Bilateral paravertebral analgesia for major abdominal vascular surgery: a preliminary report

Paravertebral analgesia is highly effective in blocking unilateral afferent input from the trunk, but its bilateral use does not appear to have been described. Eight patients undergoing major abdominal vascular surgery had pre-operative bilateral paravertebral catheters inserted. A dose of 25 ml of bupivacaine 0.5% divided between the two catheters provided the basis of an effective intra-operative analgesic regimen which was continued postoperatively by infusion of bupivacaine for 4 days. Diclofenac and morphine completed a balanced analgesic regimen which was started pre-operatively and continued for 5 and 3 days respectively. Cardiovascular stability was notable throughout surgery, even with aortic clamping and all patients were extubated at the end of surgery. Good quality analgesia was obtained as assessed by low postoperative pain scores at rest and on movement. Three patients were not admitted to the intensive care unit, where mean stays for the group was 10 h (range 0-24 h) and mean hospital stay was 10 days (range 7–14). There were no additional demands made on the nursing staff and no postoperative pain-related complications occurred. We conclude that bilateral paravertebral analgesia, as part of a balanced analgesic technique, is an alternative method of providing effective afferent blockage for major abdominal surgery.     

Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results

Shoulder surgery is often associated with severe postoperative pain. Previous results in which single or continuous subacromial infiltration of local anesthetics was used as a method of postoperative pain relief have been contradictory. This study was initiated to evaluate the postoperative analgesic effect of a subacromial continuous 0.25% bupivacaine infusion at a rate of 6 mL/h after elective open shoulder surgery. We hypothesized that this procedure would improve postoperative analgesia while reducing morphine requirements. By use of a prospective, double-blind, randomized study design, 50 consecutive patients undergoing acromioplasty and rotator cuff repair surgery received a multiorifice catheter placed in the subacromial space. Twenty patients received 0.25% bupivacaine (group 1), and twenty-two patients received saline solution (group 2). The primary endpoints in the two groups were total morphine consumption administered by patient-controlled analgesia and the patient's subjective pain level evaluated by a visual analog scale during the first 48 postoperative hours. No major technical or pharmacologic side effects were noticed, and the indwelling pain catheter was well tolerated by all patients. There was no statistically significant difference (P < .05) either in total cumulative morphine consumption microg/48 h (73.2 +/- 43.1 vs 60.9 +/- 35.9) or in subjective pain perception 10-point visual analog scale (3.2 +/- 1.4 vs 3.1 +/- 1.5) between the two study groups. The continuous subacromial infiltration of 0.25% bupivacaine at a rate of 6 mL/h is concluded to be ineffective in providing pain relief supplementary to patient-controlled analgesia after open rotator cuff repair and acromioplasty surgery.     

Continuous interscalene analgesia with ropivacaine 2 mg/ml after major shoulder surgery

BACKGROUND: In this open, randomized study, the pharmacokinetics, clinical efficacy, and safety of a 48-h continuous interscalene infusion of 2 mg/ml ropivacaine for postoperative pain relief were investigated in patients undergoing open major shoulder surgery. METHODS: An initial interscalene block with 30 ml ropivacaine, 7.5 mg/ml (225 mg), was performed. After completion of interscalene block, all patients (n = 24) received general anesthesia, and 6 h after interscalene block, a 48-h continuous interscalene infusion of 12 or 18 mg/h using 2 mg/ml ropivacaine was started. Total and unbound plasma concentrations of ropivacaine and 2.6-pipecoloxylidide (PPX; a major active metabolite) were determined during and up to 6 h after the interscalene infusion. Postoperative pain at rest was assessed by a visual analog scale. Supplementary analgesics and adverse events were recorded. RESULTS: Plasma concentrations of total and unbound ropivacaine were proportional to the total dose. At the end of the interscalene infusion of 9 ml/h, the mean +/- SD plasma concentrations of total and unbound ropivacaine were 1.40 +/- 0.54 and 0.03 +/- 0.01 mg/l, respectively, and of total and unbound PPX were 0.70 +/- 0.38 and 0.30 +/- 0.20 mg/l, respectively. Plasma concentrations of unbound ropivacaine and unbound PPX, added together, remained well below threshold levels for systemic central nervous system toxicity. There were no significant differences between the groups for postoperative pain (median maximum of about 20 mm on the visual analog scale in both groups), analgesic consumption, or quality of pain relief assessed by the patient. No signs or symptoms of systemic local anesthetic toxicity were observed. CONCLUSION: A 48-h continuous interscalene infusion of 6 or 9 ml/h ropivacaine, 2 mg/ml, started 6 h after an initial interscalene block of 30 ml ropivacaine, 7.5 mg/ml, provided satisfactory postoperative pain relief after major shoulder surgery and was well tolerated. Unbound plasma concentrations of ropivacaine and PPX remained well below threshold levels for systemic central nervous toxicity.     

收肌管阻滞技术在初次全膝置换术后早期镇痛中的应用研究

目的探讨收肌管阻滞术在全膝关节置换术术后疼痛管理及早期康复中的作用。 方法前瞻性选取于哈尔滨医科大学附属第一医院骨科行初次行单侧全膝关节置换术(TKA)的患者40例,随机分为收肌管阻滞联合帕瑞昔布镇痛组20例及单纯帕瑞昔布镇痛组20例。纳入初次单侧TKA患者,排除严重感染和精神疾病等患者。收肌管阻滞置管术后立即执行。两组患者围手术期观察术后不同时间点的静息与活动状态下视觉模拟评分、股四头肌肌力、膝关节活动范围、住院天数及有无并发症发生。所得数据通过独立样本t检验、非参数Wilcoxon秩和检验以及卡方检验进行分析。 结果与单纯应用帕瑞昔布相比,联合应用收肌管阻滞技术能够有效地降低患者术后早期VAS评分(术后6 h～72 h活动VAS：Z＝－3.124、－2.157、－2.044、－2.467、－2.471,P <0.05;术后6 h～24 h静息VAS：Z＝－2.310、－2.409、－2.208,P<0.05)。在膝关节活动度与术后住院时间上两组差异无统计学意义(P>0.05)。且收肌管阻滞组患者体现出更好的康复依从性,未出现因操作引起的并发症。 结论全膝关节置换术术后辅助收肌管阻滞术能够有效地缓解患者术后疼痛,有助于患者早期开展功能锻炼与快速康复。     

洛索洛芬在全膝关节置换的围手术期镇痛与术后镇痛中的研究

目的分析洛索洛芬钠片剂对于全膝关节置换（TKA）术后短期临床效果的影响。方法 2009年1月至2009年12月因膝骨关节炎行单侧全膝关节置换手术患者197例,其中围手术期使用镇痛药物为洛索洛芬和（或）阿片类药物的患者84例。仅使用阿片类药物镇痛的患者为对照组,共27例（男9例,女18例）;仅术后使用洛索洛芬镇痛的患者为POST组,共31例（男9例,女22例）;术前和术后均使用洛索洛芬的患者为PERI组,共26例（男7例,女19例）。结果三组患者在平均年龄、体重指数、术前患病时间、术前疼痛评分、术前膝关节活动度、术前HSS评分、手术时间、术中止血带时间、术后引流量、术后2周疼痛评分、术后2周活动度、术后2周HSS评分及术后2周行走距离等指标方面无显著差异。但POST组和PERI组阿片类药物使用时长均短于对照组,阿片类药物末次使用时间也早于对照组（P〈0.05）。与POST组相比,PERI组洛索洛芬用药总量略少,但无统计学显著意义。结论洛索洛芬联合阿片类药物可有效地控制TKA术后疼痛,达到满意的临床效果。联合用药可减少阿片类药物的用量、缩短阿片类药物的使用时间。洛索洛芬围术期镇痛与术后镇痛相比具有基本相同的临床镇痛效果,但前者的用药量略少。     

General analgesia for major surgery

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - The history of the clinical use of analgesia is briefly reviewed. Artusio’'s technique of ether analgesia is...     

Use of a stimulating catheter for total knee replacement surgery: preliminary results

Background. There is continuing debate as to whether the useof electrical stimulation that aids in localizing nerves isalso beneficial for optimizing placement of nerve cathetersand lead to improved clinical outcomes, such as reductions inpain scores and opioid consumption. Methods. We undertook a retrospective, non-randomized comparisonof stimulating and non-stimulating nerve catheters in 419 patientsundergoing total knee replacement between December 2002 andJuly 2004. Before surgery, patients received sciatic and femoralnerve blocks with a catheter for the femoral nerve. In 159 patientsa stimulating catheter system (Stimucath; Arrow International,Reading, PA, USA) and in 260 patients a non-stimulating cathetersystem (Contiplex; B. Braun, Melsungen, Germany) was used. Aftersurgery, pain scores and morphine consumption were recordedat 4-h intervals until the first postoperative morning. In asubset of 85 patients, the postoperative evaluation period waslengthened to 3 days. Results. Postoperative visual analogue scores (VAS) for painwere similar in the two groups during the first 24 h (P=0.305).In patients followed for 3 days, VAS scores did not differ onany of the days (P=0.427). Total morphine consumption did notdiffer on the first postoperative day (mean [95% CI]: stimulating,12.4 [10.1–14.7] mg; non-stimulating 10.4 [8.9–11.8]mg; P=0.140) or on subsequent days. Conclusions. The practical advantages of the stimulating catheter,as reported by previous investigators, were not obvious in thisclinical situation. In terms of outcome measures such as painscores and morphine consumption, we found no significant differencesbetween stimulating and non-stimulating catheters.     

Cardiopulmonary complications after major surgery: a role for epidural analgesia?

Improvement in postoperative pulmonary mechanics with epidural analgesia has been described. Data on the hemodynamic effects of this technique are absent from the surgical literature. To provide such data we have evaluated two groups of patients undergoing aortic reconstruction: group I (n = 25), general anesthesia and group II (n = 6), general anesthesia with adjunctive epidural analgesia. The groups were comparable preoperatively as judged by the incidence of cardiac history, preoperative ejection fraction, and measured hemodynamic parameters. Postoperatively there were no significant differences in the pressure-related parameters; however, rate-related factors including heart rate and double product were significantly decreased in group II with no reduction in cardiac index. Postoperative increases in total body oxygen consumption were also markedly attenuated by epidural analgesia. Epidural analgesia reduces the hemodynamic demands on the heart after major surgery and is a useful adjunct, especially in patients with coronary artery disease.     

Comparison of programmed intermittent epidural bolus and continuous epidural infusion for post-operative analgesia after major abdominal surgery: A randomized controlled trial

Study objectiveFew studies have compared continuous epidural infusion (CEI) against programmed intermittent epidural bolus (PIEB) epidural analgesia after major abdominal surgery. It has not been established whether the modality of epidural medication administration affects postoperative pain and other patient outcomes. The goal of this study was to compare the efficacy of PIEB against CEI in postoperative pain management after a broad range of surgeries with abdominal incisions, all managed in the context of an established enhanced recovery after surgery (ERAS) pathway.DesignProspective, randomized, controlled trial.SettingPostoperative acute care.Patients120 patients scheduled for major surgery involving abdominal incisions with planned postoperative epidural analgesia were enrolled as study participants.InterventionsAll subjects received a standardized epidural solution containing ropivacaine 0.0625% and fentanyl 2 μg/ml. The CEI group received this solution as a continuous infusion, while the PIEB group received this solution as programmed intermittent boluses.MeasurementsThe primary study outcome was the total local anesthetic used over the first 24 h post-operatively. Secondary outcomes included pain severity, pain interference, total opioid consumption, patient satisfaction, and adverse effects at 24, 48, and 72 h postoperatively.Main resultsThere was no difference in the primary outcome of total amount of local anesthetic administered in the first 24-hour postoperative period (PIEB: 123 mg [Interquartile Range (IQR): 114–136]; CEI: 126 mg [IQR: 120–134]). There were also no differences in average pain severity, total opioid consumption, patient satisfaction, number of PCEA requests and incidence of adverse events at 24, 48, and 72 h postoperatively.ConclusionsOur study suggests that within the context of an established ERAS program, PIEB and CEI modes of epidural analgesia can be equally efficacious and safe in providing postoperative analgesia after major abdominal surgery.     

Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery

BACKGROUND: Both epidural analgesia and intravenous patient-controlled analgesia (PCA) have been found efficacious after various types of surgery. We compared the efficacy, safety, side effects and patient satisfaction of these methods in a randomized double-blind fashion after elective anterior cruciate ligament reconstruction of the knee. METHODS: Fifty-six patients had an epidural catheter placed at the L2-L3 interspace. Spinal anaesthesia with 15 mg of plain bupivacaine 5 mg/ml was performed at the L3-L4 interspace. After surgery the patients were randomly divided into three groups: 19 received a continuous epidural infusion with bupivacaine 1 mg/ml and fentanyl 10 mg/ml (F10), 19 patients received bupivacaine 1 mg/ml and fentanyl 5 microg/ml (F5) and 18 patients received saline (S). The rate of the epidural infusions was 0.1 ml kg(-1) h(-1). Each patient could also use an intravenous (i.v.) PCA device with 40 microg/kg bolus doses of morphine with a lockout period of 10 min and a maximum dose 240 microg kg(-1) h(-1). At the end of surgery ketoprofen 100 mg i.v. was given and continued orally three times a day. Patients were assessed for pain with a visual analogue scale (VAS) at rest and during activity, side effects and satisfaction at 3, 9 and 20 h. RESULTS: Both epidural infusions (F10, F5) provided better analgesia than epidural saline plus i.v. PCA (S) (P<0.05). There was slightly less nausea in the S group (NS). In spite of the difference in the quality of pain relief, there was no difference between the groups in patient satisfaction regarding analgesic therapy. CONCLUSION: Epidural infusion of fentanyl (1 microg kg(-1) h(-1) or 0.5 microg kg(-1) h(-1)) and bupivacaine (0.1 mg kg(-1) h(-1)) provided better pain relief but more side effects than intravenous morphine patient-controlled analgesia after knee ligament surgery. Almost all patients in all groups were satisfied with their pain relief.     

右美托咪定用于膝关节镜术后多模式镇痛的临床观察

目的 观察右美托咪定（dexmedetomidine,Dex）用于膝关节镜术后多模式镇痛的效果.方法 90例美国麻醉医师协会（ASA）分级Ⅰ～Ⅱ级需行关节镜诊治术患者,按随机数字表法分为3组（每组30例）：A组患者关节腔内注入含1μg/kgDex的0.25％罗哌卡因混合溶液20 ml,静脉给予生理盐水20 ml;B组患者关节腔内注入0.25％罗哌卡因20 ml,静脉给予含1 μg/kg Dex的溶液20 ml;C组关节腔内注入0.25％罗哌卡因20 ml,静脉给予生理盐水20 ml.比较3组患者术后1、2、4、8、12、20、24 h的视觉模拟评分（visual analogue scale,VAS）、Ramsay镇静评分、镇痛持续时间、术后24 h芬太尼用量及副作用发生率.结果 患者术后A组,B组1、2、4、8h的VAS静息及运动状态评分明显低于C组（P＜0.05）;但术后12h后,3组患者VAS评分差异无统计学意义;B组1、2h的Ramsay评分明显高于A组、C组（P＜0.05）,A组2、4h的Ramsay评分高于C组分（P＜0.05）,但术后8h以后,A组、B组、C组3组患者Ramsay评分差异无统计学意义（P＞0.05）,镇痛持续时间A组（650±127） min较B组（452±86） min、C组（390±74）m in明显延长,B组较C组延长（P＜0.05）;术后24 h芬太尼用量A组（22±6）μg较B组（92±10） μg、C组（146±21） μg明显减少,B组较C组减少（P＜0.05）;3组心动过缓发生率B组显著高于A组、C组（P＜0.05）.结论 在膝关节镜术后多模式镇痛方案中,关节腔内注射Dex与罗哌卡因混合液可显著减轻关节镜术后疼痛,减少术后阿片类药物的使用,并延长镇痛持续时间.     

Perioperative adjuvant corticosteroids for postoperative analgesia in knee arthroplasty

Background and purpose — Immediate postoperative pain management offered in knee arthroplasty is suboptimal in up to one-third of patients resulting in high opiate consumption and delayed discharge. In this meta-analysis we investigate the analgesic effect and safety of perioperative adjuvant corticosteroids in knee arthroplasty.

Methods — Databases Medline, Embase, and Central were searched for randomized studies comparing the analgesic effect of adjuvant perioperative corticosteroids in knee arthroplasty. Our primary outcome was pain score at 24?hours postoperatively. Secondary outcomes included pain at 12, 48, and 72?hours, opiate consumption, postoperative nausea and vomiting, infection, and discharge time. Systemic (intravenous) and local (intra-articular) corticosteroids were analyzed separately.

Results — 14 randomized controlled trials (1,396 knees) were included. Mean corticosteroid dosages were predominantly 50–75mg oral prednisolone equivalents for both systemic and local routes. Systemic corticosteroids demonstrated statistically significant and clinically modest reductions in pain at 12?hours by –1.1 points (95%CI –2.2 to 0.02), 24?hours by –1.3 points (CI –2.3 to –0.26) and 48?hours by –0.4 points (CI –0.67 to –0.04). Local corticosteroids did not reduce pain. Opiate consumption, postoperative nausea and vomiting, infection, or time till discharge were similar between groups.

Interpretation — Corticosteroids modestly reduce pain postoperatively at 12 and 24?hours when used systemically without any increase in associated risks for dosages between 50 and 75?mg oral prednisolone equivalents.