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Revista Brasileira de Anestesiologia

On-line version ISSN 1806-907X

Rev. Bras. Anestesiol. vol.54 no.4 Campinas July/Aug. 2004 




Effects of low spinal morphine doses associated to intravenous and oral ketoprofen in patients submitted to cesarean sections

Post-cesarean section analgesia with low spinal morphine doses and systemic nonsteroid anti-inflammatory drug: diclofenac versus ketoprofen


Ms. Editor,

I have read with interest the above-mentioned articles recently published by the Brazilian Journal of Anesthesiology1,2 and have some comments on them:

I) I have presented the subject "Postoperative Analgesia: How to Induce it Safely" in the module Evidence-Based Medicine - Anesthesia in Obstetrics, during the 50th Brazilian Congress of Anesthesiology. There, after defining Evidence-Based Medicine (EBM), I have mentioned a major world initiative for EBM, namely Cochrane Collaboration, the objective of which is to identify randomized controlled studies relevant for several Medical fields and to encourage groups to perform systematic analyses3. Randomized and controlled studies should be the gold standard for the identification of evidence levels for each treatment. An example of evidence levels is presented below:

Level I - Evidence obtained from systematic reviews of relevant randomized controlled studies (with meta-analysis, whenever possible);

Level II - Evidence obtained from one or more well-conducted randomized controlled studies;

Level III - Evidence obtained from well-conducted however not controlled studies, or from well-conducted studies, cohort or selected case reports (preferably multicentric or performed in different times) to act as controls for the cohort;

Level IV - Opinions of recognized authorities, based on clinical experience, descriptive studies or Specialized Committees reports3,4.

I have then mentioned major literature studies about the subject, with the following major conclusions:

1) Protocols were published in 1995 for acute postoperative pain management, the understanding of which is very important for anesthesiologists and which are widely available5;

2) The National Health and Medical Research Council (NHMRC), through its Health Care Advisory Committee, has recently published a document6 which is probably the best available guideline for acute pain management in any situation, and which is based on previous protocols published in the United States by the Agency for Health Care Policy and Research (AHCPR), with data obtained from Cochrane Collaborative Group exclusively from randomized controlled studies on specific subjects, and meta-analysis.
This document has defined evidence level I just for few areas, among them: 1) postoperative epidural analgesia may significantly decrease pulmonary morbidity; 2) epidural opioids are more effective when used in association with local anesthetics (LA) to induce synergistic analgesic action and decrease doses and side-effects, as compared to their single use. They are less effective when used as a single drug (LA or opioids); 3) although current NSAIDs do not decrease severe pain when used as a single drug, their efficacy as multimodal analgesia component is confirmed; 4) paracetamol is an effective postoperative analgesic drug and 60 mg codeine induce additive analgesia7.

II) Closing the presentation I have mentioned a recent prospective study with 6000 cases of safety and efficacy of analgesia induced by spinal morphine for severe postoperative pain management, including dose protocols, which go from 0.2 mg for RTU, 0.4 mg (400 µg) for Cesarean sections and 0.8 mg for abdominal and thoracic aorta aneurysm correction. High personal satisfaction levels were detected with low incidence of side effects and no major complications8.

III) To close my comments I should mention that for more than 15 years we are using for post-Cesarean section analgesia 2 mg (200 µg) epidural morphine associated to 2 mL (100 µg) fentanyl and 24 mL local anesthetics: 2% lidocaine, then 0.5% bupivacaine, currently 0.5% levobupivacaine (total 28 mL) with excellent intraoperative anesthesia (evaluated by the surgeon) and effective postoperative analgesia lasting more than 15 hours in more than 80% of patients, without severe complications (major respiratory depression needing artificial ventilation, neurological complications, permanent sequelae or death). Patient-required analgesics are administered in our service by oral dipirone or paracetamol. Patients' satisfaction is very gratifying. We have more than 10 thousand cases (personal communication) and recommend it as an easy, safe and effective option.

IV) From what has been said, it is clear that spinal morphine (28, 50 or 100 µg)1,2 is not the best alternative, since it is less effective, not so long-lasting as shown by the authors, needs parenteral complementation potentially more dangerous than oral complementation and, last but not least, is not evidence-based.


Yours Truly.

Itagyba Martins Miranda Chaves, TSA, M.D.
Co-responsible for CET, Hospital Universitário, Juiz de Fora
Address: Av. Independência, 1585/1403
ZIP: 36016-320 City: Juiz de Fora, Brazil



01. Ganen EM, Módolo NSP, Ferrari F et al - Efeitos da associação entre pequenas doses subaracnóideas de morfina e cetoprofeno venoso e oral em pacientes submetidas à cesariana. Rev Bras Anestesiol, 2003;53:431;439.

02. Hirahara JT, Bliacheriene S, Yamaguchi ET et al - Analgesia pós-operatória em cesarianas com a associação de morfina por via subaracnóidea e antiinflamatório não esteróide: dicoflenaco versus cetoprofeno. Rev Bras Anestesiol, 2003;53:737-742.

03. Cousins MJ - IARS Review Course Lectures, 2001;15-25.

04. Stockall CA - Evidence-based Medicine and clinical guidelines: past, present and future. Can J Anaesth, 1999;46:105-108.

05. Practice Guidelines for Acute Pain Management in the Perioperative Setting. A Report by the American Society of Anesthesiology Task Force on Pain Management. Anesthesiology, 1995;82:1071-1081.

06. NHMRC Report. Acute Pain Management: the Scientific Evidence. NHMRC, Camberra, Australia, 1999.

07. Smith G, Power I, Cousins MJ - Acute pain - is there scientific evidence on which to base treatment? Br J Anaesth, 1999;82: 817-819.

08. Gwirtz KH, Young JV, Byers RS et al - The safety and efficacy of intrathecal opioid analgesia for acute postoperative pain: seven years experience with 5969 surgical patients at Indiana University Hospital. Anesth Analg, 1999;88:599-604.

06. NHMRC Report. Acute Pain Management: the Scientific Evidence. NHMRC, Camberra, Australia, 1999.