Highlights
- •Variable doses of intrathecal fentanyl for peri-operative analgesia at cesarean.
- •Meta-analysis of randomized controlled trials comparing ≤12.5 μg and >12.5 μg.
- •Higher doses result in reduced intra-operative analgesic supplementation.
- •Higher doses associated with prolonged time to first analgesia.
- •Higher doses associated with more maternal pruritus.
Abstract
Background
Variable doses of intrathecal fentanyl (ITF) have been used for peri-operative analgesia
during cesarean delivery (CD). We conducted a systematic review and meta-analysis
to compare lower doses (LD; ≤12.5 µg) and higher doses (HD; >12.5 µg) of ITF in parturients
undergoing CD.
Methods
Databases were searched from inception to December 2020 for randomized controlled
trials (RCTs) administering ITF as an additive to local anesthetic. The primary outcome
was the use of intra-operative analgesic supplementation. Time to first rescue analgesia,
the incidence of peri-operative side effects and neonatal outcomes were secondary
outcomes. Additional analysis was performed after stratifying trials using ≤15 µg
and >15 µg of ITF. Mean difference (MD) and risk difference (RD) with 95% confidence
interval (CI) were calculated.
Results
Eleven RCTs met inclusion criteria. Study groups were 601 patients (LD) and 749 patients
(HD). A HD of ITF reduced the risk for supplementation by 6% (95% CI 0 to 13%; P=0.05; I2=80%) compared with LD, and increased the time to first rescue analgesia (MD 55.2 min,
95% CI 20.3 to 90.1, P=0.002; I2=100%). The risk of pruritus increased by 13% (95% CI 5 to 21%; P=0.001; I2=81%). Pooled data suggest that the incidence of nausea and vomiting, and neonatal
outcomes did not significantly differ.
Conclusions
In women undergoing CD, doses of ITF >12.5 µg reduced the requirement for intra-operative
analgesic supplementation and prolonged the time to first rescue analgesia compared
with smaller doses, but increased pruritus. On revising the cut-off to 15 µg, no significant
difference was found.
Keywords
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References
- The increasing trend in caesarean section rates: global, regional and national estimates: 1990–2014.PLoS ONE. 2016; 11e0148343https://doi.org/10.1371/journal.pone.0148343
- Role of spinal opioid receptors in the antinociceptive interactions between intrathecal morphine and bupivacaine.Anesth Analg. 1992; 74: 726-734https://doi.org/10.1213/00000539-199205000-00018
Tsen LC. Anesthesia for caesarean delivery. In Chestnut D, Wong C, Ysen LC, Ngan W, Beilin G, Mhyre J. editors. Chestnut's Obstretic anesthesia: Principles and practice. 5th ed. Philadelphia 2014.
- Intrathecal lipophilic opioids as adjuncts to surgical spinal anesthesia.Reg Anesth Pain Med. 1999; 24: 255-263https://doi.org/10.1016/s1098-7339(99)90139-6
- Comparative study of postoperative analgesia after intrathecal administration of bupivacaine with fentanyl or morphine for elective Caesarean section.Anestezjol Intens Ter. 2009; 41: 28-32
- Effect of fentanyl on block characteristics as adjuvant to intrathecal bupivacaine for lower limb surgeries.Anesth Essays Res. 2020; 14: 343-348https://doi.org/10.4103/aer.AER_58_20
- Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery.Anesthesiology. 1989; 71: 535-540https://doi.org/10.1097/00000542-198910000-00009
- Effect of varying doses of fentanyl with low dose spinal bupivacaine for caesarean delivery in patients with pregnancy-induced hypertension.Int J Obstet Anesth. 2004; 13: 215-220https://doi.org/10.1016/j.ijoa.2004.04.006
- Efficacy of intrathecal fentanyl for caesarean delivery: a systematic review and meta-analysis of randomized controlled trials with trial sequential analysis.Anesth Analg. 2020; 130: 111-125https://doi.org/10.1213/ANE.0000000000003975
- Trial sequential analysis in systematic reviews with meta-analysis.BMC Med Res Methodol. 2017; 17: 39https://doi.org/10.1186/s12874-017-0315-7
- Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.PLoS Med. 2009; 6: e1000097https://doi.org/10.1371/journal.pmed.1000097
- Estimating the mean and variance from the median, range, and the size of a sample.BMC Med Res Methodol. 2005; 5: 13https://doi.org/10.1186/1471-2288-5-13
- Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560https://doi.org/10.1136/bmj.327.7414.557
- RoB 2: a revised tool for assessing risk of bias in randomized trials.BMJ. 2019; 366l4898https://doi.org/10.1136/bmj.l4898
- A double blinded randomized control trial to compare the effect of varying doses of intrathecal fentanyl on clinical efficacy and side effects in parturients undergoing caesarean section.J Anaesthesiol Clin Pharmacol. 2018; 34: 221-226https://doi.org/10.4103/joacp.JOACP_271_16
- Comparison of two different doses of fentanyl combined with levobupivacaine for elective cesarean section.J Anesth Clin Res. 2016; 7: 687https://doi.org/10.4172/2155-6148.1000674
- Comparative study of effect of low dose intrathecal bupivacaine with fentanyl for caesarean delivery.ISOR JDMS. 2019; 18: 20-26https://doi.org/10.9790/0853-1808072026
- Addition of fentanyl to hyperbaric bupivacaine for spinal anesthesia in cesarean delivery between potentiation of blockade versus incidence of pruritus, is it worth it?.AAMJ. 2015; 13: 517-523
- Effect of intrathecal fentanyl with bupivacaine on maternal hemodynamics and fetal outcome during cesarean section: a comparative study with two different doses.Int J Sci Study. 2016; 3: 214-217https://doi.org/10.17354/ijss/2016/88
- Comparison of clinical effects according to dosage of fentanyl added to 0.5% hyperbaric bupivacaine for spinal anesthesia in patients undergoing caesarean section.Anesth Pain Med. 2012; 7: 256-261
- Intrathecal fentanyl in different doses (10 µg, 15 µg) with hyperbaric bupivacaine (10 mg) for caesarean section: a comparative study.ISOR JDMS. 2016; 15: 40-43https://doi.org/10.9790/0853-1511034043
- Anesthetic effects of varying doses of fentanyl combined with spinal bupivacaine in caesarian delivery.MJSBH. 2018; 17: 3-10https://doi.org/10.3126/mjsbh.v17i1.18614
- Comparison of bupivacaine alone and its combination with different doses of fentanyl in spinal anesthesia for cesarean section: a prospective randomized study.Indian J Public Health Res Dev. 2013; 4: 19-23
- Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.Anesthesiology. 1999; 91: 1919-1927https://doi.org/10.1097/00000542-199912000-00045
- Opioids added to local anesthetics for single-shot intrathecal anesthesia in patients undergoing minor surgery: a meta-analysis of randomized trials.Pain. 2012; 153: 784-793https://doi.org/10.1016/j.pain.2011.11.028
- Opioid-induced pruritus: An update.Clin Exp Dermatol. 2010; 35: 2-6https://doi.org/10.1111/j.1365-2230.2009.03463.x
- ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery.Anesthesiology. 2004; 100: 676-682https://doi.org/10.1097/00000542-200403000-00031
Article info
Publication history
Published online: February 08, 2022
Accepted:
February 3,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
