Epidural buprenorphine

Psychomotor symptoms have been noted subsequent to epidural buprenorphine (563). 

MacEvilly M, Carroll CO. Hallucination repression after epidural buprenorphine. BMJ 1989 298 928. 

In one of three patients receiving epidural buprenorphine for the relief of pain from head and neck cancers, it was discontinued because of severe dizziness (SEDA-17, 87). 

Batra YK, Gill PK, Vaidyanathan S, Aggarwal A. Effect of epidural buprenorphine and clonidine on vesical functions in women. Int J Clin Pharmacol Ther 1996 34(7) 309-11. 

Markedly lipid-soluble opioids have also been reported to cause respiratory depression. There was profound respiratory depression 100 minutes after the administration of fentanyl 100 micrograms epidurally (138), whilst epidural sufentanil caused apnea within a couple of minutes, reversed by nalbuphine (139). Epidural buprenorphine 150 micrograms produced prolonged time-dependent biphasic depression of carbon dioxide response in six healthy volunteers. The second maximum occurred at 8-10 hours after injection (140). Similar cases have been reported by others. 

There were symptoms of shock lasting 2-3 hours in two women with advanced cancer who were given epidural buprenorphine 300 micrograms after becoming tolerant to epidural morphine (148). The buprenorphine was given 12 hours after the last dose of morphine. Symptoms started within 2 hours of administration and remitted spontaneously. 

Molke Jensen F, Jensen NH, Hoik IK, Ravnborg M. Prolonged and biphasic respiratory depression following epidural buprenorphine. Anaesthesia 1987 42(5) 470-5. 

A man underwent thoracotomy for carcinoma of the middle third of his oesophagus. An hour after transfer to the recovery ward he complained of severe pain at the operative site and was given epidural buprenorphine 150 micrograms (3 micrograms/kg), and 2 hours later intramuscular ketorolac 30 mg because of continued pain. During the next hour he became more drowsy, stopped obeying commands and his respiratory rate dropped to 6 breaths per minute. He recovered after 6 hours of mechanical ventilation. The authors of this report suggest that it may be necessary to use less buprenorphine in the presence of ketorolac to avoid the development of these respiratory depressant effects. This appears to be the only report of this possible interaction. 

Jain PN, Shah SC. Respiratory depression following combination of epidural buprenorphine and intramuscular ketorolac. Anaesthesia (1993) 48, 898-9. 

Mehta Y, Juneja R, Madhok H, Trehan N. Lumbar versus thoracic epidural buprenorphine for postoperative analgesia following coronary artery bypass graft surgery. Acta Anaesthesiol Scand 1999 43(4) 388-393. 

Govindarajan R, Bakalova T, Michael R, Abadir A. Epidural buprenorphine in management of pain in multiple rib fractures. Acta Anaesthesiol Scand 2002 46(6) 660-665. 

Hirabayashi Y, Mitsuhata H, Shimizu R, Saitoh J, Saitoh K, Fukuda H. [Continuous epidural buprenorphine for post-operative pain relief in patients after lower abdominal surgery]. Masui 1993 42(11) 1618-1622. 

Pruritus has been noted after epidural morphine, pethidine (meperidine), diamorphine (heroin), and fentanyl, with a quoted incidence of 1-100%. Troublesome pruritus occurs in only about 1% of cases (SED-11, 139) (102). In one study of postoperative patients who received morphine 10 mg epidurally, pruritus occurred in 28% of patients (112), but in only 1% of patients in other studies who received 5 and 2 mg morphine (SED-11, 139). With pethidine 50 mg epidurally after cesarean section, there was a 50% incidence of pruritus, but it was troublesome in only one patient (136). Pruritus has been reviewed in relation to parturition (170,171). It occurred in 593 cases (43%) in pregnant women compared with 3050 non-parturients (8.4%). These findings are borne out by other comparative work (137). Pruritus after cesarean section was more common with epidural morphine and fentanyl than with buprenorphine or butorphanol (172). 

Keaveny JP, Harper NJ. Treatment of epidural morphine-induced pruritus with buprenorphine. Anaesthesia 1989 44(8) 691. 

Intrathecal administration of buprenorphine provides potent and effective analgesia with fewer adverse effects than the epidural route since the dose of buprenorphine is significantly less [10-12]. Intrathecal buprenorphine has been used effectively to control pain after cesarean section. The doses of intrathecal buprenorphine in this study were between 0.03 mg and 0.045 mg buprenorphine with the higher dose of intrathecal buprenorphine producing a longer duration of analgesia [11]. 

Miwa Y, Yonemura E, Fukushima K. Epidural administered buprenorphine in the perioperative period. Can J Anaesth 1996 43(9) 907-913. 

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