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OBSTETRIC ANESTHESIA

Postcesarean Analgesia with Spinal Morphine, Clonidine, or Their Combination

Michael J. Paech, FANZCA^*,, Timothy J. G. Pavy, FANZCA^*, Christopher E. P. Orlikowski, FRCA^*, Seng T. Yeo, FRCA^*, Samantha L. Banks, FRCA^*, Sharon F. Evans, PhD, and Jennifer Henderson, MPH Section Editor

*School of Medicine and Pharmacology, University of Western Australia and Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth; and Biostatistics and Research Support, Women and Infants Research Foundation, Subiaco, Western Australia

Address correspondence and reprint requests to Associate Professor Michael Paech, Department of Anesthesia and Pain Medicine, King Edward Memorial Hospital for Women, 374 Bagot Rd., Subiaco 6008 Western Australia, Australia

In this randomized, double-blind trial in 240 women, we investigated the analgesic efficacy and duration of subarachnoid fentanyl 15 µg with morphine, clonidine, or both morphine and clonidine for cesarean delivery. A dose-finding analysis showed similar postoperative efficacy and side effects for groups receiving morphine 100 µg with clonidine 60, 90, or 150 µg. Data from these groups were combined (MC60–150, n = 113) and compared with groups receiving morphine 100 µg (n = 39), clonidine 150 µg (n = 39), or morphine 100 µg plus clonidine 30 µg (n = 41). The four groups differed in the time to patient-controlled morphine use and cumulative morphine consumption (P < 0.0001 and P < 0.001, respectively), with the longest duration and smallest dose in MC60–150. Pain scores were significantly different among groups. Onset of sensory block, ephedrine requirement and incidence of hypotension, patient satisfaction, and recovery were similar. Groups receiving clonidine had greater sedation, those receiving morphine had more severe pruritus, and group MC60–150 showed a trend to more vomiting intraoperatively. Compared with morphine 100 µg or clonidine 150 µg alone, the combination of subarachnoid morphine 100 µg and at least 60 µg of clonidine was found to increase the duration of postcesarean analgesia, reduce opioid requirement, and increase intraoperative sedation.

IMPLICATIONS: A multimodal approach to postcesarean analgesia, using subarachnoid bupivacaine, fentanyl, morphine 100 µg, and clonidine 60 µg, improves pain relief compared with morphine 100 µg or clonidine 150 µg alone, but increases intraoperative sedation and may increase perioperative vomiting.

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