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Continuous epidural butorphanol relieves pruritus associated with epidural morphine infusions in children
J B Gunter1, J McAuliffe, T Gregg
1Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio, USA.
Insights
Epidural butorphanol did not prevent pruritus from morphine boluses in children. However, continuous epidural butorphanol effectively relieved itching from morphine infusions, though it increased sedation.
Area of Science:
- Anesthesiology
- Pediatric Pain Management
- Pharmacology
Background:
- Pruritus is a common side effect of epidural morphine in children.
- Effective management of pruritus is crucial for pediatric postoperative care.
- Epidural butorphanol is a potential option for managing morphine-induced pruritus.
Purpose of the Study:
- To evaluate the efficacy of epidural butorphanol in preventing or relieving pruritus associated with epidural morphine in pediatric patients.
- To compare the incidence and severity of pruritus and sedation between epidural morphine alone and epidural morphine with butorphanol.
Main Methods:
- A randomized study involving 46 children receiving epidural analgesia post-surgery.
- Group M received epidural morphine; Group B received epidural morphine with butorphanol.
- Pain, pruritus, and sedation scores were monitored, with interventions for severe pruritus.
Main Results:
- There was no significant difference in the initial incidence of pruritus between groups.
- Epidural butorphanol (10 mcg/kg) did not prevent pruritus from a morphine bolus (50 mcg/kg).
- Continuous epidural butorphanol (1.2 mcg/kg/hr) effectively relieved pruritus from morphine infusion (6 mcg/kg/hr) but increased sedation.
Conclusions:
- Epidural butorphanol is not effective for preventing pruritus from epidural morphine boluses in children.
- Continuous epidural butorphanol infusion is effective in relieving pruritus associated with epidural morphine infusions in children.
- Clinicians should consider the increased risk of sedation when using continuous epidural butorphanol for pruritus management.
Abstract:
We examined the efficacy of epidural butorphanol to either prevent or relieve pruritus associated with epidural morphine infusion in children. Forty-six children were randomized to receive either epidural morphine (M) or epidural M with butorphanol (B) for postoperative analgesia. They received bupivacaine and either M 50 microg.kg-1 or the same dose of M plus B 10 microg.kg-1. Following surgery, a continuous infusion of 0.1% bupivacaine with either M 20 microg.ml-1 or M 20 microg.ml-1 + B 4 microg.ml-1 was given at a rate of 0.3 ml.kg-1.h-1. Pain scores and pruritus scores were recorded every 4 h during epidural infusion. Subjects with a pruritus score=2 received diphenhydramine 0.5 mg.kg-1 i.v. and were switched to an alternate epidural infusion; subjects receiving M (group M) were switched to M+B while subjects receiving M+B (group B) were switched to hydromorphone (H) 4 microg.ml-1. There was no difference in the initial incidence of pruritus (group M 11/18; group B 13/28). No subject in group M required a second change of epidural infusion because of continued pruritus after being switched to M+B; five of 13 subjects in group B continued to experience pruritus after being switched to H and required a second change of epidural infusion or an alternate analgesic modality (P=0.038). The median pruritus score in the first 24 h after changing epidural infusions was 0 in subjects in group MDelta (changed from M to M+B) and 1 in subjects in group BDelta (changed from M+B to H; P=0.012). While the median sedation score in the first 24 h was 1 in both groups, there was a greater incidence of sedation scores of 2 in group B than group M (28% vs 12.3%; P=0.021). B 10 microg.kg-1 was not effective in preventing pruritus associated with bolus epidural administration of M 50 microg.kg-1 in children. B 1.2 microg.kg-1. h-1 was effective in relieving pruritus associated with continuous epidural infusion of M 6 microg.kg-1.h-1.