This consensus statement from the Society for Obstetric Anesthesia and Perinatology (SOAP) provides post-operative monitoring guidelines for women receiving neuraxial morphine for cesarean section analgesia.

The context

Neuraxial morphine is a widely used and effective technique for managing post-cesarean pain in the first 24 hours. However because of morphine’s low-lipid solubility, the risk of delayed repsiratory depression has required frequent respiratory monitoring in this first 24 hour period.

The SOAP task force aimed to balance opioid safety needs while avoiding excessive respiratory monitoring in new mothers. Existing ASA/ASRA guidelines were considered by many obstetric anesthesiologists to be too rigorous when applied to the healthy post-natal population, both because of their lower risk of respiratory depression and even greater need to minimize sleep interruptions.

“The SOAP Task Force members strongly agree that neuraxial morphine should be the preferred method for postcesarean delivery analgesia in healthy women.”

The recommendations

• Ultra-low dose intrathecal (≤50 mcg) or epidural (≤1 mg) morphine in low-risk women does not require extra respiratory monitoring.
• Low dose intrathecal (50-150 mcg) or epidural (1-3 mg) morphine in low-risk women should have respiratory rate and sedation monitored every 2h for the first 12h.
• Women with significant comorbities, sedation risk factors or if receiving higher morphine doses should be monitored as per ASA/ASRA guidelines.
• Low-dose intrathecal (50-150 mcg) or epidural (1-3 mg) morphine provides the best balance between analgesia and minimising side effects.

Explore more...

The paper’s full-text goes into more detail covering the evidence for the safety and efficacy of neuraxial morphine, the incidence of respiratory depression, respiratory monitoring techniques and duration, optimal dosing and analgesic regimes.

summary

• Jeanette R Bauchat, Carolyn F Weiniger, Pervez Sultan, Ashraf S Habib, Kazuo Ando, John J Kowalczyk, Rie Kato, Ronald B George, Craig M Palmer, and Brendan Carvalho.
• From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
• Anesth. Analg. 2019 Aug 1; 129 (2): 458-474.

AbstractThe majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

This article appears in the collection: Interesting obstetric spinal anesthesia articles.

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