Cervical epidural analgesia via a thoracic approach using nerve stimulation guidance in an adult patient undergoing elbow surgery

OBJECTIVE: This case report describes the placement of a cervical epidural catheter via the thoracic approach, using nerve stimulation, in a patient undergoing elbow surgery. CASE REPORT: An epidural catheter was easily advanced to the C5 dermatome level from the T4-5 interspace, using nerve stimulation guidance. Successful perioperative analgesia was accomplished using an infusion of ropivacaine 0.2% with 0.05 mg/mL morphine at 4 mL/h. CONCLUSIONS: This case report suggests that electrical stimulation may allow one to accurately position epidural catheters in the central neuraxial space to provide reliable, effective analgesia of the upper extremity. This approach might be an alternative way to deliver cervical epidural analgesia for patients undergoing upper extremity surgery.     

Thoracic epidural analgesia via the caudal approach using nerve stimulation in an infant with CATCH22

PURPOSE: To illustrate insertion of an epidural catheter via caudal route in a small infant under electrical stimulation guidance. CLINICAL FEATURES: A six month old boy, weighting 4.25 kg, with a diagnosis of CATCH22 (Cardiac abnormality/abnormal faces, T cell deficit due to thymic hypoplasia, cleft palate, hypocalcemia due to hypoparathyroidism resulting from 22q11 deletion) was scheduled for fundoplication and gastrostomy tube (G-tube) insertion. A combined light general anesthesia and continuous epidural anesthesia technique was selected. Following induction of general anesthesia and tracheal intubation with 1.5 mg midazolam, 10 microg fentanyl and 10 mg succinylcholine, a 16G intravenous catheter was inserted into the caudal space. A 19G epidural catheter (Arrow Flextip Plus) epidural catheter was then inserted up cranially. A low electrical current (1-10mA) was then applied through the catheter. The level of motor movement was advanced from the lower limb muscles to the upper abdominal muscles as the catheter was threaded cranially. After 19 cm of epidural catheter had been inserted, intercostal muscle movement (T9-10 level) was observed at 4.2mA. The tip of the catheter was later confirmed to be at the T9-10 interspace by radiographical imaging. The patient awakened without distress and the trachea was extubated the same evening. The infant was discharged to the ward next morning with good pain relief from a continuous epidural infusion of bupivacane 0.1% with 1 microg x ml(-1) at 1.6 ml(-1). CONCLUSION: Epidural stimulation may help placement of the epidural catheter at the appropriate dermatome for effective anesthesia and analgesia.     

Ropivacaine 0.1% with fentanyl 2 microg mL(-1) by epidural infusion for labour analgesia

BACKGROUND AND OBJECTIVE: To evaluate the efficacy of 0.1% ropivacaine with fentanyl 2 microg mL(-1) via epidural for analgesia in labour. METHODS: In a randomized study, 80 nulliparous parturients in labour had epidural analgesia initiated with 0.2% ropivacaine and fentanyl and were then randomized to receive either 0.1% ropivacaine with fentanyl 2 microg mL(-1) at 10mL h(-1) (Group R1, n = 38) or 0.2% ropivacaine with fentanyl 2 microg mL(-1) at 8 ml h(-1) (Group R2, n = 39) as epidural infusions. Supplementary analgesia was provided on request with ropivacaine 0.2% 5 mL as an epidural bolus. RESULTS: There were no significant differences between the visual analogue pain scores either with respect to motor block or sensory block. The amount of local anaesthetic used was lower in the 0.1% ropivacaine group than in the 0.2% ropivacaine group (P = 0.001). Side-effects, patient satisfaction, labour outcome and neonatal outcomes were similar in both groups. CONCLUSIONS: An epidural infusion of 0.1% ropivacaine with fentanyl 2 microg mL(-1) at 10 mL h(-1) provided adequate analgesia in the first stage of labour. The level of analgesia was similar to that obtained using 0.2% ropivacaine with fentanyl 2 microg mL(-1) and with no differences with regard to motor or sensory block.     

Patient supplemented epidural analgesia after major abdominal surgery with bupivacaine/fentanyl or ropivacaine/fentanyl

PURPOSE: To compare analgesic efficacy and occurrence of motor block and other side effects during patient supplemented epidural analgesia (PSEA) with either ropivacaine/fentanyl or bupivacaine/fentanyl mixtures. METHODS: In a prospective, randomized, double-blind study, 32 ASAI-III patients undergoing major abdominal surgery received an epidural catheter at the T8- T10, followed by integrated general epidural anesthesia. Postoperative epidural analgesia was provided using a patient controlled pump with either ropivacaine 0.2%/2 microg x ml(-1) fentanyl (group Ropivacaine, n = 16) or bupivacaine 0.125%/2 microg x ml(-1) fentanyl (group Bupivacaine, n = 16) [background infusion 4-6 ml x hr(-1), 1.5 ml Incremental Doses and 20 min lock out]. Verbal pain rating score, number of incremental doses, consumption of epidural analgesic solution and rescue analgesics, sedation (four-point scale), and pulse oximetry were recorded by a blind observer for 48 hr after surgery. RESULTS: No differences in pain relief, motor block, degree of sedation, pulse oximetry and other side effects were observed between the two groups. The number of incremental doses and the volume of analgesic solution infused epidurally were higher in patients receiving the bupivacaine/fentanyl mixture (10 [0-52] I.D. and 236 [204-340] ml) than in patients receiving the ropivacaine/fentanyl solution (5 [0-50] I.D. and 208 [148-260] ml) (P = 0.03 and P = 0.05, respectively). CONCLUSION: Using a ropivacaine 0.2%/2 microg x ml(-1) fentanyl mixture for patient supplemented epidural analgesia after major abdominal surgery provided similar successful pain relief as bupivacaine 0.125%/2 microg x ml(-1) fentanyl, but patients receiving bupivacaine/fentanyl requested more supplemental.     

布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛安全性探讨

目的探讨布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛的效果、并发症及安全陛。方法1600例行连续术后硬膜外镇痛的患者,按所用镇痛药物配伍不同分为：0．1％布比卡因＋5μg／ml芬太尼组（B组,n=920）和0．2％罗哌卡因＋2μg／ml芬太尼组（R组,n=680）。对两组镇痛效果（视觉模拟评分及患者对镇痛效果的满意度）、并发症和处理措施进行总结分析。结果视觉模拟评分两组无差异（P〉0．05）。患者对镇痛的满意度R组明显高于B组（P〉0．05）。并发症的发生率B组高于R组（P〉0．05）。两组内年龄≥60岁的患者低血压的发生率高于年龄〈60岁者（P〈0．05）;女性患者恶心呕吐的发生率高于男性（P〈0．05）;腰段硬膜外镇痛患者下肢乏力或麻木的发生率明显高于胸段硬膜外镇痛患者（P〈0．05）。结论布比卡因、罗哌卡因与芬太尼不同配伍均可安全有效地用于连续术后硬膜外镇痛,罗哌卡因组并发症较少,并发症的发生与镇痛药物、年龄、性别及硬膜外置管部位有关。     

Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES: This prospective randomized controlled trial investigated the clinical efficacy of stimulating catheters for continuous femoral nerve block in patients who underwent anterior cruciate ligament reconstruction. METHODS: Seventy patients were randomized to either a stimulating catheter (SC, n = 35) or a nonstimulating catheter (NSC, n = 35) for femoral nerve block using 25 mL ropivacaine 7.5 mg/mL and clonidine 50 microg injected through the catheter. A single-injection sciatic block was also given to ensure surgical anesthesia. The time to loss of sensation to cold and pinprick of the femoral nerve was registered as the onset time. Data were registered intra- and postoperatively regarding pain scores, adverse effects, and need for supplemental anesthesia and analgesia other than a continuous postoperative infusion of ropivacaine 2 mg/mL through the continuous femoral nerve catheter set at 7 mL/h. RESULTS: Onset time was faster in the SC group (SC: 6.4 +/- 2.5, NSC: 8.3 +/- 2.9 min, P = .006). Visual analog scale pain scores were similar in both groups. The number of patient-controlled regional analgesia boluses (SC: 14.6 +/- 12.6, NSC: 23.2 +/- 13.6 mg ropivacaine 2 mg/mL, P = .008) as well as intravenous rescue ketorolac (SC: 34.3 +/- 35.7, NSC: 54 +/- 39.7 mg, P = .033) administered were higher in the NSC group. CONCLUSION: Although the use of a stimulating catheter was associated with faster onset time for the femoral nerve block and lower additional analgesics postoperatively, the clinical superiority (analgesia; lateral femoral cutaneous, and obturator nerve block) of stimulating catheters was not evident in this clinical setting.     

Ropivacaine 1 mg x ml(-1) does not decrease the need for epidural fentanyl after hip replacement surgery

BACKGROUND: Ropivacaine is a new long-acting local anesthetic. Laboratory trials have demonstrated a synergistic analgesic effect between intrathecal opioids and local anesthetics. We tested the hypothesis that addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl (10 microg x ml(-1)) postoperatively decreases the need for fentanyl, improves the quality of analgesia and decreases the side-effects of fentanyl. METHODS: Forty patients were enrolled in this double-blind, randomized study to receive either fentanyl 10 microg x ml(-1) (group F) alone or fentanyl combined with ropivacaine 1 mg x ml(-1) (group R) for 20 h as an epidural infusion at TH12-L1 or L1-L2 for analgesia after hip replacement surgery. The patients were free to use a patient-controlled epidural analgesia device, which was programmed to infuse 3 ml of the study medication hourly and to allow a 3-ml bolus when needed (maximal hourly dose of fentanyl was 150 microg). The consumption of medication, visual pain scores at rest and on movement, hemodynamic and respiratory parameters, motor and sensory block, nausea, pruritus and sedation were recorded. RESULTS: There were no significant differences between the groups in the total mean fentanyl consumption (1.10+/-0.18 mg in group F, 1.08+/-0.31 mg in group R, 95% CI: -0.14 to 0.19, P = 0.774). The pain scores were similar at rest (median scores < or = 1) and on movement (median scores < or = 3). The adverse effects were similar and of a minor nature, consisting mostly of pruritus and nausea. CONCLUSION: Addition of ropivacaine 1 mg x ml(-1) to epidural fentanyl 10 microg x ml(-1) did not significantly decrease the requirement for fentanyl administered for pain relief after hip replacement surgery.     

Comparison of three solutions of ropivacaine/fentanyl for postoperative patient-controlled epidural analgesia

BACKGROUND: Ropivacaine, 0.2%, is a new local anesthetic approved for epidural analgesia. The addition of 4 microg/ml fentanyl improves analgesia from epidural ropivacaine. Use of a lower concentration of ropivacaine-fentanyl may further improve analgesia or decrease side effects. METHODS: Thirty patients undergoing lower abdominal surgery were randomized in a double-blinded manner to receive one of three solutions: 0.2% ropivacaine-4 microg fentanyl 0.1% ropivacaine-2 microg fentanyl, or 0.05% ropivacaine-1 microg fentanyl for patient-controlled epidural analgesia after standardized combined epidural and general anesthesia. Patient-controlled epidural analgesia settings and adjustments for the three solutions were standardized to deliver equivalent drug doses. Pain scores (rest, cough, and ambulation), side effects (nausea, pruritus, sedation, motor block, hypotension, and orthostasis), and patient-controlled epidural analgesia consumption were measured for 48 h. RESULTS: All three solutions produced equivalent analgesia. Motor block was significantly more common (30 vs. 0%) and more intense with the 0.2% ropivacaine-4 microg fentanyl solution. Other side effects were equivalent between solutions and mild in severity. A significantly smaller volume of 0.2% ropivacaine-4 microg fentanyl solution was used, whereas the 0.1% ropivacaine-2 microg fentanyl group used a significantly greater amount of ropivacaine and fentanyl. CONCLUSIONS: Lesser concentrations of ropivacaine and fentanyl provide comparable analgesia with less motor block despite the use of similar amounts of ropivacaine and fentanyl. This finding suggests that concentration of local anesthetic solution at low doses is a primary determinant of motor block with patient-controlled epidural analgesia after lower abdominal surgery.     

Cervical epidural analgesia via a thoracic approach using nerve-stimulation guidance in adult patients undergoing total shoulder replacement surgery

BACKGROUND: Continuous cervical epidural anesthesia can provide excellent peri- and post-operative analgesia, although several factors prevent its widespread use. Advancing catheters from thoracic levels to the cervical region may circumvent these barriers, provided they are accurately positioned. We hypothesize that guiding catheters from thoracic to cervical regions using low-current epidural stimulation will have a high success rate and enable excellent analgesia in adults undergoing total shoulder arthroplasty. METHODS: After Institutional Review Board approval, adult patients were studied consecutively. A 17-G Tuohy needle was inserted into the thoracic epidural space using a right paramedian approach with loss of resistance. A 20-G styletted epidural catheter, with an attached nerve stimulator, was primed with saline and a 1-10 mA current was applied as it advanced in a cephalad direction towards the cervical spine. Muscle twitch responses were observed and post-operative X-ray confirmed final placement. After a test dose, an infusion (2-8 ml/h) of ropivacaine 2 mg/ml and morphine 0.05 mg/ml (or equivalent) was initiated. Verbal analog pain scale scores were collected over 72 h. RESULTS: Cervical epidural anesthesia was performed on 10 patients. Average current required to elicit a motor response was 4.8 +/- 2.0mA. Post-operative X-ray of catheter positions confirmed all catheter tips reached the desired region (C4-7). The technical success rate for catheter placement was 100% and excellent pain control was achieved. Catheters were positioned two to the left, four to the right and four to the midline. CONCLUSION: This epidural technique provided highly effective post-operative analgesia in a patient group that traditionally experiences severe post-operative pain and can benefit from early mobilization.     

Patient-controlled epidural analgesia combined with patient-controlled intravenous analgesia for postoperative analgesia after Miles' operation for rectal cancer

A 69-year-old woman (156 cm, 53 kg) underwent a Miles' operation, total hysterectomy, resection of vagina, and thigh flap to vulva for rectal cancer. Before general anesthesia, an epidural catheter was inserted at T11-12 interspace, and 1.5% mepivacaine 7ml was administered. Sensory block level spread from T4 to L1. Anesthesia was induced with propofol and maintained with sevoflurane in air oxygen mixture. Operation was performed uneventfully. After the operation, postoperative analgesia was achieved with patient-controlled epidural analgesia (PCEA). The epidural solution of 0.06% ropivacaine with 4 microg x ml(-1) fentanyl and 20 microg x ml(-1) was connected to a PCA pump (i-Fuser, JMS, Japan) that was programmed as an 8 ml initial bolus, 4 ml x hr(-1) basal infusion, 2 ml bolus dose, and 10-min lockout interval. Although abdominal pain was well controlled by PCEA, intractable pain in the pelvic nerve region existed. Patient-controlled intravenous analgesia (IV-PCA) with fentanyl, ketamine, and lidocaine was added to PCEA. Then excellent pain relief was obtained without any side effects such as nausea, vomiting, drowsiness, and respiratory depression. It could be useful to use IV-PCA together with PCEA when wide spread postoperative analgesia is necessary.     

Fentanyl added to bupivacaine 0.05% or ropivacaine 0.05% in patient-controlled epidural analgesia in labour

BACKGROUND AND OBJECTIVE: Epidural analgesia is the most effective method for pain relief during labour. The aim was to elucidate the efficacy of ropivacaine 0.05% and bupivacaine 0.05%, which were both combined with fentanyl 0.00015% to provide analgesia in labour. METHODS: Forty nulliparous females were enrolled into the study. After insertion of an epidural catheter, patients were randomly assigned into two groups. Once the os uteri had dilated to 4-5 cm, a bolus of bupivacaine 0.125% 10mL + fentanyl 50 microg (1 mL) in Group 1 patients, and ropivacaine 0.125% 10mL + fentanyl 50 microg (1 mL) in Group 2 patients was administered via the epidural catheter. Then, patient-controlled epidural analgesia was started with a basal infusion of bupivacaine 0.05% 10 mLh(-1) + fentanyl 0.00015% 1.5 pgmL(-1) in Group 1, and ropivacaine 0.05% + fentanyl 1.5 microgmL(-1) in Group 2. When needed, a 10 mL bolus infusion could be given and the lockout time was 20 min. Maternal and fetal haemodynamic variables were monitored before induction and subsequently at 5 min intervals. Using a visual analogue scale assessed the degree of pain. RESULTS: Maternal haemodynamic variables and Apgar scores were not different between the two groups. The second stage of the labour was shorter in Group 2 (P < 0.01). There were no significant differences in patients' assessment of motor block or mode of delivery between groups. CONCLUSIONS: An epidural infusion (10 mLh(-1)) of bupivacaine 0.05% or ropivacaine 0.05% together with fentanyl 1.5 microg mL(-1) provided good and safe analgesia during labour.     

Comparison of ropivacaine 0.1%-fentanyl and bupivacaine 0.125% — fentanyl infusions for epidural labour analgesia

PURPOSE: To compare analgesic efficacies of ropivacaine-fentanyl and bupivacaine-fentanyl infusions for labour epidural analgesia. METHODS: In this double- blind, randomized study 100, term, nulliparous women were enrolled. Lumbar epidural analgesia (LEA) was started at cervical dilatation < 5 cm using either bupivacaine 0.25% followed by bupivacaine 0.125% + 2 microg x ml(-1) fentanyl infusion (n=50) or ropivacaine 0.2% followed by ropivacaine 0.1% + 2 microg x ml(-1) fentanyl infusion (n=50). Every hour maternal vital signs, visual analog scale (VAS) pain score, sensory levels, and motor block (Bromage score) were assessed. Data were expressed as mean +/-1 SD and analyzed using Chi -Squared and Mann-Whitney U tests at <0.05. RESULTS: The onset times were 10.62+/-4.9 and 11.3+/-4.7 min for the bupivacaine and ropivacaine groups respectively (P = NS). The median VAS scores were not different between the groups at any of the evaluation periods. However, at least 80% of patients in the ropivacaine group had no demonstrable motor block after the first hour compared with only 55% of patients given bupivacaine (P =0.01). CONCLUSIONS: Both bupivacaine and ropivacaine produce satisfactory labour analgesia. However, ropivacaine infusion is associated with less motor block throughout the first stage of labour and at 10 cm dilatation.     

Combined sciatic-femoral nerve block with 0.75% ropivacaine: effects of adding a systemically inactive dose of fentanyl

To evaluate the effects of adding low-dose fentanyl to 0.75% ropivacaine during peripheral nerve blocks, 30 ASA physical status I-II patients undergoing hallux valgus repair under combined sciatic-femoral nerve block were randomly allocated in a double-blind fashion to receive nerve block placement with 30 mL of either 0.75% ropivacaine alone (group: ropivacaine, n = 15) or 0.75% ropivacaine plus fentanyl 1 microg kg(-1) (group: ropivacaine-fentanyl, n = 15). A blinded observer recorded haemodynamic variables and sedation, as well as the time required to achieve surgical block and the first request for analgesia. Readiness to surgery required 10 min (5-20 min) with 0.75% ropivacaine and 10 min (3-20 min) with the ropivacaine-fentanyl mixture. No differences in the degree of sedation, peripheral oxygen saturation, and haemodynamic variables were observed between the two groups. The degree of pain measured at first analgesic request, and the consumption of postoperative analgesics, was similar in the two groups, while the mean time from block placement to the first request for pain medication was 13.7 h (25-75th percentiles: 11.8-14.5 h) in the ropivacaine group and 13.9 h (25-75th percentiles: 10.5-14.5 h) in the ropivacaine-fentanyl group (P = not significant). We conclude that adding fentanyl 1 microg kg(-1) to 0.75% ropivacaine did not provide clinically relevant advantages in terms of onset time, quality and duration of combined sciatic-femoral nerve block in patients undergoing elective hallux valgus repair.     

Advantage of ropivacaine for postoperative epidural analgesia following leg orthopedic surgery

BACKGROUND: Epidural administration of local anesthetics may lead to effective pain relief. However, tachyphylaxis or other problems following prolonged epidural anesthesia may develop and in many cases difficulties exist in the maintenance of the similar degree of sensory blockade. The present study was therefore performed to investigate the analgesic effect of continuous postoperative epidural infusion of ropivacaine with fentanyl in comparison with that of bupivacaine or ropivacaine alone. METHODS: After leg orthopedic surgery with lumbar combined spinal-epidural anesthesia, thirty-six patients were randomized to one of the three postoperative epidural infusion groups: bupivacaine 0.125%, ropivacaine 0.2%, or ropivacaine 0.2% with 2.2 microg x ml(-1) (400 microg x 180 ml(-1)) of fentanyl. Continuous epidural infusion was started at a rate of 6 ml x h(-1) with possibility of an additional bolus injection of 3 ml at least every 60 min. Pain was assessed using a 10-cm visual analog scale (VAS) just before and 15 min after epidural bolus injections, and 15-20 h after the start of continuous epidural infusion as the severe at pain through the observation. The spread of analgesia (loss of sharpness in pinprick perception) and motor block (Bromage scale) were evaluated bilaterally. Systolic and diastolic blood pressure and heart rate were also measured. RESULTS: The epidural bolus infusion was associated with a significant decrease of VAS (P < 0.001) and stable blood pressure and heart rate in all groups. The maximal VAS in patients receiving 0.2% ropivacaine+fentanyl was significantly less compared to that in the other two groups. The regression of sensory blockade was significantly prolonged in patients treated with ropivacaine+fentanyl. There was no significant difference in the spread of sensory analgesia between 20 min and 15-20 h after the continuous epidural anesthesia in this group. None of the patients developed adverse effects such as respiratory depression, nausea, and pruritis. CONCLUSIONS: Epidural injection of ropivacaine with fentanyl decreased postoperative pain with stable vital signs in patients undergoing leg orthopedic surgery, as compared to bupivacaine or ropivacaine alone, possibly because of the maintenance of sensory blockade by ropivacaine and enhancement of this sensory blockade by fentanyl.     

The optimal dose of fentanyl added to 0.2% ropivacaine for postoperative epidural analgesia after gynecological surgery

BACKGROUND: Combined administration of local anesthetics and an opioid is frequently used in order to minimize the dose of each drug and to reduce adverse effects. Although fentanyl is commonly administered with local anesthetic, side effects of fentanyl increase in a dose-dependent manner. In this study, we determined the optimal dose of epidural fentanyl after gynecological surgery. METHODS: One hundred and sixteen adult patients scheduled for elective gynecological surgery were divided into 3 groups according to postoperative epidural analgesics; 0.2% ropivacaine (group R), 0.2% ropivacaine with 2 microg x ml(-1) fentanyl (group RF 2), or 0.2% ropivacaine with 5 microg x ml(-1) fentanyl (group RF 5). Each analgesic was infused at 5 ml x hr(-1) for 48 hr. Pain scores , incidence of NSAIDs administration and side effects were recorded for 48 hr after the surgery. RESULTS AND CONCLUSIONS: Ropivacaine alone could not provide sufficient analgesia. Although the addition of 5 microg x ml(-1) fentanyl to 0.2% ropivacaine at a rate of 5 ml x hr(-1) improved postoperative pain, side effects caused by fentanyl increased. Supplementing 2 microg x ml(-1) fentanyl provided sufficient analgesia with the least incidence of side effects.     

A comparison of 0.0625% bupivacaine with fentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia

We compared the analgesic efficacy and the degree of motor block achieved with epidural infusion of 0.0625% bupivacaine (Group B) versus 0.1% ropivacaine (Group R), both with 0.0002% fentanyl (2 microg/mL) in laboring patients. A prospective, double-blinded study was performed in 98 ASA physical status I-II parturients who were divided randomly into two groups to receive either bupivacaine or ropivacaine after catheter location had been tested with an initial bolus of lidocaine and fentanyl. The infusion rate was 15 mL/h in every case. When pain was perceived, 5-mL boluses of the assigned epidural analgesic were administered every 10 min until analgesia was achieved. We recorded pain intensity, level of sensory block, degree of motor block, hemodynamic variables, secondary effects, mode of delivery, neonatal outcome, and patient satisfaction. There were no statistically significant differences in any of the factors analyzed. Highly effective analgesia was achieved in both groups with a small incidence of motor block. These findings suggest that bupivacaine may be more potent than ropivacaine. IMPLICATIONS: We compared different concentrations of epidural bupivacaine and ropivacaine thought to be equipotent. Both solutions were equally efficient in providing highly effective epidural analgesia for labor with minimal motor block. These findings suggest that bupivacaine may be more potent than ropivacaine.     

Experience of ultrasound-guided popliteal sciatic nerve block and femoral nerve perineural catheter placement in a morbidly obese patient undergoing total knee arthroplasty

A 60-year-old morbidly obese woman (150 cm, 112 kg, BMI 49.8) underwent total knee replacement under general anesthesia combined with sciatic nerve block and continuous femoral nerve block. Following induction of general anesthesia and tracheal intubation, the sciatic nerve was blocked using the popliteal approach with the patient in the supine position. Then the femoral nerve block was performed, followed by perineural catheter placement for postoperative continuous local anesthetic infusion. For both procedures, real-time ultrasound imaging was used to facilitate needle placement and confirm the adequate local anesthetic deposition. Twenty-five and 30 ml of 0.375% ropivacaine was injected around the sciatic and femoral nerves, respectively. Postoperatively 0.15% ropivacaine was infused at the rate of 5 ml x hr(-1) for 60 hours through the femoral catheter, which provided satisfactory pain relief in combination with scheduled loxoprofen administration. No block-related complications were noted. Our experience suggests that the ultrasound-guided technique may prove useful to facilitate safe and accurate block when technical difficulties are anticipated with anatomic landmark-based approaches.     

Effectiveness of ropivacaine and fentanyl for postoperative epidural analgesia following thoracic surgery

BACKGROUND: Epidural ropivacaine is now a common drug used for postoperative analgesia. However, little information is available concerning regression of sensory blockade and analgesia following prolonged epidural infusion of ropivacaine. We investigated the efficacy of ropivacaine and fentanyl for postoperative analgesia after thoracic surgery. METHODS: Thirty patients undergoing thoracic surgery were enrolled. After surgery with general and thoracic epidural anesthesia, continuous epidural infusion of 0.2% ropivacaine+fentanyl (1.67 microg x ml(-1)) was started at a rate of 6 ml x h(-1) for patients whose height was more than 155 cm and 4 ml x h(-1) for those below 155 cm with possibility of an additional bolus injection of 3 ml at least every 60 min. RESULTS: An additional epidural injection of 3 ml produced a decrease in VAS without significant changes of vital signs. The greatest VAS was 10+/-25 mm in the incision site and 36+/-38 mm in the ipsilateral shoulder. Sensory blockade was sustained until the morning after the day of surgery. Also blood pressure and heart rate were stable throughout the observation period. There were no adverse effects except for slight nausea in three patients. CONCLUSIONS: A bolus of 3 ml with continuous 4-6 ml x h(-1) epidural injection of ropivacaine plus a small dose of fentanyl would decrease postoperative pain with stable vital signs in patients after thoracic surgery.     

Comparison of continuous epidural infusion of ropivacaine and sufentanil with intravenous patient-controlled analgesia after total hip replacement.

We assessed the efficacy of an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1), comparing it with intravenous patient-controlled analgesia using piritramide in this prospective, randomised, double-blind study of 24 ASA physical status I-III patients undergoing elective total hip replacement. Lumbar epidural block using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. Epidural infusion and patient-controlled analgesia were started after surgery. Twelve patients received an epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) at a rate of 5-9 ml x h(-1) and an intravenous patient-controlled analgesia device loaded with saline. Eleven patients received an epidural infusion of saline at the same rate and intravenous piritramide via the patient-controlled analgesia device. Motor block was negligible in both groups. The epidural ropivacaine group had significantly lower visual analogue pain scores at rest 4 h after surgery (p < 0.01), and on movement 4 h (p < 0.01) and 8 h (p < 0.05) after surgery, than the intravenous piritramide group. The piritramide group experienced significantly more adverse events than the epidural group (p < 0.001), especially hypotension (p < 0.01) and vomiting (p < 0.05). Patients in the epidural ropivacaine group were more satisfied with the pain management (p < 0.05). We conclude that the epidural infusion of ropivacaine 0.1% and sufentanil 1 microg x ml(-1) is superior to intravenous opioid by patient-controlled analgesia in preventing pain after total hip replacement, with fewer adverse effects and greater patient satisfaction.     

Usefulness of epidural nerve stimulation to confirm epidural catheter placement

An epidural catheter must be placed in epidural space correctly to give sufficient epidural anesthesia for patients. Recently, as a technique to confirm the catheter placement, electrical stimulation of epidural nerve using an inserted epidural catheter was introduced. This study was conducted to evaluate the reliability of this simple technique in 13 patients. Immediately after an epidural catheter (19 G Arrow Flextip Plus) was placed, an adapter with electrode (Arrow-Johans ECG Adapter) was attached to its connector and nerve stimulation was performed using a peripheral nerve stimulator (1 Hz, 10 mA). Catheter placement was judged to be correct by both presence of muscle contraction in response to stimulation and occurrence of analgesia after the administration of a local anesthetic. In 5 patients, additional roentgen examinations were performed to identify the positions of catheters. In all patients except one, muscle contraction was observed by stimulation, and analgesia was confirmed in all patients after the injection of an anesthetic. X-ray examinations revealed that the tip of catheter placed at the vertebral level corresponded with the spinal segmental level where muscle movement occurred. Our study demonstrates that nerve stimulation can be a reliable method to confirm epidural catheter placement. Our results also suggest that the position of catheter tip can be estimated easily using this technique.