41. 9. Writter WDR, James FM, Wheeler AS. Double blind comparison of morphine and bupivacaine for continuous epidural analgesia in labor. Anesthesiology 1981; 54: 215-219. 10. Desprats R, Mandry J, Grandjean H, Amar B, Pontonnier G, Lareng L. Analgesie peridurale au cours du travail: etude comparative de l'association fentanyl-marcaine et de la marcaine seule. Journal of Gyne'cologie Obstetrique et Biologie de la Reproduction 1983; 12: 901-905. 11. Justins DM, Francis D, Houlton PG, Reynolds F. A controlled trial of extradural fentanyl in labour. British Journal of Anaesthesia 1982; 54: 409^414. 12. Niv D, Rudick V, Golan A, Chayen MS. Augmentation of bupivacaine analgesia in labor by epidural morphine. Obstetrics and Gynecology 1986; 67: 206-209. 13. Youngstrom P, Eastwood D, Patel H, Bhathiar R, Cowan R, Sutheimer C. Epidural fentanyl and bupivacaine in labour: double-blind study. Anesthesiology 1984; 61: A414. 14. Cohen SE, Tan S, Albright CA, Halpern J. Epidural fentanyl/bupivacaine mixtures for obstetric analgesia. Anesthesiology 1987; 67: 403-^107. 15. Cousins MJ, Mather LE. Intrathecal and epidural administration of opioids. Anesthesiology 1984; 61: 276310. 16. Justins DM, Knott C, Luthman J, Reynolds F. Epidural versus intramuscular fentanyl analgesia and pharmacokinetics in labour. Anaesthesia 1983;.38: 937-942. 17. Vella LM, Willatts DG, Knott C, Lintin DJ, Justins DM, Reynolds F. Epidural fentanyl in labour: an evaluation of the systemic contribution to analgesia. Anaesthesia 1985; 40: 741-747. 18. Chauvin M, Samii K, Schermann JM, Sandouk P, Bourdon R, Viars P. Plasma pharmacokinetics of morphine after i.m., extradural and intrathecal administration. British Journal of Anaesthesia 1981; 54: 843-847. REFERENCES 19. Gustafsson LL, Frieberg-Nielsen S, Garle M. Extradural Booker PD, Wilkes RG, Bryson THL, Beddard J. and parenteral morphine kinetics and effects in postObstetric pain relief using epidural morphine. Anaesoperative pain. A controlled clinical study. British Journal thesia 1980; 35: 377-379. of Anaesthesia 1982; 54: 1167-1178. Carrie LES, O'Sullivan GM, Seegobin R. Epidural 20. Nordberg G, Hedner J, Mellstrand T, Dahlstrom B. Pharmacokinetics aspects of epidural morphine analgesia. fentanyl in labour. Anaesthesia 1981; 36: 965-969. Anesthesiology 1983; 58: 545-551. Crawford JS. Experience with epidural morphine in 21. Rawal N, Sjostrand JH, Dahlstrom B. Post-operative pain obstetrics. Anaesthesia 1981; 36: 207-209. relief by epidural morphine. Anesthesia and Analgesia Francis DM, Justins D, Reynolds FJM. Obstetric pain 1981; 60: 726-736. relief using epidural narcotic agents. Anaesthesia 1981; 36: 69. 22. Tamsen A, Sjostrom S, Hartvig P, Perrson P, Gabrielsson J, Paalzow L. CSF and plasma kinetics of morphine and Hughes SC, Rosen MA, Shnider SM, Abboud TK, Stefani SJ, Norton M. Maternal and neonatal effects of meperidine after epidural administration. Anesthesiology 1983; 59: A196. epidural morphine for labor and delivery. Anesthesia and Analgesia 1984; 63: 319-324. 23. Thompson WR, Smith PT, Hirst M, Varhey GP, Knill Husemeyer RP, O'Connor MC, Davenport JCT. Failure RL. Regional analgesic effect of epidural morphine in of epidural morphine to relieve pain in labour. Anaesthesia volunteers. Canadian Anaesthetic Society Journal 1981; 1980; 35: 161-163. 28: 530-536. Magora F, Olshwand D, Eimerl D, Shorr J, Katzenelson 24. Nybell-Lindahl G, Carlsson C, Ingemarsson I, Westgren R, Cotev S, Davidson JT. Observations on extradural M, Paalzow L. Maternal and fetal concentrations of morphine analgesia in various pain conditions. British morphine after epidural administration during labour. Journal of Anaesthesia 1980; 52: 247-252. American Journal of Obstetrics and Gynecology 1981; 139: 20-21. Muller A, Laugner B, Farcot JM, Singer M, Gauthier-
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of analgesia provided by bupivacaine alone administered extradurally. However, in a recent study [14] the addition of fentanyl 50 or 100 ug to 9 ml of 0.25 % extradural bupivacaine following a test dose of 1 % lignocaine 3 ml was not found to prolong analgesia. In our study, the addition of fentanyl 80 ug to 0.25% bupivacaine 8 ml after a test dose of 0.25 % bupivacaine 4 ml was found to increase significantly the duration of analgesia produced by bupivacaine. Our study confirmed the observations of Cohen [14] that the combination did not increase the success rate of complete analgesia produced by bupivacaine. In addition, no clinical respiratory depression was reported with the fentanyl combination. In non-pregnant women, extradural morphine alone provides a long-lasting analgesia of slow onset. In pregnant women, extradural morphine alone, in a dose of 5 mg or less, is ineffective in providing satisfactory pain relief throughout labour [1,3, 5-9], probably because the extradural vascular congestion of pregnancy enhances vascular absorption of morphine [18-24]. Several investigators have reported that extradural bupivacaine improves the quality of analgesia when administered after [9] or simultaneously with [12] extradural morphine during the first stage of labour. However, in our double-blind study we could not demonstrate any improvement in analgesia by combining morphine with bupivacaine.
BRITISH JOURNAL OF ANAESTHESIA
CONTROLLED TRIAL OF EXTRADURAL BUPIVACAINE WITH FENTANYL, MORPHINE OR PLACEBO FOR PAIN RELIEF IN LABOUR J. D. LIRZIN, P. JACQUINOT, P. DAILLAND, J. C. JORROT, J. JASSON, M. L. TALAFRE AND C. CONSEILLER
PATIENTS AND METHODS
The study was approved by the Hospital Ethics Committee and informed consent was obtained from all participating patients—255 healthy pregnant women with uncomplicated full-term gestation (> 38 week) who elected to have extradural analgesia for labour and delivery. All patients J. D. LIRZIN, M . D ; P. JACQUINOT, M.D. ; P. DAILLAND, M.D. ;
J. C. JORROT, M.D.; J. JASSON, M.D.; M. L. TALAFRE, M.D.; C. CONSEILLER, M.D.; Department d'Anesthesie et de Reanimation chirurgicale, Hopital universitaire Cochin-Maternites, 123, Boulevard Port-Royal 75014, Paris, France. Accepted for Publication: December 12, 1988.
SUMMARY In a prospective, randomized double-blind study carried out on 255 parturients, fentanyl 80 ug (v\ = 81), morphine 4 mg (n = 83) or placebo (n - 85) was added to 0.25% bupivacaine administered extradurally for pain relief during labour. Fentanyl increased the mean duration of bupivacaine analgesia by 30% and did not reduce the rate of inadequate pain relief. Morphine did not increase the mean duration of bupivacaine analgesia significantly, but increased the rate of inadequate pain relief. It was concluded that morphine 4 mg added to extradural 0.25% bupivacaine was of no value.
were in labour with a healthy singleton fetus in a cephalic presentation. Previous opioid administration excluded the patient from the study. When a patient requested pain relief, an extradural catheter was inserted at the L2/3 or L3/4 space via a 17-gauge Tuohy needle. A 4-ml test dose of 0.25% plain bupivacaine was injected. Patients were allocated randomly to one of the three groups. The ampoules of extradural solution had been coded randomly and prepared by the hospital pharmacy. Each ampoule contained 8 ml of 5% dextrose alone or in combination with either fentanyl 80 ug or 4 mg of preservative-free morphine hydrochloride. The pH values of the three solutions were, respectively, 4.46 (placebo), 4.83 (fentanyl) and 4.60 (morphine). The contents of the coded ampoule were administered extradurally 7 min after the test dose. Twelve minutes after the test dose, each parturient was given 0.25% plain bupivacaine 8 ml. This timing was chosen to avoid dilution of bupivacaine. The
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
The use of extradural opioids for pain relief in labour has been shown to be inefficient and hazardous [1—9]. It has been demonstrated, however, that the combination of an opioid and a local anaesthetic may improve both the onset and the duration of analgesia produced by the latter, and provide better quality of analgesia [10-13]. Niv and co-workers concluded that the concomitant use of extradural morphine 2 mg augmented the analgesic effect of 0.25% bupivacaine [12], but Cohen and colleagues found that the addition of extradural fentanyl 50 or 100 ug to 0.25 % bupivacaine 9 ml did not result in significant improvement in analgesia compared with the local anaesthetic alone [14]. The majority of clinical trials have been limited to small numbers of parturients, and none has compared fentanyl with morphine in combination with extradural bupivacaine. This study has been carried out in a prospective, randomized double-blind manner to compare, in a large study, the efficacy of extradural combinations of fentanyl with bupivacaine, morphine with bupivacaine and placebo with bupivacaine for control of labour pain.
BRITISH JOURNAL OF ANAESTHESIA
642
TABLE I. Maternal characteristics and state of cervical dilatation at the onset of the study (mean No significant differences
Placebo group (n = 85)
Morphine group (n = 83)
29.3 (0.6)
29.7 (0.6)
28.8 (0.7)
55.9 (0.9) 69.6(1.3) 163.0 (0.7)
57.1(1.0) 69.2(1.7) 164.0(0.8)
53.7(1.7) 69.8(1.8) 157.0(6.4)
57 28
53 28
58 25
39.6(0.1)
39.7(0.1)
39.7(0.1)
3.3(0.1)
3.4(0.1)
3.3(0.1)
duration of analgesia was defined as the time RESULTS between administration of the test dose and the first request for re-injection. Two hundred and fifty-five women entered the The patients were asked to rate the efficacy of study, but six coded ampoules were opened and the extradural block. Analgesia was considered not used. Thus data were obtained in 249 successful and adequate when contractions were parturients allocated randomly to one of the three painless. Inadequate pain relief was assessed as groups: placebo (« = 85), fentanyl (n = 81) and decreased but persisting painful contractions, morphine (n = 83). The three groups were compersisting painful area or lateralized analgesia. parable with regard to age, weight, height, parity, When a further injection was needed within 35 term and cervical dilatation at the time of the test min, patients were excluded from data analysis. dose (table I). Subsequently, 0.25% bupivacaine was adminDuration of analgesia. The mean duration of istered extradurally at the patient's request. pain relief induced by bupivacaine was signifiThroughout labour, fetal status was assessed by cantly greater in the group given fentanyl 80 |ig continuous fetal heart rate monitoring. The than after placebo (table II). In addition, signifipresence of adverse side-effects was also recorded, cantly more parturients were delivered vaginally including pruritus, nausea and vomiting, drowsi- without an additional dose of bupivacaine (table ness, hypotension (decrease in systolic arterial III). The time elapsed between test dose and pressure of more than 20%), respiratory de- delivery was not significantly different in these pression (ventilatory rate less than 10 b.p.m.). two groups (115 min v. 102 min). In the group The study was terminated at the first reinjection. given morphine the mean duration of pain relief All the results are presented as mean (SEM). induced by bupivacaine was not significantly Statistical analysis was performed using one-way longer than that in the placebo group. The analysis of variance, unpaired Student's t test and number of parturients delivered vaginally without Chi-square test, as appropriate. Statistical signifi- additional bupivacaine was not different in the morphine and placebo groups (table III). For the cance was assumed when P < 0.05. TABLE II. Mean duration of analgesia assessed as the interval between the test dose and first increment (mean (SEM)). *P < 0.05 compared with placebo. No other significant differences
Placebo group (n = 85) Parturients who required an increment Duration of analgesia (min)
68(80%) 97.2 (3.7)
Fentanyl group 48(54.2%) 132.5 (5.0)*
Morphine group (n = 83) 67 (80.7%) 109.6 (6.4)
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
Age (yr) Weight (kg) Before pregnancy At term Height (cm) Parity Primiparous Multiparous Term (week) Cervical dilatation (cm)
Fentanyl group (« = 81)
(SEM)).
EXTRADURAL BUPIVACAINE WITH FENTANYL OR MORPHINE
643
TABLE I I I . Parturients delivered vaginally without a further dose of bupivacaine. The data from five parturients in the fenlanyl group who progressed to Caesarean section before an increment was needed are not included in this table. *P < 0.05 compared with placebo
Placebo group (» = 85) Number Time elapsed between test dose and delivery (min)
17(20%) 102.5(9.5)
Fentanyl group
Morphine group (n = 83)
28(34.5%) 115.7(9.5)
16(19.3%) 92.3(9.9)
TABLE IV. Frequency of inadequate pain relief. *P <0.05 compared with placebo and fentanyl groups
Persisting painful contraction Residual painful area Lateralized analgesia
Fentanyl group (n = 81)
Morphine group (« = 83)
11(13%)
5(6.2%)
23(27.7%)*
4(4.7%) 4(4.7%)
4(4.9%) 0
12 (14.4%)* 4(4.8%)
TABLE V. Frequency of side-effects. *P < 0.01 compared with placebo group
Placebo group (n = 85) Itching Nausea and vomiting Drowsiness Hypotension Urinary retention
1 (1-2%) 11(13%) 1 (1-2%) 2 (2.4%) 1 (1-2%)
Fentanyl group (« = 81)
Morphine group {n = 83)
22(27.2%)* 6(7.4%) 11(13.6%)* 4(4.9%) 2 (2.4%)
20(24%)* 27(32.5%) 12(14.4%)* 3(3.6%) 5(6%)
Mode of delivery and Apgar scores. Sixty-eight parturients who were delivered without additional bupivacaine, the time elapsed between the test percent of patients had a normal vaginal delivery, dose and delivery was not significantly different 8 % had Caesarean section and 24 % had forceps (92 min v. 102 min). There was no significant delivery; there was no significant difference difference in duration of pain relief in the between the three groups. No changes in fetal heart pattern occurred in association with the morphine and fentanyl groups (table II). Efficacy of analgesia. There was an equal rate of extradural blocks. Apgar scores > 7 at 1 min and inadequate pain relief (persisting painful con- > 9 at 5 min were achieved in 94.8% and 98.4% traction or painful area) in the fentanyl and of neonates, respectively, with no significant placebo groups (table IV). However, there was a difference between the three groups. greater rate of inadequate pain relief in the morphine group, compared with the fentanyl and DISCUSSION placebo groups (table IV). Side effects. There was a higher rate of side In non-pregnant patients, extradural fentanyl effects in the fentanyl and morphine groups than produces a short lasting analgesic effect of rapid in the placebo group (table V). In both opioid onset [15]. In pregnant patients, extradural fengroups the frequency of pruritus and drowsiness tanyl has been shown to be effective only in was greater than in the placebo group (table V). achieving pain relief in the first stage of labour One patient with drowsiness in the morphine [4, 16, 17]. Several investigators [4, 10, 11, 13] group required repeated administration of reported that the combination of fentanyl with small doses of bupivacaine increased the duration naloxone.
Downloaded from http://bja.oxfordjournals.org/ at University of Saskatchewan on March 18, 2015
Placebo group (« = 85)
644
1. 2. 3. 4. 5.
6. 7.
8.
Lafaye P, Gandar R. Hypoalgesie obstetricale par injection peridurale de morphine. Anesthe'sie Analge'sie et Re'ani-
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of analgesia provided by bupivacaine alone administered extradurally. However, in a recent study [14] the addition of fentanyl 50 or 100 ug to 9 ml of 0.25 % extradural bupivacaine following a test dose of 1 % lignocaine 3 ml was not found to prolong analgesia. In our study, the addition of fentanyl 80 ug to 0.25% bupivacaine 8 ml after a test dose of 0.25 % bupivacaine 4 ml was found to increase significantly the duration of analgesia produced by bupivacaine. Our study confirmed the observations of Cohen [14] that the combination did not increase the success rate of complete analgesia produced by bupivacaine. In addition, no clinical respiratory depression was reported with the fentanyl combination. In non-pregnant women, extradural morphine alone provides a long-lasting analgesia of slow onset. In pregnant women, extradural morphine alone, in a dose of 5 mg or less, is ineffective in providing satisfactory pain relief throughout labour [1,3, 5-9], probably because the extradural vascular congestion of pregnancy enhances vascular absorption of morphine [18-24]. Several investigators have reported that extradural bupivacaine improves the quality of analgesia when administered after [9] or simultaneously with [12] extradural morphine during the first stage of labour. However, in our double-blind study we could not demonstrate any improvement in analgesia by combining morphine with bupivacaine.
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