Prophylactic Nalbuphine to Prevent Neuraxial Opioid-Induced Pruritus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

PURPOSE: Evaluate the efficacy of prophylactic nalbuphine in preventing neuraxial opioid-induced pruritus. DESIGN: Systematic review and meta-analysis. METHODS: Following the PRISMA statement, PubMed, CINAHL, Cochrane and EMBASE were searched for eligible studies. FINDINGS: A total of 17 trials consisting of 1,052 patients were evaluated. Compared to placebo, there is low quality of evidence that nalbuphine was effective in reducing the incidence of pruritus in all patient population (RR, 0.66; 95% CI, 0.52 to 0.83; P = .0004) and obstetrics (RR, 0.81; 95% CI, 0.67 to 0.98; P = .03). We also found moderate quality of evidence that nalbuphine lowered pruritus in non-obstetrics, the number of rescue pruritus therapy and severity of pruritus episodes. However, nalbuphine did not cause sedation and affect pain scores. CONCLUSIONS: Prophylactic nalbuphine decreased the incidence and severity of pruritus without adverse effects on sedation and analgesic effect of opioids.

Anesthesia Considerations of a Pregnant Woman With COVID-19 Undergoing Cesarean Delivery: A Case Report.

Physiologic changes during pregnancy may increase the risk of coronavirus disease 2019 (COVID-19) infection. Limited data show serious complications of COVID-19 infection and pregnancy. Severe adverse maternal and perinatal outcomes such as preterm delivery, intensive care unit admission, and neonatal and intrauterine death have been reported. Our knowledge of the epidemiology, pathogenesis, disease progression, and clinical course of COVID-19 is continually changing as more information and evidence emerge. The present case adds further insights on COVID-19 and anesthesia considerations for patients undergoing cesarean delivery. In this case report, we describe a successful spinal anesthetic in a pregnant woman with confirmed COVID-19. To prepare for the likelihood of caring for women during labor and cesarean delivery, anesthesia professionals must know how to provide safe, patient-centered care and how to protect every member of the obstetric team from exposure to the virus. In addition, it is paramount that our profession shares our experiences and practices to help guide our multidisciplinary approach in delivering the best care possible to these women.

Use of Nalbuphine for Treatment of Neuraxial Opioid-Induced Pruritus: A Systematic Review and Meta-Analysis.

Opioid-induced pruritus is prevalent after neuraxial administration of opioid. A number of preventive measures have been reported; however, only a few studies evaluated treatment strategies for established pruritus. The pharmacokinetics and pharmacodynamic profiles of nalbuphine make this drug ideal for the treatment of established pruritus. The primary outcome of this systematic review and meta-analysis was the incidence of pruritus after neuraxial opioid administration. Secondary outcomes were the incidence of sedation and postoperative nausea and vomiting. Pooled estimates were reported by calculating the risk ratio (RR) with 95% confidence interval (CI). Five trials consisting of 494 patients were included for analysis. There was a low quality of evidence that nalbuphine was effective in reducing the incidence of pruritus compared with active control (RR, 0.59; 95% CI, 0.38 to 0.93; P = .02). Conversely, there was no difference between the incidence of sedation (RR, 1.06; 95% CI, 0.42 to 2.71; P = .90) and postoperative nausea and vomiting (RR, 1.58, 95% CI, 0.75 to 3.31; P = .23). Although large studies are needed to decrease heterogeneity across studies, the current review showed that nalbuphine appears to reduce the incidence of opioid-induced pruritus.

Opioid-Sparing Effects of Transversus Abdominis Plane Block in Elective Hysterectomy: A Systematic Review and Meta-Analysis.

Posthysterectomy pain is caused by abdominal incision and traumatic manipulation of the intra-abdominal structures. Optimal pain management consists of a multimodal pain regimen combined with transversus abdominis plane (TAP) block. We searched PubMed, EMBASE, and Cochrane Database for randomized controlled trials evaluating the opioid-sparing effects of TAP block in patients undergoing hysterectomy. The primary outcome was morphine consumption in the perioperative phase extending to 48 hours after surgery. The secondary outcomes were pain scores at rest and during coughing, time of first postoperative analgesia, and incidence of postoperative nausea and vomiting (PONV) and sedation. Twenty-three trials were selected consisting of 1,554 patients. Morphine consumption showed a reduction of 3.6 mg intraoperatively (mean difference [MD], -3.57; 95% CI, -6.88 to -0.25); 2.9 mg in the recovery room (MD, -2.86; 95% CI, -5.55 to -0.15); 3.4 mg at 24 hours (MD, -3.43; 95% CI, -6.77 to -0.09), and 29 mg at 48 hours (MD, -28.68; 95% CI, -44.35 to -13.01) after surgery in favor of TAP block. Pain scores were lower at rest, and the incidence of PONV and sedation were reduced. Although opioid-sparing effects of TAP block were significant perioperatively, its clinical application is debatable because of substantial heterogeneity across studies.