Clinical and pharmacokinetic aspects of the combination of meperidine and prilocaine for spinal anaesthesia

Efficacy of prophylactic epidural ketamine for reducing shivering in patients undergoing caesarean section with combined spinal-epidural anesthesia

Intravenous ketamine is known to inhibit postoperative shivering; however, at present, there has been little research on whether this effect may be achieved with epidural application. The aim of the present study was to evaluate the efficacy and safety of epidural ketamine as a prophylactic agent to prevent shivering in patients undergoing caesarean section during combined spinal-epidural anesthesia. A prospective, randomized, double-blind study was performed. A total of 60 patients who were undergoing elective caesarean section under combined spinal-epidural anesthesia and had an American Society of Anesthesiologists physical status of I or II were recruited. Patients were randomly allocated to group S (epidural administration of normal saline; n=30) or group K (epidural ketamine 0.5 mg/kg; n=30). An investigator, blinded to the treatment groups, graded postoperative shivering using a 4-point scale and postoperative sedation on a 5-point scale. Operative time, hemodynamic changes and side effects, including hypotension, bradycardia, nausea and hallucinations, were recorded. The results demonstrated that patients' characteristics were not significantly different between groups. Heart rate, peripheral capillary oxygen saturation (SpO₂) values and Apgar scores at 1 and 5 min also did not differ significantly between groups. The incidence and severity of shivering in group K was significantly reduced compared with group S (P<0.05). The mean arterial pressure (MAP) was significantly different in groups S and K compared with baseline values at 10, 30 and 60 min (P<0.05). Furthermore, MAP values at 10, 30 and 60 min were significantly higher in group K compared with in group S (P<0.05). The results of the present study suggest that epidural administration of prophylactic low-dose ketamine may be an effective strategy for preventing postoperative shivering.

The effects of different doses of intrathecal meperidine on the incidence and severity of shivering during lower extremity orthopedic surgery under spinal anesthesia: A randomized, placebo-controlled, double blind-clinical trial

BACKGROUND

Shivering associated with spinal anesthesia is a common complication. It also causes more usage of oxygen, increased production of carbon dioxide (CO2), and lactic acidosis with movement of clots and bleeding after surgery. This study was performed to compare the different dosages of intrathecal meperidine and their effects on shivering during and after surgery and to compare these to the control group.

MATERIALS AND METHODS

This study is a clinical trial. Target population consisted of the patients who were candidates for lower limb orthopedic surgery under spinal anesthesia. About 120 patients were chosen and randomly divided into four groups. In group 1, spinal anesthesia was performed with 3 ml marcaine 0.5% and 0.1 mg/kg meperidine. In group 2, 3 ml marcaine 0.5% and 0.2 mg/kg meperidine was given. In group 3, 3 ml marcaine 0.5% and 0.3 mg/kg meperidine, and in the fourth group, 3 ml marcaine 0.5% and normal saline in the same volume were injected. During surgery and recovery, hemodynamic index and shivering were recorded.

RESULTS

Based on the analyzed data, in the fourth group 23 patients (76.7%) had shivering. While the prevalence of shivering in the first, second, and third groups was 15 patients (50%), 11 patients (36.7%), and 3 patients (10%), respectively. Chi-square test showed significant difference in the four groups (P < 0.001).

CONCLUSIONS

Using higher dosage of intrathecal meperidine (0.3 mg/kg) was more effective than using lower dosage of meperidine (0.1 mg/kg and 0.2 mg/kg) in reducing the incidence and severity of shivering during spinal anesthesia in lower extremity orthopedic surgeries.

Prophylactic effects of intrathecal Meperidine and intravenous Ondansetron on shivering in patients undergoing lower extremity orthopedic surgery under spinal anesthesia

Objective:

Intraoperative hypothermia is a common problem with anesthesia. Spinal anesthesia, the same as general anesthesia, affects the process of temperature regulation. The aim of this study was to compare the prophylactic effect of intravenous (IV) ondansetron with intrathecal (IT) meperidine on prevention of shivering during spinal anesthesia in patients underwent orthopedic surgery of the lower limb.

Methods:

In this study, 120 patients with American Society of Anesthesiologists physical status I to II, between the ages 16 and 65 were randomized into three groups. Group O and Group M were given IV ondansetron 8 mg and IT meperidine 0.2 mg/kg, before spinal anesthesia, respectively. Group C received IV saline 0.9%. The core and ambient temperatures, the incidence and intensity of shivering, blood pressure, heart rate, and maximum level of sensory block were recorded.

Findings:

Shivering was observed in 15%, 2.5%, and 37.5% of patients in Groups O, M, and C, respectively. There was a significant difference between Group O and M compared to Group C (P = 0.023 for Group O vs. Group C, P < 0.001 for Group M vs. Group C, P = 0.049 for Group M vs. Group O). Shivering incidence and intensity in Group M was significantly lower than Group O (P = 0.049 and P = 0.047, respectively). Twenty-two patients required additional IV meperidine among which 15 patients were from Group C (37.5%), six patients from Group O (15%) and one patient from Group M (2.5%).

Conclusion:

We concluded that IT meperidine and IV ondansetron comparably can decrease intensity and incidence of shivering compared to control group as well as decreasing the requirement to additional doses of meperidine for shivering the control without any hemodynamic side effect.

Antishivering effects of two different doses of intrathecal meperidine in caesarean section: a prospective randomised blinded study

BACKGROUND AND OBJECTIVE

Shivering causes various adverse disturbances and interferes with monitoring. The optimal dose of intrathecal meperidine to prevent shivering without producing other side-effects remains unknown. This prospective randomised double-blinded study was conducted to compare the antishivering effects of two different doses of intrathecal meperidine.

METHODS

Seventy two parturients, scheduled for elective caesarean section under spinal anaesthesia, were enrolled in three different groups. Spinal anaesthesia consisted of bupivacaine 0.5% (10 mg) for the control group (M0), and the same dose of bupivacaine with meperidine 12.5 or 25 mg for the experimental groups (M1, M2). Blood pressure, heart rate, skin and core temperatures, sensory level, capnometry, pulse oximetry, Apgar scores, shivering intensity and intrathecal opioid-related side-effects were evaluated and recorded by a blinded observer. Data were analysed using analysis of variance, χ² test, Kruskal-Wallis H-test and Mann-Whitney U-test. A P value less than 0.05 was considered to be significant.

RESULTS

Shivering was more intense in group M0 than in groups M1 and M2 with P values of 0.003 and less than 0.001, respectively. The intensity of shivering was comparable in groups M1 and M2. As regards the incidence of significant shivering, it was found to be highest in M0 (4/24 ≈16.7%) in comparison with M1 (0/24) and M2 (0/24) (P = 0.03). Nausea and vomiting occurred more frequently with higher doses of meperidine (P < 0.001 and P = 0.003, respectively). Other complications were comparable.

CONCLUSION

The use of intrathecal meperidine for caesarean section during spinal anaesthesia for the prevention of shivering cannot be recommended as its use is associated with increased incidence of nausea and vomiting.

Systematic review of spinal anaesthesia using bupivacaine for ambulatory knee arthroscopy

The use of lidocaine in spinal anaesthesia is associated with transient neurological syndrome (TNS). Bupivacaine has a lower incidence of TNS as an alternative but it may have a prolonged action. This study systematically reviews the literature about the recovery profile of patients undergoing spinal anaesthesia, using bupivacaine for arthroscopic knee surgery. We identified 17 eligible randomized clinical trials (RCTs) (1268 patients). All the articles in this review, except one, used hyperbaric bupivacaine. Five trials compared different doses of bupivacaine (range 3-15 mg). Large doses of bupivacaine (10 and 15 mg) were associated with delayed recovery, and supine positioning was associated with a high incidence of failure. With unilateral positioning, a dose as low as 4-5 mg seems to be sufficient. Five trials comparing bupivacaine or levobupivacaine with ropivacaine showed no significant difference in the time to home discharge. When bupivacaine was combined with fentanyl in two trials, marginal delay in recovery was found [time to discharge (min); weighted mean difference (WMD) 14.1, 95% CI 11.9-40.1] and increased nausea and pruritus but had reduced postoperative pain. Unilateral and bilateral spinal anaesthesia were assessed in two trials, and the latter group was associated with early recovery and discharge [time to discharge (min); WMD -41.6, 95% CI -63.6 to -19.6). The results of our systematic review suggest that 4-5 mg of hyperbaric bupivacaine can effectively produce spinal anaesthesia for knee arthroscopy with unilateral positioning. Ropivacaine or the addition of adjuvants did not improve the recovery time. There is a need for tighter RCTs with more consistent endpoints.

Intrathecal meperidine decreases shivering during cesarean delivery under spinal anesthesia

Shivering associated with spinal anesthesia is uncomfortable and may interfere with monitoring. We performed this prospective, double-blinded, and randomized study to determine whether intrathecal meperidine (0.2 mg/kg) decreases the incidence and intensity of shivering after spinal anesthesia for cesarean delivery. Forty parturients scheduled for nonemergent cesarean delivery were enrolled in two groups. Spinal anesthesia consisted of hyperbaric bupivacaine (0.75%; 10.5 mg), morphine 0.15 mg, and, in the experimental group, meperidine (0.2 mg/kg) or, in the control group, normal saline. Data collection, including sensory block level, blood pressure, core temperature, and shivering intensity, was performed every minute for 10 min, every 3 min for 33 min, and then every 5 min until the sensory level receded to L4. Time to highest sensory level, maximum number of blocked segments, sensory and motor blockade regression, and systolic blood pressure showed no difference between groups. The incidence of shivering was less (P < 0.02) in the meperidine group, as was its intensity (P < 0.003). Intrathecal meperidine (0.2 mg/kg) is effective in reducing the incidence and intensity of shivering associated with spinal anesthesia for cesarean delivery.

IMPLICATIONS

Previous studies have suggested that IV meperidine is helpful for treating intraoperative shivering. This study was undertaken to evaluate spinal meperidine and found that it decreases the incidence and intensity of shivering associated with spinal anesthesia for cesarean delivery.

The relationship between the parturient's positions and perceptions of labor pain intensity

BACKGROUND

While the effect of the maternal position on reducing labor pain has been studied, the data presented to date have not been conclusive.

OBJECTIVES

To determine if maternal position reduced the intensity of labor pain during cervical dilatation from 6 to 8 centimeters.

METHOD

Pain intensity was measured using the visual analogue scale (VAS) on 39 primiparous and 19 multiparous women (N = 58) who alternately assumed the sitting and supine positions for 15 minutes during cervical dilatation from 6 to 8 centimeters.

RESULTS

The pain scores for the sitting position were significantly lower than those for the supine position. The Wilcoxon signed-ranks test showed the VAS scores for the (a) total labor pain ("total" being defined as both abdominal and lumbar pain) during contraction (p =.011), (b) continuous total labor pain (p =.001), (c) lumbar pain during contraction (p <.001), and (d) continuous lumbar pain (p <.001) in the sitting position (significantly lower than in supine position). The diminished pain scores were greater than 13 millimeters, which is the minimum clinically significant change in patient pain severity as measured with the 100 millimeter VAS. The largest decrease occurred in lower back pain. No significant differences were found for abdominal pain scores in either the sitting or supine positions.

CONCLUSION

The sitting position offers an effective method to relieve lower back labor pain during cervical dilatation from 6 to 8 centimeters. Similar relief was experienced for women who reported pain only on contraction as well as those with continuous pain.

Adding low dose meperidine to spinal lidocaine prolongs postoperative analgesia

PURPOSE

To investigate the effects of the addition of low dose meperidine to spinal lidocaine on the sensory and motor blockade profile, and the quality and duration of postoperative analgesia.

METHODS

In a randomized double blind prospective dose finding study 40 patients undergoing transurethral prostatectomy with spinal anesthetic were allocated to receive 75 mg lidocaine 5% intrathecally as the sole agent (group A), or co-administered with 0.15 mg x kg(-1) meperidine (group B) or 0.30 mg x kg(-1) meperidine (group C). Sensory and motor blockade profiles were documented. Postoperatively, the amount of analgesics required, time to first analgesic, visual analogue scores and adverse events were recorded.

RESULTS

Sensory blocks at or above T10 was maintained for 128, 156 and 145 minutes in groups A, B and C respectively. There was no difference in the latency or duration of the motor block among the three groups. Patients in group C had lower visual analogue pain scores (VAPS) over time than did those in groups A and B (P < 0.05). Time to first analgesia was longer (429 +/- 197 minutes) in group C than in group A (254 +/- 157 minutes) (P < 0.05). Fewer patients in group C required parenteral opioid postoperatively than in group A (P < 0.05). The incidence of bradycardia was higher in the groups receiving meperidine. No symptoms of transient radicular irritation (TRI) were reported in the groups receiving meperidine.

CONCLUSION

The addition of 0.3 mg x kg(-1) of meperidine to spinal lidocaine prolongs postoperative analgesia without delaying discharge from post anesthetic care unit (Table II) and reduces the requirement for parenteral analgesics (Table III).

Intrathecal pethidine: pharmacology and clinical applications

Pethidine is the only member of the opioid family that has clinically important local anaesthetic activity in the dose range normally used for analgesia. Pethidine is unique as the only opioid in current use that is effective as the sole agent for spinal anaesthesia. In lower doses, intrathecal pethidine is also an effective analgesic for treating pain in labour. This paper reviews the pharmacology of intrathecal pethidine and clinical experience reported to date. Articles reviewed include those identified by a Medline search using keywords "intrathecal" or "spinal anaesthesia/ anesthesia" and "pethidine" or "meperidine". Reference lists from identified papers were scrutinized to identify further relevant articles.

Continuous intrathecal meperidine via an implantable infusion pump for chronic, nonmalignant pain

OBJECTIVE

To report a continuous infusion of intrathecal meperidine via an implanted infusion pump for nonmalignant, chronic pain.

CASE SUMMARY

A 69-year-old white woman had chronic, nonmalignant low-back pain and bilateral leg pain. Multiple drug therapies and other interventional techniques had failed. The patient achieved significant pain relief by a continuous infusion of intrathecal meperidine via an implanted infusion pump.

DISCUSSION

To our knowledge, this is the first report of meperidine administered intrathecally by continuous infusion. Continuous infusion of intrathecal and epidural opiates by implanted infusion pumps is becoming more widely recognized as an alternative treatment for patients with chronic, benign pain. Epidural and intrathecal meperidine is an effective analgesic for short-term surgical procedures. Data reporting effective relief and safety with continuous intrathecal meperidine remain limited.

CONCLUSIONS

Continuous intrathecal meperidine via an implantable infusion pump may be an effective alternative in the treatment of chronic pain.

Local anesthesia for arthroscopic surgery of the ankle using pethidine or prilocaine

Investigation of the intraoperative and postoperative pain-reducing effect of pethidine (meperidine) as compared with local anesthetics given into the ankle joint was performed, in a comparative and double-blind fashion, in 20 patients subjected to arthroscopy of the ankle, diagnostic and surgical procedures. These patients were randomly assigned to one of two groups. Group A consisted of 10 patients receiving prilocaine 5% with adrenaline and the patients of group B received pethidine 5% with adrenaline intraarticularly. During arthroscopy, the patients reported on pain and discomfort using visual analog scales. Ratings did not differ between the two groups, but six patients would not have chosen the local anesthetic technique again. Postoperatively, all patients rated their pain and discomfort at rest and at movement (1, 2, 3, 5, 6, 8, and 24 hours and at three times during 2 following days). No differences were found between the two groups, except for pain at rest through the whole observation period when significant lower values for pethidine. There were no differences in use of analgesics between the two groups. The current study indicates that pethidine is a potential alternative to prilocaine in arthroscopy of the ankle.

A comparison of the haemodynamic effects of intrathecal meperidine, meperidine-bupivacaine mixture and hyperbaric bupivacaine

PURPOSE

To study the haemodynamic effects of intrathecal meperidine, administered either alone or mixed with bupivacaine.

METHODS

We studied 42 Chinese patients, aged 59-87 yr, scheduled for transurethral bladder or prostate surgery, randomized into three equals groups, that received either meperidine 0.8 mg.kg-1, meperidine 0.4 mg.kg-1 plus 1.5 ml of 0.5% heavy bupivacaine or 3 ml of heavy bupivacaine 0.5%. Non-invasive systolic (SAP) and mean (MAP) arterial pressures, central venous pressure and cardiac index, stroke index and heart rate (HR) measured by the BoMed NCCOM3-R7S bioimpedance device, were recorded over the first 25 min. Systemic vascular resistance index (SVRI) was derived. Onset of sensory and motor block was also measured. Decreases in MAP of 25% were treated with colloid and metaraminol.

RESULTS

The onset of block was slower in the meperidine group (P < 0.05). Decreases in SAP, MAP and SVRI (all; P < 0.001) occurred within five minutes in all three groups. The HR was increased in the bupivacaine group (P = 0.03), but bradycardias treated with atropine occurred in six patients receiving meperidine and four patients receiving the mixture. Six patients receiving meperidine and two patients receiving the mixture required general anaesthesia for inadequate block. The incidence of nausea and vomiting was higher in the patients receiving meperidine (P < 0.05). No other complications were encountered.

CONCLUSIONS

Intrathecal meperidine used alone or mixed with bupivacaine has no intra-operative advantage over heavy bupivacaine 0.5%.

Anaesthesia and adverse effects after intrathecal pethidine hydrochloride for urological surgery

Anaesthesia, postoperative analgesia and the incidence of adverse effects after intrathecal pethidine hydrochloride 0.50 mg.kg-1 and 0.75 mg.kg-1 were assessed and compared with a conventional technique using isobaric bupivacaine 13.75 mg in patients undergoing transurethral resection of the prostate gland. Sensory and motor block were significantly shorter with both pethidine regimens than with bupivacaine (p < 0.001). Although sensory and motor block were shorter after pethidine 0.50 mg.kg-1 than after pethidine 0.75 mg.kg-1 the difference in duration was clinically insignificant. The incidence of incomplete motor block was significantly greater with pethidine 0.50 mg.kg-1 than with bupivacaine 13.75 mg.kg-1 (p < 0.01). Visual analogue pain scores recorded after the operation were low and were similar in the pethidine groups to those obtained with bupivacaine alone. Mean arterial blood pressure was significantly lower in both pethidine groups compared with the bupivacaine group between 30 and 240 min after intrathecal injection (p < 0.001). However, the within-group reductions in blood pressure were within clinically acceptable limits. The incidences of nausea and emesis were low and emesis occurred in patients in the bupivacaine group only (p < 0.03). Pruritus was seen only in patients receiving pethidine. Intra-operative sedation occurred more often in patients receiving both pethidine 0.50 mg.kg-1 and 0.75 mg.kg-1 compared with patients receiving bupivacaine (p < 0.04). Both pethidine regimens provided acceptable anaesthesia and there were no significant differences between the two regimens in quality of intra-operative anaesthesia, incidence of adverse events or postoperative analgesia.

Is intra-articular pethidine an alternative to local anaesthetics in arthroscopy? A double-blind study comparing prilocaine with pethidine

We investigated the per- and postoperative pain-reducing effect of pethidine given intra-articularly (i. art.). Thirty patients subjected to knee joint arthroscopy, diagnostic and surgical procedures, were randomly assigned to one of three groups. Group A consisted of ten patients who received 250 mg prilocaine + 200 micrograms adrenaline (i. art.) in a volume of 50 ml, group B of ten patients who received 200 mg pethidine (i. art.) in 50 ml saline, and group C of ten patients who received 200 mg pethidine + 200 micrograms adrenaline (i. art.) in 50 ml saline. During arthroscopy the patients reported on pain intensity and discomfort using visual analogue scales. Ratings were low and did not differ significantly between the three groups. Two of three patients in each group requested additional analgesics or sedatives due to pain and discomfort, but again with no difference between the three groups. Postoperatively all patients rated their pain intensity at rest and during movement (at 0, 1, 2, 3, 4, 5, 6, 12 and 24 h). The patients receiving pethidine (group B) reported significantly less pain at rest and movement than group A patients, in general at 1-4 h postoperatively. A significant difference was detected between groups B and C at 4 h postoperatively. Calculating the total sum of pain scores, patients receiving pethidine (group B) reported significantly less pain both at rest and during movement than those receiving prilocaine (group A). Furthermore, patients in group B used significantly less analgesics than those in group A. Adrenaline did not potentiate the effect of pethidine.(ABSTRACT TRUNCATED AT 250 WORDS)