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© 1999 International Anesthesia Research Society
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Abstract |
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The intrathecal injection of 0.7–1 mg/kg meperidine provides spinal anesthesia of only short duration. In this study, we investigated the effects of three different doses of meperidine for spinal anesthesia on the duration and level of sensory block and the incidence of side effects. Forty-five African men were randomly allocated to receive one of three doses of intrathecal meperidine: Group A = 1.2 mg/kg, Group B = 1.5 mg/kg, and Group C = 1.8 mg/kg. The duration of sensory block was significantly longer after 1.5 mg/kg compared with 1.2 mg/kg meperidine (112 ± 19 vs 79 ± 27 min; P = 0.001). Increasing the dose to 1.8 mg/kg did not further increase the duration of block. The level and the onset of the block were not affected by the dose. Common side effects were fatigue (27%), pruritus (20%), and nausea (7%). Seven patients had respiratory depression and seven had a decrease of systolic arterial blood pressure (SAP) >30% from baseline. There was no difference in the incidence of any side effect among groups. Respiratory depression and decreases in SAP were observed 5–50 min after meperidine injection. Twenty-two patients had no pain after the sensory block had terminated. We conclude that increasing the dose of meperidine from 1.2 to 1.5 mg/kg increased the duration, but not the level, of sensory block without an increase in side effects.
Implications: Intrathecal meperidine 1 mg/kg provides surgical anesthesia for only 40–90 min. We investigated the effects of three larger doses of meperidine in 45 African men. The 1.5 and 1.8 mg/kg doses provide a longer duration of anesthesia compared with 1.2 mg/kg. Nausea, pruritus, and respiratory depression were common in all dose groups. We conclude that increasing the dose of meperidine from 1.2 to 1.5 mg/kg increased the duration, but not the level, of sensory block without an increase in side effects.
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Introduction |
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The analgesic effect of opioids is due to binding to specific opiate receptors. In addition, weak local anesthetic effects can be demonstrated for fentanyl and sufentanil (1). Only meperidine has strong local anesthetic properties providing surgical anesthesia after intrathecal administration (2–10). Furthermore, intrathecal meperidine provides extended postoperative analgesia (3,5,6), rendering it an interesting alternative for spinal anesthesia in countries where local anesthetics are not always available. However, the side effects of meperidine spinal anesthesia are pruritus, nausea, and respiratory depression (2,3,5). A dose of 1 mg/kg intrathecal meperidine provides surgical anesthesia for 40–77 min (3,6,7,10), a duration that may be too short for some procedures (9,11).
The purpose of this study was to determine whether larger doses of intrathecal meperidine provide a longer duration of spinal anesthesia without increasing the incidence of side effects.
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Methods |
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This prospective, single-blinded, randomized study was performed in the Lilongwe Central Hospital, Malawi, Africa. The study was approved by the local ethical committee. Informed consent was provided by the patients.
Forty-five male patients, ASA physical status I or II, undergoing either transvesical prostatectomy (retropubic approach), hernia repair, or hemorrhoidectomy were randomly allocated (using a randomization table) to receive one of three doses of intrathecal meperidine: Group A = 1.2 mg/kg (n = 15), Group B = 1.5 mg/kg (n = 15), Group C = 1.8 mg/kg (n = 15). After the IV administration of 15 mL/kg lactated Ringer’s solution, lumbar puncture was performed at the L3–4 or L4–5 level with patients in the sitting position. A dose of 1.2, 1.5, or 1.8 mg/kg preservative-free meperidine 5% was injected over 10 s into the subarachnoid space. The patients were turned into the supine position without any tilt of the table. The level of the sensory block was determined using the pinprick method every 5 min before, during, and after surgery by a second anesthetist blinded to the dose injected. The assessment was continued at 5-min intervals until sensations had returned at the L5 dermatome.
Patients were given 5–10 mg of diazepam IV for sedation if needed. Measurements of heart rate (HR), arterial hemoglobin oxygen saturation (SaO2), and systolic arterial blood pressure (SAP) were noted before intrathecal injection and every 5 min until the block had terminated. Respiratory depression was defined as SaO2 <90% while the respiratory rate was <15 breaths/min. If the SaO2 decreased <90%, oxygen was given via a face mask with the patient taking deep breaths. If these measures did not increase the SaO2 within 60 s, naloxone was given IV in repeated doses of 0.08 mg until the SaO2 increased. Significant hypotension was defined as a decrease of the SAP of >30% from baseline and was treated by infusion of 1 L of lactated Ringer’s solution. If the patient did not respond, 5–10 mg of ephedrine was given IV. During and after the operation, the patient was asked about the presence of nausea, pruritus, or fatigue. When the sensory block had terminated completely, the patient was asked whether he felt no pain, slight pain, or severe pain.
One-way analysis of variance and Student’s t-test for unpaired samples with Bonferroni correction was used for analyzing the differences in parametric data among the groups. The 
2 test was used for nonparametric data. P < 0.05 was considered statistically significant.
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Results |
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Demographic data, baseline HR and SAP, and the surgical procedures did not differ significantly among the groups (Table 1). The mean dose of meperidine administered was 66 ± 11 mg in Group A, 85 ± 8 mg in Group B, and 105 ± 19 mg in Group C. Three patients in Group A and one patient in Group C required general anesthesia because of short duration of the block (<60 min). Four excited patients (one in Group A, two in Group B, and one in Group C) were sedated intraoperatively with 10 mg of diazepam IV. The sensory block was adequate in these patients. The duration of the block was significantly longer in Groups B and C (112 ± 19 and 118 ± 24 min, respectively) than in Group A (79 ± 28 min). Increasing the dose to 1.8 mg/kg had no further effect on the duration of the block compared with 1.5 mg/kg (Fig. 1). The level of the block was not affected by the dose of meperidine (T7 ± 3 segments in Group A, T7 ± 2 segments in Group B, and T6 ± 3 segments in Group C).
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The time to maximal cephalic spread of the sensory block was not affected by the dose and was reached after 13 ± 5 min in Group A, 16 ± 9 min in Group B, and 15 ± 9 min in Group C.
After the resolution of sensory block, no patient complained of severe pain. Five patients in Group A, eight in Group B, and nine in Group C did not feel any pain. Hypoxia was detected in seven patients, one of whom received diazepam for sedation (Table 2). Only one patient required naloxone 0.2 mg, after which the SaO2 increased to 97%. The sensory block was not affected by the naloxone administration, and the surgical procedure was completed without further sedation. Onset of respiratory depression was observed 15–40 min after the injection of meperidine and 5–25 min after the block had reached the maximal spread (Fig. 2).
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Hypotension was observed in seven patients (Table 2). The SAP decreased within the first 5 min after injection of meperidine in one patient and within 15–50 min in the other six patients (Fig. 2). Surgical bleeding was not observed in these patients. In three patients (two in Group A and one in Group B), the decrease in SAP was associated with respiratory depression.
There was no difference in the incidence of side effects among the groups.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This is the first study to investigate the duration of sensory block after three graded doses of intrathecal meperidine. The most important result of this study is that meperidine 1.5 mg/kg provides a longer duration of sensory block than 1.2 mg/kg. Increasing the dose further has no effect on the duration of sensory block. The 78-min duration of spinal block after the administration of 1.2 mg/kg meperidine in our study is similar to the 40–77 min duration after the administration of 1 mg/kg reported by other authors (3,6,7,10). We used a dose of 1 mg/kg in a pilot study in seven patients. In five of these patients, the duration of surgical anesthesia was too short and we had to convert to general anesthesia.
In contrast to those studies and our experience, Cozian et al. (12) reported a longer duration of sensory block (112 min) with 1 mg/kg meperidine. This discrepancy may be due to differences in methodology and patient population. In Cozian et al.’s study (12), assessment of the regression of the sensory block was performed at 30-min intervals, which may have resulted in an overestimation of block duration. Furthermore, the patients were significantly older (mean age 71 yr) than those in our study and others, a factor that may have affected the duration of sensory block. Methodological differences in the assessment of sensory block may also affect the apparent duration of sensory block. In six of nine studies, the resolution of block was not allocated to a specific dermatome (3,4,7–9,12). In the other studies, resolution to L1 (5), L2 (6), or L5 (2) was assessed. In agreement with the latter, we chose the L5 dermatome for resolution of block. Thus, we may have missed a longer duration of block in the sacral dermatomes. Body weight or ethnicity may be other factors affecting sensory block duration. The body weight of our subjects was low, resulting in a dose of meperidine <100 mg in most of the patients. Many previous studies investigating intrathecal meperidine were performed in Asians with low body weight (3–5,9,10). Whether our results apply to patients with higher body weight or to other ethnic groups must be investigated further.
Interestingly, the maximal dermatomal extent of the block was not affected by the dose. The specific gravity of the 5% meperidine solution is 1.026, rendering it hyperbaric, which may have been a more important factor than dose variations (3). We did not assess the duration and resolution of motor block because early mobilization was not an issue in our patients. Our primary interest was to extend the duration of surgical anesthesia (i.e., sensory block) of intrathecal meperidine.
Side effects are common after intrathecal meperidine. The incidence of itching can be 10%–35% (2,3,5,12), and fatigue has often been observed (3). In our study, the incidence of these side effects was similar and was not dose-related. The incidence of respiratory depression is controversial: some authors reported none (2,3,6–9), whereas others reported hypoxia in up to 10% of patients (5). Ong and Segstro (14) presented two cases of severe respiratory depression after the administration of meperidine 50 mg. We found respiratory depression a common and potentially serious complication. It occurred as late as 40 min after intrathecal injection, possibly a result of the systemic reabsorption of meperidine from the cerebrospinal fluid (15) or intrathecal cephalic spread. The peak plasma concentration of meperidine occurs 90 min after an intrathecal injection of 1 mg/kg (15).
The late hypotension observed in six patients in this study may also be a systemic effect of meperidine, adding to the hemodynamic effects induced by the block of the sympathetic nervous system.
We found no differences in the incidence of side effects among the groups. Because our study was powered to detect differences in duration of sensory block but not to find differences in side effects, this may be due to the small number of patients studied.
Only 23 of 45 patients felt slight pain after the sensory block had terminated. The duration of postoperative analgesia after intrathecal meperidine is longer than the duration of sensory block (7) and may be due to activation of intraspinally located opioid receptors.
We conclude that increasing the dose of meperidine for spinal anesthesia from 1.2 to 1.5 mg/kg provides a longer duration of sensory block without affecting the sensory level, the time to maximal spread, or the incidence of side effects. The most serious side effect was respiratory depression, which may be delayed. In countries where local anesthetics are not always available, intrathecal meperidine is an alternative for spinal anesthesia if continuous monitoring of the patient’s SaO2 and SAP for at least 90 min after meperidine administration can be provided.
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References |
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