高龄短节段腰椎融合患者术后早期功能康复的安全性及有效性

【摘要】 目的：评估高龄患者（年龄≥75岁）短节段腰椎融合手术后早期功能康复的安全性和有效性。方法：回顾性分析2018年1月~2021年4月在我院接受单/双节段腰椎融合手术的高龄患者,患者均在完成充分的术前评估后接受手术治疗。2019年7月开始对腰椎融合术后的高龄患者进行早期功能康复,即术后当日在康复医师指导下开始行规范床上康复锻炼,2d内下床活动,纳入早期康复组。2019年7月之前接受手术治疗的高龄患者术后采用传统康复措施,拔除引流管后开始下床活动,术后进行自主康复锻炼,纳入对照组。收集两组患者的临床资料,包括患者的基本信息[年龄、性别比、疾病种类、术前腰腿痛视觉模拟（VAS）评分、Oswestry功能障碍指数（ODI）、合并症、手术史和烟酒史]、手术相关资料（手术时间、术中出血量、手术节段）和结局指标（下床时间、拔除引流管时间、术后90d内的并发症情况、再入院率、术后住院时间以及术后额外的阿片类药物的使用情况）。结果：共纳入188例患者,早期康复组94例,对照组94例。早期康复组患者合并下肢静脉瓣膜功能不全及既往手术史比率较对照组高（46% vs 22%,P＜0.01;72% vs 55%,P=0.02）,其余基线资料及手术相关资料与对照组比较无显著性差异（P＞0.05）。早期康复组患者首次下地时间和拔除引流管时间较对照组明显提前（1.8±0.9d vs 4.5±1.6d和2.2±0.26d vs 3.6±0.25d,P＜0.01）,术后低蛋白血症的发生率低于对照组（28% vs 43%,P=0.03）,其余并发症发生率、术后住院时间（7.0±3.3d vs 8.7±4.3d,P=0.06）及90d内的再入院率（3% vs 7%,P=0.12）均无显著性差异;早期康复组患者术后额外应用阿片类药物比率显著性低于对照组(12% vs 34%,P=0.00)。结论：高龄单节段或双节段腰椎融合手术患者术后早期接受功能康复锻炼不会增加术后并发症的发生率、短期再入院率及住院时间,同时减少了引流管留置时间、术后低蛋白血症发生率和额外阿片类药物的应用。     

单节段微创经椎间孔腰椎体间融合术后放置引流管必要性的研究

[目的]观察微创经椎间孔腰椎体间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)治疗单节段腰椎退行性疾病的术中出血量、术后引流量和引流管放置时间等指标,探讨术后放置引流管的意义及必要性.[方法]回顾性分析本院2007年1月～ 2011年1月收治的112例单节段腰椎退行性疾病患者,其中52例行切开TLIF手术(Open-TLIF)并放置引流管,28例行MIS-TLIF手术并放置引流管,32例行MIS-TLIF手术但不放置引流管,观察术中出血量、术后引流量、引流管放置时间及并发症情况等指标,最后比较三组临床结果.[结果] Open组平均术中出血量(381±96)ml,术后引流量(324±146) ml,引流管放置时间(3.0±0.8)d;MIS引流组平均术中出血量(78±34)ml,术后引流量(46±.15) ml,引流管放置时间(1.1±0.3)d;MIS不引流组平均术中出血量(81 ±30) ml.三组间比较伤口感染、血肿压迫等并发症发生情况无统计学差异(P＞0.05).MIS引流组与不引流组术中出血量、并发症均无统计学差异(P＞0.05),但不引流组术后5d腰痛VAS评分优于引流组(P＜0.05),术后平均下地时间和住院日均短于引流组(P＜0.05).[结论]在术中止血彻底的前提下,单节段腰椎MIS-TLIF手术可以不放置引流管.     

MIS-TLIF与PLIF治疗单节段退行性腰椎疾病短期疗效对比

目的比较MIS-TLIF与PLIF治疗单节段退变性腰椎疾病的短期疗效。方法回顾分析揭阳市人民医院2017年6月至2018年12月收治的60例单节段腰椎退行性疾病患者,其中经MIS-TLIF治疗30例,PLIF治疗30例,比较两组患者手术时间、术中出血量、术后引流量、术后卧床时间、术后住院时间、VAS评分、ODI评分、椎体融合率及滑脱患者回复率。结果 MIS-TLIF组术后1月、6月VAS评分、ODI评分优于PLIF组,术中出血量、术后引流量少于PLIF组,术后卧床时间、住院时间短于PLIF组(P0.05)。PLIF组手术时间短于MIS-TLIF组,术后滑脱患者回复率优于MIS-TLIF组(P0.05)。两组术后1年VAS评分、ODI评分、椎间融合率差异无统计学意义(P0.05)。PLIF组术后一例肺部感染、一例硬膜囊破裂,MIS-TLIF组术中一例置钉位置不佳及一例对侧神经根激惹,未发生定位错误、神经损伤、手术部位感染、内固定物松脱等并发症。结论 MIS-TLIF组可达到与PLIF组相同的手术疗效,而术后短期功能状态评分优于PLIF组,有利于患者术后快速康复。     

微创可扩张通道辅助下OLIF入路治疗单节段腰椎不稳疗效分析

目的探讨OLIF入路微创可扩张通道辅助下治疗单节段腰椎不稳的疗效。方法回顾性分析我院2014年6月～2016年6月56例单节段腰椎不稳患者的临床资料,按治疗方式分为OLIF组和PLIF组,各28例,分别采用微创可扩张通道辅助下斜外侧入路椎间融合术入路(oblique lumbar interbody fusion,OLIF)和后路椎体融合术。记录并比较两组患者术前及术后1月、6月、12月的腰背疼痛VAS及ODI评分,分析两组术后并发症。结果 OLIF组平均手术时间(225±35) min,出血量(105±22) ml; PLIF组平均手术时间(135±2) min,出血量(226±85) ml;两组手术时间、出血量比较均有统计学差异(P均0. 01)。两组患者均获得随访,平均13. 5(12～16)月。两组患者术后12月VAS及ODI评分均较术前明显改善(P 0. 01)。术前组间VAS及ODI评分比较无统计学差异(P 0. 05),术后1月、6月及12月组间VAS、ODI评分比较,OLIF组优于PLIF组(P 0. 05)。所有患者均无下肢静脉血栓形成。OLIF组术后屈髋无力1例,无血管神经损伤、伤口感染、逆向射精及肠道损伤等并发症; PLIF组术后脑脊液漏3例,伤口感染1例,足下垂2例。两组并发症率比较有统计学差异(3. 6%vs. 21. 4%,P 0. 05)。结论微创可扩张通道辅助下OLIF入路治疗单节段腰椎不稳创伤小,安全性高,出血少,手术并发症少,能明显改善患者腰部疼痛。     

皮质骨通道螺钉与椎弓根螺钉行腰椎间融合术的疗效比较

目的比较皮质骨通道螺钉(CBTS)与椎弓根螺钉行腰椎后路椎间融合术(PLIF)治疗单节段腰椎退变性疾病的手术特点及临床疗效。方法对97例单节段腰椎退变性疾病患者根据内固定方式不同分为通道螺钉组(采用CBTS行PLIF,51例)和椎弓根螺钉组(采用椎弓根螺钉行PLIF,46例)。记录两组患者手术时间、术中出血量、术后引流量、双氯芬酸钠使用总量、术后住院天数、卧床时间及并发症情况;比较术后12个月腰痛VAS评分、ODI及椎间融合率。结果患者均获得12个月随访。手术时间、术中出血量、术后引流量、双氯芬酸钠使用总量、卧床时间、住院时间通道螺钉组均少于椎弓根螺钉组(P0.001,P0.05);两组并发症发生率、术后12个月腰痛VAS评分、ODI及椎间融合率比较差异均无统计学意义(P0.05)。结论采用腰椎后路椎弓根螺钉与CBTS行PLIF治疗单节段腰椎退变性疾病,均可获得满意的椎间融合率和临床疗效。CBTS行PLIF有术中出血量少、肌肉损伤小、患者痛苦小等优点。     

MIS-TILF与PLIF治疗单节段退行性腰椎疾病的护理比较

[目的]观察扩张通道管系统(X-tube)辅助微创经椎间孔入路腰椎椎体间融合术(minimally invasive surgery transforaminal lumbar interbody fusion,MIS-TLIF)与传统开放后路腰椎椎体间融合术(posterior lumbar interbody fusion,PLIF)治疗单节段退行性腰椎疾病的相关临床疗效,并比较其护理措施。[方法]回顾性分析2013年12月~2014年12月本院骨科行手术治疗的单节段退行性腰椎病变患者,其中行MIS-TLIF手术的患者48例、行PLIF手术的患者39例,统计术前心理评估指标、术中出血量、术后伤口引流量、术后1d直腿抬高度数、术后卧床时间、术后平均住院天数、腰背痛视觉模拟评分(visual analogue scale,VAS)以及术后康复锻炼的完成情况,并对两组结果进行比较。[结果]手术前HAMA评分、HAMD评分、SAS评分和SDS评分,PLIF组均高于MIS-TLIF组(P0.05);MIS-TLIF组术中出血量、术后伤口引流量、术后卧床时间、术后平均住院天数均比PLIF组明显减少(P0.05),术后1 d直腿抬高度数则明显增加(P0.05),术后第3、5 d及3个月,MIS-TLIF组腰背痛VAS评分明显低于PLIF组(P0.05),术后1 d和3 d,MIS-TLIF组康复锻炼完成率明显高于PLIF组。[结论]MIS-TLIF手术治疗单节段退行性腰椎疾病手术切口小,术前患者的心理负担较小,术后伤口疼痛轻,可提早进行康复锻炼,缩短了平均住院天数,减少并发症的发生,一定程度减轻了护理工作量,在把握好适应证的情况下,值得在有条件开展此类手术的医院进行推广。     

加速康复外科理念在甲状腺肿瘤手术中的应用

目的探讨加速康复外科治疗理念和措施在甲状腺肿瘤患者围术期的安全性和有效性。方法 116例甲状腺肿瘤患者随机分为对照组(常规围术期处理方案)和加速康复外科组(加速康复围术期处理方案),各58例。比较两组患者手术时间、术中失血量、术后住院时间、住院费用,观察两组患者术后并发症的发生情况。结果加速康复组患者术中手术时间([110.33±28.79)minvs(112.72±33.63)min]和术中失血量([100.86±42.27)mlvs(95.22±32.54)ml]与常规对照组比较,差别无统计学意义;加速康复组患者术后住院时间([2.24±0.82)dvs(3.84±1.02)d]、治疗费用([4980.13±575.38)元vs(7843.14±473.63)元],恶心呕吐发生率(34/58vs44/58)明显低于对照组(P0.05),而术后并发症的发生并没有增加。结论加速康复外科治疗理念可加快甲状腺肿瘤患者术后的恢复,缩短住院时间,节省医疗费用。     

改良单侧PLIF治疗腰椎间盘突出症伴腰椎不稳的疗效观察

目的比较改良单侧后路腰椎椎体间融合术(PLIF)与传统PLIF治疗腰椎间盘突出症伴腰椎不稳症的临床疗效。方法回顾性分析自2014-07—2015-06诊治的60例单节段腰椎间盘突出症伴腰椎不稳,采用改良单侧PLIF治疗30例(观察组),采用传统PLIF治疗30例(对照组)。比较2组手术时间、术中出血量、植骨融合率,术后4周及末次随访时的VAS评分、ODI指数,末次随访时的JOA评分及优良率,以及并发症情况。结果观察组手术时间、术中出血量少于对照组,差异有统计学意义(P0.05)。观察组28例获得随访,随访时间(16.81±4.27)个月;对照组26例获得随访,随访时间(15.59±4.49)个月。2组植骨融合率差异无统计学意义(P0.05)。观察组术后4周及末次随访时的VAS评分、ODI指数均低于对照组,末次随访时JOA评分优良率高于对照组,差异有统计学意义(P0.05)。结论改良单侧PLIF治疗腰椎间盘突出症伴腰椎不稳的创伤相对较小,有利于患者后期的功能恢复;同时术中能够有效减少对椎管内的干扰,减少术中出血量,有效缩短手术时间,疗效满意。     

微创与开放后路椎体间融合术治疗单节段退行性腰椎疾病对比研究

[目的]前瞻性对比研究微创手术与开放手术行单节段腰椎后路椎间融合术的临床疗效和影像学结果。[方法]2011年10月²012年10月,采用腰椎后路椎间融合手术治疗65例单节段腰椎退行性疾病患者。术前根据计算机随机分配方法将患者分为微创手术(微创组,n=33)和开放手术(开放组,n=32)。两组一般资料比较差异均无统计学意义(P>0.05),具有可比性。最低随访1年,记录两组的手术时间、术中及术后失血量、总输血量、术后腰背痛程度(VAS评分)、卧床时间、住院时间、术后并发症、术后临床和影像学结果,并进行比较分析。[结果]65例患者,4例失访,其中微创组失访1例,开放组失访3例,余61例均获随访,时间12012年10月,采用腰椎后路椎间融合手术治疗65例单节段腰椎退行性疾病患者。术前根据计算机随机分配方法将患者分为微创手术(微创组,n=33)和开放手术(开放组,n=32)。两组一般资料比较差异均无统计学意义(P>0.05),具有可比性。最低随访1年,记录两组的手术时间、术中及术后失血量、总输血量、术后腰背痛程度(VAS评分)、卧床时间、住院时间、术后并发症、术后临床和影像学结果,并进行比较分析。[结果]65例患者,4例失访,其中微创组失访1例,开放组失访3例,余61例均获随访,时间1²年,末次随访时,微创组优良率为90.7%,开放组为89.6%,差异无统计学意义(P=1.000);两组平均椎间高度分别为(10.16±1.37)mm和(10.45±1.30)mm;两组平均椎间高度丢失率差异无统计学意义(P=0.852);微创组31例(96.9%)椎体间达骨性融合,两组融合率差异无统计学意义(P=1.000)。但是微创手术相比传统开放手术术中出血量较少[(432.8±294.8)ml]vs.(737.9±224.3)ml,P=0.000]、手术时间短[(148.8±24.2)min vs.(191.7±37.7)min,P=0.000]、术后引流量少量[(175.3±162.2)ml vs.(482.9±165.3)ml,P=0.000]、术后输血少[(0.2±0.6)u vs.(0.9±1.1)u,P=0.002]、卧床时间短[(1.2±0.6)d vs.(2.9±1.1)d,P=0.000]、住院时间短[(5.3±2.6)d vs.(10.8±2.5)d,P=0.000]、术后疼痛轻(2.1±1.4 vs.3.8±1.8,P=0.000)。[结论]微创手术和开放手术入路行单节段腰椎后路椎间融合术治疗退行性腰椎疾病,具有相似的临床疗效和放射学结果,但微创手术出血量和输血量较少、术后疼痛较轻、术后恢复较快及住院天数较短。     

MI-TLIF与传统PLIF手术治疗单节段腰椎管狭窄症的疗效比较

目的比较微创经椎间孔入路腰椎间融合技术(MI-TLIF)与传统后路腰椎椎体间融合术(PLIF)治疗单节段腰椎管狭窄症的疗效。方法回顾性分析自2012-03—2013-06分别采用MIS-TLIF与PLIF手术治疗的80例单节段腰椎管狭窄症,40例行MI-TLIF手术(MI-TLIF组),40例采用传统PLIF手术(PLIF组)。结果所有患者均获得随访12~35个月,平均18个月。2组切口长度、手术时间、并发症发生率比较差异无统计学意义(P0.05);MI-TLIF组术中出血量、术后引流量、住院时间、术后至下地时间均少于PLIF组,差异有统计学意义(P0.05)。术后1年随访时2组腿痛VAS评分差异无统计学意义(P0.05);术后1年随访时MI-TLIF组腰痛VAS及ODI评分均低于PLIF组,差异有统计学意义(P0.05)。术后1年腰椎融合情况采用Bridwell等的标准评定:2组结果差异无统计学意义(χ2=2.132,P=0.093)。结论MI-TLIF与传统PLIF手术治疗单节段腰椎管狭窄症均有效,但MI-TLIF技术手术创伤较小、恢复较快,且恢复更满意。     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.