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In this episode, episode 58, I welcome our two OB Anesthesia fellows to the show, Dr. Dave Berman and Dr. Anh Nguyen. We discuss the medications used for neuraxial anesthesia including local anesthetics, opioids, and adjuncts such as epinephrine, clonidine and more.
CME: https://earnc.me/N8xw8b
Outline by Brian Park: Outline
Dave’s email is dberma20@jhmi.edu and Anh’s is tnguy193@jhmi.edu.
References can be found here: Neuraxial references
I am wondering what you use as an anti-pruritic and is it prophylactic or only after itching develops? Ive used nalbuphine and naloxone in my practice.
Hi Patrick. Great question. Here is the response from Dave and Anh.
Anh says: I’ve used both during residency, here I’ve seen nalbuphine used. Typically we don’t use it prophylactically, but for when itching starts.
Dave says: In typical Anh & Dave fashion, Anh will give the correct answer and I will give the long answer. Also as usual, Anh’s answer more than suffices. That said, here goes…
Needless to say, the first solution is withdrawal of the offending agent if possible. If pruritus is worrisome enough to begin treatment, it might be worthwhile to consider switching the epidural solution to a non-opiate-containing solution such as 0.125% bupivacaine. This will obviously be at the expense of some analgesia, but it’s a discussion I have with the patient. This is not an option with single-shot duramorph.
At Sinai as a resident I used butorphanol and we also had buprenorphine when that failed. If patients failed all of those therapies, a naloxone infusion would be started.
But also at Sinai our CSEs were all 25mcg fentanyl only in the spinal, so everyone itched. On the DL (don’t tell my old attendings), whenever I did a CSE on a patient I would also give them 40-80mcg naloxone after the onset of itching before I left the room. By the time the single shot of naloxone had worn off, the itching was receding.
Below are some references from both classic papers and some newer developments.
Dave
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References
Davis, Mellar P., Jan L. Frandsen, Declan Walsh, Steven Andresen, and Sandy Taylor. 2003. “Mirtazapine for Pruritus.” Journal of Pain and Symptom Management 25 (3): 288–91.
Dawn, Aerlyn G., and Gil Yosipovitch. 2006. “Butorphanol for Treatment of Intractable Pruritus.” Journal of the American Academy of Dermatology 54 (3): 527–31.
Kumagai, Hiroo, Toshiya Ebata, Kenji Takamori, Taro Muramatsu, Hidetomo Nakamoto, and Hiromichi Suzuki. 2010. “Effect of a Novel Kappa-Receptor Agonist, Nalfurafine Hydrochloride, on Severe Itch in 337 Haemodialysis Patients: A Phase III, Randomized, Double-Blind, Placebo-Controlled Study.” Nephrology, Dialysis, Transplantation: Official Publication of the European Dialysis and Transplant Association – European Renal Association 25 (4): 1251–57.
Peer, G., S. Kivity, O. Agami, E. Fireman, D. Silverberg, M. Blum, and A. Laina. 1996. “Randomised Crossover Trial of Naltrexone in Uraemic Pruritus.” The Lancet 348 (9041): 1552–54.
Penning, J. P., B. Samson, and A. D. Baxter. 1988. “Reversal of Epidural Morphine-Induced Respiratory Depression and Pruritus with Nalbuphine.” Canadian Journal of Anaesthesia = Journal Canadien D’anesthesie 35 (6): 599–604.
Phan, Ngoc Quan, Jeffrey D. Bernhard, Thomas A. Luger, and Sonja Ständer. 2010. “Antipruritic Treatment with Systemic μ-Opioid Receptor Antagonists: A Review.” Journal of the American Academy of Dermatology 63 (4): 680–88.
Yuan, C. S., J. F. Foss, M. O’Connor, J. Osinski, M. F. Roizen, and J. Moss. 1998. “Efficacy of Orally Administered Methylnaltrexone in Decreasing Subjective Effects after Intravenous Morphine.” Drug and Alcohol Dependence 52 (2): 161–65.