Reversal of epidural morphine-induced respiratory depression and pruritus with nalbuphine

Abstract

Epidural morphine has become accepted as an efficient means of postoperative pain management. However, the problem of delayed respiratory depression has restricted its use, and in most centres patients are monitored for 24 hours following the last dose of epidural morphine, in an intensive care setting. Naloxone has been found to reverse this respiratory depression ~ but there are reported problems with reversal of analgesia. 2 Many investigators now believe naloxone to have significant effects on cardiovascular function with or without prior narcotic analgesia administration. 3-s Nalbuphine has been shown to reverse intravenous opioid-indnced respiratory depression. 6'7 It might have a lesser tendency for reversal of analgesia since it is a partial agonist at the ma opioid receptor and an agonist at the Kappa opioid receptor. ~2There have been no previous published studies of nalbuphine's effect on the respiratory depression and analgesia produced by epidural morphine. The purpose of our study was therefore to determine if intravenously administered nalbuphine could reverse epidural morphineinduced respiratory depression, pruritus and to assess its effects on analgesia. MethodsAfter approval by our Human Research Ethics Committee, informed consent was obtained from 20 ASA physical status I patients scheduled for elective total abdominal hysterectomy. The study was prospective, randomized, double-blind and placebo controlled. Randomization was achieved using a random numbers table.Premedication was with diazepam 5 mg PO 1.5 hours preoperatively. Ventilatory ~esponse to CO2 was assessed using the rebreathing method described by Read) A Portex epidural catheter was introduced 3-4 cm into the epiduml space at spinal level L2-a or L3-4 via a 17 gauge Touhy needle, the bevel of which faced cephalad. A test dose of 3 ml carbonated lidocaine with 1:200,000 epinephrine was then administered. While awaiting the development of some sensory block to confirm successful CAN J ANAESTH 1988 / 35:6 / pp599-604

Roles of Mast Cells and Histamine in Mosquito Bite-Induced Allergic Itch-Associated Responses in Mice

“…With regard to human subjects, itch is the common side effect of epidural and intrathecal injections of morphine (for review, see ref. 30), and itch induced by epidural morphine is inhibited by naloxone and opioid receptor antagonist (31,32). Thus, it is possible that opioid antagonists act on the central nervous system to inhibit itching in human subjects and itch-associated response in mice.…”

The effect of subhypnotic doses of propofol on the incidence of pruritus after intrathecal morphine for Caesarean section

“…Whether or not an HDU can alter this is impossible to know and, in any case, some patients are deliberately discharged to permit a more natural terminal stage. However, it would seem that there must be room for improvement in the expected to live group [14,15].…”

“…Whether or not an HDU can alter this is impossible to know and, in any case, some patients are deliberately discharged to permit a more natural terminal stage. However, it would seem that there must be room for improvement in the expected to live group [14,15].Compared to an ICU the costs after initial outlay are likely to be modest [16] but as the demand increases these will rise [4]. The major cost is in nursing provision and it is difficult to match nurse staffing with bed occupancy although the high usage for elective surgery may make this more predictable than ICU staffing.…”

Compatibility and Stability of Morphine Sulphate and Naloxone Hydrochloride in 0.9% Sodium Chloride for Injection

“…14 In children, however, nalbuphine has been shown to increase drowsiness 14,17 and is ineffective in treating pruritus. 19 Droperidol has been found to decrease the incidence of pruritus, but it also increases somnolence relative to placebo.…”

“…10 Most existing therapeutic approaches to treatment of opioid-induced pruritus are unreliable, are often ineffective, and may increase the risk of adverse drug reactions. [12][13][14] For example, naltrexone was more effective than placebo in reducing the incidence of pruritus (reduction of 34% to 62%), but this drug also decreases analgesia. 15,16 Studies of nalbuphine in adults have generated conflicting data: some studies reported no reduction in pruritus, 13,17 whereas others showed a lower incidence of pruritus with nalbuphine than with placebo (13% versus 78%, respectively) 18 and lower pruritus scores (by 1 to 2 points on a 4-point scale).…”