Ondansetron does not prevent pruritus induced by low-dose intrathecal fentanyl

BACKGROUND: Addition of an opioid to low-dose spinal anesthesia with bupivacaine improves the quality and success of anesthesia. However, the intrathecal fentanyl-induced pruritus is as high as 75%. We hypothesized that after administration of 4 or 8 mg of prophylactic IV ondansetron, the incidence of pruritus induced by low-dose intrathecal fentanyl would be significantly lower than after placebo. METHODS: In this double-blind study, 90 outpatients undergoing knee arthroscopy received 3 mg of bupivacaine + 10 micro g fentanyl intrathecally. Before spinal puncture, the patients received randomly either saline (P) or ondansetron 4 mg (O4) or 8 mg (O8) IV. They were asked about pruritus frequently, and they estimated its severity on a scale of 0-10. RESULTS: There was no difference in the incidence of pruritus between the three groups: pruritus occurred in 17 (57%), in 21 (75%) and in 19 patients (70%) in P, O4 and O8 groups, respectively. The pruritus was mostly mild. Four patients in the placebo group, three in the O4 and four patients in the O8 groups considered it severe. One patient in each group requested treatment for pruritus; after IV naloxone their pruritus was relieved. Neither time to pruritus nor duration of pruritus differed between the groups. One patient in each group developed a long-lasting (>10 h) pruritus. CONCLUSIONS: After prophylactic administration of 4 or 8 mg of ondansetron IV, the incidence, duration and severity of pruritus were similar to placebo. Ondansetron does not prevent pruritus induced by low-dose intrathecal fentanyl.     

预防性给于恩丹西酮可以降低蛛网膜下腔注入阿片药所致瘙痒的发生

目的:观察预防性静脉给与恩丹西酮对蛛网膜下腔芬太尼和吗啡所致瘙痒的作用。方法:随机选择ASA Ⅰ～Ⅱ级拟行下肢和下腹部手术的病人240例,按双盲原则分为OBM、OBF、BM和BF4组,所有病人均采用蛛网膜下腔重比重液布比卡因麻醉,在蛛网膜下腔注入布比卡因和吗啡或芬太尼前,随机静脉给与恩丹西酮8mg或生理盐水。蛛网膜下腔注药后分别于15min、30min、45min、60min及1h、2h、3h、4h、5h和6h对病人进行瘙痒情况评估。采用x~2和q检验进行统计学分析。结果:生理盐水组(BM和BF)瘙痒发生率明显高于恩丹西酮组(OBM和OBF)(P<0.05和P=0.001)。四组病人瘙痒发生时间和持续时间相似(P>0.05)。结论:预防性给与恩丹西酮可以降低吗啡、芬太尼和布比卡因蛛网膜下腔注射引起的瘙痒的发生,对芬太尼组效果更为显著。     

Intrathecal fentanyl-induced pruritus during labour: the effect of prophylactic ondansetron

Fentanyl is commonly used for spinal analgesia during labour but it is associated with a high incidence of pruritus. This randomised, double-blind, placebo-controlled study was performed to evaluate the effect of prophylactic ondansetron on the incidence and severity of pruritus among parturients receiving intrathecal fentanyl as part of combined spinal-epidural analgesia. Seventy-three women were randomised to receive either saline placebo (group P, n = 25), ondansetron 4 mg (group O4, n = 23) or ondansetron 8 mg (group O8, n = 25) intravenously before intrathecal fentanyl 25 micrograms and bupivacaine 2 mg. The incidence and severity of pruritus were measured using a verbal rating and a visual analogue scale, and by the requirement for rescue anti-pruritic medication (naloxone). The overall incidence of pruritus was 95% (group P 100%, group O4 95%, group O8 90%). There were no significant differences between groups for severity of pruritus or requirement for treatment (naloxone given to 45%, 28% and 35% of groups P, O4 and O8 respectively). Secondary outcomes such as the incidence of headache, pain and nausea were not significantly different between groups. We conclude that prophylactic ondansetron 4 or 8 mg intravenously was ineffective in reducing the incidence or severity of intrathecal fentanyl-induced pruritus during labour.     

Prophylactic intravenous ondansetron and dolasetron in intrathecal morphine-induced pruritus: a randomized, double-blinded, placebo-controlled study

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 = 35), 12.5 mg dolasetron IV (group D, n = 35) or 5 mL placebo (group P, n = 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. Patients were evaluated for incidence and severity of pruritus at arrival to the postanesthesia care unit and at 2, 4, 8, and 24 h postoperatively. The incidence and severity of pruritus was significantly less frequent in the ondansetron and dolasetron groups compared with placebo (34%, 20%, and 66% respectively, P < 0.01). Patients who received 5-HT3 antagonist reported significantly less total severity of pruritus compared with placebo during the first 8 h and the severe pruritus was observed only in patients within P group (P group: 4 of 35; 11%, O or D group: 0 of 35; 0%, P < 0.05). We conclude that the prophylactic use of ondansetron and dolasetron helps to reduce the incidence and severity of intrathecal morphine-induced pruritus.     

Lornoxicam and ondansetron for the prevention of intrathecal fentanyl-induced pruritus

Purpose In this randomized, double-blind study, we aimed to compare the effectiveness of lornoxicam and ondansetron for the prevention of intrathecal fentanyl-induced pruritus in patients undergoing cesarean section. Methods One hundred and eight parturients (American Society of Anesthesiologists [ASA] I-II status) requesting neuraxial analgesia by a combined spinal-epidural (CSE) technique were recruited for this study. A CSE technique was performed and anesthesia was achieved with fentanyl 25 μg and hyperbaric bupivacaine 12 mg. Patients were randomly allocated to three groups, each with 36 participants. Immediately following delivery, patients received either lornoxicam 8 mg IV (group L; n = 36), ondansetron 8 mg IV (group O; n = 36), or normal saline 2 ml IV (group P; n = 36). Pruritus, pain, and nausea and vomiting scores were recorded during the initial 24 h postoperatively. Results The incidence of pruritus was significantly lower in group O from 4 to 12 h postoperatively when compared to that in group L and group P. According to the pruritus grading system we used, the number of patients without pruritus was significantly higher in group O when compared to that in group L and group P. The number of patients experiencing moderate pruritus was significantly lower in group O when compared to that in group P. Conclusion We observed that the administration of 8 mg IV lornoxicam failed to prevent intrathecal fentanyl-induced pruritus in parturients. Also, our data confirmed that ondansetron is likely to attenuate intrathecal fentanyl-induced pruritus.     

Intrathecal versus intravenous fentanyl for supplementation of subarachnoid block during cesarean delivery

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 microg of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 microg of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 +/- 35 microg was required in the IV Fentanyl group, whereas no supple- mentation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 +/- 39 min versus 119 +/- 44 min; P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25; P = 0.02). IMPLICATIONS: Supplementation of spinal bupivacaine anesthesia for cesarean delivery with intrathecal fentanyl provides a better quality of anesthesia and is associated with a decreased incidence of side effects as compared with supplementation with the same dose of IV fentanyl.     

Prophylactic intravenous ondansetron reduces the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery

Pruritus is a common side effect of intrathecal morphine injection for postoperative pain control. Its incidence is especially high in patients undergoing cesarean delivery. We investigated the effectiveness of ondansetron in preventing intrathecal morphine-induced pruritus in such patients. We included 60 consecutive nonbreastfeeding women who were scheduled for elective cesarean delivery. After the administration of spinal anesthesia with bupivacaine and intrathecal morphine 0.15 mg injection, the patients were randomly divided into three groups. Group 1 received placebo (normal saline) IV injection, Group 2 diphenhydramine 30 mg IV injection, and Group 3 ondansetron 0.1 mg/kg IV injection. The incidence of pruritus was significantly lower in the ondansetron group (25%) when compared with that in the placebo group (85%) and in the diphenhydramine group (80%) (both P < 0.05). The postoperative pain score and time to flatus passage were not significantly different among the three groups. There were no headache or extrapyramidal signs associated with ondansetron use. In conclusion, ondansetron prophylaxis significantly reduced the incidence of intrathecal morphine-induced pruritus in patients undergoing cesarean delivery. IMPLICATIONS: Ondansetron prophylaxis significantly decreases the incidence of pruritus, a common side effect of intrathecal morphine used to treat postcesarean delivery pain.     

Effect of epinephrine on intrathecal fentanyl analgesia in patients undergoing postpartum tubal ligation

Eighty women receiving spinal anesthesia for postpartum tubal ligation were entered into a double-blind, randomized protocol studying the effects of epinephrine on intrathecal fentanyl-induced postoperative analgesia. All patients received 70 mg hyperbaric lidocaine with either 0.2 mg epinephrine (LE), 10 micrograms fentanyl (LF), epinephrine and fentanyl (LFE), or 0.4 ml saline (L). Onset and regression of anesthesia, degree of intraoperative comfort, incidence of pruritus, and extent of postoperative analgesia were evaluated. The simultaneous administration of epinephrine and fentanyl prolonged the duration of complete analgesia (137 +/- 47 min (LFE); 76 +/- 32 min (LE); 85 +/- 44 min (LF); 65 +/- 36 min (L)) and the duration of effective analgesia (562 +/- 504 min (LFE); 227 +/- 201 min (LE); 203 +/- 178 min (LF); 198 +/- 342 min (L)). Administration of epinephrine decreased the incidence of pruritus associated with intrathecal fentanyl (1/18 (LFE); 1/21 (LE); 8/19 (LF); 2/19 (L)).     

Ondansetron, orally disintegrating tablets versus intravenous injection for prevention of intrathecal morphine-induced nausea, vomiting, and pruritus in young males

In this study we compared the efficacy of orally disintegrating tablets (ODT) and IV ondansetron for preventing spinal morphine-induced pruritus and postoperative nausea and vomiting (PONV) in healthy young male patients. Patients who received bupivacaine with 0.20 mg morphine for spinal anesthesia were randomly assigned to the ODT group (ODT ondansetron 8 mg, n = 50), the IV group (4 mg ondansetron IV, n = 50), or the placebo group (n = 50). Each individual was assessed for pruritus, postoperative nausea and vomiting, and pain at 0, 2, 6, 12, 18, and 24 h after surgery using three distinct visual analog scales. The frequencies of postoperative nausea and vomiting and frequencies of requirement for rescue antiemetic and antipruritic were recorded. There were no significant differences among the three groups with respect to incidence or severity of PONV or postoperative pain visual analog scale scores. The incidences of pruritus in the ODT (56%) and IV (66%) groups were significantly different from that in the placebo group (86%) (P < 0.02 for both). Only the ODT group had significantly lower mean pruritus visual analog scale scores at 0, 2, 6, and 12 h postsurgery than the placebo group (P < 0.023 for all). The frequency of requirement for rescue antipruritic was significantly less in the ODT group than the placebo group (P = 0.013). Both ODT ondansetron 8 mg and IV ondansetron 4 mg are more effective than placebo for preventing spinal morphine-induced pruritus, but neither form of this agent reduces spinal morphine-induced postoperative nausea and vomiting in this patient group.     

Spinal anesthesia for arthroscopic knee surgery

BACKGROUND AND OBJECTIVE: The purpose of the study was to compare the effects of adding 50 microg of morphine, 25 microg of fentanyl or saline to 6 mg of hyperbaric bupivacaine on postoperative analgesia and time to urination in patients undergoing arthroscopic knee surgery under spinal anesthesia. METHODS: The study was designed in a prospective, randomized, double-blinded and placebo-controlled manner. Sixty ASA I-II patients were randomized into the following three groups: Group BM: 6 mg of bupivacaine and 50 microg of morphine, Group BF: 6 mg of bupivacaine and 25 microg of fentanyl, and Group BS: 6 mg of bupivacaine and saline. Selective spinal anesthesia was performed in a lateral decubitus position, with the operative knee dependent for 10 min. RESULTS: In all groups satisfactory anesthesia was provided during the operation. There was a statistically significant difference between all the groups in times to voiding [Group BM 422 +/- 161 min; Group BF 244 +/- 163 min; Group BS 183 +/- 54 min (mean +/- SD)]. The incidence of pruritus was significantly greater in Group BM (80%) and BF (65%) in comparison with Group BS (no pruritus) (P < 0.05). The incidence of nausea was significantly increased in Group BM (35%) in comparison with Group BF (10%) and Group BS (P < 0.05). Analgesic consumption was significantly greater in Group BS in comparison with Groups BM and BF (P < 0.01). CONCLUSIONS: We conclude that during spinal anesthesia even mini-dose intrathecal morphine is not acceptable for outpatient surgery due to side-effects, especially severely prolonged time to urination.     

Intrathecal fentanyl is superior to intravenous ondansetron for the prevention of perioperative nausea during cesarean delivery with spinal anesthesia

This study compares intrathecal (IT) fentanyl with IV ondansetron for preventing intraoperative nausea and vomiting during cesarean deliveries performed with spinal anesthesia. Thirty healthy parturients presenting for elective cesarean delivery with standardized bupivacaine spinal anesthesia were randomized to receive 20 microg IT fentanyl (Group F) or 4 mg IV ondansetron (Group O) by using double-blinded methodology. At eight specific intervals during the surgery, a blinded observer questioned the patient about nausea (1 = nausea, 0 = no nausea), observed for the presence of retching or vomiting (1 = vomiting or retching, 0 = no vomiting or retching), and recorded a verbal pain score (0-10, 0 = no pain, 10 = worst pain imaginable). Cumulative nausea, vomiting, and pain scores were calculated as the sum of the eight measurements. Intraoperative nausea was decreased in the IT fentanyl group compared with the IV ondansetron group: the median (interquartile range) difference in nausea scores was 1 (1, 2), P = 0.03. The incidence of vomiting and treatment for vomiting was not different (P = 0.7). The IT fentanyl group had a lower cumulative perioperative pain score than the IV ondansetron group; the median difference in the cumulative pain score was 12 (8, 16) (P = 0.0007). The IT fentanyl group required less supplementary intraoperative analgesia. The median difference in the cumulative fentanyl dose was 100 (75, 100) microg fentanyl, (P = 0.0002).     

An evaluation of general and spinal anesthesia techniques for prostate brachytherapy in a day surgery setting

We evaluated four anesthetic techniques for transperineal brachytherapy of the prostate in a day-surgery setting: general anesthesia with either fentanyl and propofol total IV anesthesia (TIVA) or with fentanyl, thiopental, and isoflurane (F-P-I), versus spinal block using 5 mg of 0.5% large-dose spinal hyperbaric bupivacaine (LDS) or 2.5 mg of 0.5% hyperbaric bupivacaine plus fentanyl 25 mug small-dose spinal (SDS). Operating room time was shorter in the general anesthesia groups. TIVA patients voided earlier (103 +/- 41 min) than F-P-I patients (131 +/- 65 min), SDS (126 +/- 55 min), and LDS patients (169 +/- 65 min; P < 0.05 TIVA versus all groups and between spinal groups). TIVA patients were discharged earlier (119 +/- 42 min) than F-P-I patients (160 +/- 69 min) and SDS or LDS patients (132 +/- 53 and 186 +/- 72 min, respectively; P < 0.05 versus all groups and between the spinal groups). There were no intergroup differences regarding postanesthesia nausea or vomiting, pain score, return to normal function at home, or overall satisfaction. Whereas all four techniques are suitable for this procedure, TIVA provides the earliest voiding and consequently fastest discharge. Between spinal techniques, the SDS technique requires more intraoperative sedation but provides earlier voiding and consequently earlier discharge. TIVA, general anesthesia with isoflurane and fentanyl, and two spinal techniques (5 mg of bupivacaine 0.5% or 2.5 mg of bupivacaine 0.5% plus 25 mug of fentanyl) are suitable techniques for transperineal brachytherapy in the day-surgery setting. TIVA allows for earliest voiding and therefore fastest discharge home. Spinal block with 2.5 mg of bupivacaine plus 25 mug of fentanyl provides earlier voiding and consequently earlier discharge than 5 mg of bupivacaine alone.     

The addition of morphine prolongs fentanyl-bupivacaine spinal analgesia for the relief of labor pain

The combination intrathecal fentanyl (25 microg) and bupivacaine (2.5 mg) provides effective labor analgesia for approximately 90 minutes. The purpose of this prospective, randomized, double-blinded investigation was to determine if the addition of morphine (150 microg) to the intrathecal combination of fentanyl (25 microg) and bupivacaine (2.5 mg) would prolong labor analgesia. By using the combined spinal epidural technique, 95 healthy primiparous laboring women in early labor received 2 mL of one of the two intrathecal study solutions, either FB (n = 48): fentanyl (25 microg) and bupivacaine (2.5 mg); or FBM (n = 47): fentanyl (25 microg) and bupivacaine (2.5 mg) plus morphine (150 microg). The mean duration of labor analgesia was significantly longer in the FBM group than in the FB group (252 +/- 63 min vs 148 +/- 44 min, P < 0.01). There were no significant differences between the two groups regarding the sensory levels, the incidence of nausea, vomiting, pruritus, hypotension, or operative delivery. In conclusion, the addition of 150 microg of morphine to the intrathecal combination of fentanyl plus bupivacaine prolonged the duration of labor analgesia duration without increasing adverse effects. IMPLICATIONS: The addition of morphine (150 microg) to intrathecal fentanyl (25 microg) and bupivacaine (2.5 mg) prolongs the duration of labor analgesia duration without increasing adverse effects.     

Nalbuphine versus ondansetron for prevention of intrathecal morphine-induced pruritus after cesarean delivery

In this prospective, randomized, double-blinded study, we compared the prophylactic efficacy of nalbuphine and ondansetron for the prevention of intrathecal morphine-induced pruritus after cesarean delivery. Two-hundred-forty parturients were randomly allocated into four groups. The N-4 group, O-4 group, O-8 group, and placebo group received IV 4 mg of nalbuphine, 4 mg of ondansetron, 8 mg of ondansetron, and 4 mL of normal saline, respectively, immediately after the baby was delivered. In the postanesthesia care unit, we found that the severity of pruritus score in the four groups was significantly different (P < 0.001). The prophylactic success rate for pruritus of the N-4, O-4, O-8, and placebo groups was 20%, 13%, 12%, and 6%, respectively (P < 0.001). The pruritus score between N-4 and placebo and O-4 and placebo was significantly different (P < 0.001 and P = 0.006, respectively). Treatment for pruritus was requested by patients in 25%, 47%, 51%, and 72% of patients in the N-4, O-4, O-8, and placebo groups, respectively (P < 0.001). There were no differences among groups in nausea/vomiting score, pain score, sedation score, or shivering score at 4, 8, and 24 h after surgery. Nalbuphine and ondansetron are more effective than placebo for the prevention of intrathecal morphine-induced pruritus after cesarean delivery. IMPLICATIONS: Nalbuphine and ondansetron are more effective than placebo for the prevention of intrathecal morphine-induced pruritus after cesarean delivery.     

Effects of immediately initiating an epidural infusion in the combined spinal and epidural technique in nulliparous parturients

BACKGROUND AND OBJECTIVES: Intrathecal fentanyl with bupivacaine provides rapid labor analgesia of limited duration. We investigated the effect of initiating an epidural infusion of 0.1% ropivacaine with fentanyl 2 microg/mL and epinephrine 1:400,000 (REF) on the duration of analgesia and incidence of side effects after intrathecal injection in the combined spinal and epidural technique. METHODS: Thirty-four nulliparous parturients with a cervical dilation of 3 to 5 cm were randomized to receive epidural saline or REF at 10 mL following the intrathecal injection of fentanyl 25 microg and bupivacaine 2.5 mg. Degree of analgesia, severity of pruritus, motor block, blood pressure, and sensory level to coolness were assessed until the patient requested additional analgesia. RESULTS: Analgesia was significantly longer in the REF group, 158.4 +/- 59.6 minutes versus 103.8 +/- 26.2 minutes. The decrease in blood pressure compared with the blood pressure at intrathecal injection was greater for the REF group at all times, but achieved statistical significance at 60 minutes. There was no difference in ephedrine use, pruritus, or motor block between groups. There was no difference in sensory level to coolness at 90 minutes after intrathecal injection between groups. CONCLUSIONS: Initiating an infusion of REF prolongs the duration of analgesia, but also results in a greater decrease in blood pressure. Despite this effect on blood pressure, there was no difference in ephedrine use.     

Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n=50) or spinal anesthesia (n=50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 mug followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 mug for spinal anesthesia. The initial sensory block level was higher in the spinal group (P<0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P<0.05) and nausea and vomiting (P<0.05). Motor recovery was faster in the combined spinal-epidural group (P<0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.     

Ondansetron and tropisetron do not prevent intraspinal morphine- and fentanyl-induced pruritus in elective cesarean delivery

BACKGROUND: Although intraspinal morphine has been shown to be effective in providing analgesia after cesarean delivery, pruritus as a side-effect remains a common cause of dissatisfaction. The role of ondansetron has been studied in preventing pruritus but the results have been contradictory. METHODS: We randomized 98 parturients undergoing elective cesarean section using combined spinal-epidural anesthesia into a double-blinded trial to receive tropisetron 5 mg (T group) or ondansetron 8 mg (O group) or placebo (NaCl group) after delivery, when intrathecal morphine 160 microg and fentanyl 15 microg were used for post-operative pain control. The patients additionally received ketoprofen 300 mg per day. Post-operative itching, nausea and vomiting, sedation and need for rescue analgesics were registered every 3 h up to 24 h, and all patients were interviewed on the first post-operative day. RESULTS: Seventy-six percent of the parturients in the placebo group, 87% in the ondansetron, and 79% in the tropisetron group had itching. The incidence of post-operative nausea and vomiting was 21%, 20% and 11% of the patients in the placebo, ondansetron and tropisetron groups, respectively. Medication for pruritus was needed by 31%, 23% and 39% of the patients in the placebo, ondansetron and tropisetron groups, respectively. In the post-operative questionnaire, the patients reported less post-operative nausea in the tropisetron group than in the placebo group (P < 0.01). CONCLUSION: Neither ondansetron nor tropisetron prevent itching caused by intrathecal morphine with fentanyl. However, tropisetron reduced post-operative nausea.     

Epinephrine is not a useful addition to intrathecal fentanyl or fentanyl-bupivacaine for labor analgesia

BACKGROUND AND OBJECTIVES: Intrathecal fentanyl provides effective labor analgesia for a limited time with frequent side effects. We evaluated the effects of adding epinephrine to intrathecal fentanyl with and without bupivacaine. METHODS: Eighty healthy, term, nulliparous parturients with cervical dilation of 5 cm or less received combined spinal-epidural (CSE) analgesia. Subjects were randomized in a double-blind fashion to 1 of 4 intrathecal solutions containing fentanyl 35 microg with either saline (F); bupivacaine 2.5 mg + saline (FB); bupivacaine 2.5 mg + epinephrine 100 microg (FBE); or epinephrine 100 microg + saline (FE). Patients were evaluated for visual analog pain score, duration of spinal analgesia (time until patient request for additional analgesia), nausea/vomiting, pruritus, sensory and motor block, maternal blood pressure, and fetal heart rate (FHR). RESULTS: Intrathecal bupivacaine significantly prolonged fentanyl analgesia with or without epinephrine (P =.018), but epinephrine did not significantly prolong the duration of fentanyl alone or with bupivacaine (F, 92 +/- 39 minutes; FB, 125 +/- 31 minutes; FBE, 134 +/- 42 minutes; and FE, 117 +/- 48 minutes). Intrathecal epinephrine was associated with a higher incidence of severe nausea (P =.001), and the FBE group had more lower extremity weakness (P =.047). There was no difference in the incidence of severe pruritus, FHR deceleration, or delivery outcome between the groups. CONCLUSIONS: These results suggest that intrathecal epinephrine does not prolong the duration of fentanyl or fentanyl with bupivacaine for labor analgesia in nulliparous parturients. Additionally, intrathecal epinephrine did not decrease the incidence of side effects and therefore cannot be recommended.     

The effect of the addition of ropivacaine or bupivacaine upon pruritus induced by intrathecal fentanyl in labour

Sixty patients in early labour were randomly allocated to one of three groups. The control group received intrathecal fentanyl 25 microg, the ropivacaine group received intrathecal fentanyl 25 microg and ropivacaine 2.5 mg while the bupivacaine group received intrathecal fentanyl 25 microg and bupivacaine 2.5 mg. The incidence of pruritus was 100% in controls, compared with 85% in the ropivacaine group (not significant) and 75% in the bupivacaine group (p = 0.003). The severity of pruritus was significantly less in the ropivacaine (p = 0.006) and bupivacaine (p = 0.001) groups. Most patients developed pruritus by 30 min. Pruritus above the abdomen was not reduced in patients receiving local anaesthetics. There were no significant differences in the mean pain visual analogue score, systolic blood pressure, maternal heart rate and upper level of reduced pin-prick sensation in the first 30 min. Intrathecal ropivacaine and, more so, intrathecal bupivacaine reduce the incidence and severity of pruritus from intrathecal fentanyl for labour analgesia.     

Two doses of intrathecal sufentanil (2.5 and 5 microg) combined with bupivacaine and epinephrine for labor analgesia.

In this study, we evaluated the effect of two doses of intrathecal sufentanil combined with bupivacaine and epinephrine on the incidence of pruritus and on the duration and quality of analgesia. One hundred five parturients were enrolled in this randomized, double-blinded, placebo-controlled study. They received either intrathecal 1.25 mg bupivacaine and 25 microg epinephrine (control group); 1.25 mg bupivacaine, 25 microg epinephrine, and 2.5 microg sufentanil (2.5-microg group); or 1.25 mg bupivacaine, 25 microg epinephrine, and 5 microg (5-microg group). Pain relief was assessed 10 min after injection, and pruritus was recorded at 30 min by a blinded observer. The study ended when the parturients requested further analgesia. There were no demographic differences among groups. Ninety of 103 parturients achieved complete pain relief with the initial dose, 11 patients in the control group (P < 0.004, control versus both sufentanil groups), and 2 patients in the 2.5-microg group needed a supplemental epidural bupivacaine. Pruritus was absent in the control group (P < 0.0001, control versus both sufentanil groups), whereas it was present in 36% of the 2.5-microg group and in 66% of the 5-microg group (P = 0.015, 2.5-microg versus 5-microg group). The mean duration of analgesia was similar in patients receiving sufentanil (2.5-microg group: 133 +/- 55 min; 5-microg group: 142 +/- 52 min) but was significantly higher than the control group (56 +/- 32 min). Reducing the sufentanil dose from 5 microg to 2.5 microg when combined with bupivacaine and epinephrine, decreases the incidence of pruritus without impeding the quality or duration of analgesia. IMPLICATIONS: We evaluated two different doses of intrathecal sufentanil combined with bupivacaine and epinephrine for labor analgesia. Sufentanil 2.5 microg offered an advantage over sufentanil 5 microg because, while providing the same quality and duration of analgesia, it was associated with a reduced incidence of pruritus.