Suzanne M. Cox

Postcesarean analgesia with both epidural morphine and intravenous patient-controlled analgesia: neurobehavioral outcomes among nursing neonates.

PhD*‘I[ Departments of *Anesthesia and Critical Care, P[Statistics, and SObstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Anesthesia, tuniversity of Washington, Seattle, Washington, and §Saint Francis Hospital, Blue Island, Illinois; and IlDepartment of Psychology, University of Beloit, Beloit, Wisconsin Among nursing parturients after cesarean delivery, in- travenous patient-controlled analgesia (PCA) with me- peridine is associated with significantly more neonatal neurobehavioral depression than PCA with morphine. A single dose of epidural morphine (4 mg) decreases postcesarean opioid analgesic requirements and may reduce or prevent neonatal neurobehavioral depres- sion associated with PCA meperidine. Prospectively, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. After umbilical cord clamping, each patient received epidural morphine 4 mg and was randomly allocated to receive either PCA meperidine or PCA morphine. Initial neonatal characteristics, included ges- tational age, Apgar scores, weight, and umbilical cord gas partial pressures. Brazelton Neonatal Behavioral Assessment Scale (NBAS) examinations were per- formed on each of the first 4 days of life. Nursing infants (n = 47) were grouped according to maternal PCA opi- oid in breast milk (meperidine [n = 241 or morphine [n = 231); bottle-fed infants (n = 56) served as the con- trol group. The three infant groups were equivalent with respect to initial characteristics and NBAS scores on the first 2 days of life. On the third day of life, infants in the morphine group were significantly more alert and oriented to animate human cues compared with infants in the meperidine or control group. On the fourth day of life, infants in the morphine group re- mained significantly more alert and oriented to animate human auditory cues than infants in the meperidine group. Average PCA opioid consumption through 48 h postpartum was equivalent (0.54 mg/ kg morphine and 4.7 mg/kg meperidine); however, even with these small doses, meperidine was associated with signifi- cantly poorer neonatal alertness orientation than morphine. Morphine is the PCA opioid of choice for postcesarean analgesia among nursing parturients. Im- plications: Among nursing parturients after cesarean delivery, intravenous patient-controlled analgesia with meperidine is associated with more neonatal neurobe- havioral depression than patient-controlled analgesia with morphine. In this study, we found that nursing infants exposed to morphine were more alert and ori- ented to animate human cues than those exposed meperidine. (Anesth Analg 1997;85:600-6)

Opioid antagonist adjuncts to epidural morphine for postcesarean analgesia: maternal outcomes.

This prospective, randomized, controlled investigation compared the effects of three prophylactic mu-opioid antagonists, epidural butorphanol (BU) 3 mg, epidural nalbuphine (NB) 10 mg, and oral naltrexone (NX) 6 mg, on postcesarean epidural morphine analgesia. After randomization, 102 term parturients underwent cesarean delivery with epidural anesthesia, 2% lidocaine and epinephrine 1:200,000. When the umbilical cord was clamped, each patient received one epidural solution (containing morphine 4 mg plus either saline or treatment drug), and one oral capsule (containing either placebo or treatment drug) in a double-blind manner. Maternal outcomes included pain and satisfaction [assessed with 100-mm visual analog scales (VAS)], and the incidence and severity of respiratory depression, somnolence, pruritus, nausea, and emesis. Through the first 12 h postpartum, the BU group achieved significantly greater analgesia than the morphine sulfate (control) (MS), NB, and NX groups, a significantly lower incidence of severe pruritus than the MS group, and significantly greater satisfaction than MS and NX groups. Epidural morphine and BU promoted better analgesia and satisfaction than any previously documented postcesarean regimen.