Significance of patient-controlled analgesia in combination with continuous epidural block for patients who underwent posterior lumbar surgery

The purpose of the study was to evaluate the efficiency of patient-controlled analgesia (PCA) combined with continuous epidural block in patients who underwent lumbar spine surgery. In group 1 (postoperative PCA group), 23 patients were administered postoperative continuous epidural block in combination with analgesics, which was self-regulated by the patient using a device. In contrast, the 22 patients in group 2 (control group) received suppositories or intramuscular injections of analgesics on request. The following factors were compared between the two groups: pain relief according to the visual analog scale for pain assessment, the frequency of administration of analgesics, and side effects of the postoperative analgesia. The patients in group 1 had more satisfactory relief of pain according to the visual analog scale for pain assessment and needed suppositories and intramuscular injection of analgesics less frequently on the 1st, 2nd, and 3rd postoperative day. The time spent by nurses on pain management in group 1 was less than that in group 2. No patient had any serious complications in either group. In conclusion, the present patient-controlled method combined with postoperative continuous epidural block could decrease the intensity of postoperative pain and the amount of time spent by nurses on the administration of postoperative analgesics after lumbar spine surgery. Received: 17 July 1997 Revised: 30 September 1997 Accepted: 14 October 1997     

氯诺昔康及曲马多用于妇科剖腹手术后病人自控镇痛的临床比较研究

目的 评价氯诺昔康及曲马多用于妇科剖腹手术后病人自控镇痛（PCA）的安全性及有效性。方法 60例在全麻下行开腹妇科手术的患者,随机双盲分为氯诺昔康组（L组）和曲马多组（Q组）。病人根据镇痛需要启动PCA泵（氯诺昔康每次1mg或曲马多每次12.5mg,锁定时间5分钟）,并由病人从疼痛程度差值（PID）、疼痛缓解程度（PAR）、疼痛缓解总和（TOTPAR）完成对疼痛的评分（VRS,口述描绘5组评分法）,并记录发生的副作用。结果 L组和Q组的TOTPAR无显著性差异,两组病人各时间点的PID和PAR的趋势相同,在病人镇痛总体印象评分中,L组镇痛满意的比例略高于Q组,但无统计学差异。Q组恶心与呕吐的发生率明显高于L组。结论 氯诺昔康用于妇科开腹手术后PCA的效应与曲马多接近,副作用少,适用于PCA。     

氯胺酮与吗啡超前镇痛对内脏牵拉痛及术后镇痛的影响

目的探讨氯胺酮与吗啡复合液硬膜外超前镇痛对抑制手术内脏牵拉痛的影响及术后镇痛情况的影响。方法60例ASAⅠ~Ⅱ级择期全子宫切除术患者,均于硬膜外麻醉下行全子宫切除术。随机分为两组,每组30例,即Ⅰ组(对照组):术前不施行超前镇痛;Ⅱ组(实验组):切皮前10 min将氯胺酮30 mg与吗啡2 mg用生理盐水稀释成5 ml注入硬膜外腔。所有患者术后均行自控硬膜外镇痛(PCEA)。镇痛药物为0.15%罗哌卡因+5 mg吗啡,共100 ml。观察两组患者术中牵拉反应、术后镇痛情况及并发症。结果Ⅱ组用药对抑制术中牵拉痛的效果明显优于Ⅰ组(P<0.01);Ⅱ组PCEA泵首次触发时间较Ⅰ组显著延长(P<0.01),48 h内有效触发次数显著减少(P<0.01),24 h PCEA泵总用量明显减少(P<0.05),术后并发症无明显差异。结论氯胺酮与吗啡硬膜外超前镇痛能明显抑制术中牵拉痛,提供良好的术后镇痛效果,减少阿片类药物的用量。     

Epidural diamorphine for post-caesarean pain: a dose response study

The effectiveness of postoperative pain relief and the frequency of side effects with three different doses of epidural diamorphine (2.0, 3.5 and 5 mg) was investigated. The study was carried out double-blind in 30 women undergoing awake elective caesarean section. Postoperative pain intensity was measured on a linear analogue scale. The time to onset of analgesia (TOA), time taken to reach a pain score of zero or become comfortable, and time to next analgesia (TNA) were not significantly different between groups. Three patients in the 2 mg group failed to achieve scores of zero but were comfortable. No nausea or vomiting was seen but the incidence of itching was 0, 30% and 80% in the 2.0, 3.5 and 5 mg groups respectively. We conclude that epidural diamorphine 2 mg is adequate for relief of post-caesarean pain and higher doses may increase the incidence of unwanted side-effects.     

曲马多硬膜外腔或肌肉注射用于术后镇痛的观察与比较

本文通过４０例硬膜外腔麻醉行中、上腹部手术后硬膜外腔注入曲马多（ＥＴ）与肌肉注射曲马多（ＭＴ）１００ｍｇ的观察比较发现，ＥＴ组舒张压下降有显著性（Ｐ＜０．０５），两组的镇痛效果及副作用的出现相似（Ｐ＞０．０５），镇痛起效时间ＥＴ组快于ＭＴ组（Ｐ＜０．００１），镇痛维持时间ＥＴ组短于ＭＴ组（Ｐ＜０．０５），２４ｈ内重复注药次数的发生率ＥＴ组高于ＭＴ组（Ｐ＜０．０５），且ＥＴ组多数病人有带管不适感。表明曲马多术后镇痛选用ＭＴ法更具优越性     

Effects of postoperative continuous epidural analgesia after laparoscopy-assisted colectomy

BACKGROUND: This study was conducted to evaluate the effects of continuous epidural analgesia on the postoperative pain and the early recovery after laparoscopy-assisted colectomy (LAC). METHODS: A total of 50 patients undergoing elective LAC were investigated for postoperative pain score and other variables retrospectively. RESULTS: Thirty patients who had received epidural analgesia (E group) showed significantly lower pain scores for 2 and 24 hours after surgery, compared with twenty patients who had received analgesics intramuscularly or transrectally (C group). The patients in the E group needed significantly less supplemental analgesics than those in C group for 12 to 24 hours after the operation. The incidence of postoperative complications and the early recovery were not significantly different between the two groups. CONCLUSIONS: These results show that postoperative continuous epidural analgesia is effective for postoperative pain relief in patients after laparoscopy-assisted colectomy.     

Peridural opiate analgesia. Clinical results of a 2-year study

Postoperative pain relief, consumption of analgesics and the incidence of postoperative complications were investigated in a retrospective cohort-study on 470 patients following abdominal surgery. 221 of these patients received epidural morphine or buprenorphine for postoperative pain relief (Group I). Another group of 249 patients received conventional opiate analgesics intravenously or intramuscularly (Group II). On average the analgesia lasted 14 h after epidural morphine and 11 h after epidural buprenorphine. The overall amount of morphine in the postoperative period was 13.3 +/- 14.9 mg and 0.89 +/- 0.55 mg buprenorphine respectively. 5 cases of pneumonia (2.3%) were seen in the epidural group (Group I). 22 pneumonia cases (8.8%) were registered in the group with conventional analgesics (Group II). Besides the advantage of stronger and longer duration, small dosage and minor central depressive side effects, epidural opiate analgesia has proven to result in positive clinical consequences. The low incidence of postoperative pneumonia is due to the strong regional pain relief, which improves mechanical pulmonary function and gas exchange.     

The effects of postoperative continuous epidural analgesia after laparoscopy-assisted distal gastrectomy

BACKGROUND: This study was conducted to evaluate the effects of continuous epidural analgesia on the postoperative pain and the early recovery after laparoscopy-assisted gastrectomy (LAG). METHODS: A total of 66 patients undergoing elective LAG were investigated for postoperative pain score and other variables retrospectively. RESULTS: Forty-four patients who had received epidural analgesia (E group) showed significantly lower pain scores for 2, 12 and 48 hours after surgery, compared with 22 patients who had received analgesics intramuscularly or transrectally (C group). The patients in the E group needed significantly less supplemental analgesics than those in C group for 2 and 12 hours after the operation. The early recovery and the incidence of postoperative complications were not significantly different between the two groups. CONCLUSIONS: These results show that postoperative continuous epidural analgesia is effective for postoperative pain relief in patients after laparoscopy-assisted gastrectomy.     

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

OBJECTIVE: To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures. SUMMARY BACKGROUND DATA: Even though many beneficial aspects of epidural anesthesia have been reported, clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results. METHODS: The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic, gastric, biliary, or colon operations. They were assigned randomly to receive either general anesthesia and postoperative analgesia with parenteral opioids (group 1) or epidural plus light general anesthesia and postoperative epidural morphine (group 2). The patients were monitored for death and major complications during and for 30 days after surgery, as well as for postoperative pain, time of ambulation, and length of hospital stay. RESULTS: Overall, there was no significant difference in the incidence of death and major complications between the two groups. For abdominal aortic surgical patients, unlike the other three types of surgical patients, the overall incidence of death and major complications was significantly lower in group 2 patients (22%) than in group 1 patients (37%), stemming from differences in the incidence of new myocardial infarction, stroke, and respiratory failure between the two groups. Overall, group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients. In group 2 aortic patients, endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter. CONCLUSIONS: The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief. Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations.     

静脉与硬膜外泵注曲马多病人自控镇痛的比较

目的　比较术后静脉和经硬膜外应用曲马多病人自控镇痛 (PCA)的临床效果和安全性。方法　 5 2例胸部和上腹部手术病人随机分为静脉注射曲马多病人自控镇痛 (PCIA)组和经硬膜外曲马多病人自控镇痛 (PCEA)组 ,每组 2 6例。两组曲马多负荷量为 1mg/kg ,PCA药物配方均为曲马多 60 0mg +氟哌利多 5mg + 0 9%氯化钠至 10 0ml,持续给药注速 2ml/h ,单次PCA剂量 0 5ml,锁定时间 15分钟。术后定时进行镇痛、镇静评分 ,2 4小时曲马多用量 ,患者满意度及不良反应的观察比较。结果　PCIA组 2 4小时用药量、按键次数及术后视觉模似评分 (VAS)均明显低于PCEA组 (P<0 0 5 )。两组镇静评分低且无明显差异。患者对术后镇痛总体满意程度良好至优秀均在 84 6%以上 ,不良反应发生率两组间无显著性差异。结论　曲马多用于术后镇痛安全有效。但曲马多PCIA镇痛效果明显优于曲马多PCEA ,且用药量少。     

Epidural analgesia with bupivacaine reduces postoperative paralytic ileus after hysterectomy

This study was undertaken to compare the effects of postoperative bupivacaine epidural analgesia with those of intermittent injections of ketobemidone (a synthetic opioid) on postoperative bowel motility in patients who had had hysterectomies. The epidural group (N = 20) received continuous epidural anesthesia with bupivacaine postoperatively for 26-30 hours and the control group (N = 20) received intermittent injections of ketobemidone for postoperative pain relief. Postoperative bowel movements and propulsive colonic motility were estimated from the first passage of flatus and feces and by following radiopaque markers by serial abdominal radiographs. In the epidural group, the times for first passing of flatus (31 +/- 22 hours; mean +/- SD) and feces (70 +/- 44 hours) were significantly shorter than in the control group (flatus 58 +/- 14 hours and feces 103 +/- 26 hours). The average position of the markers was significantly more distally in the epidural group immediately after operation and the markers continued to move forward during the first postoperative day. In the control group, the markers did not move during this period. The results demonstrate that postoperative bowel peristalsis returned earlier in the patients given epidural analgesia with bupivacaine for pain relief than in patients given a narcotic.     

Epidural anesthesia during upper abdominal surgery provides better postoperative analgesia

Since repeated noxious stimuli may sensitize neuropathic pain receptors of the spinal cord, we tested the hypothesis that the appropriate blockade of surgical stimuli with epidural anesthesia during upper abdominal surgery would be beneficial for postoperative analgesia. Thirty-six adult patients undergoing either elective gastrectomy or open cholecystectomy were randomly allocated to receive either inhalational general anesthesia alone (group G) or epidural anesthesia along with light general anesthesia (group E) throughout the surgery. Postoperative pain management consisted of patient-controlled analgesia (PCA) with bupivacaine accompanied by the continuous infusion of buprenorphine. To assess postoperative pain, a visual analogue scale (VAS) was employed at 2, 24, and 48 h postoperatively. While there was no significant difference in the bupivacaine dose, more patients undergoing gastrectomy in group G required supplemental analgesics than those in group E, and the VAS scores in group E demonstrated significantly better postoperative analgesia compared to group G after both types of surgery. Thus, an appropriate epidural blockade during upper abdominal surgery likely provides better postoperative pain relief.     

Preincisional dextromethorphan combined with thoracic epidural anesthesia and analgesia improves postoperative pain and bowel function in patients undergoing colonic surgery

Colonic surgery is associated with severe postoperative pain and postoperative ileus, which contribute to delayed hospital discharge. In previous studies, we demonstrated that IM dextromethorphan (DM) provided preemptive analgesia and improved postoperative pain. The benefit of thoracic epidural anesthesia (TEA) and postoperative epidural analgesia on postoperative pain was well demonstrated. The goal of this study was to investigate the effect of preincisional IM DM combined with intraoperative TEA and postoperative patient-controlled epidural analgesia (PCEA) on pain and bowel function after colonic surgery. Patients were randomized into 3 equal groups to receive: 1) chlorpheniramine maleate (CPM) 20 mg and general anesthesia (CPM-GA); 2) CPM 20 mg and GA combined with TEA (CPM-TEA); or 3) DM 40 mg (containing 20 mg of CPM) and GA combined with TEA (DM-TEA). The CPM, DM, and TEA with lidocaine were administered after GA induction via an IM injection and 30 min before the skin incision. All patients received postoperative PCEA for pain control. Analgesic effects were evaluated for 72 h after surgery using visual analog scale pain scores at rest and moving, time to first PCEA request for pain relief, total PCEA consumption, and the time to first passage of flatus. Statistically significant improvement of postoperative pain and bowel function was observed in the following order: DM-TEA > CPM-TEA > CPM-GA. Compared with the CPM-TEA group, the DM-TEA group averaged 1.6 points lower on first-hour pain scores, 40 min longer to first PCEA request, 15.8 mL less PCEA drug over 72 h, and 14.7 h earlier bowel function (all P < 0.01). We conclude that the combination of preincisional DM (40 mg IM), intraoperative TEA, and postoperative PCEA enhances analgesia and facilitates recovery of bowel function, suggesting possible synergistic interaction with local anesthetics and opioids.     

Analgesia by wound infiltration after surgical excision of benign breast lumps.

Wound infiltration with bupivacaine provided complete postoperative pain relief in 14 of 19 women undergoing excision biopsy of a benign breast lump under general anaesthesia. Fifteen patients formed a control group in whom the wound was infiltrated with saline. They had inadequate relief of pain despite receiving significantly more opioid analgesia than the bupivacaine group in the postoperative period. The analgesia from bupivacaine usually outlasted the postoperative pain. No adverse reactions were apparent.     

Caudal anesthesia combined with general anesthesia in comparison with general anesthesia in ambulatory circumcision

In 100 boys (5.9 +/- 3.2 years old) undergoing outpatient circumcision, analgesia was provided with 0.375% bupivacaine 1 ml/year of age by caudal injection (group I), administered after induction of general anesthesia. This group was compared with 100 boys (6.3 +/- 3.4 years old), who received only general anesthesia (group II). The puncture technique described was free of complications and the caudal blocks were 98% successful. There was a great difference with regard to the levels of general anesthesia: the average enflurane concentrations required to block autonomic reactions during surgical intervention was 1.3 vol% in group I and 2.7 vol% in group II. The amount of pethidine needed for perioperative pain relief was 8 mg (+/- 5.7) in 17/100 of group I and 17.3 mg (+/- 6.8) in 91/100 of group II. In addition, paracetamol was given in 10/100 of group I and 30/100 of group II. The boys in group I showed calm postoperative behavior. In both groups there were only slight differences in hemodynamic parameters. Of the parents who answered our questionnaire (50 answers to 60 questionnaires), 68% were amazed at the duration of analgesia. During the late postoperative period, in group I there was an almost total absence of vomiting (4%), with an associated rapid return to normal feeding. In 83% the effect of late postoperative analgesia worked so well that no subsequent analgesic was given. In 15% the pain relief lasted 6.3 +/- 2.5 h. The excellent postoperative pain relief produced by caudal anesthesia justifies its frequent use for children subjected to genital surgery.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral infraorbital nerve block is superior to peri-incisional infiltration for analgesia after repair of cleft lip.

Cleft lip repair is a common operation in infants and requires that the child is pain-free during the postoperative period so that handling does not affect the integrity of the delicate surgical site. This study was designed to compare the efficacy and duration of effect of 0.125% bupivacaine given preoperatively as a bilateral infraorbital nerve block with peri-incisional infiltration of the same local anaesthetic for postoperative analgesia in cleft lip repair. It was a randomised, double blind, prospective study in 30 children aged 4-20 months (ASA grade 1). After a standard induction, group A (n = 15) were given a bilateral infraorbital nerve block with 0.125% bupivacaine and group B (n = 15) had peri-incisional infiltration with the same solution. No additional systemic analgesics were given before or during the operation. Intraoperative monitoring comprised measurement of heart rate and blood pressure and post-operatively pain relief was recorded using a behavioural pain relief score. The heart rate, respiratory rate, and blood pressure were also monitored at 0, 1, 2, 4, 8, and 24 hours after tracheal extubation. The results showed that group A had significantly better pain relief (higher scores) than group B for eight hours postoperatively (p < 0.05). The analgesic requirement in group B became significant at two hours postoperatively, while group A had significant analgesic requirements only after eight hours. The significant rise in heart rate and blood pressure that accompanied tracheal intubation in both groups suggested that while both methods of analgesia may be adequate to prevent responses to skin incision, they do not substitute for adequate systemic analgesia during the operation. We conclude that infraorbital nerve block with 0.125% bupivacaine provides better and more prolonged analgesia than peri-incisional infiltration in cleft lip repair.     

Postoperative pain management: epidural analgesia

BACKGROUND: Epidural analgesia is one of the most effective regimens for postoperative pain relief after abdominal surgery. The use of epidural analgesia in high risk patients has been associated with significant decrease in surgical stress response, in cardiac and pulmonary morbidity, in recovery of gastrointestinal function and in thromboembolic events. The aim of this paper is to describe pain relief, side effects and recovery of gastrointestinal function during epidural analgesia. METHODS: During the period January 1999 to September 2001, 590 patients undergoing elective major abdominal surgery received epidural analgesia. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0.5% ml 7-12 combined with sufentanil 30 microg or with morphine 2 mg was injected. General anesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 microg/ml or ropivacaine 0.2% plus morphine 0.02 mg/ml was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 4 days. RESULTS: Resting and incident pain scores were <4 and <5; 20% of patients received a rescue dose; the incidence of nausea was 6%, pruritus 5%; all patients also recovered from postoperative ileus. CONCLUSIONS: Continuous epidural analgesia resulted in good pain relief, provided the best balance of analgesia and side effects and improved postoperative outcome.     

Effect of scalp block on postoperative pain relief in craniotomy patients

The efficacy of scalp nerve block using 0.5% bupivacaine with adrenaline for postoperative pain relief in craniotomy patients was evaluated in 40 ASA I or II adult patients undergoing supratentorial craniotomy. A standard general anaesthesia technique was followed. Patients were randomly divided into two groups. Group B received 0.5% bupivacaine with 1:400,000 adrenaline and group S received normal saline with 1:400,000 adrenaline, both after skin closure. Postoperative pain was assessed at 30 seconds and 1, 2, 4, 6, 8 and 12 hours using a numerical rating scale. Diclofenac IM was administered as rescue analgesia if patients reported a numerical rating scale of 40 or more. Tramadol IV was administered as second rescue analgesia. Sixty per cent of patients in group S experienced moderate to severe pain (numerical rating scale of 40 or more) at some time during the first 12 postoperative hours in comparison to 25% patients in group B. Median pain scores were significantly lower in group B for up to 6 hours. Significantly more patients were pain free up to four hours in group B. Median duration for the requirement of first dose of diclofenac was longer in group B compared to group S (360 min vs 30 min, P < 0.01). The number of doses of diclofenac (5 vs 19) was significantly lower in group B compared to group S (P < 0.01). Tramadol was required by six patients in group S only. Scalp nerve block using 0.5% bupivacaine with 1:400,000 adrenaline decreases the incidence and severity of postoperative pain in patients undergoing supratentorial craniotomy.     

Pain relief and safety after major surgery. A prospective study of epidural and intravenous analgesia in 2696 patients

BACKGROUND: Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population. METHODS: During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0-10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest. RESULTS: Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements. CONCLUSION: In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.     

Postoperative pain and pulmonary complications: comparison of three analgesic regimens

In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05).