Itching after epidural and spinal opiates

Abstract

When opiates are administered by the epidural and spinal routes, itching occurs as a side effect. We reviewed 52 reports in the literature of the use of epidural and spinal opiates to assess the incidence of itching and found an overall incidence of 8.5% in patients receiving epidural opiates, and 46% in patients receiving spinal opiates. The symptom is a recognised, though rare, side effect of systemically administered opiates, and in the case of systemic administration the itching is generalised. In the case of epidural and spinal administration, the itching may be generalised. But often a segmental distribution is demonstrable, centred on the level of injection, or the itching is localised to a particular area such as the nose and face. It is likely therefore, in the latter case, that there is an effect upon the spinal cord itself. Although occasionally spinal opiate-induced itching is extremely troublesome and lessens the value of spinal opiate pain relief, in the majority of cases, the itching is not severe and is treatable with naloxone. However, the frequent occurrence of the symptom and the likelihood of a spinal cord mechanism do provide valuable information about opioid actions, and benefit may be derived from better understanding the phenomenon. This paper states a hypothesis to explain spinal opiate-induced itch and explores the possible mechanisms of the effect.

Bupivacaïne intrathécale pure vs hyperbare pour l’analgésie du travail obstétrical: efficacité et effets secondaires

“…6,7 Pruritus associated with intrathecal opioids might result from both segmental spinal and supraspinal actions. 21,22 Rapid cephalad spread rather than systemic absorption with redistribution to the brain possibly causes the pruritus and hypotension seen with solutions of lipophilic opioids and plain local anesthetics. 6,7,[23][24][25][26] Both our study and that of Paez et al 27 support this explanation by showing less pruritus when fentanyl is combined with hyperbaric rather than plain bupivacaine.…”

Prophylacticiv ondansetron reduces nausea, vomiting and pruritus following epidural morphine for postoperative pain control

“…The precise cause of pruritus is not clear but the most convincing hypothesis remains that pruritus is caused by a direct, excitatory effect of morphine on the dorsal horn of the spinal cord and the trigeminal nuclei by the cephalad migration of morphine following its epidural administration. 6,7,13 Since both the 5-HT 3 and µ-opioid receptor systems in the central nervous system are involved in the regulation of pruritus, [1][2][3]6,7,[14][15][16] ondansetron may exert its anti-pruritic action through one or both of these receptor systems.…”

Anaesthesia for daycase gynaecological laparoscopy: a survey of clinical practice in the United Kingdom

“…Pethidine usage was lower in those patients receiving tenoxicam, reflecting better pain relief in this group and the opioid sparing effects of NSAIDs [15]. It might be argued that increased pethidine administration could influence the sensation of pruritus, but it was administered intramuscularly and is much less pruritogenic via this route [1]. There were significant correlations observed between pruritus and pain at all time intervals examined and these were strongest at 30 min postoperatively.…”

“…Pruritus is a subjective unpleasant sensation arising from irritation of the nociceptor fibres in the superficial layers of the skin which provokes the urge to scratch. It is common following opioid administration and may be more unpleasant than the pain itself [1][2][3][4]. While pruritus has been reported following intravenous or intramuscular administration, it has been suggested that it is most common following intrathecal or epidural administration of opioids [5,6].…”

“…Gynaecological laparoscopy is considered to be a suitable daycase procedure [1,2]. However, laparoscopy under general anaesthesia, particularly when sterilisation is performed, can be associated with significant morbidity in the form of pain, nausea and vomiting, dizziness and delayed mobilisation [3,4].…”