Intrathecal morphine does not prevent chronic postsurgical pain after elective Caesarean delivery: a randomised controlled trial

Background: Morphine is frequently added to spinal anaesthesia for Caesarean delivery. We aimed to determine whetherintrathecal morphine for spinal anaesthesia decreases the risk of chronic postsurgical pain (CPSP).Methods: In this randomised, double-blind, placebo-controlled trial, 290 healthy parturients undergoing electiveCaesarean delivery were randomly assigned in a 1:1 ratio to receive either intrathecal morphine 100 mg (n 145) or normalsaline (control; n 145) as a part of spinal anaesthesia. Anaesthetic care and postoperative pain management werestandardised in all patients. The primary outcome was the incidence of CPSP at 3 months. Secondary outcomes includedCPSP at 6 months, pain severity, and pain interference, measured by the Brief Pain Inventory questionnaire using an 11-point numeric rating scale, at 3 and 6 months after the surgery.Results: Two hundred and seventy-six patients completed the 3-month follow-up, 139 in the morphine group and 137 inthe placebo group. The incidences of CPSP at 3 months were 19% (27 of 139) in the morphine group and 18% (25 of 137) inthe placebo group (odds ratio, 1.08; 95% confidence interval, 0.59e1.97; P 0.803). At 6 months, CPSP was present in 23 of139 (16%) morphine group patients compared with 19 of 137 (14%) in the placebo group (odds ratio, 1.23; 95% confidenceinterval, 0.63e2.38; P 0.536). Brief Pain Inventory questionnaire scores for pain severity and pain interference at 3 and 6months were similar between groups.Conclusions: Administration of morphine 100 mg as a component of spinal anaesthesia for elective Caesarean deliveryfailed to reduce the incidence of chronic pain at 3 and 6 months after surgery.Perioperative Medicine: Efficacy, Safety and Outcome (Anesthesiology/Intensive Care

Factors associated with failed epidural blood patch after accidental dural puncture in obstetrics: a prospective, multicentre, international cohort study

BackgroundEpidural blood patch is commonly used for management of post-dural puncture headache after accidental dural puncture. The primary aim was to determine factors associated with failed epidural blood patch.MethodsIn this prospective, multicentre, international cohort study, parturients ≥18 yr receiving an epidural blood patch for treatment of post-dural puncture headache were included. Failed epidural blood patch was defined as headache intensity numeric rating scale (NRS) score ≥7 in the upright position at 4, 24, or 48 h, or the need for a second epidural blood patch, and complete success by NRS=0 at 0–48 h after epidural blood patch. All others were considered partial success. Multinominal logistic regression was used for statistical analyses with PResultsIn all, 643 women received an epidural blood patch. Complete data to classify failure were available in 591 (91.9%) women. Failed epidural blood patch occurred in 167 (28.3%) patients; 195 (33.0%) were completely successful and 229 (38.7%) partially successful. A total of 126 women (19.8%) received a second epidural blood patch. A statistically significant association with failure was observed in patients with a history of migraine, when the accidental dural puncture occurred between lumbar levels L1/L3 compared with L3/L5 and when epidural blood patch was performed bleeds were diagnosed.ConclusionsFailed epidural blood patch occurred in 28.3% of women. Independent modifiable factors associated with failure were higher lumbar level of accidental dural puncture and short interval between accidental dural puncture and epidural blood patch. A history of migraine was associated with a higher risk of second epidural blood patch.</div

Management practices for postdural puncture headache in obstetrics: a prospective, international, cohort study

Background: Accidental dural puncture is an uncommon complication of epidural analgesia and can cause postdural puncture headache (PDPH). We aimed to describe management practices and outcomes after PDPH treated by epidural blood patch (EBP) or no EBP. Methods: Following ethics committee approval, patients who developed PDPH after accidental dural puncture were recruited from participating countries and divided into two groups, those receiving EBP or no EBP. Data registered included patient and procedure characteristics, headache symptoms and intensity, management practices, and complications. Follow-up was at 3 months. Results: A total of 1001 patients from 24 countries were included, of which 647 (64.6%) received an EBP and 354 (35.4%) did not receive an EBP (no-EBP). Higher initial headache intensity was associated with greater use of EBP, odds ratio 1.29 (95% confidence interval 1.19–1.41) per pain intensity unit increase. Headache intensity declined sharply at 4 h after EBP and 127 (19.3%) patients received a second EBP. On average, no or mild headache (numeric rating score≤3) was observed 7 days after diagnosis. Intracranial bleeding was diagnosed in three patients (0.46%), and backache, headache, and analgesic use were more common at 3 months in the EBP group. Conclusions: Management practices vary between countries, but EBP was more often used in patients with greater initial headache intensity. EBP reduced headache intensity quickly, but about 20% of patients needed a second EBP. After 7 days, most patients had no or mild headache. Backache, headache, and analgesic use were more common at 3 months in patients receiving an EBP. © 2020 British Journal of Anaesthesi