heroin and Pruritus

This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group.. One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain.. There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups.. We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

Topics: Analgesics, Opioid; Analysis of Variance; Anesthesia, Spinal; Anti-Inflammatory Agents, Non-Steroidal; Cesarean Section; Diclofenac; Dose-Response Relationship, Drug; Double-Blind Method; Drug Interactions; Female; Heroin; Humans; Ireland; Medical Audit; Pain, Postoperative; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

Debate has proliferated as to the true site of action of opioids when placed in the epidural space. The aim of this study was to compare the analgesic effects of a bolus of diamorphine given by the epidural or intramuscular route.. Sixty patients having elective primary total knee replacements were recruited and randomized to receive epidural or intramuscular diamorphine. A lumbar epidural catheter was sited and 10 mL of bupivacaine 0.5% wt vol-1 was injected. Patients subsequently received diamorphine 5 mg into the epidural space or as an intramuscular injection. Patient-controlled analgesia with intravenous morphine was used for postoperative analgesia. The primary outcome measures included time to first patient-controlled analgesia use and total morphine consumption in 24 h. Secondary end-points considered possible treatment complications.. All primary end-points showed significant differences in favour of epidural diamorphine. Medians for times to first patient-controlled analgesia use and total 24 h morphine requirements were significantly different (P < 0.001) at 418 vs. 198 min and 11 vs. 39 mg, respectively. There were no significant differences in secondary end-points.. This study has shown the superior analgesic efficacy of epidural diamorphine when compared to intramuscular injection.

Topics: Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Arthroplasty, Replacement, Knee; Female; Heroin; Humans; Injections, Intramuscular; Male; Morphine; Pain Measurement; Pain, Postoperative; Postoperative Nausea and Vomiting; Pruritus; Treatment Outcome

Intraoperative discomfort during spinal anaesthesia for Caesarean section is the commonest cited anaesthetic cause of litigation in obstetric practice. Intrathecal opioids are used to improve intraoperative comfort and postoperative analgesia for these operations. The minimum intrathecal diamorphine dose that prevents intraoperative supplementation requires determination.. After ethics committee approval, 200 ASA I, II women with > or = 37 weeks gestation and planned for elective Caesarean section under combined spinal-epidural anaesthesia were recruited. They were randomized into four groups to receive hyperbaric bupivacaine 0.5% 12.5 mg with diamorphine 0.2, 0.3, 0.4 or 0.5 mg by intrathecal injection. The need for intraoperative i.v. supplementation with alfentanil, time to first requests for postoperative analgesia, incidence of nausea and vomiting and requirement for antiemetic and antipruritic were noted.. Intraoperative supplementation was inversely proportional to the dose of diamorphine used (P=0.004). The ED(95) value for intrathecal diamorphine to prevent intraoperative supplementation was 0.39 mg. Mean time interval for request for postoperative analgesia was 446 min in the 0.2 mg group, 489 min in the 0.3 mg group, 601 min in the 0.4 mg group and 687 min in the 0.5 mg group (P=0.003 for trend). Incidence of nausea, vomiting and pruritus increased with dose of diamorphine used (P values for trend: nausea, 0.04; vomiting, 0.008; pruritus, 0.004). Requests for antiemetic increased with dose but achieved significance only for requirement for second antiemetic (P=0.03). Request for antipruritic did not achieve significance.. The ED(95) for the amount of intrathecal diamorphine required to prevent intraoperative supplementation during spinal anaesthesia for Caesarean section is 0.4 mg in clinical terms. Times to first requests for analgesia, incidence of nausea, vomiting and pruritus increase with dose.

Topics: Adult; Alfentanil; Analgesics, Opioid; Anesthesia, Epidural; Anesthesia, Obstetrical; Anesthesia, Spinal; Cesarean Section; Double-Blind Method; Drug Administration Schedule; Female; Heroin; Humans; Pain, Postoperative; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Prospective Studies; Pruritus

To assess calculated equivalent doses of intrathecal and epidural opioids for elective Caesarean section in terms of quality and duration of analgesia, and incidence of side effects, we have compared 50 patients, allocated randomly to one of two groups to receive either diamorphine 0.25 mg intrathecally (group 1) or 5 mg epidurally (group 2), in addition to intrathecal bupivacaine 10 mg, using a combined spinal-epidural technique. There was no significant difference in duration of analgesia between groups (group 1 mean 14.6 (SD 5.9) h, group 2 14.2 (6.5) h; mean difference 0.8 h; 95% Cl -2.8-4.5; P = 0.65) or quality of analgesia (VAPS and VRS scores). The degree of pruritus was similar in both groups (80-88%) but the incidence of postoperative nausea and vomiting was significantly higher in the epidural group (24% vs 4%; P < 0.05). Intrathecal diamorphine 0.25 mg produced the same duration and quality of postoperative analgesia as epidural diamorphine 5 mg for elective Caesarean section but with significantly less nausea and vomiting.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesics, Opioid; Cesarean Section; Female; Heroin; Humans; Injections, Spinal; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

To try to decrease the incidence of side-effects associated with postoperative extradural infusions of local anaesthetics in combination with opioids, we have used plain ropivacaine solutions in 200 children. The first 72 children received an infusion of bupivacaine 0.125% + diamorphine 20 microg x ml-1, then 200 children received plain ropivacaine solutions. The children who received ropivacaine were found to have lower incidences of nausea, pruritus, urinary retention, and were less sedated, despite comparable analgesia. The management of plain ropivacaine for extradural analgesia is discussed.

Topics: Amides; Analgesics, Opioid; Anesthetics, Local; Bupivacaine; Child; Costs and Cost Analysis; Drug Combinations; Heroin; Humans; Infusions, Intravenous; Injections, Epidural; Pain, Postoperative; Postoperative Nausea and Vomiting; Pruritus; Ropivacaine; Sleep Stages; Urinary Retention

Sixty patients took part in a randomised, double-blind study to compare the analgesic and side effects of three opioid-containing solutions for patient-controlled epidural analgesia following abdominal surgery. Patients in group 1 received a solution containing bupivacaine 0.125% with fentanyl 10 micrograms.ml-1, group 2 bupivacaine 0.125% with diamorphine 125 micrograms.ml-1, group 3 pethidine 2.5 mg.ml-1. All groups received 4 ml.h-1 background infusion and 3 ml boluses every 20 min if necessary. There were no significant differences between the groups in visual analogue scale pain scores (p = 0.537) or volumes of solution used at 24 h (p = 0.351) or 48 h (p = 0.105). Motor block was significantly higher in group 2 (p < 0.004) and pruritus occurred significantly less in group 3 (p < 0.05). We conclude that these three solutions produce equivalent analgesia but that pethidine 2.5 mg.ml-1 may be associated with fewer side effects.

Topics: Aged; Analgesia, Epidural; Analgesia, Patient-Controlled; Analgesics, Opioid; Bupivacaine; Double-Blind Method; Female; Fentanyl; Heroin; Humans; Hypotension; Male; Meperidine; Middle Aged; Pain Measurement; Pruritus; Time Factors

We have studied the efficacy of two extradural infusions (10 ml h-1) in 50 patients in active labour. Patients in the diamorphine group (n = 25) received 0.0625% plain bupivacaine 6.25 mg h-1 mixed with 0.005% diamorphine 0.5 mg h-1 and those in the control group (n = 25) received 0.125% plain bupivacaine 12.5 mg h-1. Both groups received intermittent "top-ups" of 0.25% bupivacaine 10 ml when indicated. Although median pain scores during the infusion were similar in both groups, patients in the diamorphine group indicated greater satisfaction with the infusion (88% very satisfied, compared with 52% in the control group (P < 0.02)). There were no differences in the incidence of hypotension, instrumental vaginal delivery, number of "top-ups", duration of the second stage or extent of motor block. However, patients in the diamorphine group had a high incidence of pruritus (44%, compared with 0% in the control group (P < 0.01)).

Topics: Adolescent; Adult; Analgesia, Epidural; Analgesia, Obstetrical; Bupivacaine; Delivery, Obstetric; Double-Blind Method; Drug Combinations; Female; Heroin; Humans; Pain Measurement; Pregnancy; Pruritus

In a randomised study of analgesia following Caesarean section, we compared the efficacy and side effects of on-demand epidural diamorphine 2.5 mg with intravenous patient-controlled analgesia using diamorphine from the Baxter infusor system. Pain scores fell more rapidly in the epidural group, but by the fourth hour, and thereafter, both techniques had a similar analgesic effect. The patient-controlled analgesia group used significantly more diamorphine (p < 0.001), median 62 mg (range 18-120 mg) compared to the epidural group, median 10 mg (range 2.5-20 mg), over a significantly longer time period (p < 0.001), median 54.25 h (range 38-68 h) compared to the epidural group, median 40.75 h (range 6-70 h). The frequency and severity of nausea, vomiting and pruritus were similar in the two groups, however, the patient-controlled analgesia group were more sedated during the first postoperative day. This reached statistical significance (p < 0.05) between 9-24 h. Overall satisfaction scores (0-100) were high, but the patient-controlled analgesia group scored significantly higher: mean 85.5 (SD 12.2) compared to mean 77.0 (SD 11.7) in the epidural group.

Topics: Adult; Analgesia, Epidural; Analgesia, Obstetrical; Analgesia, Patient-Controlled; Cesarean Section; Female; Heroin; Humans; Infusions, Intravenous; Nausea; Pain, Postoperative; Patient Satisfaction; Pregnancy; Pruritus; Time Factors; Vomiting

Analgesia provided by either 5 mg diamorphine, or 5 mg methadone administered by the epidural route during elective caesarean section was compared in 40 women. The median time to further analgesia in the methadone group was 395 min, and 720 min in the diamorphine group, P = 0.0003. Linear analogue scores to assess pain were measured 2-hourly for 12 h, then again at 24 h postoperatively. Pain scores were significantly lower in the diamorphine group at 8 and 10 h. The median cumulative i.m. morphine dose administered during the first 24 h was 20 mg in the methadone group and 0 mg in the diamorphine group (P = 0.0005). Nausea and pruritus were common side effects in both groups. Continuous pulse oximetry data were available for 12 h post-operatively in 15 patients receiving methadone, and in 17 patients receiving diamorphine. One or more episodes of significant desaturation (< 90% for 30 s), occurred in three patients receiving methadone, and in nine patients receiving diamorphine. Desaturation to 90-92% occurred in a further three patients given epidural diamorphine, and in one further patient given epidural methadone.

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Cesarean Section; Double-Blind Method; Female; Heroin; Humans; Hypoxia; Incidence; Methadone; Morphine; Nausea; Oxygen; Pain Measurement; Pain, Postoperative; Pregnancy; Prochlorperazine; Pruritus; Time Factors

Topics: Adult; Analgesics, Opioid; Anesthesia, Obstetrical; Antiemetics; Cesarean Section; Female; Heroin; Humans; Injections, Spinal; Length of Stay; Ondansetron; Postoperative Complications; Postoperative Nausea and Vomiting; Pregnancy; Pruritus

One hundred and fifty extradural infusions of diamorphine and bupivacaine after major surgery in children were audited over a 15 month period. The majority of the children (69%) were less than 5 years of age. Analgesia was assessed or self-rated as 'very good' in over 75% of patients. Urinary retention was seen in 11% of patients and pruritus in 10%. Respiratory depression requiring intervention was only seen in one patient--a premature infant of 39 weeks post-conceptual age. Technical complications resulted in the early loss of 16.7% of the infusions. Although analgesia was good the complexity of the extradural infusion technique demanded significant medical and nursing time especially to overcome technical problems.

Topics: Adolescent; Analgesia, Epidural; Bupivacaine; Child; Child, Preschool; Heroin; Humans; Infant; Infant, Newborn; London; Medical Audit; Pain, Postoperative; Patient Satisfaction; Pruritus; Respiratory Insufficiency; Treatment Outcome; Urinary Retention

Topics: Analgesia, Epidural; Analgesia, Obstetrical; Female; Heroin; Humans; Pregnancy; Pruritus

Topics: Acanthosis Nigricans; Acne Vulgaris; Dental Caries; Dermatitis, Contact; Drug Eruptions; Edema; Gangrene; Hepatitis A; Heroin; Humans; Impetigo; Life Style; Pigmentation Disorders; Pruritus; Psychophysiologic Disorders; Purpura; Skin Diseases; Skin Manifestations; Substance-Related Disorders; Thrombophlebitis; Urticaria

Topics: Abscess; Acanthosis Nigricans; Adult; Burns; Edema; Heroin; Humans; Jaundice; Male; Melanosis; Pigmentation; Pruritus; Skin Manifestations; Skin Ulcer; Substance-Related Disorders