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208]

Clinical
Investigation
A comparative study of intrathecal and epidural
buprenorphine using combined spinal-epidural
technique for caesarean section

Shaloo Ipe, Sara Korula, Sreelatha Varma1, Grace Maria George, Saramma P
Abraham, Leena Rachel Koshy
Department of Anaesthesiology, MOSC Medical College, Kolenchery, Kerala, 1Department of Anaesthesiology,
Malabar Institute of Medical Sciences, Kozhikode, India

Address for correspondence: ABSTRACT

Dr. Sara Korula,
Department of Neuraxial opioids provide excellent analgesia intraoperatively and postoperatively while allowing
Anaesthesiology, MOSC
Medical College, Kolenchery, early ambulation of the patient by sparing sympathetic and motor nerves. A prospective, randomised
Kerala - 682 311, India. double blind study was conducted involving 90 patients of ASA 1 physical status coming for elective
E-mail: skorula@rediffmail.com cesarean section to evaluate the analgesic effect of neuraxial buprenorphine. They were allocated
into three groups. Spinal local anaesthetic was used as the main stay of anaesthesia for surgery and
spinal and epidural analgesia with opioids continued as the main stay for postoperative analgesia.
All the groups were given 0.5% Bupivacaine intrathecally for the surgery. Besides this, group I
was given 150 mcg Buprenorphine intrathecally and group II and III were given 150 mcg and 300
mcg Buprenorphine respectively, epidurally. In the present study, we observed that 150 mcg of
Buprenorphine given intrathecally provided much longer duration of analgesia compared to 150
mcg of Buprenorphine given epidurally. Increasing the epidural dose of Buprenorphine from 150
mcg to 300 mcg proved to produce prolonged analgesia comparable to intrathecal Buprenorphine
without compromising patient safety and neonatal outcome. The minor side effects were more
with intrathecal Buprenorphine than epidural Buprenorphine. We concluded that 300 mcg of
Buprenorphine epidurally is equianalgesic to 150 mcg Buprenorphine intrathecally.
DOI: 10.4103/0019-5049.65359

Key words: Buprenorphine, caesarean section, epidural, intrathecal

www.ijaweb.org

INTRODUCTION route or intrathecal route separately. But there are

few studies comparing the effects of the same opioid
Opioids are widely used for providing postoperative given intrathecally and epidurally and few studies on
analgesia and advantages of neuraxial narcotics over analgesic effects of neuraxial buprenorphine.
systemic narcotics are well established.[1] Opioids,
when compared to local anaesthetics, offers the The present study is undertaken to compare the
advantage of providing good analgesia while allowing effects of intrathecal and epidural buprenorphine
early ambulation of the patient by sparing sympathetic and to find a safe equianalgesic dose of intrathecal
and motor nerves.[2] Buprenorphine is a long acting, and epidural Buprenorphine. Quality and duration of
highly lipophilic opioid, which has proved to be a analgesia was assessed for 24 hours postoperatively.
promising analgesic, by epidural and intrathecal route.[3,4] Occurrence of adverse effects like hemodynamic
It is about 25 times more potent than morphine and effects, respiratory depression, Post Dural Puncture
has a low level of physical dependence.[5] Headache, Nausea and vomiting, drowsiness and
pruritus when given through each of the routes were
There are numerous studies comparing opioid agents also assessed. Neonatal outcome was evaluated using
in varying concentrations given through either epidural Apgar score[6] and neonatal umbilical cord pH.[7]

How to cite this article: Ipe S, Korula S, Varma S, George GM, Abraham SP, Koshy LR. A comparative study of intrathecal and epidural
buprenorphine using combined spinal-epidural technique for caesarean section. Indian J Anaesth 2010;54:205-9.

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Ipe, et al.: Analgesic effects of intrathecal and epidural buprenorphine

Patient’s and surgeon’s acceptability of the technique The procedure was carried out in lateral decubitus
was noted. position using combined spinal epidural needle.
Epidural space was identified in L2-L3 region using loss
METHODS of resistance technique. The anaesthetist conducting
the study was blinded to the study drug which was
A randomised controlled double blind prospective prepared by another anaesthetist as per instructions.
study was done to compare the effects of intrathecal Epidural test dose of 3 ml of xylocaine with adrenaline
and epidural Buprenorphine. The study was conducted was given and observed for any motor block or
after approval by the hospital Ethics Committee and significant rise in heart rate. After injecting 7 ml of the
an informed written consent was obtained from all the epidural test drug, spinal needle was advanced into
patients. A total number of 90 ASA I patients belonging the subrachanoid space and 2.5 ml of intrathecal test
to age group 20-40 years posted for elective lower drug was given. A left uterine displacement of 150 was
segment cesarean section were divided into three maintained during surgery. Supplemental oxygen was
groups of 30 each. Group allocation was achieved by a given through a poly mask.
computer generated randomisation list. Patients with
any variations from normal were excluded. Three groups were compared.

The patients were kept fasting for 6 hours prior to Sensory block was tested by pinprick till level reached
surgery and premedicated with oral Ranitidine 150 T4. The total duration of analgesia was calculated
mg at night and oral Metoclopramide 10 mg and from onset of sensory block to end of analgesia i.e.;
Ranitidine 150 mg two hours prior to the surgery. pain score of 5 or more on the Verbal Numerical Rating
NIBP, ECG, SPO2, RR were monitored up to 24 hrs Scale [Figure 1].[8]
postoperatively. An 18g IV canula was secured and all
patients were preloaded with 750 ml of Ringer Lactate Verbal numerical rating scale
before the neuraxial block. Spinal local anaesthetic Pain score Degree of pain Degree of analgesia
was used as the main stay of anaesthesia for surgery 0 No pain Profound Analgesia
and spinal and epidural analgesia with buprenorphine 2-4 Mild pain Moderate Analgesia
continued as the main stay for postoperative analgesia. 5-7 Moderate pain Mild Analgesia
8-10 Worst pain No Analgesia
A single space Combined Spinal Epidural technique
was chosen and the same volume of drug was injected Criteria for hypotension was taken as a systolic BP less
intrathecally and epidurally in all study groups. than 100 mm Hg and bradycardia as heart rate less
To make the intrathecal volume of drug equal in all than 60. Hypotension was treated with IV ephedrine
groups, group II and III were given 0.5% Bupivacaine and rapid infusion of fluid. Criteria for respiratory
2.5 ml intrathecally while group I was given 0.5% depression were a fall in oxygen saturation to <90%,
Bupivacaine 2 ml and 0.5 ml of buprenorphine (a total a respiratory rate less than 12/min. At the end of the
of 2.5 ml) surgery, the overall quality of anaesthesia was judged

Grouping of cases was in the following manner:-

Intrathecal Epidural
Gp I : 2ml of Bupivacaine 3 ml of 2% xylocaine with
0.5% with 0.5 ml adrenaline(15mcg) and
Bupinorphine (150mcg) 7ml Normal saline
Gp II: 2.5 ml 3 ml of 2% xylocaine with
Bupivacaine 0.5% adrenaline( 15mcg) and
6.5ml of Normal Saline
+ 0.5ml Bupinorphine
(150mcg)
Gp III : 2.5 ml 3 ml of 2% xylocaine with
Bupivacaine 0.5% adrenaline( 15mcg) and 6
ml of Normal Saline + 1ml
Bupinorphine (300mcg) Figure 1: Duration of analgesia

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Ipe, et al.: Analgesic effects of intrathecal and epidural buprenorphine

by the surgeon and patient on a Numerical Rating Incidence of nausea and vomiting was 20% in
Scale (NRS) from 1 (unsatisfactory) to 10 (excellent). group I and 16% in group II and III. Incidence
Neonatal outcome was assessed by APGAR score at of pruritus was 20% in group I, 4% in group II
I min and 5 min and by umbilical arterial blood gas and 16% in group III. No patient had post dural
analysis. APGAR score of <7 and an umbilical arterial puncture headache, backache or drowsiness in any
blood pH <7.2 was considered abnormal. group [Table 2].

Postoperatively patients were monitored in post The 1 minute and 5 minute Apgar score and the
anaesthesia care unit and complications like umbilical cord pH of babies in all the three groups were
hypotension, respiratory depression, drowsiness, acceptable and there was no significant differences
between the groups (P>.05) [Table 3].
post dural puncture headache, nausea, vomiting and
pruritus were assessed for 24 hours. Occurrence of
In all groups the surgeon enjoyed adequate muscle
urinary retention could not be assessed as the patients
relaxation for performing the surgery and patient was
for LSCS are routinely catheterised for 24 hours comfortable throughout the procedure. There was no
postoperatively in our institution. statistically significant difference between the groups
in the NRS scores [Table 4].
Statistical analysis
Parametric data were analysed using Z test. P < 0.05 Time in hours
was considered as significant. In group I (intrathecal 150 mcg Buprenorphine),
100% of patients had analgesia till 2.5 hours and
RESULTS 50% had analgesia till 6 hours. At 20 hours and 24
hours 16% and 1% of patients, respectively, had
In all the three groups, there was no significant
analgesia.
change in heart rate and blood pressure from the
base line value, neither in intraoperative nor in the In group II (epidural 150 mcg Buprenorphine) 100%
postoperative period (P>0.05). The minimum blood of patients had analgesia till 2 hours and 50% till 3
pressure recorded was systolic BP of 84 mm Hg and hours. Thereafter the analgesia was poor.
fall in BP was transient and responded to one dose of
6mg ephedrine IV. There was no significant variation In group III (epidural 300 mcg Buprenorphine) till 3.5
in respiratory rate and saturation in all three groups hours 100% of patients had analgesia and it took 16
and were within acceptable limits [Table 1]. hours for the percentage to drop to 50%. At 20 hours
and 24 hours, 20% and 4% of patients, respectively,
had analgesia.
Table 1: Demographic and other data (mean ± SD)
Group I Group II Group III DISCUSSION
Age (Years) 24.5 ± 3.38 23.7 ± 2.07 24.1 ± 3.28
Weight (kg) 67.77 ± 5.29 69.01 ± 4.71 66.27 ± 4.6 Any method of postoperative analgesia must meet
Height (cm) 155.7 ± 5.3 155.3 ± 5.6 155.6 ± 4.01 three basic criteria; it must be simple, safe, clinically

Table 2: Complications and side effects

Groups Max. fall in RR SpO2 Change in heart Nausea and Pruritus (%)
systolic BP rate vomiting (%)
I 19.76 ± 7.38 17 ± 1.5 98.64 ± 0.40 12.73 ± 2.91 20 20
II 19.88 ± 5.40 17.2 ± 1.3 98.64 ± 0.49 13.07 ± 3.65 16 4
III 19.36 ± 6.5 16.8 ± 1.00 98.43 ± 0.61 12.56 ± 3.01 16 16
P value
I vs. II P = 0.94 P = 0.58 P=1 P = 0.68 P = 0.68 P = 0.048
NS NS NS NS NS S
I vs. III P = 0.82 P = 0.54 P = 0.114 P = 0.82 P = 0.68 P = .0.68
NS NS NS NS NS NS
II vs. III P = 0.73 P = 0.18 P = 0.1416 P = 0.55 P=1 P = 0.109
NS NS NS NS NS NS

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Ipe, et al.: Analgesic effects of intrathecal and epidural buprenorphine

Table 3: Neonatal assessment Table 4: Surgeon’s and patient’s acceptability of

anaesthesia
Groups Umbilical pH APGAR score APGAR score
1 min 5 min Groups NRS* surgeon NRS patient
I 7.29 ± 0.04 8.32 ± 0.75 9.36 ± 0.49 I 9.2 ± 1.4 8.8 ± 2.6
II 7.27 ± 0.08 8.4 ± 0.76 9.44 ± 0.51 II 9.0 ± 1.2 8.4 ± 1.2
III 7.28 ± 0.02 8.44 ± 0.51 9.44 ± 0.52 III 9.1 ± 2.4 9.0 ± 2.4
P value P value
I vs. II P = 0.22 P = 0.68 P = 0.53 I vs. II P = 0.552 P = 0.77
NS NS NS NS NS
I vs. III P = 1.22 P = 0.47 P = 0.54 I vs. III P = 0.84 P = 0.31
NS NS NS NS NS
II vs. III P = 0.66 P = 0.81 P=1 II vs. III P = 0.84 P = 0.225
NS NS NS NS NS
* NRS - Numerical rating scale

appropriate and evidence based.[9] The majority of

any respiratory support. The mean fall in BP was
postoperative patients managed with parenteral or
comparable in all groups and hypotension if present
intramuscular opioid drugs are left with unrelieved
was transient. The blood pressure and heart rate were
pain.[10,11] The discovery of opioid receptors in the
acceptable in all groups. This was similar in earlier
brain and spinal cord started a new era in the field of
studies.[21]
postoperative analgesia.[12,13]
The incidence of Nausea and Vomiting was 20% in
Buprenorphine is a mixed agonist – antagonist type
GP I which was slightly higher than the other groups.
of opioid with a long duration of action. The high
Pruritus is one of the commonest side effects of
lipid solubility; high affinity for opioid receptors and
neuraxial opiods. It is more likely to occur in obstetric
prolonged duration of action makes Buprenorphine a
patients due to the interaction of estrogen with opioid
suitable choice for intrathecal and peripheral nerve
receptors. Previous studies show the incidence of
site administration.[3,4]
pruritus after epidural administration of 50 mcg
fentanyl was 47% and with 300 mcg Buprenorphine,
Addition of Buprenorphine 150 mcg intrathecally
10%.[22] In our observation, pruritus of a mild nature
or epidurally and 300 mcg epidurally provided
occurred in all three groups but was slightly higher
good postoperative analgesia without prolonged
with subarachnoid Buprenorphine than epidural
motor block.[14,15] In all three groups, 100% patients
groups.
had analgesia till two hours. 50% of patients had
analgesia up to 6 hours in group I, 3 hours in group Incidence of PDPH, backache and drowsiness were not
II and 17 hours in group III. Duration of analgesia reported. This was comparable to the results obtained
was poor with 150 mcg Buprenorphine epidurally. by Fuller JG et al.,[23] and Escarment J et al.,[21] The high
The mean duration of analgesia was highest in Group rate of nausea and pruritus in these patients warrants
III with 300 mcg Buprenorphine epidurally, 4% of the use of ondansetron for premedication and for at
patients had analgesia till 24 hours. Subarachnoid least 24 hours postoperatively till the effect of opioids
and epidural 150 mcg Buprenorphine are not equi- wear off.[24]
analgesic. When epidural dose of Buprenorphine
was increased from 150 mcg to 300 mcg, analgesia Neonatal outcome was good in all the groups as assessed
improved considerably. This confirms the observation by 1min and 5 min Apgar and umbilical arterial blood
that lipophilic opioids need higher doses epidurally pH.[25] In all patients the anaesthesiologist and surgeon
to be effective.[16,17] found the anaesthesia to be adequate for the operative
procedure in terms of pain relief and relaxation. All
One of the main concerns with Buprenorphine is patients were comfortable and willing to accept the
respiratory depression.[18-20] In our study, none of same anaesthetic technique for a similar procedure in
the patients in the study groups had respiratory future.
depression. Arterial oxygen saturation in all the cases
remained above 96% and mean respiratory rate of all One of the drawbacks of the study was that the latency
patients were above 17. None of the patients required of onset of action of Buprenorphine could not be studied

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Ipe, et al.: Analgesic effects of intrathecal and epidural buprenorphine

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Source of Support: Nil, Conflict of Interest: None declared
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