spinal morphine, Is it worth the itching?

[seinfeld]

I tell my patients it is but has anyone out there stop giving morphine in the spinal for csections secondary to regular complaints of itching? I am giving only 100mcg plus 15mcg of fentanyl.

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[sevoflurane]

I tell my patients it is but has anyone out there stop giving morphine in the spinal for csections secondary to regular complaints of itching? I am giving only 100mcg plus 15mcg of fentanyl.

That is exactly what I give. If they get hives with codeine or morphine, they only get LA. PCA post op to cover pain if they need it or I'll do bilateral TAP blocks which seems to help for 24 hrs:

http://www.anesthesia-analgesia.org/content/106/1/186.full

I used to give higher doses of morphine during residency and quickly learned that patients complain more of itching than anything else.

 

[proman]

I had 1 patient (for non OB related operation) who had 3 CS with IT morphine. She said the itching drove her nuts each time, but the analgesia was so good she would do it again, and again, and again.

 

[Trisomy13]

When I use it (100-200 mcg), I try to warn the OB nurses about itching, and how it is ok to use naloxone in small doses that will help with the itching but not take away the analgesia. Just 40 mcg of naloxone can make a huge difference in itching, if you can convince the OB nurse that 1/10th of an mL is an actual dose. 😉

 

[Jeff05]

no issues if you use nalbuphine prn
http://www.ncbi.nlm.nih.gov/pubmed/10467795
lots of other studies available, as well.

 

[Idiopathic]

agree, i do 200mcg IT/2mg EPI and write for nubain 5mg, itching usually not a problem. for a while we were doing IT duramorph for knees and hips (surgeons preference against LA) which i thought was kind of ridiculous but a good percentage of people had 12-18 hours pain relief which was nice (a few also had respiratory arrest overnight as well)

 

[pgg]

I use 200 mcg morphine and 15 mcg fentanyl in my spinals for c-sections.

I warn the patients up front that itching is the most common side effect, to expect it, and if it bothers them that we can almost always fix it quickly and easily. Most never complain.

Benadryl is in our preset order lists and is worthless. Nubain works but I've seen a few people complain of pain after their pruritis was treated with it.

I was taught as a resident to put an ampule of naloxone (0.4 mg) in 1000 cc LR and run it at 100 ml/hr. I've found that it always fixes the itching and doesn't adversely affect analgesia. It freaks out some nurses initially (OMG SHE'S ON A NARCAN DRIP WTF DIDJA OVERDOSE HER!) but it works.

 

[proman]

Agree with the naloxone. I've found 40mcg bolus to break the cycle, repeated occasionally. Problem with the infusion is that it can't be done on the floor.

Anesth Analg. 2005 Apr;100(4):953-8. PubID 15781505
The effects of a small-dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia: a double-blind, prospective, randomized, controlled study.

We conclude that, in children and adolescents, a small-dose naloxone infusion (0.25 microg . kg(-1) . h(-1)) can significantly reduce the incidence and severity of opioid-induced side effects without affecting opioid-induced analgesia. When initiating morphine IV patient-controlled analgesia for the treatment of moderate to severe pain, clinicians should strongly consider starting a concomitant small-dose naloxone infusion.

 

[pgg]

Agree with the naloxone. I've found 40mcg bolus to break the cycle, repeated occasionally. Problem with the infusion is that it can't be done on the floor.

We overcame that by explaining (and explaining, and re-explaining) that the Narcan infusion was safe to do on the floor because it was being used to treat pruritis and not opiate overdose. Our floor nurses feared Narcan infusions because they were accustomed to them being used only for patients who got too much long acting IV narcotic.

Once the clipboard-commando nurses got it through their 80%-osseous heads that these itchy postpartum patients weren't at risk for respiratory failure, they were cool with it.

 

[Idiopathic]

i like that and ill try it next time i run into this

 

[Noyac]

I used to give higher doses of morphine during residency and quickly learned that patients complain more of itching than anything else.

Of course they do, they need to complain about something.😉

But honestly, I don't remember ever having a c/s pt complain about pruritis. Oe thing tat may be limiting their complaints is that the nurses love it when we use duramorph and probably wouldn't tell us if the pt had complaints b/c the pain control is so superior to anything else.

plus, nubain works very well.

 

[tucker27705]

I think everyone in our group uses Duramorph and then puts Nubain in the NS for a slow infusion. Works fairly well.
With regard to the dosing, I was on the lower end like you guys 100-200mcg. But I soon found out that all of the more senior guys were using 400-500mcg. I was totally surprised. I now use 400mcg.
Our anesthetists round on the post ops in our group. Which is nice for me. But I really have no idea how these C/S pts are doing except through word of mouth. More puritis with no better pain relief is my suspicion for 400 v 200 mcg, but who knows? Not me, sadly.
Tuck

 

[lushmd]

I will frequently skip fentanyl altogether (instead using a little extra bupivicaine to make up the difference in volume) and use 150-200 mcg duramorph depending on pt size. This seems to provide nice post-op analgesia and decrease the incidence of pruritis.

 

[pgg]

More puritis with no better pain relief is my suspicion for 400 v 200 mcg, but who knows? Not me, sadly.
Tuck

I use 3 mg epidural morphine and 0.2 mg intrathecal morphine. Doesn't seem to be any improvement beyond 3.75 mg and 0.2 mg, respectively.

Cut & paste from Blade in another thread -

"One randomized dose-response study (43) allowed patients free access to IVPCA after epidural administration of saline or 1 of 4 doses of morphine (1.25, 2.5, 3.75, or 5 mg). Quality of analgesia improved as the dose of epidural morphine increased to 3.75 mg. Beyond that, there was no difference in analgesic effect as measured by IVPCA use. All women given epidural morphine experienced pruritus, but there was no correlation with the dose of epidural morphine. Analgesia lasted for 18–26 h. "

http://www.anesthesia-analgesia.org/cgi/content/full/101/5S_Suppl/S62

Spinals:

"A meta-analysis (33) demonstrated excellent efficacy of morphine doses of 0.1 to 0.2 mg but no additional pain relief with doses >0.2 mg. Median time to first request for supplemental analgesics in that study was 27 h. In contrast, doses smaller than 0.1 mg had little effect on pain relief. "

 

[sevoflurane]

If I remember correctly, once you get above .2mg of intrathecal morphine all you will get is extra side effects (pruritis, 2ndary resp. depression, n/v, etc) with no increase in analgesia or duration of analgesia.
Adding Fentanyl to your intrathecal LA dose is supposed to create a more "dense" block. I believe that after you have gone above 15 mcgs you end up with more s/e with no gain in analgesia.

With regard to dose of IT morphine, .2mg will give you slightly longer duration of action (24hrs) vs .1mg (18hrs.) but with more s/e and necessary treatment of said s/e.

Here are a couple of papers from A&A.


http://www.anesthesia-analgesia.org...ract?sid=ea498c25-3855-46c4-af33-8aa92edd2d9b

"In both groups I and II excellent postoperative analgesia with longduration was obtained (27.7 ± 4.0 and 18.6 ± 0.9 hours, respectively, X̄ ± SEM). All patients in group III required an analgesic (8 mg subcutaneous morphine) within 3 hours of spinal anesthesia. Seven patients in group I and four patients in group II developed mild pruritus that did not require treatment. Ventilatory responses to CO2 showed no evidence of depression attributable to either the 0.25 or 0.1 mg of morphine, but significant depression of the CO2 responses was observed in group III patients after administration of subcutaneous morphine. It is concluded that a dose as low as 0.1 mg of intrathecal morphine gives excellent analgesia with minimal to no side effects and that subcutaneous morphine is associated with marked depression of the Ventilatory variables."

http://www.anesthesia-analgesia.org...ract?sid=ea498c25-3855-46c4-af33-8aa92edd2d9b

"Spinal morphine is an effective analgesic after cesarean delivery, but it has several side effects. The purpose of this study was to compare the prevalence of side effects and the level of analgesia of epidural morphine with two different doses of spinal morphine after elective cesarean delivery. Although rescue analgesics may be required, intrathecal morphine 100 µg is suggested for postoperative analgesia after cesarean delivery."



I'm not sure how I feel about giving IT MS followed by Narcan. I see it as back pedaling a little bit, but then again, I have not tried this apporach. I prefer to lower my dose and not give meds for s/e.
That being said, I know a lot of anesthesiologists who use .2mg of IT morphine routinely and many papers support it's use up to, but not exceeding .2mg. I might approach that dose in tall parturients. Usually I'll give .1mg and have seen little to no s/e with plenty of happy customers with adequate analgesia into POD#1.
Finally, if a patient is not affected by s/e of IT MS they might remember their experience more favorably, IMHO.

My 2cents. 😀

 

[sevoflurane]

Of course they do, they need to complain about something.😉

Yes... I remember how much you love OB... Almost as much as my love for trauma. 😉
Actually, I like it in small potent doses. Residency doses however... It's sad when your pager fills up twice in one night.

 

[tucker27705]

Hey guys, thanks for your posts with the supporting literature. I'll change my practice accordingly. We have over 5,000 dels / yr with about 25% c/s. I'll see if I can get the other 25 guys to change too.
Tuck

 

[lushmd]

Adding Fentanyl to your intrathecal LA dose is supposed to create a more "dense" block.

I find IT fentanyl to be useful in cases where there is likely to be significant peritoneal manipulation (i.e. tubal ligation following C/S or significant risk of severe bleeding that may result in C-hyst). Otherwise, for a run of the mill C/S, these patients seem to do well with IT bupivicaine and duramorph, with less prurititis to boot (I haven't formally studied this, just an observation).

 

[ssmallz]

We don't use any IT morphine, just 20 mcg fentanyl and write for PCA orders post op. Most pts don't have much pain or itch. How common is IT morphine for c-sections?

 

[IlDestriero]

We don't use any IT morphine, just 20 mcg fentanyl and write for PCA orders post op. Most pts don't have much pain or itch. How common is IT morphine for c-sections?

I've never done a spinal for a c/s w/o duramorph.

 

[Noyac]

We don't use any IT morphine, just 20 mcg fentanyl and write for PCA orders post op. Most pts don't have much pain or itch. How common is IT morphine for c-sections?

use it in every single one.