الفهرس 
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Abstract
Subarachnoid block is the preferred anesthesia for cesarean section, being simple to perform and economical with rapid onset. Adding adjuvant drugs to intrathecal local anesthetics improves quality and duration of sensory blockade and prolongs postoperative analgesia. Intrathecal opioids are synergistic with local anesthetics, thereby intensifying the sensory block without increasing sympathetic block. (181)
Nalbuphine when used as adjuvant to hyperbaric bupivacaine has also improved the quality of perioperative analgesia with fewer side effects. It is a mixed synthetic agonist antagonist which attenuates the μ-opioid effects and enhances the κ-opioid effects. (182)
It has been advocated that the addition of morphine to hyperbaric bupivacaine during spinal anesthesia for caesarean section improves the quality of subarachnoid block and provides satisfactory postoperative pain relief. (183)
Aim of the study was to compare between intrathecal morphine and nalbuphine in different doses of nalbuphine (1 & 2 mg) in elective cesarean delivery.
Patients were randomly allocated into three equal groups and received intraoperatively analgesia; group M (n= 50) :received 150 µg morphine in a 1 ml volume , mixed with 10mg of hyperbaric bupivacaine 0.5 % (total volume 3 ml), group N1 (n= 50) : received 1 mg nalbuphine in a 1 ml volume , mixed with 10mg of hyperbaric bupivacaine 0.5 % (total volume 3 ml)and GroupN2 (n=50) :received 2 mg nalbuphine in a 1 ml volume , mixed with 10mg of hyperbaric bupivacaine 0.5 % (total volume 3 ml).
The study results showed:
1. Patients’ characteristics (age, BMI and ASA) were insignificantly different among the three groups (P = 0.265, 0.55 and 0.811 respectively).
2. Intraoperative and postoperative mean arterial blood pressure were insignificantly different among the three groups at all time measurements.
3. Intraoperative and postoperative heart rate were insignificantly different among the three groups at all time measurements.
4. Respiratory rate was insignificantly different among the three groups both intraoperatively and postoperatively.
5. SpO2 was insignificantly different among the three groups both intraoperatively and postoperatively.
6. VAS at 3, 4 and 6 hours was significantly decreased in group M than groups N1, N2 and was insignificantly different between group N1 and group N2.
7. Intraoperative BROMAGE was insignificantly different among the three groups at all time measurements. While Postoperative BROMAGE at 1.5, 2, 3, 4 and 6 hours was significantly increased in group M than group N1 and group N2 and was insignificantly different between group N1 and group N2
8. APGAR score was insignificantly different among the three groups at 1 and 5 minutes.
9. Time of rescue analgesia was significantly increased in group M than group N1 and group N2 and was insignificantly different between group N1 and group N2.
10. VBGs (PH, PCO2, PO2 and HCO3) were insignificantly different among the three groups.
11. Side effects, PONV was insignificantly different among the three groups and Pruritis was significantly decreased in group N1 than group M and group N2.
Conclusion
As an adjunct to hyperbaric bupivacaine in spinal block, Morphine was superior to nalbuphine in decreasing VAS and increased time for rescue analgesia by prolonged sensory block. Increasing dose of nalbuphine up to 2mg did not increase the analgesic effect. Nalbuphine is superior to morphine in decreasing incidences of pruritus, and both drugs have similar effects on neonatal APGAR score and hemodynamic parameters.
Recommendations
1) The concurrent study recommends using morphine as adjuvant in spinal block.
2) Morphine as adjuvant in spinal block can be used as a step in ERAS (Enhanced Recovery After Surgery) to improve potency of intraoperative and postoperative analgesia, hemodynamic stability and offer early mobilization, so enhanced early discharge from hospital.
3) It can be recommended for further studies to evaluate the effect of smaller dose of morphine to avoid incidence of pruritis.
4) Additional studies including a large number of patients are required for generalization of these results.
5) Also, further studies assessment of adding morphine in different concentrations to bupivacaine.
Limitations of the study
1) The present study didn’t compare the effect of different doses of morphine intrathecally.
2) Sample size was relatively small and may need further studies with increasing sample size. More randomized trials need to be conducted to verify the findings of our study.