Effects of Epidural Morphine and Intramuscular Diclofenac Combination in Postcesarean Analgesia: A Dose-Range Study

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To assess the efficacy of combinations of epidural morphine and intramuscular diclofenac in postcesarean analgesia, a double-blind, randomized study was conducted. Epidural anesthesia was administered to 120 parturients who were randomly allocated into six treatment groups; these groups, A, B, C, D, and E, received 0.5, 1, 2, 3, and 4 mg of epidural morphine in 10 mL of normal saline solution, respectively, and 75 mg (3 mL) of diclofenac intramuscularly (IM). Group F received 4 mg of epidural morphine in 10 mL of normal saline solution and 3 mL of normal saline solution IM. Epidural injections were given after delivery of the placenta and IM injections were given on arrival in the recovery room. Verbal analogue pain score and pruritus score were recorded at 2, 4, 8, 12, 18, and 24 h after epidural injection. Subjective scores of overall pain relief also were recorded at 24 h. Results showed that group A had the highest pain scores and required more supplemental meperidine than groups C, D, E, and F. None of the patients in groups D and E requested supplemental analgesia. There were no differences in wound pain score among groups B, C, D, E, and F. Compared with group F, groups D and E experienced a superior analgesic effect in relieving uterine contraction pain from 4 to 12 h (P < 0.05). There were no differences in overall pain relief among the six groups. The incidence of nausea or vomiting or both, pruritus, and bleeding was similar. There was no evident relationship between severity of pruritus and morphine doses. No bradypnea was observed during the study period. In conclusion, 3 and 4 mg of epidural morphine when combined with 75 mg of IM diclofenac, appeared to be superior to 4 mg of epidural morphine alone for postcesarean analgesia. Epidural morphine, 3 mg, with 75 mg of IM diclofenac appears to be the optimum combination in the treatment of postcesarean pain. Compared to epidural morphine alone, this regimen provides superior analgesia, especially for relieving uterine cramps, without increasing the incidence of side effects.(Anesth Analg 1993;76:284-8)

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