Neuraxial anesthesia for pain control after cesarean section: a prospective randomized trial comparing three different neuraxial techniques in clinical practice.

BACKGROUND: Cesarean section (CS) is associated with a moderate-high intensity of postoperative pain. We investigate whether continuous local anesthetic/opioid administration using patient controlled epidural anesthesia (PCEA) is superior in controlling pain after CS than epidural (ED) or intrathecal (IT) opioid bolus administration.

METHODS: One hundred ninety-nine women undergoing elective CS were randomized into 3 groups: PCEA: Combined spinal-epidural anesthesia (CSE) with a PCEA of ropivacaine 0.1% + sufentanil 0.5 μg/mL for 24 hours after CS. ED: CSE with an ED bolus of 3 mg morphine after CS. IT: spinal anesthesia with an IT bolus of 0.1 mg morphine before CS. Primary objectives were pain (VAS/Visual Analogue Scale 0-100) at 9 h, VAS at 1, 2, 6, 24 and 48 hours, side effects and additional analgesic requirements as secondary endpoints.

RESULTS: VAS (rest/mobilization) 10(0-23)/40(20-56) at 9 hours for IT was lower (P=0.11/P=0.003) than VAS 20(0-30)/50(30-60) for ED and 20(0-40)/50(30-70) for PCEA (P=0.005/P=0.01). VAS 10(0-29)/40(20-60) at 6 hours for IT was significantly lower than VAS 20(4-40)/50(30-70) for ED (P=0.02/P=0.02). During mobilization at 24/48 hours VAS 40(20-58)/30(20-40) between IT and PCEA with VAS 50(40-70)/40(20-63) differed significantly (P=0.04/P=0.001). With exception of pruritus, which was less in the PCEA group at 9 hours, side effects were similar in all groups. Ibuprofen consumption in the first 24 hours was significantly lower for IT and PCEA compared to ED.

CONCLUSIONS: PCEA is less effective then IT and ED opioid bolus administration for post cesarean pain relief. IT provides better analgesia than ED or PCEA, as pointed out by lower ibuprofen consumption.