To the Editor
I read with interest the article by Dr. C.D. Blitt and associates published recently in the APSF Newsletter. However, I disagree with No. 2 of their “New Guidelines’ which states: “Avoidance of subarachnoid opioids.’ My concern is that they gave no scientific evidence to support their statement while, historically, the safety of subarachnoid opioids has been established, provided the type is carefully chosen and the dose is properly administered. For example, we have been adding 0.2 mg morphine to spinal bupivacaine for cesarean section for many years’ and published the safety of the technique in a prospective study in 19911. In fact, no special monitoring equipment or place for postoperative stay is required if the dose of intrathecal morphine is limited to 0.2 mg. For vaginal delivery, intrathecal opioids, either alone or part of combined spinal-epidural technique, have been found useful and safe.” We have been routinely using intrathecal opioids for labor. Therefore, if ‘avoidance of subarachnoid opioids’ is chosen to be the guideline for a certain group of physicians, I hope this is not misinterpreted to be the standard of care for all. Otherwise, their statement could have serious medicolegal consequences.
Ezzzat 1. Abouleish, M.D. Department of Anesthesiology
The University of Texas Health Science Center Houston, TX
- Blitt CD, Kaufer-Bratt C, Ashby J, Caillett JR: QA program reveals safety issues, promotes development of guidelines: Arizona practice is model. APSF Newsletter 9:17-19,1994.
- Abouleish El Rawal N, Fallon K, Hernanez D:Combined intrathecal morphine and bupivacaine for cesarean section. Anesthesia & Analgesia 67:370-374,1988.
- Abouleish El Rawal N, Rashad N: The addition of subarachnoid morphine 0.2 to hyperbaric bupivacaine for cesarean section: A prospective study of 856 cases. Regional Anesthesia 16:137-140,1991.
- Abouleish El Rawal N, Tobon-Randall 8, Rivera-Weiss M, Meyer B, Wu A, Rashad MN: A clinical and laboratory study to compare the addition of 0.2 mg morphine, 0.2 mg epinephrine or their combination to hyperbaric bupivacaine for spinal anesthesia in cesarean section. Anesthesia & Analgesia 77:457-462,1993.
- Abouleish A, Abouleish El Camann W: Combined spinal epidural analgesia in advanced labor. Canadian Journal of Anesthesia 41: 575-578,1994.
- Camann W: Intrathecal sufentanil for labor analgesia: effect of added epinephrine. Anesthesiology 78: 870874,1993.
- Howet JE, Arkoosh VA, Norris MC, Huffnagle HJ, Silverman NS, Leighton BL: Comparison among intrathecal fentanyl, meperidine, and sufentanil for labor analgesia: Anesthesia & Analgesia 75:734-739,1992.
- Coldwell LE, Rosen MA, Schnider SM: Subarachnoid morphine and fentanyl for labor analgesia: efficacy and adverse effects. Regional Anesthesia 19:2-8,1994.