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Department of Anesthesia; Stanford University School of Medicine; Stanford, CA
In Response:
Studies by Dualé et al. (1) and Sarvela et al. (2), as highlighted by Dr. Roboubi (3), found similar analgesic efficacy and duration when comparing equianalgesic doses of intrathecal and epidural morphine for the first 24 h postcesarean. In light of the fact that we found extended-release epidural morphine provided superior analgesia compared with epidural morphine (4), and in keeping with Duale et al. (1) and Sarvela et al.’s. (2) findings, we would expect extended-release epidural morphine to provide superior analgesia over an equianalgesic dose of intrathecal morphine, especially 24–48 h after cesarean delivery when the intrathecal morphine dose is no longer effective and peak pain levels are experienced.
Despite patients using more than twice the amount of postoperative analgesics in the second 24 h postcesarean, serial pain scores at rest and activity were consistently lower (approximately a 50% reduction in pain in the 24–48 h postoperative period) in the extended-release epidural morphine compared with the morphine group (4). As Dr. Roboubi highlights, the overall pain scores during the 24–48 h period were 3.5 in the morphine vs 2.2 in the extended-release epidural morphine group a >33% reduction in pain, a level most clinicians accept as clinically significant pain relief.
We agree with Dr. Roboubi that spinal anesthesia offers advantages over epidural anesthesia in terms of time and cost (5). The simplicity and advantages of spinal anesthesia, not differences in postdural puncture headache or complications, has in part resulted in spinal anesthesia becoming the most commonly utilized technique for elective cesarean delivery (6). Although one of our patients experienced a dural puncture, the risk of postdural puncture headache is no different with spinal, epidural, or combined spinal-epidural techniques (7).
Clinicians may be able to incorporate extended-release epidural morphine into their practice without significantly adjusting their anesthetic technique. Many clinicians use combined spinal-epidural for all elective cesarean deliveries or in selected patients where the duration of the cesarean delivery is expected to extend beyond that provided by spinal anesthesia. In addition, many cesarean deliveries are performed during labor in women with epidurals in situ.
In conclusion, based on our finding (4) and results from the previous multicenter study of extended-release epidural morphine postcesarean (8), we feel that extended-release epidural morphine provides statistically and clinically superior pain relief for up to 48 h following cesarean delivery compared with standard neuraxial morphine. Even if routine use is not practical, selective use of extended-release epidural morphine may be beneficial in a subset of patients with significant analgesic needs.
REFERENCES
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