Extended Release Epidural Morphine, Far from Ideal for Postcesarean Delivery Pain Control

To the Editor: The recent paper by Carvalho et al. (1) describing the use of single dose, extended-release epidural morphine (DepoDur) for postcesarean pain does not support the authors’ conclusion that extended release epidural morphine, (DepoDur) seems to be superior to neuraxial morphine sulfate. Two prospective randomized double blind studies have shown that intrathecal morphine sulfate provides excellent postcesarean analgesia (2,3). Furthermore, the advantages of spinal anesthesia for elective cesarean delivery in terms of time management, costs, charges, and complications have been well documented (4). Since extended-release epidural morphine is only approved for epidural injection and can not be co-administered with local anesthetic, it is hard to justify a combined spinal epidural technique versus a single shot spinal for elective cesarean delivery primarily so that extended-release epidural morphine can be utilized. In their study, the authors had one case of accidental dural puncture with an epidural needle in the 70 enrolled patients. Dural puncture with a 17-gauge epidural needle has a substantially higher morbidity when compared with a spinal needle; this will negate the benefit of any marginal improvement with extended-release epidural morphine in postcesarean delivery pain control. Finally, does it really matter if the median verbal rating scale for pain is 3.5 vs 2.2 for morphine versus extended-release epidural morphine at 24–48 h, the only statistically significant pain score of the study, if the patients were equally satisfied with either pain control modalities? Babak Roboubi, MD Director, Acute Pain Management Washington Hospital Center Clinical Assistant Professor of Anesthesiology Georgetown University Washington, DC [email protected]