Postoperative analgesia by epidural methylprednisolone after posterolateral thoracotomy

The aim of this study was to evaluate the potential analgesiceffect of epidural methylprednisolone (MP) after posterolateralthoracotomy (PLT). Adult male patients undergoing PLT for lungsurgery were included in a prospective, randomized, double blindstudy. Peroperative analgesia (bupivacaine plus sufentanil)was given by a thoracic epidural catheter associated with generalanaesthesia. After surgery, patients received either MP 1 mgkg^–1 followed by a continuous epidural infusion of MP1.5 mg kg^–1 during 48 h (MP group) or 0.9% saline as abolus injection and continuous epidural infusion (P group).Additional morphine analgesia was administered by i.v. patient-controlledanalgesia. Pain was assessed at rest and with mobilization every4 h after operation during 48 h with a visual analogue scale(VAS). The primary end-point was the total morphine requirementsduring the 48 first postoperative hour. Twenty-four patientswere allocated to MP (n=12) and P (n=12) groups. Characteristicsof the two groups were similar. There were no differences betweengroups for morphine requirements (median and interquartile range)during the 48 h: 59 mg (40–78) in MP group vs 65 mg (59–93)in P group. There were no differences between groups for morphinerequirements every 4 h during the 48 h and VAS for pain at restand evoked pain. No side effects were reported. It was concludedin this small study that these results did not support the useof epidural steroids for postoperative analgesia after PLT. Br J Anaesth 2001; 87: 635–8     

Intrathecal morphine and clonidine for coronary artery bypass grafting

Background. After cardiac surgery adequate postoperative analgesiais necessary. We assessed analgesia using intrathecal morphineand clonidine. Methods. In a double-blind randomized study, 45 patients havingcoronary artery bypass graft surgery were allocated randomlyto receive i.v. patient-controlled analgesia (PCA) morphine(bolus, 1 mg; lock-out interval, 7 min) (control group), eitheralone or combined with intrathecal morphine 4 µg kg^–1or with both intrathecal morphine 4 µg kg^–1and clonidine 1 µg kg^–1. Intrathecal injectionswere performed before the induction of general anaesthesia.Pain was measured after surgery using a visual analogue scale(VAS). We recorded i.v. PCA morphine consumption during the24 h after operation. Results. Morphine dosage [median (25th–75th percentiles)]was less in the first 24 h in the patients who were given intrathecalmorphine + clonidine [7 (0–37) mg] than in other patients[40.5 (15–61.5) mg in the intrathecal morphine group and37 (30.5–51) mg in the i.v. morphine group]. VAS scoreswere lower after intrathecal morphine + clonidine compared withthe control group. Time to extubation was less after intrathecalmorphine + clonidine compared with the i.v. morphine group [225(195–330) vs 330 (300–360) min, P<0.05]. Conclusion. Intrathecal morphine and clonidine provide effectiveanalgesia after coronary artery bypass graft surgery and allowearlier extubation. Br J Anaesth 2003; 90: 300–3     

Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoracotomy

Background. The aim of this prospective, double-blind, randomizedcontrolled trial was to investigate the analgesic and adverseeffects of three commonly used concentrations of thoracic epiduralfentanyl with bupivacaine in patients undergoing thoracotomyfor lung resection. Methods. We studied 99 patients who were randomized to receivefentanyl 2 µg ml^–1 (group 2), fentanyl 5 µgml^–1 (group 5) and fentanyl 10 µg ml^–1 (group10) in bupivacaine 0.1% via a thoracic epidural. Postoperatively,pain on coughing was assessed using a visual analogue scale(VAS) and an observer verbal rating score (OVRS) at 2, 8, 16and 24 h. At the same times, sedation, pruritus and nausea wereassessed. Results. Of 29, 28 and 32 patients who completed the study ingroups 2, 5 and 10 respectively, there was no significant differencein baseline characteristics between the three groups. The numberof patients with episodes of unsatisfactory pain, i.e. VAS scores>30 mm and OVRS >1, at each of the four assessments postoperativelywas significantly (P<0.01) higher in group 2 than in groups5 and 10. In group 10, 16 patients had sedation scores >1compared with 10 each in groups 2 and 5. In addition, 19 patientsin group 10 experienced pruritus compared with 12 each, in groups2 and 5. These differences were not significant. Nausea wasnot significantly different between the three groups. Conclusion. We conclude that thoracic epidural fentanyl 5 µgml^–1 with bupivacaine 0.1% provides the optimum balancebetween pain relief and side effects following thoracotomy. Br J Anaesth 2004: 92: 670–4     

Influence of peroperative opioid on postoperative pain after major abdominal surgery: sufentanil TCI versus remifentanil TCI. A randomized, controlled study

Background. Sufentanil and remifentanil are characterized bytwo different pharmacokinetic profiles. The aim of this studywas to compare the effects of sufentanil and remifentanil administeredusing target-controlled infusion (TCI) on recovery and postoperativeanalgesia after major abdominal surgery. Methods. Thirty adult patients scheduled for open colorectalsurgery were included in a prospective, randomized study. SufentanilTCI (sufentanil group) or remifentanil TCI (remifentanil group)was administered during surgery. In the remifentanil group,30 min before the anticipated end of surgery, morphine 0.15mg kg^–1 was administered i.v. In the sufentanil group,an effect-site concentration of 0.25 ng ml^–1 wastargeted at extubation. In both groups, postoperative pain wascontrolled by titration of i.v. morphine and then patient-controlledanalgesia with morphine. Results. The extubation time was similar in the two groups (mean(SD) 13 (6) and 14 (6) min in the sufentanil and remifentanilgroups respectively). Visual analogue scale scores were significantlygreater during the first 2 h after tracheal extubation in theremifentanil group than in the sufentanil group. The time tofirst analgesic request in the postanaesthesia care unit wassignificantly longer in the sufentanil group than in the remifentanilgroup (55 (64) (range 2–240) vs 11 (7) (1–29) min;P<0.001). The cumulative morphine dose for titration wassignificantly greater in the remifentanil group (P<0.01).The cumulative morphine dose used during titration and patient-controlledanalgesia was significantly greater in the remifentanil group4, 12 and 24 h after extubation (P<0.05). Conclusion. TCI sufentanil (0.25 ng ml^–1 effect-siteconcentration at extubation) is more effective than the intraoperativecombination of remifentanil TCI infusion with morphine bolus(0.15 mg kg^–1) for postoperative pain relief aftermajor abdominal surgery and does not compromise extubation andrecovery. Br J Anaesth 2003; 91: 842–9     

No clinical evidence of acute opioid tolerance after remifentanil-based anaesthesia

We have prospectively assessed whether remifentanil-based anaesthesiais associated with clinically relevant acute opioid tolerance,expressed as greater postoperative pain scores or morphine consumption.Sixty patients undergoing elective gynaecological, non-laparoscopic,surgery were randomly assigned to receive remifentanil (groupR, n=30) or sevoflurane (group S, n=30) based anaesthesia. Postoperativeanalgesia was provided with morphine through a patient-controlledinfusion device. Mean (SD) remifentanil infusion rate in groupR was 0.23 (0.10) µg kg^–1 min^–1 and mean inspiredfraction of sevoflurane in group S was 1.75 (0.70)%. Mean (SD)cumulative morphine consumption during the first 24 postoperativehours was similar between groups: 28.0 (14.2) mg (group R) vs28.6 (12.4) mg (group S). Pain scores, were also similar betweengroups during this period. These data do not support the developmentof acute opioid tolerance after remifentanil-based anaesthesiain this type of surgery. Br J Anaesth 2001; 87: 866–9     

Rectal acetaminophen does not reduce morphine consumption after major surgery in young infants

BACKGROUND: The safety and value of acetaminophen (paracetamol) in additionto continuous morphine infusion has never been studied in newbornsand young infants. We investigated the addition of acetaminophento evaluate whether it decreased morphine consumption in thisage group after major thoracic (non-cardiac) or abdominal surgery. METHODS: A randomized controlled trial was performed in 71 patients giveneither acetaminophen 90–100 mg kg^–1 day^–1orplacebo rectally, in addition to a morphine loading dose of100 µg kg^–1 and 5–10 µg kg^–1h^–1 continuous infusion. Analgesic efficacy was assessedusing Visual Analogue Scale (VAS) and COMFORT scores. Extramorphine was administered if VAS was 4. RESULTS: We analysed data of 54 patients, of whom 29 received acetaminophenand 25 received placebo. Median (25–75th percentile) agewas 0 (0–2) months. Additional morphine bolus requirementsand increases in continuous morphine infusion were similar inboth groups (P = 0.366 and P = 0.06, respectively). There wasno significant difference in total morphine consumption, respectively,7.91 (6.59–14.02) and 7.19 (5.45–12.06) µg kg^–1 h^–1for the acetaminophen and placebo group (P = 0.60). COMFORT[median (25–75th percentile) acetaminophen 10 (9–12)and placebo 11 (9–13)] and VAS [median (25–75thpercentile) acetaminophen 0.0 (0.0–0.2) and placebo 0.0(0.0–0.3)] scores did not differ between acetaminophenand placebo group (P = 0.06 and P = 0.73, respectively). CONCLUSIONS: Acetaminophen, as an adjuvant to continuous morphine infusion,does not have an additional analgesic effect and should notbe considered as standard of care in young infants, 0–2months of age, after major thoracic (non-cardiac) or abdominalsurgery.     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

Emetic effects of morphine and piritramide

Background. Successful management of postoperative pain requiresthat adequate analgesia is achieved without excessive adverseeffects. Opioid-induced nausea and vomiting is known to impairpatients’ satisfaction, but there are no studies providingsufficient power to test the hypothesis that the incidence ofopioid-induced nausea and vomiting differs between µ-opioidreceptor agonists. Thus, we tested the hypothesis that the incidenceof vomiting and nausea differs between morphine and piritramide. Methods. In a prospective, randomized, double-blind fashion,we administered either morphine (n=250) or piritramide (n=250)by patient-controlled analgesia (PCA) for postoperative painrelief. We used a bolus dose of 1.5 mg with a lockout time of10 min. Incidence and intensity (numerical rating scale) ofpostoperative nausea, vomiting, pain, patient satisfaction (score0–10), side-effects (score 0–3) and drug consumptionwere measured. Results. Mean drug consumption did not differ between the piritramideand morphine groups (30.8 (SD 22.4) mg day^–1 vs 28.4 (21.8)mg day^–1) during the first postoperative day and therewere no significant differences in the overall incidence ofnausea (30% vs 27%) and vomiting (19% vs 15%). Intensity ofnausea correlated inversely (P=0.01) with morphine consumptionbut not with piritramide consumption. Pain scores both at rest(2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9(2.3)) were slightly but significantly less with morphine. Conclusions. Opioid-induced emesis was observed in about one-thirdof the patients using morphine and piritramide for PCA and theincidence of vomiting was one-half of that. Potential differencesin the incidence of vomiting during PCA therapy between theseµ-opioid receptor agonists can be excluded. Br J Anaesth 2003; 91: 218–23     

Effect of continuous low-dose intravenous diltiazem on epidural fentanyl analgesia after lower abdominal surgery

Background. The postoperative opioid-sparing effects of systemicL-type calcium channel blockers are controversial. We investigatedwhether the postoperative analgesic effect of epidural fentanylwas enhanced by i.v. infusion of diltiazem at a rate that wouldminimize any cardiovascular depressant effect. Methods. After elective lower abdominal gynaecological surgery,30 patients were randomized to receive continuous i.v. diltiazem1 µg kg^–1 min^–1 (diltiazem group)or the same volume of saline (control group) for 24 h. Cumulativepostoperative epidural fentanyl consumption, visual analoguescale (VAS) scores and verbal rating scores (VRS) at rest andduring mobilization, sedation scores, incidence of side-effectsand overall patient satisfaction were assessed. Results. There was no significant difference in cumulative epiduralfentanyl consumption between the groups at any period. Althoughthere were no statistically significant differences in VAS scores,VRS, sedation scores, incidence of side-effects and overallpatient satisfaction, there was a trend to an increased incidenceof nausea in the diltiazem group. Conclusions. Continuous i.v. infusion of diltiazem did not reduceepidural fentanyl consumption when administered at dosages havingminimal haemodynamic depressant effects. Br J Anaesth 2003; 90: 507–9     

Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia

Background. This multicentre, double-blind, placebo-controlledstudy compared the opioid-sparing effectiveness and clinicalsafety of parecoxib sodium over 48 h, in 195 postoperativepatients after routine total knee replacement surgery. Methods. Elective total primary knee arthroplasty was performedunder spinal anaesthesia, with a single dose of spinal bupivacaine10–20 mg, and intraoperative sedation with midazolam0.5–1.0 mg i.v., or propofol <6 mg kg^–1h^–1. Patients were randomized to receive either parecoxibsodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium40 mg bd i.v. (n=67), or placebo (n=63) at the completionof surgery, and after 12, 24, and 36 h. Morphine (1–2 mg)was taken by patient-controlled analgesia or by bolus dosesafter 30 min. Results. Patients receiving parecoxib sodium 20 mg bd and40 mg bd consumed 15.6% and 27.8% less morphine at 24 hthan patients taking placebo (both P<0.05). Both doses ofparecoxib sodium administered with morphine provided significantlygreater pain relief than morphine alone from 6 h (P<0.05).A global evaluation of study medication demonstrated a greaterlevel of satisfaction among patients taking parecoxib sodiumthan those taking placebo. Parecoxib sodium administered incombination with morphine was well tolerated. However, a reductionin opioid-type side-effects was not demonstrated in the parecoxibsodium groups. Conclusion. Parecoxib sodium provides opioid-sparing analgesiceffects in postoperative patients. Br J Anaesth 2003; 90: 166–72     

Pre-emptive analgesic efficacy of tramadol compared with morphine after major abdominal surgery

Background. Studies of pre-emptive analgesia in humans haveshown conflicting results. This prospective, randomized, double-blind,controlled study was designed to test the hypothesis that areduction in postoperative morphine consumption can be achievedby tramadol administered after induction of anaesthesia. Methods. Ninety patients were allocated randomly to receivei.v. tramadol (1 mg kg^–1) (Group T), morphine(0.1 mg kg^–1) (Group M) or saline 2 ml(Group S) after induction of anaesthesia. At peritoneal closure,a standardized (0.1 mg kg^–1) morphine loadingdose was given to all patients for postoperative pain management.Patients were allowed to use a patient-controlled analgesia(PCA) device giving bolus doses of morphine 0.025 mg kg^–1.Discomfort, sedation, pain scores, cumulative morphine consumption,and side-effects were recorded at 1, 2, 6, 12 and 24 hafter the start of PCA. Results. There were no significant differences between groupsin mean pain, discomfort, and sedation scores at any study period.Cumulative morphine consumption was significantly lower in GroupM at 12 and 24 h after starting the PCA than in Group S.In Group T, it was lower only after 24 h (28% less in GroupM and 17% less in Group T; P<0.017). There were no significantdifferences in morphine consumption between Groups T and M. Conclusions. Tramadol (1 mg kg^–1), administeredafter induction of anaesthesia, offered equivalent postoperativepain relief, and similar recovery times and postoperative PCAmorphine consumption compared with giving morphine 0.1 mg kg^–1.These results also suggest that presurgical exposure to systemicopioid analgesia may not result in clinically significant benefits Br J Anaesth 2003; 91: 209–13     

Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia

Background. Dextromethorphan is an N-methyl-D-aspartic acidantagonist which can attenuate acute pain with few side-effects.In this prospective, randomized, double-blind study of dextromethorphanand intrathecal morphine, we investigated postoperative pain,pruritus, nausea and vomiting in women undergoing Caesareansection under spinal anaesthesia. Methods. Women were allocated randomly to one of six groups,to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plusoral dextromethorphan 60 mg or placebo. Results. The addition of dextromethorphan did not reduce postoperativepain scores (P=0.83). Compared with women receiving intrathecalmorphine 0.05 mg, women receiving higher doses had a significantlyhigher incidence of nausea and vomiting [odds ratio for intrathecalmorphine 0.1 mg, 4.0 (95% confidence interval 1.2–14.1);for intrathecal morphine 0.2 mg, 7.9 (2.3–27.1)].Compared with women receiving intrathecal morphine 0.05 mg,women receiving higher doses also had a significantly higherincidence of pruritus [odds ratio for intrathecal morphine 0.1 mg,3.2 (95% confidence interval 1.3–8.2); for intrathecalmorphine 0.2 mg, 3.7 (1.4–9.5)]. Women receivingdextromethorphan had a lower incidence of nausea and vomiting[odds ratio 2.6 (1.1–6.3)]. Conclusions. Postoperative pain after Caesarean section underspinal anaesthesia was not reduced by the addition of oral dextromethorphanto a multimodal approach including intrathecal morphine. Br J Anaesth 2003; 90: 653–8     

Analgesic effects of parecoxib following total abdominal hysterectomy

Background. Forty-eight ASA I–II patients undergoing totalabdominal hysterectomy (TAH) were studied in a double blind,randomized placebo controlled trial of parecoxib for postoperativeanalgesia. Methods. All patients were given propofol 2–4 mg kg^–1i.v., a non-depolarizing muscle relaxant, morphine 10 mg i.v.and prochlorperazine 12.5 mg i.m. intraoperatively. Their lungswere ventilated with nitrous oxide and isoflurane 1–1.5%in oxygen. Morphine was self-administered for postoperativeanalgesia via a patient controlled analgesia (PCA) device. Patientswere allocated randomly to receive either parecoxib 40 mg i.v.or normal saline on induction of anaesthesia. Results. Twelve patients did not complete the study. Of theremaining 36 patients, there was no significant difference betweenthe treatment groups in age, weight, ASA status, duration ofsurgery, or intraoperative dose of morphine. However, mean (95%CI) 24 h morphine consumption of 54 (42–65) mg in theparecoxib group was significantly (P=0.04) lower than that of72 (58–86) mg in the placebo group. Pain intensity scoreson sitting up were significantly lower (P=0.02) in the parecoxibgroup compared with placebo. There was no significant differencebetween the treatment groups in pain intensity scores at restand on deep inspiration, or in nausea, total number of vomitingepisodes, median number of rescue antiemetic doses, and sedationscores. Conclusions. Parecoxib 40 mg i.v. may be recommended in patientshaving TAH as it provides morphine-sparing analgesia. Br J Anaesth 2003; 90: 746–9     

Cross-tolerance between spinal neostigmine and morphine in the rat

Background. Direct or indirect acting cholinergic muscarinicagonists such as neostigmine, are potent antinociceptives whenadministered intrathecally (i.t.). This study examines whetherspinal neostigmine tolerance and cross-tolerance to spinal morphineoccurs. Methods. Rats (32/group) were implanted with miniosmotic pumpsdelivering either i.t. saline 1 µl h^–1 (S), morphine10 nmol µl^–1 h^–1 (M), or neostigmine 3 nmolµl^–1 h^–1 (N). Latencies (infrared thermalwithdrawal rear paw) were measured daily for 6 days after whichfour animals from each group were given one i.t. challenge doseof morphine (m) 0.1, 1, 10, or 100 nmol, or neostigmine (n)0.3, 3, 10, or 30 nmol. Results. Neostigmine and morphine-infused animals both developedtolerance to spinal neostigmine, but neostigmine-infused animalsshowed no significant cross-tolerance to spinal morphine; meanED₅₀ nmol (CI 95%) dose–response values were Sn 2.6 (1.9–3.5),Mn 15.6 (9.9–24.6)*, Nn 18.7 (11.7–29.8)*, Sm 0.7(0.4–1.1), Nm 1.2 (0.8–2.0), Mm 152 (50–461)*(*significance vs saline infused control group). Conclusion. Thus, unidirectional cross-tolerance from morphineto neostigmine was evident. Previous studies suggest morphinehas a cholinergic mechanism of action partially accounting forits antinociceptive effect, which may explain this observedunidirectional cross-tolerance. Br J Anaesth 2003; 91: 427–9     

Efficacy of prophylactic ketamine in preventing postoperative shivering

Background. Treatment with ketamine and pethidine is effectivein postoperative shivering. The aim of this study was to comparethe efficacy of low-dose prophylactic ketamine with that ofpethidine or placebo in preventing postoperative shivering. Methods. A prospective randomized double-blind study involved90 ASA I and II patients undergoing general anaesthesia. Patientswere randomly allocated to receive normal saline (Group S, n=30),pethidine 20 mg (Group P, n=30) or ketamine 0.5 mg kg^–1(Group K, n=30) intravenously 20 min before completion of surgery.The anaesthesia was induced with propofol 2 mg kg^–1, fentanyl1 µg kg^–1 and vecuronium 0.1 mg kg^–1. It wasmaintained with sevoflurane 2–4% and nitrous oxide 60%in oxygen. Tympanic temperature was measured immediately afterinduction of anaesthesia, 30 min after induction and beforeadministration of the study drug. An investigator, blinded tothe treatment group, graded postoperative shivering using afour-point scale and postoperative pain using a visual analoguescale (VAS) ranging between 0 and 10. Results. The three groups did not differ significantly regardingpatient characteristics. The number of patients shivering onarrival in the recovery room, and at 10 and 20 min after operationwere significantly less in Groups P and K than in Group S. Thetime to first analgesic requirement in Group S was shorter thanin either Group K or Group P (P<0.005). There was no differencebetween the three groups regarding VAS pain scores. Conclusion. Prophylactic low-dose ketamine was found to be effectivein preventing postoperative shivering.     

Continuous spinal microcatheter (28 gauge) technique for arterial bypass surgery of the lower extremities and comparison of ropivacaine with or without morphine for postoperative analgesia

Background. The aim of this study was to evaluate a microcathetertechnique for continuous spinal anaesthesia (CSA) and continuousspinal postoperative analgesia (CSPA) in vascular surgery. Methods. A total of 47 patients (range 51–95 yr, ASA II–IV)undergoing peripheral bypass surgery of the lower extremitiesreceived a spinal microcatheter (28 gauge) at L3–L4 orL2–L3. For CSA, ropivacaine 7.5 mg ml^–1 was givenin small increments. Central venous pressure was maintained3 mm Hg. Of 47 patients, 44 received CSPA, either using ropivacainealone 2 mg h^–1 (group R, n=22) or ropivacaine 1 mg h^–1with morphine 8 µg h^–1 (group RM, n=22) for 24 hafter surgery (randomized, double-blinded). Results. Intraoperative haemodynamic control was good; duringthe initial 60 min only four patients received phenylephrinei.v. for hypotension. Up to 30% of the patients felt mild painat incision but surgery [mean duration 173 min (range 66–327)]was successfully completed under CSA in 45 patients. In fourinstances of acute revision surgery, a new block was administeredutilizing the spinal catheter in place. Postoperative pain reliefwas comparably adequate in both groups with no difference inrescue pain medication. Four patients (three in R, one in RM)had weak motor blockade in the first postoperative morning. Conclusions. The described CSA technique offered good haemodynamiccontrol, ease of maintaining spinal anaesthesia, and ease ofproviding a new spinal block for revision. The combination oflow-dose ropivacaine and morphine for CSPA did not offer anybenefit compared with the higher ropivacaine dose alone. Presented in part at the 28th Congress of the Scandinavian Societyof Anaesthesiology and Intensive Care Medicine, Reykjavik, Iceland,June 29–July 3, 2005     

Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty

Background. Peripheral neural blockade appears to provide effectiveanalgesia with potentially less morbidity than central neuraxialtechniques. We compared the relative benefits of combined femoral(3-in-1) and sciatic nerve block with epidural blockade forpostoperative knee arthroplasty analgesia. Methods. Sixty patients, ASA I–III, undergoing unilateralknee replacement were prospectively randomized to receive eithera lumbar epidural infusion or combined single-shot femoral (3-in-1)and sciatic blocks (combined blocks). All patients receivedstandard general anaesthesia. Visual analogue pain scores andrescue opioid requirements were recorded at four time pointspostoperatively. Patient satisfaction, morbidity, block insertiontime, perioperative blood loss and rehabilitation indices werealso assessed. Results. In both groups, pain on movement was well controlledat discharge from recovery and 6 h postoperatively but increasedat 24 and 48 h. Median (95% CI) analogue scale scores were 0(0–0), 15 (0–30), 55 (38–75) and 54 (30–67)mm for epidural block and 0.5 (0–22), 21.5 (10–28),40 (20–50) and 34.5 (21–55) mm for combined block.VAS pain scores with the combined blocks were significantlylower at 24 h (P=0.004). Total morphine usage was low in bothgroups: median epidural group 17 mg (8–32) versus combinedblocks 13 mg (7.8–27.5). Patient satisfaction was highin both groups with median (95% CI) scores of 100 (85–100),83 (70–100) and 82 (57–90) mm for epidural and 90(73–100), 100 (77–100) and 97 (80–100) mmfor combined blocks (not significant). Perioperative blood lossand rehabilitation indices were also similar. Conclusions. Combined femoral (3-in-1) and sciatic blocks offera practical alternative to epidural analgesia for unilateralknee replacements.      

Adjunctive analgesia with intravenous propacetamol does not reduce morphine-related adverse effects

Background. Propacetamol is widely used in the management ofpostoperative pain. It decreases morphine requirements but itseffect on the incidence of morphine-related adverse effectsremains unknown. Methods. Patients (550) were randomly assigned to receive propacetamolor a placebo over the first 24 h after operation in a blindedstudy. Intravenous morphine titration was performed, after whichmorphine was administered s.c. every 4 h according to theirpain score. Pain was assessed using a visual analogue scale(VAS). The primary end-point was the incidence of morphine-relatedadverse effects. The main secondary end-points were morphinerequirements and VAS score. Results. After morphine titration, the VAS score and the numberof patients with pain relief did not differ between groups.Morphine requirements were decreased in the propacetamol group(21 vs 14.5 mg, P<0.001) but the incidence of morphine-relatedadverse effects did not differ between groups (42 vs 46%, notsignificant). In patients with moderate pain (n=395), morphinerequirements decreased by 37% (P<0.001) and the percentageof patients requiring no morphine was greater (21 vs 8%, P=0.002)in the propacetamol group. In patients with severe pain (n=155),morphine requirements decreased by 18% (P=0.04) in the propacetamolgroup and the number of patients who did not require morphine(3 vs 8%) did not differ significantly. Conclusions. Although propacetamol induced a small morphine-sparingeffect, it did not change the incidence of morphine-relatedadverse effects in the postoperative period. Moreover, no benefitcould be demonstrated in patients with severe postoperativepain. Br J Anaesth 2003; 90: 314–19     

Intrathecal morphine overdose during combined spinal-epidural block for Caesarean delivery

We describe a 25 mg intrathecal morphine overdose duringa combined spinal–epidural block for a Caesarean delivery.Naloxone infusion (5.24 mg over 24 h) was startedprior to the patient becoming symptomatic and almost immediatelyafter the overdose. Invasive therapeutics such as mechanicalventilation were avoided. Br J Anaesth 2002; 89: 925–7