Superior postoperative analgesic efficacy of a continuous infusion of tramadol and dipyrone (metamizol) versus tramadol alone

In this prospective, randomised and double-blind clinical study the analgesic efficacy of a continuous infusion of tramadol combined with the non-opioid dipyrone (metamizol) was compared with tramadol alone or with placebo during first 24 h postoperatively. Ninety patients were allocated to the three study groups. In group 1, patients received 600 mg tramadol with 2.5 mg droperidol (DHB); in group 2, 600 mg tramadol together with 4.0 g dipyrone and 2.5 mg DHB; and in group 3, only 2.5 mg DHB. Additionally, a patient-controlled analgesia (PCA) device with morphine was provided to each patient as a rescue in the case of insufficient pain relief. Pain at rest and during movement was measured with a visual analogue scale (VAS, 0–10) during the study time. Side effects and vital parameters were also recorded. After the 24 h study period, a significant pain relief was observed in all three groups. The consumption of morphine via PCA, however, was significantly lower in group 2 (tramadol/dipyrone) than in the tramadol or the placebo group, and also the patients in group 1 (tramadol) had received significantly less morphine than those in the placebo group. Our data suggest a significantly superior analgesic efficacy of a continuous infusion of tramadol combined with dipyrone compared to an infusion of tramadol alone or placebo.     

Postoperative patient controlled analgesia using a low-tech PCA system

The aim of this randomised, double-blind study was to determine whether a low-tech patient controlled analgesia (PCA) model with various dose aliquots of piritramid or a combination of tramadol/dipyrone is suitable for use in postoperative pain therapy. By suitable the authors mean (a) whether effective analgesia can be attained; (b) whether patients can understand and appropriately use the PCA pump; and (c) whether good patient acceptance is achieved.The authors studied 82 patients (ASA I–II) aged between 18–70 years. The patients were divided into four subgroups. All patients received a start-up loading dose of the same analgesic which they thereafter received via the PCA pump. The aliquots of drug provided by the PCA pump were always contained in 0.5 ml. This volume, however, contained different amounts of analgesic: piritramid either (1) 1.5 mg (high dose) or (2) 0.75 mg (low dose); (3) tramadol 10 mg with dipyrone 50 mg (high dose mixture); (4) tramadol 5 mg with dipyrone 25 mg (low dose mixture).The results showed that the PCA device is suitable for use in postoperative pain therapy. The rate of side effects was low. In the first 24 hours, the consumption of analgesics was similar in the low dose aliquot and high dose aliquot groups: Group (1) 43.5 mg piritramid; Group (2) 37.2 mg piritramid; Group (3) 267 mg/1335 mg tramadol/dipyrone; Group (4) 256 mg/1275 mg tramadol/dipyrone.Analgesia was effective, as judged by visual analogue scale (VAS) scores of 4 or less. Up to the 12th hour the VAS score was noted to be lower (more effective analgesia) in the tramadol/dipyrone group as compared to the piritramid group.In conclusion, a postoperative PCA regimen using a low-tech PCA device provides effective analgesia with a low rate of side effects and is suitable for use in postoperative patients.     

氯诺昔康用于学龄儿童术后自控镇痛的临床研究

目的评价氯诺昔康用于小儿术后自控镇痛的安全性及有效性。方法60例拟行臀筋膜松解术的患儿,随机均分为L组(氯诺昔康组)和T组(曲马多组)。均采用硬膜外加氯胺酮分离麻醉。术毕,L组静注氯诺昔康0.15mg/kg为负荷量,继用0.3mg/kg氯诺昔康加生理盐水稀释至100ml后置于PCA泵药池内。T组静注曲马多1mg/kg为负荷量,继用10mg/kg曲马多加生理盐水稀释至100ml后置于PCA泵药池内。PCA泵背景剂量为5ml/h,PCA量为2ml/次,锁定时间为15分钟。记录使用PCA后1h,4h,8h,12h,20h患儿的疼痛评分、对疼痛治疗总体印象评分及所出现的副作用。结果两组患儿镇痛治疗评分及对镇痛治疗总体印象评分,组间对比均无显著性差异(P>0.05);曲马多组出现恶心,呕吐的病例数目明显高于氯诺昔康组(P<0.01);两组患者PCA治疗前后肝肾功能及出凝血时间比较无统计学意义(P>0.05)。结论氯诺昔康用于小儿术后镇痛是安全有效的,可作为小儿术后镇痛治疗的一种选择药物。     

Impact of CYP2D6 genotype on postoperative tramadol analgesia

Genetic polymorphisms result in absent enzyme activity of CYP2D6 (poor metabolizers, PM) in about 10% of the Caucasian population. This study investigates whether the PM genotype has an impact on the response to tramadol analgesia in postoperative patients. A prospective study design was used and 300 patients recovering from abdominal surgery were enrolled. After titration of an individual loading dose, patients could self-administer 1 ml bolus doses of the drug combination tramadol 20 mg/ml, dipyrone 200 mg/ml and metoclopramide 0.4 mg/ml via patient-controlled analgesia (PCA). Patients' genotype was analyzed considering the most prevalent PM associated CYP2D6 mutations using a real-time PCR and hybridization based genotyping method. Demographic data, surgery related variables, pain scores, analgesic consumption and need for rescue medication were compared between extensive metabolizers (EM) and PM. The primary outcome criterion 'response' was defined as responder or non-responder status by the need for rescue medication and patients' satisfaction at the final interview. Demographic and surgery related data were comparable between EM (n=241) and PM (n=30). The percentage of non-responders was significantly higher in the PM group (46.7%) compared with the EM group (21.6%; p=0.005). Tramadol loading dose amounted to 108.2+/-56.9 and 144.7+/-22.6 mg (p<0.001) in EM and PM, respectively. More patients displaying the PM genotype needed rescue medication in the recovery room and during PCA period than patients with at least one wild type allele (21.6 versus 43.3%, p=0.02). PM for CYP2D6 showed a lower response rate to postoperative tramadol analgesia than EM. Therefore, CYP2D6 genotype has an impact on analgesia with tramadol. Pharmacogenetics may explain some of the varying response to pain medication in postoperative patients.     

Factors That Influence Pain Intensity and Fentanyl Requirements After a Gynecologic Laparotomy

The association between pain intensity and its control by intravenous patient-controlled analgesia (IV-PCA) with fentanyl after a laparotomy for cystectomy/salphingoophorectomy, myomectomy, or hysterectomy was investigated. IV fentanyl infusion was administered to patients (n = 94) at 3 μg/kg/h to provide intraoperative analgesia after induction of general anesthesia. Postoperative fentanyl requirements were quantified via IV-PCA, and the amounts of rescue fentanyl required both during and after surgery were recorded. Mean values for PCA use as well as the visual analog scores (VAS) for pain were documented for up to 24 hours. The association between postoperative fentanyl requirements and VAS were then analyzed by using Mann-Whitney or Kruskal-Wallis tests. Patients with lower midline incisions had greater degrees of pain (p < .05) during the first 16 hours after surgery but did not consume more fentanyl compared with patients with Pfannenstiel incisions. Subjects who underwent operations lasting >4 hours required more rescue fentanyl during surgery (p < .05). However, this group consumed less fentanyl during the first 4 hours after surgery (p < .05). The demand at the fourth 4-hour period was lower among subjects undergoing myomectomy compared with cystectomy/salphingoophorectomy or hysterectomy (p = .045). Only a poor correlation was observed between pain intensity and analgesic usage. Postoperative pain intensity is influenced by the type of surgical incision but not the type of gynecologic surgery nor the duration of surgery. The relationship between subjective pain ratings with analgesic consumption is weak. Prolonged intraoperative administration of continuous IV fentanyl infusion may reduce fentanyl requirements in the immediate postoperative period.     

罗哌卡因切口预注射联合曲马多对腹腔镜下胆囊切除术后疼痛的影响

目的评估罗哌卡因切口预注射联合曲马多对腹腔镜下胆囊切除术（laparoscopic cholecystectomy,LC）术后疼痛的影响。方法选取2010年6月2011年4月行择期LC患者120例,年龄18～65岁,美国麻醉师协会Ⅰ～Ⅱ级,采用完全随机的设计分组：0.75%罗哌卡因10mL切口注射＋术毕静脉注射曲马多（2mg/kg）组（A组,n=30）;生理盐水10mL切口注射＋术毕静脉注射曲马多（2mg/kg）组（B组,n=30）;0.75%罗哌卡因10mL切口注射＋术毕静脉注射生理盐水10mL组（C组,n=30）;生理盐水组（D组,n=30）。术后2、4、6、12、24h分别评估右上腹部、右肩背部和腹壁切口疼痛进行视觉模拟评分（visual analog scale,VAS）。结果右上腹部及右肩背部疼痛VAS比较：与D组相比,A、B组VAS评分明显减少（P〈0.05）,而C组无明显统计学差异（P〉0.05）;B组与A组相比,2～24hVAS评分明显增加（P〈0.05）;C组与A组相比,2～24hVAS评分增高（P〈0.01）。腹壁切口疼痛VAS比较：与D组相比,A、B、C组VAS评分明显减少（P〈0.05）;B组与A组相比,2～24hVAS评分明显增加（P〈0.05）;C组与A组相比,2～24hVAS评分显著增高（P〈0.01）。结论腹腔镜胆囊切除术术前切口罗哌卡因预注射-术毕曲马多静脉注射对减轻术后疼痛有良好效果。     

Opioid‐Free Perioperative Analgesia for Hemicolectomy in a Patient With Opioid‐Induced Delirium: A Case Report and Review of the Analgesic Efficacy of the Alpha‐2 Agonist Agents

Abstract: Surgical pain in patients with documented opioid‐induced delirium can be difficult to treat. We present a case of a patient undergoing laparoscopic hemicolectomy effectively treated with an opioid‐free, alpha‐2 adrenoreceptor agonist analgesic regimen. Case report: A 21‐year‐old woman with persistent abdominal pain presented to the operating room for laparoscopic hemicolectomy for redundant right colon. Her medical history included a recently diagnosed postoperative opioid‐induced delirium. Epidural infusion with local anesthetic offered partial pain relief with sensory levels of T9‐L2. With the addition of dexmedetomidine infusion in the immediate postoperative period, the patient was comfortable with pain scores of 1 to 2/10 on Numerical Rating Scale (NRS). On postoperative day 1, the infusion was discontinued and the clonidine, 12 μg/hours was added to the epidural bupivacaine. With increased sedation 48 hours later, neuraxial clonidine was discontinued in favor to transdermal clonidine 0.1 mg/week, which was maintained until hospital discharge. Pain scores were maintained at 2 to 3/10 on NRS for the next 3 days when increased abdominal distention because of abscess formation rendered a new surgical intervention. The analgesia for the exploratory laparoscopy was maintained using epidural clonidine and bupivacaine infusion as well as intravenous dexmedetomidine, which were maintained another 2 days. Pain scores remained minimal until discharged home 3 day later. Discussion: Nonopioid analgesic regimens are beneficial in patients at risk of postoperative cognitive dysfunction attributable to opioids. Successful postoperative analgesia was achieved in our patient by alternating various routes of administration of alpha‐2 adrenoreceptor agonists.     

普瑞巴林剂量对腹腔镜子宫全切术患者术后疼痛的影响

目的探讨不同剂量(75、150和300 mg)普瑞巴林预先给药在腹腔镜子宫切除术患者中的术后镇痛效果。方法该研究为前瞻性、随机、安慰剂对照和双盲研究。共纳入82例美国麻醉医师协会(ASA)分级为Ⅰ～Ⅱ级并择期行腹腔镜子宫切除术的患者。患者随机分成4组,其中第1、2和3组(每组20例)术前1晚、术前30 min和术后6 h分别口服浓度为75、150和300 mg的普瑞巴林,而对照组(n=22)按照相同方案接受安慰剂治疗。主要临床结局是术后24 h静息和运动时的疼痛视觉模拟评分(VAS)。药物相关副作用评估作为次要观察指标。嗜睡采用Ramsay镇静评分评估,而恶心和呕吐用数值评分评估。结果不同浓度预先普瑞巴林给药的镇痛效果优于安慰剂。事后检验显示,4组间AVS评分差异有统计学意义,表明浓度下降,疼痛评分作为时间自变量而下降。普瑞巴林浓度达到最高(300 mg)时,镇静评分高于其他组。结论预先服用75、150和300 mg普瑞巴林对减轻腹腔镜子宫切除术后疼痛具有重要作用。比较不同浓度与副作用表明,口服150 mg普瑞巴林是减轻腹腔镜子宫切除术后疼痛的安全有效方法。     

Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial

A total of 100 osteoarthritis patients undergoing unilateral total knee arthroplasty were randomly assigned to receive either a multimodal analgesia protocol, comprising oral celecoxib and tramadol before and after surgery and intra-articular injection of large doses of morphine, ropivacaine, adrenaline and betamethasone during surgery (trial group), or oral and intra-articular placebo (control group). All patients received patient-controlled analgesia for 48 h after surgery. Morphine consumption up to 48 h after surgery was significantly lower in the trial than in the control group. Compared with the control group, the trial group had significantly lower visual analogue scale (VAS) scores for pain at rest from 6 h to 7 days after surgery and significantly lower VAS scores during activity from 24 h to 7 days after surgery. Active straight leg raise and active 90 degrees knee flexion were achieved sooner and range of knee movement at postoperative days 1 - 15 were significantly greater in the trial group. Postoperative wound healing, infection, blood pressure, heart rate, rash, respiratory depression, urinary retention and deep vein thrombosis were similar in the two groups, but nausea and vomiting were significantly less frequent in the trial group.     

Efficacy of Intravenous Ibuprofen and Intravenous Paracetamol in Multimodal Pain Management of Postoperative Pain After Percutaneous Nephrolithotomy

PurposeMany different techniques, including multimodal analgesia, have been used for the management of postoperative pain after Percutaneous nephrolithotomy (PCNL). Ketorolac, intravenous (IV) paracetamol, rofecoxib, and IV ibuprofen have been used as a part of a multimodal analgesic approach in different surgical procedures. However, the efficacy of IV ibuprofen has not been well elucidated in adult patients undergoing elective PCNL. The aim of the study was to examine the efficacy of IV ibuprofen compared to IV paracetamol after elective PCNL.DesignThis was a prospective randomized clinic study.MethodsThe study was conducted with 50 patients scheduled for PNCL between the ages of 18 and 65. IV ibuprofen 800 mg infusion was used for Group I, and 1 g IV paracetamol infusion Group P. IV tramadol infusion was administered with a Patient Controlled Analgesia device for postoperative analgesia. The primary outcome was 24-hour tramadol consumption. Secondary outcomes were pain intensity and side effects of the drugs. All outcomes were recorded in the 30th minute in the PACU and in 2, 4, 6, 12, 24 hours postoperatively.FindingsTotal postoperative tramadol consumption was significantly lower in Group I compared with Group P (P = .031). There was also a significant decrease in the cumulative tramadol consumption between the two groups in the 2nd and 24th hours (P < .012). In all measurement periods, pain intensity, sedation score, nausea and vomiting, itching, additional analgesia, and satisfaction with pain management were similar between the two groups.ConclusionIV ibuprofen, used as a part of multimodal tramadol-based analgesia reduced tramadol consumption compared with IV paracetamol in the first 24 hours postoperatively after elective PCNL. The IV ibuprofen-tramadol combination seems appeared superior to a paracetamol-tramadol combination.     

Perioperative analgesia with intraoperatively started infusion of high-dose dipyrone in orthopaedic and trauma surgery

The aim of this double blind, placebo-controlled trial was to determine the analgesic efficacy of high-dose dipyrone (metamizol) infusion for perioperative pain treatment. Local ethics committee approval and written informed consent was obtained for 160 patients undergoing orthopaedic or trauma surgery. Dipyrone 5 g was given intravenously within 1 hour, starting 30 minutes before the end of surgery. Quality of analgesia was improved with a significant reduction in the visual analogue scores (VAS) (p<0.006) and the doses of opioids (piritramid 0.1mg kg⁻¹ i.m.) required (p<0.0001), with no additional side effects. High-dose dipyrone combined with opioids proved effective in the treatment of perioperative pain treatment when compared with opioids only. Acute Pain 1999; 2 (4): 167–171.     

加巴喷丁对腹腔镜子宫切除术患者曲马多术后镇痛的影响

目的：评价术前应用加巴喷丁,对曲马多术后镇痛效果及术后镇痛副反应的影响。方法40例ASA I~II级行择期腹腔镜子宫切除术患者随机分为两组,观察组术前服用加巴喷丁600mg,术后采用曲马多PCA;对照组：术前服用安慰剂,术后采用曲马多PCA。使用视觉模拟量表（VAS）在手术后1、3、6、12、24h时间点评价患者的疼痛情况,采用Ramsay镇静评分评价患者的镇静情况,进行记录,并记录上述各时间点的血压、心率。记录各患者手术后24h内PCA按压次数。记录手术后不良反应：恶心、呕吐、眩晕、呼吸抑制的发生情况。结果两组患者VAS评分无显著差异,观察组与对照组比较,PCA按压次数较少。在Ramsay镇静评分上,两组无显著差异。观察组与对照组相比,恶心、呕吐的发生率较低,两组患者眩晕、呼吸抑制等副反应的发生率相似。结论在腹腔镜子宫切除手术前口服600mg加巴喷丁,可增强曲马多的术后镇痛效果,并降低恶心、呕吐的发生率,且无其他明显的副作用。     

腹腔镜和开腹手术治疗异位妊娠的临床对比研究

目的探讨腹腔镜手术治疗异位妊娠的临床疗效并与开腹手术对比。方法2007年3月至2008年10月,在本院采用腹腔镜手术治疗的异位妊娠患者共32例,观察手术时间、术后镇痛例数、术后发热例数、肠蠕动恢复时间、住院时间。同期行开腹手术治疗的患者共47例作为对照。结果除手术时间无显著性差异外,术后镇痛例数,术后发热例数,肠蠕动恢复时间,住院时间经统计学处理,差异均有统计学意义。结论与开腹手术相比,腹腔镜手术疗效确切,并且对患者创伤小,恢复快,并发症少,是治疗异位妊娠的首选方法。     

Patient-controlled femoral nerve analgesia versus patient-controlled intravenous analgesia for postoperative analgesia after trochanteric fracture repair

We assessed the efficacy of intravenous patient-controlled analgesia (PCA) and femoral nerve PCA after trochanteric fracture repair. A total of 40 patients were randomised to receive either femoral nerve PCA (Group I) or intravenous (IV) PCA (Group II) in the postoperative period. Group I received a continuous infusion of 0.125 bupivacaine at rate of 4 ml h⁻¹ plus PCA boluses of 3 ml with lockout time of 20 min. Morphine by IV PCA was applied as 1 mg bolus dose and 7 min lockout time in Group II. Pain scores (active–passive movement and during the resting), side effects, and patient satisfaction were recorded. Pain scores at rest were similar in both groups. Significantly better pain control at movement was observed in the Group I. Side effects were observed significantly more frequently in the Group II. Patient satisfaction was greater in Group I. Of the two PCA techniques tested, femoral nerve PCA with continuous infusion provides greater patient comfort both at rest and with ambulation than does IV PCA.     

Clinical aspects of analgesia with intravenous paracetamol in the early postoperative period

This open one-center study included 40 patients operated on the abdomen and chest, who had moderate resting pain in the immediate postoperative hours. Paracetamol was used as a dropwise intravenous 1-g infusion for 10-15 min; the dose of the agent was 4 g. The interval of paracetamol re-infusion was not early than 4 hours. If additional analgesia was required, opioid analgesics (promedol, tramadol) were administered. As a whole, assessment of analgesia within 24 hours showed excellent and good results reported by patients in 85% of cases; and in 71% of the patients the intensity of postoperative pain was less than they had expected before surgery. The use of opioid analgesics was required in 65% of the patients and 25% did not need these agents. The remaining 10% of the patients received a combination of nonsteroidal anti-inflammatory drugs, paracetomol, and opioids. Postoperative analgesia based on the intravenous infusion of paracetamol in a single dose of 1 g (4 g/day) caused a reduction in the intensity and duration of pain. The intravenous formulation of paracetamol should be regarded as one of the essential nonopioid components of multimodality therapy for pain in patients in the early postoperative period.     

腹腔镜和开腹手术治疗异位妊娠的临床对比研究

目的 探讨腹腔镜手术治疗异位妊娠的临床疗效并与开腹手术对比.方法 2007年3月至2008年10月,在本院采用腹腔镜手术治疗的异位妊娠患者共32例,观察手术时间、术后镇痛例数、术后发热例数、肠蠕动恢复时间、住院时间.同期行开腹手术治疗的患者共47例作为对照.结果 除手术时间无显著性差异外,术后镇痛例数,术后发热例数,肠蠕动恢复时间,住院时间经统计学处理,差异均有统计学意义.结论 与开腹手术相比,腹腔镜手术疗效确切,并且对患者创伤小,恢复快,并发症少,是治疗异位妊娠的首选方法.     

腹腔镜和开腹手术治疗异位妊娠的临床对比研究

目的 探讨腹腔镜手术治疗异位妊娠的临床疗效并与开腹手术对比.方法 2007年3月至2008年10月,在本院采用腹腔镜手术治疗的异位妊娠患者共32例,观察手术时间、术后镇痛例数、术后发热例数、肠蠕动恢复时间、住院时间.同期行开腹手术治疗的患者共47例作为对照.结果 除手术时间无显著性差异外,术后镇痛例数,术后发热例数,肠蠕动恢复时间,住院时间经统计学处理,差异均有统计学意义.结论 与开腹手术相比,腹腔镜手术疗效确切,并且对患者创伤小,恢复快,并发症少,是治疗异位妊娠的首选方法.     

曲马多不同方式预注用于腹腔镜胆囊切除术镇痛

目的通过不同方式静脉滴注曲马多用于腹腔镜胆囊切除术以评价其镇痛作用。方法 2007年8月-2009年8月择期行腹腔镜胆囊切除术患者90例,ASAⅠ或Ⅱ级,随机分成A、B、C、D组,在全身麻醉诱导后和手术结束时两个时间点分别给予曲马多2.5mg/kg或生理盐水,A组曲马多,生理盐水;B组生理盐水,曲马多;C组曲马多;D组生理盐水。分别于手术后2、4、8、24h进行视觉模拟评分法（VAS）评分,了解不良反应的发生情况及镇痛药的使用情况。结果手术后2、4、8、24h,A、B、C组VAS评分低于D组（P〈0.05）;手术后8h,A、C组明显低于B、D组（P〈0.05）。结论曲马多2.5mg/kg预注用于腹腔镜胆囊切除术的超前镇痛是可行而有效的。     

Paediatric cancer pain management using the WHO analgesic ladder--results of a prospective analysis from 2265 treatment days during a quality improvement study.

OBJECTIVE: To collect data on pain management in paediatric oncology with respect to the WHO ladder approach. SETTING, DESIGN, PATIENTS AND METHODS: Eight German tertiary care paediatric oncology centres prospectively documented all their in-patient pain treatment courses from June 1999 to December 2000. Pain was scored using a 1-6 faces scale. RESULTS: Two hundred and twenty four patients (median age, 9 years; range 0.2-32.1) were enrolled. Three hundred and thirty three pain episodes comprising a total of 2265 treatment days were documented. Pain was mostly therapy associated. The most frequently administered non-opioid analgesics were dipyrone and paracetamol. On WHO step 2, tramadol was almost the only opioid used. During tramadol monotherapy average daily pain scores were lower than with a combination of tramadol and non-opioid analgesics. On WHO step 3, morphine was at least part of the analgesic regimen on most treatment days. Strong opioids were combined with a non-opioid analgesic on 41% of the treatment days. The mean intravenous morphine equivalence dose was 0.034 mg/kg/h. During opioid and non-opioid combination therapy, adverse effects were more frequent, and average pain scored higher than on opioid monotherapy. CONCLUSIONS: WHO-guidelines were closely followed in Germany and seem to provide effective analgesia for children with cancer pain. In our patient group there is no evidence that a combination of an opioid with a non-opioid is more effective than opioid therapy alone in in-patient paediatric oncology pain treatment.     

Continuous epidural infusion of ropivacaine for the prevention of postoperative pain after major orthopaedic surgery: A dose-finding study

The present study investigated the dose relationship of ropivacaine with regard to analgesia and motor block when administered as a continuous 21 hour epidural infusion following major orthopaedic surgery.Forty six patients scheduled for elective total knee or hip arthroplasty were compared in this double-blind study. Patients were randomly assigned to one of four treatment groups: saline (n=12); ropivacaine 0.1% (n=11); ropivacaine 0.2% (n=12); ropivacaine 0.3% (n=11). Initial epidural analgesia was established with 0.5% ropivacaine and general anaesthesia was then induced for surgery. Within 30 minutes of the end of surgery, epidural infusions were commenced at a rate of 10 ml/hour for 21 hours. All patients had access to PCA morphine. Morphine consumption, VAS pain scores at rest, sensory and motor block and overall quality of treatment were assessed at regular intervals.The morphine consumption and VAS scores were lower overall in the ropivacaine groups than in the group receiving only PCA morphine. The difference was more evident during the first 8 hours of postoperative infusion, when significant differences between the ropivacaine 0.2% and 0.3% groups and the saline group were found. The incidence and degree of motor block were dose dependent. There was significantly higher patient satisfaction in all ropivacaine groups compared to the saline control group.In conclusion, 21 hour epidural infusion of ropivacaine, combined with PCA morphine, provides effective pain relief following major joint surgery and without significant adverse events. Morphine consumption and pain scores were lowest in the 0.3% ropivacaine group but this group had a higher degree of motor block. Pain relief with the combination of ropivacaine and PCA morphine is superior to that of PCA morphine alone.