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PREVENTION OF PRURITUS FOLLOWING NEURAXIAL MORPHINE ANALGESIA FOR CAESAREAN SECTION - A SYSTEMATIC REVIEW

Department of Anesthesia, Women’s College Hospital, 76 Grenville Street, Toronto, Ontario, M5S 1B2

INTRODUCTION

Neuraxial morphine is widely used to provide pain relief following Caesarean section (CS) but it can cause pruritus, which may limit its beneficial effects. The purpose of this systematic review was to investigate the prevention of pruritus in this clinical setting.

METHODS

We searched for articles reporting the pharmacological prophylaxis of pruritus among women receiving neuraxial morphine for post-CS analgesia. A decrease in the incidence or severity of pruritus was used to measure a successful outcome. The search strategy included the use of electronic databases [Medline 1966–2003, Embase 1980–2003, Cochrane Register and DARE (including the following key words: pruritus, itch, morphine, spinal and epidural)] and a hand search of major anesthetic journals from the last five years. Abstracts from major scientific meetings including ASA, IARS, SOAP and CAS (1998–2003) and the reference lists of retrieved articles were searched. Review articles and letters were not included for analysis. Only randomized trials and abstracts of randomized trials meeting relevance and quality ( 3 points on the Jedad scale ¹) criteria were analyzed.

RESULTS

We retrieved 17 RCTs and 2 abstracts that met the criteria for relevance and quality. Drugs reported to be effective, compared with placebo in preventing pruritus attributed to neuraxial morphine included; oral naltrexone 6–12.5 mg (4 articles), iv ondansetron 4–8 mg (2 articles), iv alzipride 50 mg (1 article) and IV hydroxyzine 50 mg (1 article). Drugs reported to be ineffective, compared with placebo included; IV propofol 10 mg (1 article) and IV nalmefene 0.25–0.5mcg/kg (2 articles). Drugs reported in separate studies to be both effective and ineffective compared with placebo included; IV nalbuphine 4–20 mg (3 articles), IV naloxone infusion (4 articles) and both IV (2.5 mg) and epidural (1.25–5 mg) droperidol (4 articles).

DISCUSSION

This review highlights the wide variety of pharmacological agents that may be used to minimize post-CS pruritus following neuraxial morphine administration. No one agent can reliably claim to abolish this symptom completely. This fact must be considered when contemplating the use of opioid antagonists that may potentially reverse the beneficial effects of opioid analgesia.

REFERENCES

1 Controlled Clinical Trials 1996; 17: 1–12.[Medline]

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