Intrathecal morphine for post caesarean section analgesia: does naloxone reduce the incidence of pruritus?

doi:10.1016/0959-289X(92)80004-C

International Journal of Obstetric Anesthesia

Volume 1, Issue 4, 1992, Pages 191-194

https://doi.org/10.1016/0959-289X(92)80004-C Get rights and content

Summary

Good quality, long lasting pain relief can be achieved with intrathecal opiates, but often at theexpense of pruritus, nausea and vomiting. Two groups of patients undergoing caesarean section under spinal anaesthesia with heavy bupivacaine 0.5% plus 0.2 mg preservative-free intrathecal morphine were studied. Patients were randomly selected to receive an infusion of dextrose saline with or without naloxone at 0.1 mg/h (over 8 h) after delivery of the baby and were studied for 24 h to assess analgesic requirements and side-effects. There was a significant reduction in the frequency and severity of pruritus in the naloxone group while the infusion was running, but pain relief was not impaired.

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Cited by (9)

Pharmacological agents for prevention of pruritus in women undergoing Caesarean delivery with neuraxial morphine: a systematic review and Bayesian network meta-analysis
2023, British Journal of Anaesthesia
Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery.
Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis.
The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be ‘definitely superior’ to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be ‘definitely superior’ to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists.
Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted.
PROSPERO (CRD42022367058).
Strategies of analgesic treatment after cesarean delivery. Current state and new alternatives
2020, Revista Espanola de Anestesiologia y Reanimacion
El número de cesáreas que se realizan en todo el mundo es cada vez más frecuente. Por tanto, para estas pacientes resulta crucial ofrecer las medidas analgésicas más óptimas. Una deficiente analgesia durante el periodo postoperatorio está asociada con altas necesidades de opioides, la recuperación más tardía, el dolor crónico y la depresión posparto. Es fundamental encontrar estrategias que faciliten un buen control del dolor postoperatorio para facilitar la movilidad, la recuperación de la parturienta y el alta más precoz, ocasionando mínimos efectos secundarios sobre la madre y el recién nacido.
La analgesia multimodal basada en anestesia neuroaxial con morfina, junto a fármacos no opioides como los antiinflamatorios no esteroideos y el paracetamol, forman la mejor combinación analgésica tras la cesárea. Esto permite limitar el uso de opioides, corticoides, gabapentina, magnesio o ketamina para los casos donde la anestesia neuroaxial no sea posible, se incrementen los riesgos, o también cuando la mujer padezca un dolor de difícil control. Además, existe la posibilidad de añadir bloqueos periféricos, como por ejemplo el bloqueo transverso de la pared del abdomen, el bloqueo del plano erector del espinal o infiltraciones de la herida quirúrgica.
The number of caesarean sections performed worldwide is increasing, and with it, the need for the optimal analgesia strategies. Deficient postoperative analgesia increases the need for opioids, delays recovery, and is associated with chronic pain and postpartum depression. It is essential to find good postoperative pain control strategies that facilitate early mobility, early recovery, and early hospital discharge with minimal side effects on the mother and infant.
Multimodal analgesia based on neuroaxial anaesthesia with morphine in combination with non-opioids such as non-steroidal anti-inflammatory drugs and paracetamol, gives the best post-caesarean analgesia outcome, and allows anaesthesiologists to reserve opioids, corticoids, gabapentin, magnesium or ketamine for situations where neuroaxial anaesthesia cannot be performed, for high-risk patients, or when pain is difficult to control. Peripheral nerve block techniques can also be added, such as transverse abdominis plane block, erector spinae block, or continuous wound infiltration.
Monitoring, prevention and treatment of side effects of long-acting neuraxial opioids for post-cesarean analgesia
2019, International Journal of Obstetric Anesthesia
Citation Excerpt :
Lockington et al. found that subcutaneous naloxone (0.4 mg) administered at the end of a cesarean delivery was ineffective for reducing the incidence of pruritus or need for treatment in patients receiving spinal anesthesia that included 25 µg intrathecal fentanyl and 150 µg intrathecal morphine.32 On the other hand, Luthman et al. found that a naloxone infusion at 0.1 mg/h intravenously (IV) significantly reduced the incidence of intrathecal morphine-induced pruritus compared with control (28% vs. 90.5%, P <0.001).33 Jeon et al. randomized women undergoing elective cesarean delivery to receive a continuous infusion of 6 mg epidural morphine in 0.1% bupivacaine, with or without 1.2 mg of naloxone at 2 mL/h, after receiving an epidural bolus of morphine 4 mg in the post-anesthesia care unit. 34
Long-acting neuraxial opioids such as morphine and diamorphine, administered via spinal or epidural routes, are staple components of a multimodal approach to postoperative analgesia following cesarean delivery. The widespread use of neuraxial opioids is due largely to their significant analgesic efficacy and favorable safety profile. The most common side effects of neuraxial opioids are pruritus, nausea and vomiting. These symptoms appear to be dose-related. The most serious complication of neuraxial opioids is respiratory depression, which occurs in 0–0.9% of cases. Hypothermia has also been reported in association with neuraxial morphine use at cesarean delivery. This article will review recent advances in prophylaxis, treatment and monitoring of the side effects of long-acting neuraxial opioids.
A comparison of bupivacaine-fentanyl-morphine with bupivacaine-fentanyl-diamorphine for caesarean section under spinal anaesthesia
2001, International Journal of Obstetric Anesthesia
In a randomised double-blind trial, postoperative analgesia and side effects of intrathecal morphine 0.1 mg and intrathecal diamorphine 0.25 mg were compared. Sixty women were randomised to receive intrathecal injection of 12.5 mg hyperbaric bupivacaine and 12.5 μg fentanyl with either morphine 0.1 mg (group M), or diamorphine 0.25 mg (group D). All women received 100 mg diclofenac rectally at the end of surgery and were given intravenous morphine via a patient controlled analgesia (PCA) system. Pain, PCA morphine usage and side effects were assessed at 2, 4, 8 and 24 h after spinal anaesthesia. The two groups were comparable for quality of intraoperative analgesia. There were no significant differences between the groups in time to first PCA demand, morphine consumption or oral analgesic use in each time period. Significantly more patients in group M were nauseated at 4 h whilst at 24 h nausea was significantly worse in group D. There was no significant difference between the groups in the number of women vomiting in the 24-h period. The two groups were comparable for pruritus and drowsiness. We conclude that 0.25 mg subarachnoid diamorphine is a suitable alternative to 0.1 mg morphine for post caesarean section analgesia.
Intrathecal diamorphine compared with morphine for postoperative analgesia after Caesarean section under spinal anaesthesia
1998, British Journal of Anaesthesia
A randomized, double-blind study of 40 women was performed to compare patient controlled anaesthesia (PCA) morphine requirements after spinal anaesthesia for elective Caesarean section. The women received 0.2 mg of either morphine or diamorphine mixed with 0.5% bupivacaine in 8% dextrose. There were no significant differences between the groups in terms of VAS for pain, either while supine or trying to turn over. The median VAS for itching were significantly higher in the morphine group at 3, 4, 6, 8 and 12 h. Similarly, the VAS for drowsiness were significantly higher in the morphine group at 6 and 8 h. Overall there was no difference in the 24-h PCA morphine demands between the two groups (diamorphine patients 5.5 mg, morphine patients 5.0 mg.
Nalmefene or naloxone for preventing intrathecal opioid mediated side effects in cesarean delivery patients
1997, International Journal of Obstetric Anesthesia
This study was designed to evaluate the efficacy of nalmefene vs. naloxone in preventing side effects resulting from intrathecal opioids, in patients undergoing cesarean delivery. Eighty patients who were scheduled for elective cesarean delivery under spinal anesthesia were included in a double-blind, placebo-controlled study. Patients were randomized into four groups: saline; intravenous nalmefene 0.25 μ·kg⁻¹ every 12 h × 2; intravenous nalmefene 0.5 μg·kg⁻¹ every 12 h × 2; and naloxone infusion 48 μg·h⁻¹ (1.2 μg·ml⁻¹). There were no significant differences among the groups with respect to pain, sedation, satisfaction, or the occurrence or treatment of pruritus or nausea. There was a significant difference among the groups with respect to the occurrence of vomiting (P<0.03): both nalmefene groups had a higher rate of vomiting than did the control group; the 0.25 μg·kg⁻¹ nalmefene group had a higher rate than did the naloxone group. The use of narcotic antagonists does not result in improved comfort in obstetrical patients receiving intrathecal morphine and fentanyl.

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¹: J. A. Luthman BSc, MB BS, FCAnaes, Senior Registrar

²: N. H. Kay BSc, MB BS, FCAnaes, Consultant Anaesthetist

³: J. B. White, MB BS, FCAnaes, Consultant Anaesthetist, Department ofAnaesthesia, Northampton General Hospital, Billing Road, Northampton, NNI 5BD, UK.

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Intrathecal morphine for post caesarean section analgesia: does naloxone reduce the incidence of pruritus?

Summary

Br J Anaesth

Br J Anaesth

Pain

Intrathecal morphine for postoperative pain

Anesthesiology

When do patients given intrathecal morphine need postoperative systemic opiates?

Ann R Coll Surg Engl

Intrathecal morphine's effect on the postoperative aortic surgery

Anesth Analg

Intrathecal and epidural morphine sulphate for post cesarean analgesia — a clinical comparison

Anesthesiology