Prophylactic mirtazapine reduces intrathecal morphine-induced pruritus (original) (raw)
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Preoperative Gabapentin Prevents Intrathecal Morphine-Induced Pruritus After Orthopedic Surgery
Anesthesia & Analgesia, 2008
BACKGROUND: Pruritus is the most common side effect of intrathecal morphine. Gabapentin is an anticonvulsant and had been reported to be effective in some chronic pruritus conditions. Its effect in intrathecal morphine-induced pruritus has not yet undergone an evaluation. METHODS: We randomly allocated 86 patients scheduled for lower limb surgery under spinal anesthesia into two equal groups that received either gabapentin 1200 mg or placebo 2 h before operation in a prospective, double-blind manner. All patients received an intrathecal injection of 15 mg of 0.5% isobaric bupivacaine and 0.2 mg preservative-free morphine. Pruritus was evaluated at 3, 6, 9, 12, and 24 h after intrathecal morphine administration. RESULTS: The incidence of pruritus was significantly more frequent in the placebo group compared with the gabapentin group (77.5% vs 47.5%; P ϭ 0.01). The onset time of pruritus in the gabapentin group (6.2 Ϯ 1.8 h) was significantly delayed compared with that in the placebo group (3.1 Ϯ 0.8 h) (P Ͻ 0.0001). The severity of pruritus was significantly more in the placebo group compared with the gabapentin group at 3 and 6 h after intrathecal morphine injection. CONCLUSION: Preoperative gabapentin prevents pruritus induced by intrathecal morphine in patients undergoing lower limb surgery with spinal anesthesia.
Pain Practice, 2014
Methylnaltrexone is a peripheral opioid receptor antagonist that does not cross the blood-brain barrier; so without interference with pain relief, it could reverse the peripheral opioid side effects such as constipation, pruritus, postoperative ileus, and urinary retention. This study has been designed to evaluate the effect of methylnaltrexone on postoperative side effects of intrathecal morphine. In seventy-two 18-to 55-year-old patients scheduled for elective orthopedic operations under spinal anesthesia, neuraxial blockade was achieved using 10 mg 0.5% hyperbaric bupivacaine and 0.1 mg preservative-free morphine sulfate. The first group (M) received 12 mg methylnaltrexone, while the second group (P) received normal saline, subcutaneously, immediately after spinal block in a randomized, double-blind fashion. There was a significant decrease in the rate of nausea and vomiting in group M, but there was no significant difference in the rate of pruritus or urinary retention between the two groups. Pain score was significantly lower in group M. Respiratory depression or decreased level of consciousness was not reported in any patient. Subcutaneous administration of methylnaltrexone was not effective in decreasing postoperative urinary retention and pruritus, but lowered the rate of nausea and vomiting and pain score after intrathecal bupivacaine and morphine. &
PubMed, 2012
Objective: Gabapentin has an antipruritus effect, which its efficacy in reducing pruritus induced by intrathecal morphine has not been well documented. The purpose of the present study was to know if a single smaller dose of gabapentin could decrease the intrathecal morphine-induced pruritus. Material and method: One hundred sixty eight patients from the 180 recruited patients fulfilled the trial requirement and were scheduled for orthopedic surgery under spinal anesthesia using 0.5% isobaric bupivacaine and 0.2 mg preservative-free morphine. The patients were divided into two groups, each of 84 subjects and received either gabapentin 600 mg or a placebo, two hours preoperatively, in a prospective, randomized, double-blind, placebo-controlled trial. The pruritus was evaluated at 1, 2, 3, 4, 6, 9, 12 and 24 hours after intrathecal morphine administration. Adverse events were noted. Results: The overall incidence of pruritus was not significantly different between the two groups while the incidence and severity of pruritus was significantly decreased in the gabapentin group at four hours after intrathecal morphine injection (18 of 84 subjects, 21.4% vs. 35 of 84 subjects, 41.7%; p = 0.008 and 0.045 respectively). The urinary retention was significantly higher in the study group compared to the placebo group (50.0% (42 of 84 subjects) vs. 33.3% (28 of 84 subjects) p = 0.042). Conclusion: Preoperative gabapentin 600 mg did not significantly reduce the postoperative intrathecal morphine-induced pruritus.
Anesthesia & Analgesia, 2005
Pruritus is the most common side effect of intrathecal morphine for postoperative pain relief. Activation of central 5-hydroxytryptamine subtype 3 (5-HT3) receptors is one of its possible mechanisms. The role of 5-HT3 antagonists in the prevention of pruritus has not been clearly established. In a prospective, randomized, double-blind, placebo-controlled study, we evaluated the efficacy of prophylactic administration of ondansetron and dolasetron for the prevention of intrathecal morphine-induced pruritus. The patients were randomized into 3 groups to receive either 4 mg ondansetron IV (group O, n ϭ 35), 12.5 mg dolasetron IV (group D, n ϭ 35) or 5 mL placebo (group P, n ϭ 35) 30 min before administration of spinal anesthesia with 10 to 17.5 mg of 0.5% hyperbaric bupivacaine and 0.25 mg of morphine for urologic, orthopedic, or vascular surgery.
Prevention and Treatment of Neuraxial Morphine-Induced Pruritus: A Scoping Review
Journal of Pain Research
The addition of morphine to neuraxial anaesthesia leads to improved postoperative analgesia and lower opioid consumption, but is often accompanied by pruritus. Studies on preventing or treating pruritus show contradictory results. Our objective was to identify effective drugs for the prevention or treatment of pruritus by a scoping review of clinical trials. A systematic literature search was conducted in PubMed, Embase and Web of Science. We identified clinical trials investigating the prevention or treatment of neuraxial morphine-induced pruritus in adults. Systematic reviews and meta-analyses were screened for eligible studies. One-hundredand-four articles were included covering 13 pharmacological groups. We conclude that dopamine antagonists, µ-opioid agonist/ antagonists and neuraxial or orally administered µ-opioid antagonists prevent pruritus caused by neuraxial morphine regardless of the timing of administration. In the reviewed literature, 5HT3-antagonists prevent neuraxial morphine-induced pruritus when administered before morphine administration. For the treatment of neuraxial morphine-induced pruritus, only nalbuphine appears to be consistently effective. More research is needed to find the most effective doses and the optimal timing of the effective medication.
Perioperative Nimodipine and Postoperative Analgesia
Anesthesia & Analgesia, 2006
There is experimental evidence that nimodipine, an L-type dihydropiridine calcium channel blocker with relatively high blood-brain barrier penetration, enhances the antinociceptive properties of morphine. We tested the hypothesis that oral nimodipine taken preoperatively and 6 hourly for 48 h postoperatively would reduce visual analog scale pain scores and morphine consumption in morphine-naive patients with acute postoperative pain. Forty patients undergoing total knee replacement surgery (age 70 Ϯ 7 yr, 28 male) were randomized by computer-generated numbers to receive capsules containing either nimodipine 30 mg or placebo in a double-blind study design. All patients received 3 capsules (nimodipine 90 mg or placebo) 1-2 h before induction of anesthesia followed by oral nimodipine 30 mg or placebo 6 hourly for 48 hours postoperatively. Spinal anesthesia was induced with hyperbaric bupivacaine 0.5% (2.4 -3.0 mL) and fluids and ephedrine were given at the discretion of the anesthesiologist.
Background: post-operative pain management in major spine surgery is important to ensure early ambulation and good functional outcome. This study compared the effectiveness of intravenous (IV) fentanyl 4 μg/kg to IV morphine 0.1 mg/kg for immediate post-operative pain after major spinal surgery under remifentanil-based anesthesia. Methods: Seventy-eight patients undergone major spine surgery were randomly assigned to two groups: group A received iv fentanyl 4 μg/kg and Group B received IV morphine 0.1 mg/kg given at skin closure. Total dosage of intra-operative remifentanil and the time taken for extubation were recorded. The immediate post-operative pain was assessed using the behavioural pain score (BpS) or visual analogue scale (vAS). The time to the first rescue analgesia, total cumulative morphine given and number of patients required rescue analgesia, pain score and sedation score were recorded. The assessments were done at 10 minutes interval upon patient arrival at recovery for one hour. The side effects of fentanyl or morphine were recorded. Results: There was a delayed time for extubation in Group A compared to Group B (23.39 ± 6.1 vs 14.78 ± 6.8 minutes; p<0.001). The median time to the first rescue analgesia was longer in Group A compared to Group B (30(20-60) vs 20(10-60) minutes; p<0.001). The number of patients required rescue analgesia and the total cumulative morphine dosage in the first 30 minutes in the recovery were both less in group A compared to group B (24 vs 34 patients, p=0.027; 1(1-7) vs 2(0.5-4) mg, p<0.001). Median sedation score up to T 40 showed statistically significant difference between two groups (p<0.05). At T 10 and T 20 , median BpS was lower in group A compared to group B (1(1-1) vs 1(1-2), p<0.01; 0(0-0), 2(0-2), p<0.022). However, there was no statistically significant difference in VAS from 20 minutes to 60 minutes for both groups. No other opioids side effects were noted.
Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis
Anaesthesia, 2009
Intrathecal morphine is often used for postoperative analgesia after surgery. We performed a meta-analysis to obtain more detailed information on the frequency of side-effects in patients receiving intrathecal morphine in combination with spinal anaesthesia compared with placebo treated patients. We clustered the analysis to patients receiving placebo, less than morphine 0.3 mg (M < 0.3), or equal to or more than morphine 0.3 mg (M ‡ 0.3) and calculated the risk ratios of morphine vs placebo. Twenty-eight studies investigating 46 morphine groups vs placebo were included. A total of 790 patients with intrathecal morphine and 524 patients who received placebo were analysed. Compared with placebo the lower dose of morphine resulted in an increase of nausea (RR 1.4, 95% CI 1.1-1.7), vomiting (RR 3.1, 95% CI 1.5-6.4) and pruritus (RR 1.8, 95% CI 1.4-2.2). The higher dose resulted in an increased risk ratio for pruritus (RR 5.0, 95% CI 2.9-8.6), but not nausea (RR 1.2, 95% CI 0.9-1.6) or vomiting (RR 1.3, 95% CI 0.9-1.9). Overall, intrathecal morphine did not increase respiratory depression. However, the higher dose of intrathecal morphine was associated with more episodes of respiratory depression (7 ⁄ 80) compared with the lower dose (2 ⁄ 247). Intrathecal morphine is associated with a mild increase in side-effects. With a dose < 0.3 mg we found there were no more episodes of respiratory depression than in placebo patients who received systemic opioid analgesia.
Treatment of intrathecal morphine-induced pruritus following Caesarean section
Canadian Journal of Anaesthesia, 1997
To compare both the efficacy and cost of nalbuphine and diphenhydramine in the treatment of intrathecal morphine-induced pruritus following Caesarean section. Methods: Eighty patients, undergoing elective Caesarean section under spinal anaesthesia, were randomized, in a prospective, double-blind trial, to receive either nalbuphine (Group NAL) or diphenhydramine (Group DIP) for the treatment of SAB morphine-induced pruritus. All patients received an intrathecal injection of 1 0-12 mg hyperbaric bupivacaine 0.75% and 200 ~tg preservative free morphine. Postoperative pruritus was assessed, using a visual analogue scale (VAS), for 24 hr. Pruritus treatment was administered upon patient request and by a nurse blinded to the treatment given. Patients who failed to respond to three doses of the study drug were deemed treatment failures. Patient satisfaction was assessed with a questionnaire given 24 to 48 hr after surgery. Direct drug costs were calculated based on the pharmacy provision costs as of April 1996. Results: Eighty patients were enrolled and 45 requested treatment for pruritus. Patients treated with NAL (n = 24) were more likely to achieve a VAS score of zero with treatment (83% vs 43%, P < 0.01), had a higher AVAS following treatment (4 + 2 vs 2 ___ 2, P < 0.003), and experienced fewer treatment failures (4% vs 29%, P < 0.04), than those treated with DIP (n = 21). Group NAL patients were also more likely to rate their pruritus treatment as being good to excellent (96% vs 57%, P < 0.004). Direct drug costs were higher for NAL than for DIP ($6.4 +_ 3. I vs $1.7 _+ 0.7, respectively, P < 0.0001). Conclusion: Nalbuphine is more effective than diphenhydramine in relieving pruritus caused by intrathecal morphine and the cost differences are small. Objectif : Comparer I'efficacit~ et le cofit de la nalbuphine avec ceux de la diphenhydramine administr6e apr& la c&arienne comme traitement du prurit provoqu~ par la morphine sous-arachndfdienne. M&hodes : Dans cette 6tude prospective en double aveugle, 80 parturientes op6r6es pour une c&arienne non urgente sous rachianesth&ie ont ~t~ r6parties au hasard pour recevoir comme traitement du prurit provoqu6 par la morphine soit de la nalbuphine (groupe NAL), soit de la diphenhydramine (groupe DIP). Toutes les patientes ont re~u une injection sous-arachndidienne de 10-12 mg de bupivac~'ne 0,75% hyperbare avec 200/~g de morphine sans pr&ervatif. Une &helle visuelle analogique (EVA) a servi ~ 6valuer I'intensit~ du prurit postop&atoire pendant 24 h. Le traitement antiprurigineux a &6 administr6 ~ la demande de la patiente et par une inflrmi&e ignorant la nature du traitement. On consid&ait le traitement comme un &hec en I'absence de r6ponse ~trois doses de la drogue &udi&. La satisfaction de la patiente &ait ~valu& avec un questionnaire administr~ 24 ~ 48 h apr& la chirurgie. Les coots d'approvisionnement de la pharmacie en avril 1996 repr~sentaient les coots directs des produits utilis&. R~sttltats : Quarante-cinq des 80 participantes ~ I'&ude ont demand~ un tra!tement antiprurigineux. Les patientes trait~es avec NAL (n=24) avaient plus de chance d'obtenir la cote z&o sur I'EVA (83% vs 43%, P <0,01), avaient un AI~VA plus ~lev~ apr& traitement (4 + 2 vs 2-2, P < 0,003) et ont subi moins d'&hecs th~rapeutiques (4% vs 29%, P < 0,04) que cetles du groupe DIP (n=2 I). Le groupe NAL avait une plus forte tendance ~ juger le traitement antiprurigineux de bon ~ excellent (96% vs 57%, P < 0,004). Les coOts directs 6taient plus 61ev6s pour NAL que pour DIP (
Journal of Clinical Anesthesia, 2014
Study Objective: To investigate the potential benefit of postoperatively providing a patient-controlled anxiolytic agent, midazolam, in addition to morphine. Design: A double-blinded, placebo-controlled trial of patient-controlled midazolam. Setting: A Community hospital. Participants: 29 patients undergoing elective spinal surgery. Interventions: Postoperatively, via two separate patient-controlled pumps, the treatment group received morphine and midazolam, and the control group received morphine and saline solution. Measurements: Repeated measures using numerical rating scales of the primary outcomes of pain and anxiety were obtained every two hours postoperatively. Amount of morphine and midazolam/placebo administered was assessed, as were other secondary outcomes. Main Results: Anxiety level in the treatment group declined more rapidly over the 24 hours after surgery than in the control group. The treatment group used less morphine than the control. Preoperative positive affect was the only significant psychological predictor of postoperative outcomes. Conclusions: Patients who received both midazolam and morphine experienced a more rapid decline in anxiety and used less opioid medication than those receiving morphine alone.