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Wang L, Huang J, Hu H, Chang X, Xia F. Commonly used antiemetics for prophylaxis of postoperative nausea and vomiting after Caesarean delivery with neuraxial morphine: a network meta-analysis. Br J Anaesth 2024; 132:1274-1284. [PMID: 38627136 DOI: 10.1016/j.bja.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 03/01/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Dopamine antagonists, 5-HT3 antagonists, and dexamethasone are frequently used in obstetrics to prevent postoperative nausea and vomiting (PONV). However, the superiority of any drug class is yet to be established. This network meta-analysis aimed to compare the efficacy of these antiemetics for PONV prophylaxis in women receiving neuraxial morphine for Caesarean delivery. METHODS We searched PubMed, Embase, CENTRAL, Web of Science, and Wanfang Data for eligible randomised controlled trials. Primary outcomes were the incidences of postoperative nausea (PON) and postoperative vomiting (POV) within 24 h after surgery. We used a Bayesian random-effects model and calculated odds ratios with 95% credible intervals for dichotomous data. We performed sensitivity and subgroup analyses for primary outcomes. RESULTS A total of 33 studies with 4238 women were included. In the primary analyses of all women, 5-HT3 antagonists, dopamine antagonists, dexamethasone, and 5-HT3 antagonists plus dexamethasone significantly reduced PON and POV compared with placebo, and 5-HT3 antagonists plus dexamethasone were more effective than monotherapy. In the subgroup analyses, similar results were seen in women receiving epidural morphine or intrathecal morphine alone but not in women receiving intrathecal morphine with fentanyl or sufentanil. However, most included studies had some concerns or a high risk of bias, and the overall certainty of the evidence was low or very low. CONCLUSIONS Combined 5-HT3 antagonists plus dexamethasone are more effective than monotherapy in preventing PONV associated with neuraxial morphine after Caesarean delivery. Future studies are needed to determine the role of prophylactic antiemetics in women receiving intrathecal morphine and lipophilic opioids. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023454602.
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Affiliation(s)
- Lizhong Wang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China.
| | - Jiayue Huang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Huijing Hu
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Xiangyang Chang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
| | - Feng Xia
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital of Jiaxing University, Jiaxing, Zhejiang, China
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Wang P, Yu P, Cheng S, Wu X, Li X, Zeng Y, Liu S. Efficacy and safety of nalbuphine for epidural labor analgesia at high altitude: An observational study. Medicine (Baltimore) 2024; 103:e37509. [PMID: 38518033 PMCID: PMC10956986 DOI: 10.1097/md.0000000000037509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/21/2023] [Indexed: 03/24/2024] Open
Abstract
Xining is located at the eastern edge of the Qinghai-Tibet Plateau, with an average altitude of >7000 feet (>2000 m). Nalbuphine is a kappa-opioid receptor agonist that can provide analgesia with fewer side effects than other opioid analgesics. This study aimed to evaluate pain control, side effects, and neonatal outcomes from combining nalbuphine with sufentanil and ropivacaine in 600 women during epidural anesthesia while giving birth at a high altitude in Xining, China. A total of 600 parturients receiving epidural labor analgesia were randomly divided into 2 groups, each group 300 parturients. The nalbuphine group received nalbuphine, sufentanil, and ropivacain, the control group only received sufentanil and ropivacain. The analgesic effect was evaluated through the Visual Analogue Scale scores. Neonatal outcomes were mainly evaluated through the Apgar Scores. Compared to the control group, the nalbuphine group showed lower Visual Analogue Scale scores at all time points after analgesia (P < .05). In comparison with the control group, parturients in the nalbuphine group showed lower incidence rates of fever at delivery, 24-hour postpartum bleeding, and pruritus (P < .05). However, between the 2 groups, there were no statistically significant differences in the remaining maternal and infant outcomes and neonatal outcomes (P > .05). Moreover, no adverse effects on neonatal outcomes were observed. The findings from this study support findings from previous studies that nalbuphine provided safe epidural analgesia without significant side effects for the mother and infant, and showed both safety and efficacy when used during labor at high altitude.
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Affiliation(s)
- Pengxia Wang
- Department of Anesthesia, Affiliated Chenggong Hospital of Xiamen University, Xiamen, Fujian, PR China
| | - Ping Yu
- Department of General Surgery, Affiliated Chenggong Hospital of Xiamen University, Xiamen, Fujian, PR China
| | - Sen Cheng
- Department of Anesthesia, Affiliated Chenggong Hospital of Xiamen University, Xiamen, Fujian, PR China
| | - Xinting Wu
- Department of Anesthesia, Guang’an People’s Hospital, Sichuan, PR China
| | - Xuemei Li
- Department of Hematology, Affiliated Hospital of Qinghai University, Xining, Qinghai, PR China
| | - Yinying Zeng
- Department of Anesthesia, Affiliated Chenggong Hospital of Xiamen University, Xiamen, Fujian, PR China
| | - Shanshan Liu
- Department of Anesthesia, Affiliated Chenggong Hospital of Xiamen University, Xiamen, Fujian, PR China
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Cadd M, Jackson P, Ewnetu B. Ondansetron for the Prevention of Pruritus in Women Undergoing Cesarean Delivery With Intrathecal Opioid: A Systematic Review and Meta-Analysis. Anesth Analg 2024; 138:70-84. [PMID: 37167702 DOI: 10.1213/ane.0000000000006526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Pruritus is a frequently reported and unpleasant side effect following intrathecal opioid use with frequency further increased among parturients. We have performed a systematic review to assess the overall efficacy of ondansetron for the prevention of pruritus in patients receiving intrathecal opioid as part of spinal anesthesia for cesarean delivery. METHODS A literature search of MEDLINE, Embase, Cochrane, and Web of Science databases was conducted from date of inception to September 2022. Studies that included patients undergoing cesarean delivery with spinal anesthesia using intrathecal opioid were included. The primary outcome was the presence of pruritus, and the secondary outcome was time to onset of pruritus. Data from included studies were pooled for analysis using an appropriately determined random-effects model. Outcomes were presented using forest plots and 95% confidence intervals. Additional sensitivity and subgroup analysis were performed. Trial sequential analysis was conducted for the primary outcome. RESULTS Twenty-three randomized controlled trials with a total of 2586 patients were included: 1219 received ondansetron, 1030 received a placebo, and a further 337 received a different study drug and were excluded from analysis. Opioids used in the included studies were morphine, fentanyl, and sufentanil. Patients who received ondansetron showed a significant reduction in the incidence of pruritus compared to the control group (RR, 0.81; 95% confidence interval [CI], 0.71-0.92; I 2 = 64%). There was no significant difference in pruritus onset between the groups (mean difference [MD], 17.54 minutes; 95% CI, -2.18 to 37.26; I 2 = 83%). The overall Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment of quality of evidence was low. CONCLUSIONS This systematic review has demonstrated a significant reduction in the incidence of pruritus following the use of ondansetron. This is in contrast to previously published meta-analyses. Studies included were of varying quality and some at high risk of bias with a high degree of statistical heterogeneity. Furthermore, high-quality and well-powered studies are required to confirm these findings.
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Affiliation(s)
- Matthew Cadd
- From the Anaesthetics Department, Conquest Hospital, East Sussex Healthcare Trust, United Kingdom
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Geetha S, Rudrakshala S, Kar P, Durga P, Charitha K. Comparison of fentanyl and nalbuphine as adjuvants to intrathecal 0.5% bupivacaine in lower limb surgeries: A randomised double-blind prospective study. J Perioper Pract 2023; 33:318-323. [PMID: 36301019 DOI: 10.1177/17504589221119907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Local anaesthetics used in spinal anaesthesia have a limited duration of action. To prolong postoperative analgesia, adjuvants, mainly opioids, are used. As µ agonist drugs have side effects, other receptor agonists are considered. Nalbuphine is a safe and effective kappa agonist adjuvant. AIM To compare the analgesic efficacy between fentanyl and nalbuphine adjuvants added to 3 mL of 0.5% intrathecal hyperbaric bupivacaine. MATERIALS AND METHODS This prospective, double-blind, comparative study was conducted in 60 patients of either sex belonging to the American Society of Anesthesiologists classes I and II aged 18-65 years undergoing lower limb surgery with entropy monitoring, randomly allocated into two groups. Group F (n = 30) received 0.5% hyperbaric bupivacaine (3 mL) + 25 µg (0.5 mL) fentanyl. Group N (n = 30) received 0.5% hyperbaric bupivacaine (3 ml) + 0.8 mg (0.5 mL) nalbuphine intrathecally. Hemodynamics, entropy, motor and sensory block characteristics, and complications were noted. RESULTS The nalbuphine group had a significantly longer two-segment regression time of sensory blockade and extended analgesia duration than the fentanyl group. Haemodynamics, entropy, time for onset of sensory and motor blockade and adverse effects were comparable in both groups. CONCLUSION Nalbuphine prolongs sensory blockade and postoperative analgesia duration with minimal side effects and is a safe intrathecal adjuvant.
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Affiliation(s)
- Singam Geetha
- Nizam's Institute of Medical Sciences, Hyderabad, India
| | | | - Prachi Kar
- Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Padmaja Durga
- Nizam's Institute of Medical Sciences, Hyderabad, India
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Singh PM, Sultan P, O'Carroll J, Blake L, Carvalho B, Singh NP, Monks DT. Pharmacological agents for prevention of pruritus in women undergoing Caesarean delivery with neuraxial morphine: a systematic review and Bayesian network meta-analysis. Br J Anaesth 2023; 131:556-571. [PMID: 37455197 PMCID: PMC10515090 DOI: 10.1016/j.bja.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Neuraxial opioids provide effective analgesia for Caesarean delivery, however, pruritus can be a troubling side-effect. Effective agents to prevent pruritus are needed. Our objective was to perform an updated systematic review and network meta-analysis to provide clinicians with a comparison of relative efficacy of available interventions to reduce the incidence of pruritus, induced by either intrathecal or epidural single-shot morphine, in women undergoing Caesarean delivery. METHODS Databases systematically searched (up to January 2022) included PubMed MEDLINE, Web of Science, EBSCO CINAHL, Embase, LILACS, and two Cochrane databases. We included randomised, controlled trials involving adult female patients undergoing Caesarean delivery. We pooled trials comparing interventions used for preventing pruritus after Caesarean delivery and performed a Bayesian model network meta-analysis. RESULTS The final primary network included data from comparisons of 14 distinct interventions (including placebo) used to reduce the incidence of pruritus in 6185 participants. We judged five interventions to be 'definitely superior' to placebo: propofol, opioid agonist-antagonists (neuraxial), opioid antagonists, opioid agonist-antagonists (systemic), and serotonin antagonists. For the network evaluating the incidence of severe pruritus (warranting additional therapeutic treatment of pruritus), data were available for 14 interventions (including placebo) in 4489 patients. For this outcome, we judged three interventions to be 'definitely superior' to placebo: dopamine antagonists (neuraxial) and systemic and neuraxial opioid agonist-antagonists. CONCLUSION Our analysis found several interventions to be effective in reducing the incidence of pruritus. Although sub-hypnotic doses of propofol appear to have an antipruritic effect, replication of this finding and further investigation of optimal dosing are warranted. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42022367058).
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Affiliation(s)
- Preet M Singh
- Washington University in Saint Louis, Anesthesiology, Barnes Jewish Hospital, Saint Louis, MO, USA.
| | - Pervez Sultan
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - James O'Carroll
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Lindsay Blake
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brendan Carvalho
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Narinder P Singh
- Department of Anesthesia, Mount Sinai Hospital, Toronto, ON, Canada
| | - David T Monks
- Washington University in Saint Louis, Anesthesiology, Barnes Jewish Hospital, Saint Louis, MO, USA
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Tang Y, Li N, Ye L, Yang F, Huang S, Peng Z, Xie J, Wan L. Nalbuphine attenuates morphine‐induced scratching by inhibiting
PKCβ
‐dependent microglial activation and p38 phosphorylation in male mice. J Neurosci Res 2023. [DOI: 10.1002/jnr.25189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 03/28/2023]
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Zheng G, Zhang J, Liu J, Chen C, Zhang L, Cao F. A meta-analysis of randomized controlled trials: efficiency and safety of ondansetron in preventing post-anesthesia shivering during cesarean section. Arch Gynecol Obstet 2023; 307:223-231. [PMID: 35325278 DOI: 10.1007/s00404-022-06523-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/08/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Although ondansetron was considered to prevent post-anesthesia shivering during cesarean section, its efficiency remained controversial. Our review was conducted to estimate the efficiency and safety of ondansetron in preventing post-anesthesia shivering during cesarean section. METHODS The literature were searched from their inception to October 2020 without restriction of language. All randomized controlled trials investigating the efficacy of ondansetron versus placebo in preventing shivering during cesarean section under neuraxial anesthesia were included. The meta-analysis was conducted using Stata software. RESULTS Eleven randomized controlled studies with a total of 748 individuals were finally included in our meta-analysis. Our results manifested that intravenous ondansetron compared with intravenous placebo significantly reduced the incidence of post-anesthesia shivering (PAS) (RR 0.53, 95% CI 0.14-0.68). Subgroup analysis according to doses of ondansetron indicated that the efficacy of 4 mg doses of ondansetron (RR 0.37, 95% CI 0.21-0.64) is equivalent to that of 8 mg doses of ondansetron (RR 0.61, 95% CI 0.47-0.81) in preventing PAS. In addition, the intravenous ondansetron led to a lower incidence of hypotension than intravenous placebo (OR 0.47, 95% CI 0.32-0.70). We could not demonstrate differences in the incidence of bradycardia between intravenous ondansetron and intravenous placebo. CONCLUSION Our results found that intravenous ondansetron was effective in preventing shivering during cesarean section under neuraxial anesthesia, and had an advantage in reducing the incidence of hypotension compared with intravenous placebo.
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Affiliation(s)
- Guanghao Zheng
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China
| | - Jieyu Zhang
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China
| | - Jianpin Liu
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China
| | - Chunxiang Chen
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China
| | - Li Zhang
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China
| | - Fei Cao
- Fuzhou Medical College of Nanchang University, No.9 Donglin Road, Fuzhou, 344000, China.
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Ondansetron Reduces the Incidence of Hypotension after Spinal Anaesthesia: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2022; 15:ph15121588. [PMID: 36559039 PMCID: PMC9787671 DOI: 10.3390/ph15121588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Hypotension induced by spinal anaesthesia is a common clinical complication associated with multiple perioperative adverse events. We conducted a systemic review and meta-analysis to confirm whether ondansetron could alleviate hypotension following spinal anaesthesia. PubMed, Embase, Web of Science, and Cochrane Library were searched to identify eligible randomised controlled trials from their respective database inception dates to 30 September 2022. The primary outcome of the meta-analysis was the incidence of hypotension after spinal anaesthesia. The risk of bias in the included studies was evaluated using the revised Cochrane risk of bias tool for randomised trials (RoB 2.0). Grading of Recommendations, Assessment, Development, and Evaluation was applied to assess the level of certainty. A total of 25 studies were included in this research. The meta-analysis revealed that ondansetron significantly decreased the incidence of hypotension (RR = 0.65, 95% CI 0.53−0.80, p < 0.01, I2 = 64%) and bradycardia. In addition, patients treated with ondansetron had a reduced need for vasopressors administration. This study suggests that ondansetron may be recommended as a prophylaxis for hypotension and bradycardia following spinal anaesthesia; the level of evidence was moderate with a high level of heterogeneity.
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Xue Y, Huang Z, Cheng B, Sun J, Zhu H, Tang Y, Wang X. Analgesic efficacy and safety of nalbuphine versus morphine for perioperative tumor ablation: a randomized, controlled, multicenter trial. Trials 2022; 23:887. [PMID: 36273202 PMCID: PMC9587534 DOI: 10.1186/s13063-022-06825-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
Background The study will compare the efficacy and safety of nalbuphine hydrochloride injection and morphine hydrochloride injection for perioperative analgesia in tumor ablation and the differences between the two groups regarding duration of surgery, average daily dose, patient satisfaction with analgesia, quality of life, and other indicators. Furthermore, it will evaluate the clinical application of nalbuphine and morphine for perioperative analgesia in ablation surgery and provides important reference and guidance for clinical practice. Methods This is a randomized controlled study. Patients who were diagnosed by clinicians and required tumor ablation are enrolled and randomized to the experimental groups. In the test group, nalbuphine 80 mg + 0.9% normal saline (72 ml) is set in the patient-controlled analgesia pump, which is connected 15 min before ablation under electrocardiogram monitoring and surgery is performed immediately. The doses are as follows: initial,: 0.15 ml/kg,; background:, 0.5 ml/h,; compression:, 2 ml,; and lockout time:, 15 min. If the numeric rating scale is ≥ 4 points, the drug is administered by compression. The control group receives similar treatment under similar conditions as the test group except morphine (80 mg) is administered instead of nalbuphine (80 mg). The primary endpoints are the effective rate of analgesia and the incidence of adverse reactions (nausea and vomiting, dizziness, itching, constipation, hypoxemia, and urinary retention); the secondary endpoints are pain intensity, satisfaction with analgesia, duration of surgery, postoperative hospital stay, average daily dose, uninterrupted completion rate of surgery without complaints of pain, quality of life assessment, and vital signs. Discussion This study, to the best of our knowledge, is the first randomized controlled trial of nalbuphine patient-controlled analgesia in ablation surgery. Trial registration U.S. Clinical Trials Network Registration No.: NCT05073744. Registered on 11 October, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06825-5.
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Affiliation(s)
- Youhua Xue
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Zhengli Huang
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Bingwei Cheng
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University, Nanjing, 210009, China
| | - Jie Sun
- Department of Anaesthesiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Haidong Zhu
- Center of Interventional Radiology and Vascular Surgery, Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yuting Tang
- Nursing Department, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009, China
| | - Xiaoyan Wang
- Nursing Department, Zhongda Hospital, Medical School, Southeast University, Nanjing, 210009, China.
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Putnam EM, Hong RA, Park JM, Li Y, Leis A, Malviya S. Intravenous ondansetron reduced nausea but not pruritus following intrathecal morphine in children: Interim results of a randomized, double-blinded, placebo-control trial. Paediatr Anaesth 2022; 32:1151-1158. [PMID: 35778960 PMCID: PMC9540995 DOI: 10.1111/pan.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 06/20/2022] [Accepted: 06/25/2022] [Indexed: 12/01/2022]
Abstract
STUDY OBJECTIVE This study's purpose was to determine if ondansetron can prevent pruritus after administration of intrathecal morphine in children, as has been demonstrated in adults. DESIGN A double-blinded, randomized placebo-controlled trial. SETTING Operating room and first 24 h postoperative inpatient stay at an academic children's hospital. PATIENTS Forty-six children aged 3-17 years, who received 4-5 mcg/kg intrathecal morphine for urological or orthopedic procedures were included. INTERVENTIONS Children were randomized to receive intravenous ondansetron (treatment) or saline placebo (placebo), prior to intrathecal morphine administration, and q6H for 24 h thereafter. Intraoperative anti-emetics and postoperative rescue treatments for pruritus and nausea were standardized. MEASUREMENTS Patients were interviewed q6H for scored pruritus, nausea, and pain, using standardized scales. MAIN RESULTS The trial was terminated for futility after interim analysis. Forty-six children were recruited and 45 completed data collection. No significant difference was found between both groups for incidence of pruritus (requiring treatment) [relative risk (RR) 0.9, 95% CI: 0.7, 1.2], during the first postoperative 24 h. Notably, the incidence of pruritus was 84% overall, much higher than rates in previously published studies. Intravenous ondansetron significantly reduced the incidence of nausea, compared with the placebo group [RR 0.5, 95% CI: 0.3, 0.9]. CONCLUSIONS This study found no evidence for intravenous ondansetron as an effective preventative for pruritus following intrathecal morphine in children. However, this RCT did find that the rate of pruritus following intrathecal morphine administration may be significantly higher than previously thought. Nausea and vomiting (a secondary outcome) were reduced significantly in the treatment group. The negative findings of this study reinforce the potential dangers of extrapolating the drug effects seen in adults onto pediatric patients.
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Affiliation(s)
- Elizabeth M. Putnam
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Rebecca A. Hong
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - John M. Park
- Department of UrologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Ying Li
- Depatment of Orthopaedic SurgeryUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Aleda Leis
- Department of EpidemiologyUniversity of Michigan Health SystemAnn ArborMIUSA
| | - Shobha Malviya
- Department of AnesthesiologyUniversity of Michigan Health SystemAnn ArborMIUSA
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Tubog TD, Bramble RS. Ondansetron for Shivering after Spinal Anesthesia in Cesarean Delivery: A Systematic Review and Meta-Analysis. J Perianesth Nurs 2021; 37:105-113. [PMID: 34836765 DOI: 10.1016/j.jopan.2021.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/11/2021] [Accepted: 05/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Evaluate the efficacy of ondansetron in preventing shivering after spinal anesthesia in cesarean delivery. DESIGN Systematic review and meta-analysis METHODS: Following the PRISMA statement, PubMed, CINAHL, Cochrane, EMBASE, Google scholar and other grey literature databases were searched for eligible studies. FINDINGS The overall incidence of shivering after spinal anesthesia in cesarean delivery is 32%, with 24% in patients who received ondansetron compared to 40% in the placebo group. A total of 19 trials consisting of 1399 patients were evaluated. Compared to placebo, ondansetron is effective in reducing the incidence of shivering (RR, 0.47; 95% CI, 0.29 to 0.78; P = 0.003). The quality of evidence is low due to substantial heterogeneity, imprecision and suspected publication bias. Patients who received ondansetron are less likely to require rescue treatment for shivering (RR, 0.34; 95% CI, 0.15 to 0.76; P = 0.009). Also, ondansetron is associated with a lower incidence of hypotension necessitating vasopressor treatment, and nausea and vomiting with no effects on the incidence of bradycardia. CONCLUSION Ondansetron is effective in mitigating shivering after spinal anesthesia in cesarean delivery.
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Payne C, Curtis B, Dan D, Dunston S, Moore C, Hefley J. Prevention of Pruritis following Spinal Morphine for Scheduled Cesarean Birth. MCN Am J Matern Child Nurs 2021; 46:97-102. [PMID: 33630492 DOI: 10.1097/nmc.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intrathecal morphine provides effective analgesia after cesarean birth, yet up to 90% of women who receive it experience excessive itching, an undesirable dose-dependent effect. Pruritis may increase nursing workload, delay breastfeeding, and decrease patient satisfaction. When 0.1 mg spinal morphine is given, pruritis is markedly reduced while analgesia is preserved. PURPOSE The purpose of this project was to determine possible causes and solutions for pruritus after cesarean birth. METHODS Anesthesia providers were educated and encouraged to limit spinal morphine to 0.1 mg as a strategy to prevent pruritus. In a repeated measures design, the rate of treatment-required pruritus and opioid consumption were measured 24 hours after surgery. The project included an evaluation of 30 medical records before and 30 medical records after the project intervention. RESULTS Preintervention rate of treatment-required pruritis was 37%, all received spinal morphine ≥ 1.5 mg. Postintervention rate of treatment-required pruritis was 13% and 57% after spinal morphine 0.1 mg and 0.2 mg, respectively. Opioid consumption was similar between groups. CLINICAL IMPLICATIONS Mother-baby nurses can have an impact on the practice of anesthesia providers by advocating for evidence-based dosing of intrathecal morphine to reduce the incidence of pruritis while maintaining effective analgesia for women after cesarean birth.
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Application of Nalbuphine in Trigeminal Ganglion Pulse Radiofrequency Surgery in Patients with Postherpetic Neuralgia. Pain Res Manag 2021; 2021:6623112. [PMID: 33747319 PMCID: PMC7943312 DOI: 10.1155/2021/6623112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/02/2021] [Accepted: 02/23/2021] [Indexed: 02/05/2023]
Abstract
This study aimed to explore the application value of nalbuphine in pulsed radiofrequency operation of trigeminal ganglion in patients with postherpetic neuralgia (PHN). Thirty patients with PHN were randomly divided into the nalbuphine (Nalbu) group and ketorolac tromethamine (KT) group and received CT-guided pulsed radiofrequency surgery on trigeminal ganglion. The numeric rating scale (NRS) scores of patients were recorded at preoperative, intraoperative, and postoperative time points, before going to bed, and the next morning after the operation. In addition, the number of breakthrough pain before operation and within 24 hours after operation, the incidence of nausea and vomiting within 24 hours after surgery, and the patient's sleep quality before and on the day after surgery were evaluated. The outcome data demonstrated that patients treated with nalbuphine had lower NRS scores after the pulse radiofrequency operation during and after the pulse radiofrequency operation compared to those with KT. In addition, nalbuphine effectively decreased the number of breakthrough pain, reduced the occurrence of nausea and vomiting after surgery, and improved the sleep quality. In conclusion, intramuscular injection of nalbuphine 30 min before trigeminal ganglion pulse radiofrequency surgery can be conducive to pain relief and improve the postoperative comfort of patients, providing an effective alternative for the alleviation of PHN in clinic.
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Medications for the prevention of pruritus in women undergoing cesarean delivery with Intrathecal morphine: A systematic review and bayesian network meta-analysis of randomized controlled trials. J Clin Anesth 2020; 68:110102. [PMID: 33129065 DOI: 10.1016/j.jclinane.2020.110102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE Intrathecal morphine-induced pruritus can cause significant discomfort in parturients and is refractory to conventional antipruritic treatment. This systematic review and network meta-analysis evaluates the effectiveness of the medications used for prevention of intrathecal (IT) morphine-induced pruritus after cesarean delivery under spinal anesthesia. METHODS A literature search was conducted from 1946 up to October 2019. We included all randomized controlled trials (RCTs) that compared medications used for prevention of pruritus with a control group in women undergoing cesarean delivery under spinal anesthesia with IT morphine. The primary outcome examined was the incidence of pruritus up to 24 h after cesarean delivery. Dichotomous data were extracted and summarized using odds ratios (OR) and 95% credible intervals (CrI) with Bayesian random effects network meta-analysis model. The GRADE approach was used to evaluate quality of the studies and effect evidence. RESULTS Of the 26 studies included in the systematic review, 21 studies with a total of 2594 patients were included in the network meta-analysis [prophylaxis, n = 1603 (62%) vs. control, n = 991 (38%)]. These studies investigated seven classes of drugs including serotonin-receptor antagonists, dopamine-receptor antagonists, opioid agonist-antagonists, opioid-receptor antagonists, histamine-receptor antagonists, propofol and celecoxib. The network meta-analysis showed that serotonin-receptor antagonists' prophylaxis [control vs. prophylaxis: 60% vs. 47%; OR (95% CrI): 2.69 (1.43-5.36)] and opioid agonist-antagonists prophylaxis [control vs. prophylaxis: 72% vs. 47%; OR (95% CrI): 4.57 (1.67-12.91)] decreased the incidence of pruritus compared to the control group. Although all included studies were at low risk of bias, the quality of the overall network meta-analysis pooled estimates was low. CONCLUSION This bayesian network meta-analysis of RCTs demonstrates serotonin-receptor antagonists and opioid agonist-antagonists may prevent pruritus in women undergoing cesarean delivery with intrathecal morphine compared to control group. However, further RCTs of adequate power and clearly defined end points are warranted.
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions. Pain Manag Nurs 2020; 21:7-25. [DOI: 10.1016/j.pmn.2019.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/25/2019] [Accepted: 06/14/2019] [Indexed: 01/12/2023]
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Nalbuphine, a kappa opioid receptor agonist and mu opioid receptor antagonist attenuates pruritus, decreases IL-31, and increases IL-10 in mice with contact dermatitis. Eur J Pharmacol 2019; 864:172702. [PMID: 31568781 DOI: 10.1016/j.ejphar.2019.172702] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/25/2019] [Accepted: 09/26/2019] [Indexed: 12/13/2022]
Abstract
Chronic itch is one of the disturbing symptoms of inflammatory skin diseases. Kappa opioid receptor agonists are effective in suppressing scratching in mice against different pruritogens. Nalbuphine, a nonscheduled kappa opioid receptor agonist and mu opioid receptor antagonist, has been in clinical use for post-operative pain management since the 1980s and recently has been in clinical trials for chronic itch of prurigo nodularis (https://www.trevitherapeutics.com/nalbuphine). We studied whether nalbuphine is effective against chronic scratching induced by rostral neck application of 1-fluoro-2,4-dinitrobenzene (DNFB), an accepted mouse model of contact dermatitis to study pruritoceptive itch. Mice were treated once a week with either saline or nalbuphine 20 min before the third, fifth, seventh, and ninth sensitizations with DNFB and the number of scratching bouts was counted for 30 min. Skin samples from the neck of mice at week 4 were used to measure protein levels and mRNA expressions of chemokines and cytokines. Different sets of mice were used to study sedation and anhedonic-like behavior of nalbuphine. We found that: nalbuphine (a) antagonized scratching in a dose- and time-dependent manner without affecting locomotion, b) decreased IL-31, and increased anti-inflammatory IL-10, and c) induced more elevations in the levels of CCL2, CCL3, CCL12, CXCL1, CXCL2, CXCL9, CXCL10, IL-1β, IL-16, TIMP-1, M-CSF, TREM-1 and M1-type macrophages compared to saline. Increases in chemokines and cytokines and M1 macrophages by nalbuphine suggest an inflammatory phase of healing in damaged skin due to scratching. Our data indicate that nalbuphine is an effective antipruritic in murine model of pruritoceptive itch.
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Tubog TD, Harenberg JL, Buszta K, Hestand JD. Prophylactic Nalbuphine to Prevent Neuraxial Opioid-Induced Pruritus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Perianesth Nurs 2019; 34:491-501.e8. [DOI: 10.1016/j.jopan.2018.06.098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/24/2018] [Accepted: 06/30/2018] [Indexed: 12/29/2022]
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Cao X, Zhang X. Comparison of different sufentanil-tramadol combinations for pain relief within the first 24 hours after cesarean section: a retrospective study. J Pain Res 2018; 11:2445-2451. [PMID: 30425558 PMCID: PMC6205140 DOI: 10.2147/jpr.s177500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Postcesarean section pain management is important for both the mother and the newborn. This study compared the analgesic effects and incidence of adverse events associated with intravenous patient-controlled analgesia (iv-PCA), using different sufentanil–tramadol combinations for postoperative pain control. Methods Parturients (n=5,794) who had been scheduled for cesarean section under neuraxial anesthesia and had received iv-PCA between September 2013 and March 2017 were retrospectively analyzed. These patients were assigned to three groups, based on different sufentanil–tramadol combinations: ST1 (n=1,347), ST2 (n=2,401), and ST3 (n=2,046). The analgesic efficacy, total drug consumption, and incidence of adverse effects within 24 hours after surgery were compared among the three groups. Results The ST3 group had lower visual analog scale pain scores at rest and with movement at all time points during the first 24 hours postoperatively than the other two groups (P<0.01, Bonferroni corrected). The sufentanil dosage administered to the ST3 group was lower, and the tramadol dosage was higher than those administered to the other groups within 24 hours after surgery (P<0.01, Bonferroni corrected). Moreover, all parturients scored 2 points on the Ramsay sedation scale. Adverse reactions such as pruritus and respiratory depression were not observed in any group. No significant differences were noted in the incidence of nausea/vomiting, abdominal distension, and dizziness among the three groups (P>0.05). Conclusion The visual analog scale scores for postoperative pain decreased as the concentrations of sufentanil and tramadol administered in iv-PCA moderately increased over 24 hours after surgery. This analgesic strategy resulted in a significant reduction in the total sufentanil requirement without increasing the incidence of adverse effects.
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Affiliation(s)
- Xueqin Cao
- Department of Anesthesiology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China,
| | - Xianwei Zhang
- Department of Anesthesiology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China,
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Evaluation of the epidural analgesic effect of Nalbuphine, Lidocaine and Nalbuphine-Lidocaine combination in bucks. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2018. [DOI: 10.1016/j.bjbas.2017.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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20
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Gong Y, Zhang Y, Tao S. Nalbuphine for analgesia after fracture surgery and its effect on circulating inflammatory factors. Exp Ther Med 2018; 15:859-863. [PMID: 29434688 PMCID: PMC5772924 DOI: 10.3892/etm.2017.5452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/14/2017] [Indexed: 11/27/2022] Open
Abstract
The present study evaluated the use of nalbuphine for analgesia after fraction reduction surgery. Eighty lower limb fracture patients needing open reduction and internal fixation were selected in the First People's Hospital of Jingzhou from January 2015 to December 2015. Patients were randomly divided into observation and control groups (with 40 cases in each). After surgery, the patients in the observation group were treated with nalbuphine (2 mg/kg) for patient-controlled intravenous analgesia (PCIA), while sufentanil (2.5 µg/kg) was used for patients in the control group. The analgesia treatment lasted for 48 h after surgery. Changes in inflammatory factors and catecholamine hormones during the observation period were determined and compared between the groups. Pain, sedation scores and the number of times the analgesia pump was used were recorded at different time-points. Additionally, the life and sleep qualities and any adverse reactions were also recorded. Our results showed that after the operation, the levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1), high-sensitivity CRP (hs-CRP) cortisol, adrenaline epinephrine (AD) and norepinephrine (NE) were significantly lower in the observation group than in the control group (P<0.05). Pain and sedation scores of patients in the observation group were better than those in the control group at all time-points after operation (P<0.05). Life and sleep qualities of patients in the observation group were also better than those in the control group (P<0.05). Finally, the rates of nausea, vomiting, dizziness, lethargy, urinary retention, skin itch and constipation were significantly lower in the observation group than in control group (P<0.05). Based on our findings, the application of nalbuphine for analgesia in patients with fracture surgeries can reduce the levels of inflammatory cytokines, improve the analgesic effect, bring beneficial sedative effects and reduce the occurrence of adverse reactions.
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Affiliation(s)
- Yong Gong
- Department of Anesthesiology, The First People's Hospital of Jingzhou, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei 434020, P.R. China
| | - Yang Zhang
- Department of Anesthesiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Shoujun Tao
- Department of Anesthesiology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang 310006, P.R. China
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Zhou C, Zhu Y, Bao Z, Wang X, Liu Q. Efficacy of ondansetron for spinal anesthesia during cesarean section: a meta-analysis of randomized trials. J Int Med Res 2017; 46:654-662. [PMID: 28856920 PMCID: PMC5971492 DOI: 10.1177/0300060517716502] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the efficacy and safety of ondansetron during cesarean section under spinal anesthesia. Methods We sought randomized controlled trials (RCTs) on ondansetron during spinal anesthesia for cesarean section in The Cochrane Library, PubMed, MEDLINE, and Web of Science from their inception to September 2016. Results Altogether, 21 RCTs were included in this study. Meta-analysis showed that the ondansetron group had a lower incidence of nausea/vomiting and bradycardia than the placebo group during cesarean section under spinal anesthesia [relative risk (RR) = 0.43, 95% confidence interval (CI) (0.36, 0.51) and RR = 0.45, 95% CI (0.26, 0.80), respectively]. There were no significant differences in the incidences of pruritus, hypotension, or shivering during cesarean section under spinal anesthesia [RR = 0.92, 95% CI (0.83, 1.02); RR = 0.72 (0.50, 1.06), 95% CI (0.50, 1.06); and RR = 0.89, 95% CI (0.71, 1.11), respectively]. Conclusion Ondansetron effectively reduces the incidences of nausea/vomiting and bradycardia under spinal anesthesia during cesarean section.
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Affiliation(s)
| | - Yu Zhu
- 1 117835 Zhaoqing Medical College , Zhaoqing, China
| | - Zeqing Bao
- 1 117835 Zhaoqing Medical College , Zhaoqing, China
| | - Xianxue Wang
- 2 Department of Anesthesiology, The First People's Hospital of Changde, Changde, China
| | - Qili Liu
- 1 117835 Zhaoqing Medical College , Zhaoqing, China
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Intrathecal nalbuphine – Will it gain wider acceptance? – A narrative review. EGYPTIAN JOURNAL OF ANAESTHESIA 2017. [DOI: 10.1016/j.egja.2017.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Wang W, Zhou L, Sun L. Ondansetron for neuraxial morphine-induced pruritus: A meta-analysis of randomized controlled trials. J Clin Pharm Ther 2017; 42:383-393. [PMID: 28464238 DOI: 10.1111/jcpt.12539] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 03/29/2017] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Pruritus is one of the most common adverse effects associated with neuraxial morphine. Ondansetron has been used to deal with the problem of neuraxial morphine-induced pruritus (NMIP). The aim of this meta-analysis was to evaluate the preventive efficacy of ondansetron on NMIP. METHODS Online databases such as PubMed, EMBASE and the Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). The primary outcome was the incidence of NMIP. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data. Trial sequential analysis (TSA) was performed to avoid the risk of making a spurious claim of significant effect and to calculate the sample size necessary to make a robust claim of effect. RESULTS AND DISCUSSION Our traditional meta-analysis showed that prophylactic ondansetron could significantly reduce the incidence of NMIP in non-obstetric patients (three trials, RR=0.63, 95% CI 0.45-0.89, P=.008) with modest heterogeneity (I2 =47%) while it did not show the preventive efficacy of NMIP in obstetric patients (seven trials, RR=0.84, 95% CI 0.69-1.03, P=.10) with obvious heterogeneity (I2 =82% ). However, TSA demonstrates that more high-quality RCTs are still needed to confirm the preventive efficacy of ondansetron on NMIP in non-obstetric populations and to study whether ondansetron prevents NMIP in obstetric patients. WHAT IS NEW AND CONCLUSION Prophylactic ondansetron can significantly reduce the incidence of NMIP in non-obstetric patients but not in obstetric patients. However, more well-designed trials are still required to test the reliability of the results in our traditional meta-analysis.
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Affiliation(s)
- W Wang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - L Zhou
- Department of Anesthesiology, Peking University Shougang Hospital, Beijing, China
| | - L Sun
- Department of Anesthesiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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