morphine induced pruritus after cesarean delivery - ThaiJo

nrttfi s'r ondansetron rfi ofl

o u

fluar nrrf,uer

n

nr:lfr sr

mo rp hin e

^rfr

rti

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r

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rr

Prophylactic ondansetron for prevent of intrathecal morphine induced pruritus after cesarean delivery

??rru'r a-ad

o$fiileiluB il.u.*

ABSTRACT

Background The intrathecal molphine is highly effective in providing analgesia for post- operative pain management, pruritus is a common side effect. Its incidence is especially high in patients undergoing cesarean delivery.

This study was performed

to

investigate the efficacy

of

ondansetron in preventing pruritus following intrathecal morphine in patient undergoing cesarean delivery.

ln a

prospective, double-blinded, randomized study, ninety parturients undergoing cesarean delivery

with

spinal anesthesia were studied. All patients received 0.5% hyperbaric bupivacaine

2 ml

and intrathecal molphine 0.2 mg. After a child birth, the patients were randomized into three groups. Group L received normal saline (placebo group), group 2

received ondansetron

4 mg

intravenously (O-4 group), and group 3 received ondansetron 8 mg intravenously (O-8 group). Patients were evalu- ated for severity of pruritus and nausea/vomiting at 2 and 24 hr. postop- eratively.

Objective

Methods

Statistical analysis : ANOVA, Kruskal-Wallis's, and Mann-Whitney U-test

:

2 hr postoperatively, the incidence of pruritus was significantly lower in ondansetron group 4 and 8 mg group when compared with the placebo group (46.7o/", 30%, and 50% respectively, p<0.05). At24 hr, ondansetron 4

and 8 mg group ^less frequent

in

pruritus when compared with placebo

group (13.3"/o, 6.7o/", and 40"/" respectively, p<0.05). The postoperative nausea/vomiting at 24 hr were not significant different.

Conclusion Prophylactic ondansetron prevents intrathecal morphine induced pruritus after cesarean delivery, particularly in patients suffering from both pruritus and nausea/vomiting.

ondansetron, intrathecal morphine, pruritus Key words

Results

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normal saline 4 il0. yt'lut4oon168nri't nniuii z

16ilur

ondansetron 4 iln. y'l\:l4donrfionrf't naiuii ^g

lfiiuur

ondansetron 8 iln. r'tut4donrfionn"t

frr,J:aqv1fr5unr:l:vrfiu:vd'unr:rYu

uovndulfiorriuu fr 2

uov z+

tirllu

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ANOVA , Kruskal-Wallis's test ttov Mann-Whitney U-test

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tiriuu ndufrlfiiuur

ondansetron

4 iln. rdy 8 ln.

^rfiBr

o1nrr6'ufi o u n'jr n air

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(46.7%, 30%,

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rrilrrai'rrriu

p <

^0.05)

*a*fi

24 t"rTluuour.irfr'n qrifinr:nisouarnr:d'utu

najuiilfiiuur

ondansetron

4 !n.

^uoy

8

un.

fioun'jrnnilnrunu

lrruumn riruodrufiriudrfi'ry (13.3%, 6.7%, uov 40%

rlru6irrt! p <

0.05) drraiu

A 1v t 41 ev

- e

Rl?u n fl U !il 01 tauu ^y,lu?] n oilyt LFtSuu't ondansetron 8 u n. ^tn- oruauniln

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n'ruqlrorirufifiadrfi'rgii z tirtuur,rf,unirfr'n urifi za drTuuyd'uairm"nrvr&u 3

n{u

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[ilfr nrru um n riru fluyru n n fi

ur ondansetron Nlilttnflouri'unrrrfinornr:riulufrr-l:ur.ird'rrnoonfilfiiunr:

f n

ar

molphine rf,rtjourirlziluraii'ulfi

ondansetron,

nr:hiur

moqphine rtlrtj o urirh f,uu f,u, or nr: 6'u

flfi za ar-irfi

1

^nsliul ondansetron tfiailaoriuatnnduqinnlhil.tn morphine til'nioti:illduuilrt'lul;itltur.hfrnnaan

xntnl-tlvtlu2552 Prophylactic ondansetron for ^pr@ffit of intrathecal morphine irdrrrd pruritus rfterirror"o, ddirery

@

uvru'l

o

nlr,.ir ^n''n n N o rr 16 nvrr urarirrlau (cesar-

ean delivery)

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Id']

nl ual uuuvt'tu 3e1 rrluuu LUvtlu dl rl? uN vlJl t?

il

61 e)lt

Lluur

Zunntduu

Inu trigeminal

nerve o1n11d',ulir?tuElJn U

IoulouFl']t a1

^rflu

. , .j ' ; u au

Frl ttl4uUvrv'tulJ our q

n 0lnllnuEtnnll

[vu't

morphine

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antihistamine lvll'tv

' I

'le- d, -

olnllnUFlUnNll l}lLn[nnE]nnllu0u

hista- mine(s)

uritfirrqrnur

morphine

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lu

^medulla(u)

- Y av

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^selective serotonin type 3 receptor antagorlist [tju ondansetron(t) Q vd'] u

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0.5% hyperbaric bupivacaine rlflilrYu molphine 0.2 un.

fnrtir

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uu'rn 4 ttou 8 un.

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il

ASA physi.rr ,trt* I II ;Iilfif,oriruri'r

spinal anesthesia uovlrifirJ:sifi urr{urfit#lu

a..j;tad

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iltuli

spinal anesthesia vifoltiorirBuaou

', 1eu

r?J1:-tlJn11nnul il1J?UilnlTU!Al!nlttuULJ

val :

n?1!iilnLnunr:ilnu1 0.5%

hyperbaric bupiulcaine

2 uo. r'lnlfll

preservative-free morphine 0.2

un.

ul-rtjourjr[z#uvd'u uov uurju{r-hurflu

3

n6j}r nejrov 30

nu

Tnranr:

{'rmnrn

&o

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t. hior:nsn'lu

Acetated Ringer's solution ^10-15 uo./n.n.

Iut-lor

15-20 urfr

riounr:hf,u-ncriu n?iilf

f,n

uuu

^spinal

anesthesia

@

^2,ril1 ilnfifrcnlf

c'lrf('lrnlrtlvtY]ti 1:{nsrurnr?nvnu ^q?urf q?ir.ui

2. rir

spinal anesthesia

fiivilu

L2-3

via

Lg-4 interspace luviruounsunu Tnul6 rfiruvuud'uru a{27G ufiorr.Jorufr'nr f nar 0.5%

hyperbaric bupivacaine

2 uo.

zu6ilfi'1-l mor- phine 0.2

ln.

3. fufrnn:rudld'rzouoonfi

tqu

ut ^

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n{lii r

^{(placebo group)}

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^normal

saline 4 ,.rd. tdtrtul4oonrfiann"r

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z (O-4 group)

lfr

ondansetron

4 un. zunldt

normal saline

2 tto.

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najufi 3 (O-8 group)

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ondansetron 8

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5.

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^ra#uair fr'rr ^du fir-l:uuriirfiouyl'nflu rjrc rilunrrv n6u1fi/or 16uu

rovornl:n'ulu

^z

Table 1 Demographic data, mean (SD)

uov 24 tirTlurad'uaird'n Tnrutfr pruritus score

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ttov[liuurfiulf,ouo

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ruriovnajud':u Mann-Whitney U-test lnufio

^^ di

i1n1]ud1Flruil'r\JNCIFrilo p < 0.05

flonlrfinu'l

{r-harfu 3

n{}l

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1rjil!

n'tltJ ttDl n rlluo u'rf iluu d1 n rufl 1u iln --a^Dl tuFnuo]q

rirvrin :cd'!nr:ut

:vasrrorairm''n (Table 1)

i ^ O u 1v

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ut - ⁶

n'rrilbYuINfi rl Di'r

olnrrvul1f,u

^LLdunr?u

n6iulfior16uu ^(Table 2)

Placebo (n =

30) 04

group (n = 30) O-8 group (n =

30)

p value

Age (yr) Weight ^(kg) Anesthetic level (T) Time (min)

28.80 (7.64) 67.13 (12.27) 5.07 (0.e4) 42.66 (1,6.90)

2e.00 (s.62) 67.10 (11.26)

5.07 (1.28) 37.1,6 (10.1.4)

28.80 (s.04) 66.e5 (8.31) 4.80 (0.76) 3e.66 (13.4s)

0.99 0.99 0.51 0.31 O-4 = ondansetron 4 mg, O-8 = ondansetron 8 mg

ifi ^za oriri 1 n11lrta1 ondansetron tfrailaoiuatntsfruqlnn1zlrtu-1 ^morphine tittja,si'ilttduuiolufi-lnahfronaao LnJolrllu*"nu ^zssz Prophylorti, ordonr"tron fo, pr**t of irtroth"col *orphi,e idu,d p'u'itu' ofte'""'o"on deliu'ry @ Table 2 Intraoperative complications

Placebo (n =

30) 04

group (n = ³⁰⁾ O-8 group (n = ³⁰⁾ P value Hypotension

Shivering Nausea/vomiting

\e

(63.3%)

8 ^(26.7%) 3 ^(10.0%)

17 (56.7%) 3(10.0%)

2 ^(6.7%)

21 (70%)

s ^(1.6.7%) 2 (6.7%)

0.57 0.24 0.8 O-4 = ondansehon 4 mg, O-8 = ondansetron 8 mg

: ^{v DYlr o 1} n'tl 6'uu o u {rJ r ufr rJ: v rfi

ulu

frour{nf,u r,ld'us.ird'nr 2 u"tfuu

nuir

nniuiild

ilar

ondansetron

4 un.

uNv

8 un.

tfin ornlrFYufi ounirn

{r nll 4u

atirufi riu dr fr'rg

r]uflfifi

(46.7%,30% uov 60% mrurird'l p ^<

0.05) uovuiutfiu?flu

d za

u"':luuraous.irDl-n

)d

rfi o ril5 uu rfr uu tfu n

{r

^n':u 4tr ^(13.3%, 6.7o/". *av 40% mrlohn'u Tnru

p .

0.05) (Table 3)

d':uornr:nduldorr6au lru'ir ii

^z

u"r1uuvd'ualrd'nr

najufilfiilul

ondansetron 8

iln.

^fi

olnrr

nduIfi or riuurioun'lrn {u ^n-lu 4}l otlrufiriudrfr'rg (p = ^0.0a) $nfr 24 ti':Tlur,rd'u

r.ir n nr rfu 3 n 6j1ililfi n1lil urln Di'turiuvt'l$ 6fi fi

or-ifi nr :niu ^{o u} nr: ^{rYu'lun ailJ} ondansetron 4 u n.

--- -- q

ruov

8 lJn.

rnnDi'tuodrufiriudr6'ryfl1uNfi ^fi

Table 3 ^Incidence of pruritus and nausea/vomiting at recovery room and ward

Placebo (n =

30)

^O'4 group (n = ³⁰⁾ p value

O-8 group (n = ³⁰⁾ p value Recovery room

pruritus score.

0=no

1 = mild 2 = ^Severe nausea/vomiting Ward

pruritus score.

0=no

1 = mild 2 = Severe

12 (40%)

8 ^(25.7%) 10 (33.3%) 10 (33.3%)

18 (40%)

6 ^(20%) 6 (20'/") 2 ^(6.7%)

16 (s3.3%) 13 (43.4'/")

1 ^(3.3%) e (30%)

25 (86.7%)

3 ^(10%)

1. (3.3%) 0

21, (70'/,) 6 ^(20'/,) 3 ^(10%) 4 (13.3%)

28 (e3.3%) 1(3.3%) 1 (3.3%)

0.05 0.02

0.003 0.81

0.02

the Kruskal Wallis's

0.15

@

^{2?tIU1 AlflUqnnfl} 11rft1:nlrrMnti Irrnmrrnain;mn q?uvrf :1?ilti ad

?qliil

nrrl#u1r eui! nrrri 5f, nTnr u nrrfi n u1u-r 0.5% hyperbaric bupivacaine tJ6!tY!U'l mor-

phine

uirdourirls f,urao''u rfiio rniuqvrdnr:

lvulju-lFrlvvl-luzu]Fln

uA ![NsLvl]JluuvLlN-l

u r u nora - : 1v

I ^vUl-Jl-J? Fr14 0U zuT rl n''-', Ln UIJ qvr 0t vuulj? n tnulu

ds

1.2-24

zirTlu

r,l#uErnAnul ?Ju'rFr?rouui morphine

firirlr

.jo ^zu nl ^ri'l ulu1fi uur n 0.05-0.25

rtn. y{u'jr

r.J:vfiuinryrlunr::v'5urJ?Ft r[Nv

e d i-

r.rodru rfr uufr rnrralnur morphine f,uriluurnr

uouurfil#

(dosedependent) Tnrazunf,ru16uu fi rfluoium:ruriofir-l:u

Ifiuri nr:nnnlrulutq

!-gune-)tA

ou rnnuuuauilln n11v !!ynnu ouytlllJlJ ouy q Fr

fi o ornr: 6'u (pruritus) tiufi :r

uurui'n{dfifir

7o-85'h@ finE s rfi nruouqlnfln ur rflrd ourir

hf,uvo''u e-z #-rTlu ornlr6'uEvrdrqrn

- .Jd y g e 1,u

u: L?nJfl

qnu1

ttN?ntvE'tuuuynu Fl'tulJuLlJuu -qvi-Yt

dl ^Fl? uovu: r'tcu Lu14u't u unn [NUu LFI u trigemi- nal nerve

olnliniuui

t?ilElJn LLN ulolJ 0)?\J rl't rflunfr uvriuiinrr.joufi q

n

^{ourfluzu dETnu't}

morphine }Jn:v6'u serotonin type 3 receptor Torumtu

du

receptor d'unair-:fiurntu dorsal

horn

uoulud'uyd'u

ttflv

spinal tract uou trigeminal

.r"-" tu

medulla(u) alnturlrlod

t u1,

o 1 n r r 6'u d'u n ai r': rTn Lri m o u fl u o u Di o n I : in u't

Trranr:triur

antihistamine durfluurfifiaulfi

v -cl q

lnUT 01n11nU TUUEEUU tl',ll'l v01n1l nUFIU ' .it,:s- ' _'

n air:fi ^Lil [fi rfi nqr nnr:udr'rJ histamine(s)

arnf,rufru atnttd'uE'tnnttAnBl

morphine uirdomirluilur,lo''u Lfi

nElnnrr n:vfru

serotonin

gpe 3

^{receptor n-utiu}

nr:}iurnaju serotonin type 3 receptor antago-

nist tdu

ondansetron ilresd'tufl ouriuuov

'le ay

lnul0'rn1:nunun

^N1'l

Ln !Eluunuil

tu

ondansetron

.Aeu lvl0lJOUnUIdulnUl01n1l

A 1e a 1vu

nouLdo'r rEUualnnrl tFmuuT rnilu'tuFt INu

ulnniil

opioid Tnrutriurzurn 4-8 lJn. il'tu voo n rfi o Fr Ei'r d?uuu-r FlfitrirlourYunIr ^{rn Ft}

arnl:FYuolnnrrlfrul

morphine rrjryrudau rirlu iluuii'u 6o 0.1 -0.15 _il n./n.n. fi :vrr ^y u't or

nlroonqyidulu

4-6

ti':Iuu ur

ondansetron

o ;u I l

pndrorafi d't-rloru rauLsxj cytocfuome P-450

' . d 1v t v i

tJdu'rurnuulouu-r tnttn !']F]Fltlry ^ylauzun tsu

rfinniouniriauou 10

qrnnltfinutuorl

_Yeh uosnruv(n)

Li

ondansetron 0.1

ln./n.n.

r'l\iydonrdann'-l

rfr ofl ouniunr:fr'uernnr:Ifii!u't morphine 0.1 5

t eo1 a y,, ; -

}Jn. v-ruuouu'rtudu140u tue.t!?uxlJ15unlt

ajr m''rr n o o or nJi ul ^rfi ul ^{rYl n}

aii

^placebo vrli-r

q

rifi

n I r rilu o u

n'rI

6'ulu n aju

iil fiir

^u

r

ondansetron tfinSouns 25 urucfindu placebo tfinr5osnv

85 nr:flnuruau

Kyriakides K

LLovnruv(o'

lfi

ondansetron 4 ttn. rfiiorlourYu

e 1e-

nrr FYuErnnt:

lfi5lur

opioid fl ruudo n [6 o n ri'r

?,<d

t Fl u [lJ I UU ryr u! nu n N il ⁿ ?u n ]J ^y'l1J ?'t 0 u ^m n tr ru ua , ;t'u-

q q

?Jounlln'uLundufr

lfiinut

ondansetron lfi Fl

iouov

^qz.s

flaunltH{ln':lqlfi1frir-r

saline

turnnlouNv 70

nrif, nutu ou

olimri

qr:d'nururfiut4

![ N v n r[v('o) lfi ur o.du.,setron 4 ]J n. ^y-t u14 N o Fl

4 o 6l q v v 6l yr ; -

rd0nnl tunltt0unuolnllFutufl!'tufi il'tiu

nrr,.ilntinndon

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1.

2.

4.

7.

ut5culuntil

q

Glonsten B. Anesthesia for Obstetrics. In :

Miller RD. editor. Anesthesia,5ft ed. Phila- delphia

:

Churchill Livingstones 2000 ^:

2024-68.

Dahl, |organ ^{B, Inge S.} Inhaoperative and postoperative analgesic efficacy and ad- verse effects of intrathecal opioids in pa- tients undergoing cesarean section with spinal anesthesia. Anesthesiology. 1999 _; 91(6) : 1979-27.

Milner

AR, Bogod DG, Harwood Rj lntrathecal adminishation of moqphine for elective cesarean section.

A

comparison between 0.1 mg and 0.2 mg. Anesthesia 1996 ;51. :871-3.

Yeh H, Chen L, Lin C. Prophylactic intra- venous ondansetron reduces the incidence of inhathecal morphine-induced pruritus in patients undergoing cesarean delivery.

Anesth Analg 2000 :97 : 772-5.

Crighton IM, Hobbs

GJ,

Reid

^MF.

Ondansehon for the heatment of pruri- tus after spinal opioids. Anesthesia 1996;

51 :199-2Cf.

Kyriakides

K,

Hussain SK, Hobbs G|.

Management of opioid-induced pruritus ^: a role for 5-HT. antagoinst. B]A 1999 :

82(3): 439-4r.

Chaney MA. Side effeAs

of

intrathecal and epidural opioidf

.94

^ZmO ;42(70):

891.

1?rtu'l oJttuqfi{n

A. Stimemann HR. Ondansetron effective

to

treat spinal

or

epidural pruritus. Anesthesiol-

P, Cohen SE, Ward ME.

blockade for obstetric and gyne-

surgery. In : Cousin

^MJ,

PO, eds. Neural Blockade :

clinical anesthesia and management of

in,

3'd ed. Philadelphia

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Lippincott-

1998 :557-604.

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10. Churaluxananan S, Somboonviboon W,

Kyokong O, Nimcharoendee K. Ondan-

setron for treatment of

intrathecal molphine induced pruritus after cesarean delivery. Reg Anesth Pain Med 2000; 25(5) : 535-9.

11. Churaluxananan S, Somboonviboon W, Narasethakamol A, Promlok P. Nalbuphine versus ondansetron for prevent of intra thecal moqphine induced pruritus after cesarean delivery. Anesth Analg 2004 ;

96(6) :1789-93.