Perioperative analgesia in pulmonary surgery

AIM: In pulmonary surgery many studies have shown how pain associated with residual doses of anaesthetic drugs can cause a decrease in pulmonary volumes and depression of the cough reflex. Both these phenomena are responsible for a rising incidence of postoperative mortality and morbidity. The most widely used postoperative analgesic techniques are continuous systemic analgesia and epidural analgesia. The aim of this study is to verify the advantages and the disadvantages of both analgesic techniques. METHODS: Fifty patients, undergoing pulmonary surgery, were recruited and divided, after randomization into 2 groups. Patients included in A group received an epidural administration of naropina 0.2%+fentanyl 4 microg/mL by elastomeric pump (rate 5 ml/h). Patients included in B group received an ev continuous infusion of tramadol 600 mg+ketorolac trometamina 120 mg+ranitidina 200 mg+ondansetron 16 mg by elastomeric pump (rate 5 ml/h for 48 hours). RESULTS: Both groups showed good analgesic effects. Pain rest relief was between 3 and 1.7 points in group B and between 2.5 and 0.4 points in group A. Incident pain was 4.8 at awakening time and it decreased to 4 after 48 hours in group B while in group A it was from 3.2 to 1.8 in the same period of B group. CONCLUSIONS: Our data show that both analgesic techniques are able to guarantee a good rest pain relief after thoracotomy. Epidural analgesia showed more efficacy as far as incident pain relief but it was more difficult to realise and it showed less acceptance by patients.     

Patient-controlled fascia iliaca compartment block versus fentanyl patient-controlled intravenous analgesia in patients undergoing femur fracture surgery

Background and objectives

Postoperative pain relief is crucial in elderly, however, the use of opioids is limited owing to their potential side effects. We studied the effects of patient-controlled ultrasound guided fascia iliaca compartment block (FICB) with Levobupivacaine versus patient-controlled intravenous fentanyl on postoperative pain score in patients scheduled for fixation of femur fractures under general anesthesia.

Continuous subgluteus sciatic nerve block after orthopedic foot and ankle surgery: comparison of two infusion techniques

BACKGROUND AND OBJECTIVE: To compare continuous infusion or a patient-controlled technique for postoperative analgesia after foot surgery, using a new subgluteus approach for continuous sciatic nerve block. METHODS: Fifty healthy patients, undergoing orthopedic foot surgery, received a continuous sciatic nerve block using a new subgluteus approach. All blocks were placed with the aid of a nerve stimulator using a 10-cm, 18-gauge insulated Tuohy needle. After either plantar flexion or dorsiflexion of the operated foot was elicited at < or = 0.5 mA, 20 mL of 0.75% ropivacaine was injected incrementally using repeated aspiration tests, then followed by the introduction of a 20-gauge epidural catheter. Postoperatively, 0.2% ropivacaine was infused with either a 10 mL/h continuous infusion (group Continuous, n = 25) or with a 5 mL/h basal rate with 5 mL bolus every 60 minutes (group patient-controlled analgesia [PCA], n = 25). Intraoperative analgesic supplementation, as well as postoperative pain relief, morphine consumption, incidence of complication, and patient satisfaction were recorded by an observer unaware of group assignment. RESULTS: The sciatic catheter was successfully placed in all patients. Intravenous fentanyl supplementation (dose range, 50 to 150 microg) was required in 4 patients in each group, but no patient required general anesthesia. Catheter dislocation was reported in 2 patients (4%). The quality of pain relief was good in both groups, and none experienced complications. Nine patients of the Continuous group (37%) and 7 patients of the PCA group (29%) required rescue morphine analgesia because of pain in the femoral dermatomes (P =.76). Ropivacaine consumption was 240 mL in the Continuous group (range, 200 to 240 mL) and 140 mL in the PCA group (range, 120 to 290 mL) (P =.0005). Patient acceptance was good in both groups. CONCLUSIONS: The continuous subgluteus sciatic nerve block represents an easy and reliable option for postoperative analgesia after foot surgery; using a patient controlled rather than a continuous infusion technique reduces the consumption of local anesthetic solution without affecting the quality of pain relief.     

Postoperative analgesia with tramadol and metamizol. Continual infusion versus patient controlled analgesia

OBJECTIVE: The study compares the i.v. analgesia of tramadol and dipyrone delivered either as continuous infusion or as patient controlled analgesia (PCA). METHODS: After approval by the local ethics committee and informed consent 203 patients recovering from abdominal surgery were randomly assigned to pain treatment either by PCA or continuous intravenous infusion.Both groups received the same analgesic drug combination of tramadol (20 mg/ml) and dipyrone (200 mg/ml).The PCA bolus was set to 1 ml, the continuous infusion varied between 0-8 ml/h according to individual needs.Demographic and surgery related data were compared between the treatment groups, as well as pain scores, analgesic consumption and response rates over a 48 hour study period.A patient was assessed as non responder when rescue medication was necessary during the study period or the patient rated analgesia as insufficient during the final interview. RESULTS: In total,data of 191 patients (infusion-group: 94, PCA-group: 97) could be analyzed.Tramadol consumption was higher in the infusion group compared to the PCA-group (48 hours: 1009.4+/-494.4 vs. 813.0+/-585.3 mg;p<0.001) with no difference in pain scores. In the infusion group, significantly more interventions were necessary to adjust the infusion rate to individual needs (min-max: 1-15 vs. 0-2).The number of non responders amounted to 30 (31.9%) and 18 (18.6%;p=0.03) in the infusion and PCA group, respectively. CONCLUSIONS: PCA with tramadol and dipyrone can be considered an alternative for postoperative pain management and provided a more individualized treatment approach with lower analgesic consumption and more responders compared to a continuous infusion.     

氟比洛芬酯在膝关节置换手术后的应用

目的观察氟比洛芬酯对膝关节置换手术后患者运动痛及功能恢复的镇痛的效果。方法本组333例TKA手术患者,术后镇痛方式随机分为二组：A组PCA镇痛＋氟比洛芬酯,B组PCA镇痛。记录两组各时间点的VAS评分,镇静状态评分,活动度评分,安全评价指标。结果二组之间VAS评分（t=2．900,P〈0．05）、活动度评分差异有统计学意义（t=3．027,P〈0．05）,镇静状态评分无统计学意义（t=1．337,P〉0．05）。恶心、呕吐、瘙痒、运动及感觉障碍,A组发生率明显高于B组,差异有统计学意义。结论氟比洛芬酯用于膝关节置换手术,术后静脉镇痛效果确切,镇痛满意度高,可安全用于膝关节置换患者手术镇痛,值得推广。     

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty

BACKGROUND AND OBJECTIVES: Regional analgesic techniques allow better postoperative rehabilitation and shorter hospital stay after major knee surgery. The authors tested the hypothesis that similar results could be obtained after total-hip arthroplasty. METHODS: Forty-five patients scheduled for THA under general anesthesia were randomly divided into 3 groups. Postoperative analgesia was provided during the first 48 hours, with intravenous patient-controlled analgesia (IV PCA) induced by morphine (dose, 1.5 mg; lockout interval, 8 min) in group IV, continuous femoral nerve sheath block in group FNB, and continuous epidural analgesia in group EPI. The day after surgery, the 3 groups started identical physical therapy regimens. Pain scores at rest and on movement, supplemental analgesia, side effects, daily degree of maximal hip flexion and abduction, day of first walk, and duration of hospital stay were recorded. RESULTS: Population data, quality of pain relief, postoperative hip rehabilitation, and duration of hospital stay were comparable in the 3 groups. When compared with the two other techniques, continuous FNB was associated with a lower incidence of side effects (no nausea/vomiting, urinary retention, arterial hypotension, or catheter problem during the first 48 hours in 20%, 60%, and 13% of patients in groups IV, FNB, and EPI, respectively). CONCLUSIONS: This study suggests that IV PCA with morphine, continuous FNB, and continuous epidural analgesia provide similar pain relief and allow comparable hip rehabilitation and duration of hospital stay after total-hip arthroplasty (THA). As continuous FNB is associated with less side effects, it appears to offer the best option of the three.     

Treatment of postoperative pain for burn patients with intravenous analgesia in continuous perfusion using elastomeric infusors

INTRODUCTION: Postoperative pain after surgery with patients suffering from burns tends to be moderate or severe, and its treatment requires a combination of high-strength analgesics (opioids) with others having different action mechanisms according to the concept of multimodal analgesia. AIMS: In this article we propose the use of continuous intravenous analgesia with morphine using elastomeric infusors at fixed dose for the treatment of this kind of pain. An evaluation is made of its analgesic efficacy, side effects and level of satisfaction. MATERIAL AND METHODS: A study was made of 17 burn patients operated on in our unit who received continuous intravenous analgesia during the postoperative period, with morphine at 1mg/h, using elastomeric infusors for a period of 24h. Its analgesic efficacy was analysed using the visual analogical scale (VAS) at different moments; side effects and the level of acceptance by the patient was also evaluated. RESULTS: The results confirm a good analgesic effect after 2h from starting perfusion (VAS < 3). The side effects reveal a similar or lesser incidence to the use of morphine in bolus or using the PCA system, and in no cases did they require treatment to be halted. The level of acceptance of the procedure by patients was good. CONCLUSION: This method reveals a high level of analgesic efficacy in the postoperative period with burn patients in this study. However, it is important to note the lower results obtained in the first hours of perfusion, and proposing a heavy initial dose of analgesics when starting perfusion. This is presented as an efficient analgesic method that is easy to apply, has a low cost, and the possibility of extending its indications to ambulatory treatment.     

Improved pain management outcomes with continuous infusion of a local anesthetic after thoracotomy

OBJECTIVE: We sought to determine the effectiveness of an incisional infusion of local anesthetics through a continuous-infusion elastomeric pump for the management of postoperative pain after thoracotomy. METHODS: We performed a retrospective comparative analysis of 110 patients undergoing thoracotomies between November 1999 and March 2003. Postoperative pain management with a continuous-infusion elastomeric pump providing local anesthetic into the incisional area was compared with a single-shot epidural in combination with continuous local anesthetic infusion and continuous thoracic epidural infusion. Data sources were reviewed for mean narcotic use, pain score, and complications. RESULTS: After thoracotomy procedures, 38 patients received the ON-Q Pain Relief System (I-Flow Corp, Lake Forest, Calif), 32 received the ON-Q device and single-shot epidural infusion, and 40 received continuous epidural infusion. Demographic attributes, including age, body mass index, and sex were similar between the groups. Preoperative American Society of Anesthesiologists status was significantly higher in the ON-Q group compared with that in the other groups (P = .02). Narcotic use and pain scores were significantly reduced in the ON-Q group compared with that in the epidural group at all time points (P < .001). There were no wound-healing complications or infections associated with the use of the pump. CONCLUSION: A continuous infusion of 0.25% bupivacaine at 4 mL/h through the ON-Q elastomeric infusion pump is a safe and effective adjunct in postoperative pain management after thoracotomy. The use of the ON-Q Pain Relief System results in decreased narcotic use and lower pain scores compared with continuous epidural infusion.     

Efficacy of patient-controlled epidural analgesia using a disposable PCA device

We evaluated efficacy of patient-controlled epidural analgesia (PCEA) using a disposable PCA device (3.0 ml type). Twenty-two patients for elective gynecological surgery were randomized into two groups. Patients of the continuous epidural group received epidural fentanyl (15 micrograms.ml-1) with bupivacaine (1.25 mg.ml-1) from a disposable infusion pump (infusion rate: 2.1 ml.hr-1). Patients of the PCEA group received the same anesthetic solution from the same infusion pump serially connected to the disposable PCA device. There were no significant differences in postoperative visual analogue scale (VAS) scores at rest and with movement between the two groups. However, VAS scores significantly decreased from 6.8 +/- 1.6 to 1.0 +/- 1.3 when the PCA device was used for severe pain. This suggests that segmental analgesic effect might be obtained by diffusion of anesthetic solution in the epidural space after 3.0 ml PCEA bolus administration. The incidences of side effects were similar in both groups. Respiratory depression and sedative effects were not observed in both groups. We conclude that PCEA using a disposable PCA device (3.0 ml type) seems to be effective for postoperative pain relief.     

Extubation time, hemodynamic stability, and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal antiinflammatory drugs with propofol for perioperative and postoperative management

STUDY OBJECTIVE: To compare three anesthetic strategies with respect to the time of extubation after coronary artery bypass graft (CABG) surgery and to assess patient satisfaction with the procedure. DESIGN: Prospective, randomized, clinical study. SETTING: Tertiary-care referral center. PARTICIPANTS: 180 cardiac surgical patients undergoing primary CABG from January through June 2004. INTERVENTIONS: After induction of general anesthesia, patients were allocated to one of three groups. All three groups received a continuous infusion of intravenous (IV) propofol perioperatively and postoperatively. Group 1 (fentanyl infusion group, n = 60) received continuous IV fentanyl infusion perioperatively and postoperatively for analgesia. Group 2 (diclofenac group, n = 60) received fentanyl bolus doses intraoperatively and diclofenac suppository postoperatively. Group 3 (remifentanil group, n = 60) received continuous infusion of IV remifentanil perioperatively and IV fentanyl as an immediate postoperative bolus followed by continuous fentanyl infusion. Duration of postoperative ventilation up to the time of extubation, inotrope requirement, time at which analgesic infusion was discontinued, postextubation arterial blood gas analysis, pain evaluation via visual analog scale, need for rescue analgesia, awareness during surgery, and length of postcardiac surgical unit stay, were evaluated in each patient. MAIN RESULTS: The diclofenac group exhibited the shortest time to extubation, the least inotrope use, and the fewest rescue doses of analgesic than did patients of the other two groups. CONCLUSION: Intravenous propofol with bolus doses of IV fentanyl intraoperatively in combination with postoperative nonsteroidal antiinflammatory drugs had the best recovery profile in patients undergoing primary CABG than did the other two regimens studied.     

罗哌卡因硬膜外持续输注下氯诺昔康PCIA的临床效应

目的 研究硬膜外持续输注罗哌卡因期间氯诺昔康静脉PCA的临床效应和不良反应,并以吗啡对照比较。方法 选择60例(ASAⅠ～Ⅱ)妇科经腹子宫全切手术病人,随机分为L组与M组,双盲观察,均采用双泵行PCA治疗。其PCA设置为Bolus 1ml/次,锁定时间为5min,1h限量12ml。镇痛效果和副作用评定:(1)采用视觉模拟评分(VAS),0为无痛、10为剧痛。(2)BCS舒适评分。(3)病人对PCA总体印象评分。(4)记录可能出现的并发症和不良反应。结果 两组病人的一般情况相似,24h硬膜外罗哌卡因使用剂量均为192mg,L组与M组未按压PCA泵的病人各为5例(21.7％),静脉PCA用药剂量分别为(3.4±2.8)mg(L组)和(4.7±3.5)mg(M组),两药用量比值为1:1.4(P>0.05);相同时间段内两组间VAS、BCS、Bromage评分及D1/D2比值均无统计学差异。结论0.2％罗哌卡因硬膜外持续输注(4ml/h)能明显减少静脉PCA用量,新型非甾体类抗炎药氯诺昔康与吗啡静脉用药效价相似,但氯诺昔康对病人恶心呕吐的不良反应具有明显减少的优点。     

Continuous psoas and sciatic block after knee arthroplasty: good effects compared to epidural analgesia or i.v. opioid analgesia: a prospective study of 63 patients

Introduction For endoprosthetic knee surgery, intensive postoperative pain therapy is necessary. We therefore evaluated whether the combination of continuous psoas compartment and sciatic analgesia (PSC) is as effective as epidural analgesia (EPI) and whether it provides better analgesia than patient-controlled intravenous analgesia with piritramide (PCA).

Methods We studied 63 patients who underwent total knee arthroplasty (TKA). The PSC group received a combination of continuous psoas and sciatic nerve block, the EPI group an epidural analgesia, and the PCA group an intravenous patient-controlled piritramide pump. Pain scores, satisfaction, flexion and side effects were recorded.

Results Pain scores (0-10) were higher in the PCA group (on movement, day 1/day 2: 7.0/6.5) than in the EPI group (5.0/5.0) and the PSC group (4.0/3.5). Postoperative opioid consumption over 48 h was higher in the PCA group (51 mg) than in the EPI group (0 mg) and the PSC group (0 mg). There were no differences in functional recovery. Pruritus occurred more frequently in the PCA and EPI groups than in the PSC group. Patients receiving a PSC and EPI were more satisfied than those treated with PCA.

Interpretation Analgesia with PSC catheters or EPI catheter is superior to PCA regarding pain levels, analgesic requirements, and patient satisfaction. There was no difference in functional outcome between the 3 groups.     

Continuous psoas and sciatic block after knee arthroplasty: good effects compared to epidural analgesia or i.v. opioid analgesia: A prospective study of 63 patients

Introduction?For endoprosthetic knee surgery, intensive postoperative pain therapy is necessary. We therefore evaluated whether the combination of continuous psoas compartment and sciatic analgesia (PSC) is as effective as epidural analgesia (EPI) and whether it provides better analgesia than patient-controlled intravenous analgesia with piritramide (PCA).

Methods?We studied 63 patients who underwent total knee arthroplasty (TKA). The PSC group received a combination of continuous psoas and sciatic nerve block, the EPI group an epidural analgesia, and the PCA group an intravenous patient-controlled piritramide pump. Pain scores, satisfaction, flexion and side effects were recorded.

Results?Pain scores (0–10) were higher in the PCA group (on movement, day 1/day 2: 7.0/6.5) than in the EPI group (5.0/5.0) and the PSC group (4.0/3.5). Postoperative opioid consumption over 48 h was higher in the PCA group (51?mg) than in the EPI group (0?mg) and the PSC group (0?mg). There were no differences in functional recovery. Pruritus occurred more frequently in the PCA and EPI groups than in the PSC group. Patients receiving a PSC and EPI were more satisfied than those treated with PCA.

Interpretation?Analgesia with PSC catheters or EPI catheter is superior to PCA regarding pain levels, analgesic requirements, and patient satisfaction. There was no difference in functional outcome between the 3 groups.     

Use of a continuous local anesthetic infusion for pain management after median sternotomy

BACKGROUND: The use of large doses of opioid analgesics to treat pain after cardiac surgery can prolong the time to tracheal extubation and interfere with recovery of bowel and bladder function in the postoperative period. Therefore, the authors investigated the efficacy of a continuous infusion of bupivacaine 0.25% or 0.5%, at the median sternotomy site, for 48 h after cardiac surgery in reducing the opioid analgesic requirement and improving the recovery process. METHODS: In this prospective, randomized, placebo-controlled, double-blind clinical trial, 36 consenting patients undergoing open-heart surgery with a standardized general anesthetic technique had two indwelling infusion catheters placed at the median sternotomy incision site at the end of surgery. The patients were randomly assigned to receive normal saline (control), bupivacaine 0.25% or bupivacaine 0.5% via an elastomeric infusion pump at a constant rate of 4 ml/h for 48 h. Patients evaluated their chest pain using an 11-point verbal rating scale, with 0 = no pain to 10 = worst pain imaginable. In addition, the postoperative opioid analgesic requirements and opioid-related adverse effects were recorded. Patient satisfaction with their pain management was assessed at specific intervals during the postoperative period using a 100-point verbal rating scale, with 1 = highly dissatisfied to 100 = highly satisfied. Finally, serum bupivacaine concentrations were measured 24 and 48 h after surgery. RESULTS: Compared with the control group, there was a statistically significant reduction in verbal rating scale pain scores and patient-controlled analgesia morphine use in the bupivacaine-0.5% group. Patient satisfaction with their pain management was also improved in the bupivacaine-0.5% (vs. control) group. However, there were no significant differences in patient-controlled analgesia morphine use between the bupivacaine-0.25% and control groups. Although the duration of the intensive care unit stay (30 vs. 34 h, respectively) was not significantly decreased, the time to ambulation (1 +/- 0.5 vs. 2 +/- 1 days, respectively) and the duration of hospital stay (4.2 vs. 5.7 days, respectively) were lower in the bupivacaine-0.5% group than in the control group. Mean +/- SD serum bupivacaine concentrations at 48 h in the bupivacaine-0.25% and bupivacaine-0.5% groups were 0.5 +/- 0.5 and 1.3 +/- 0.7 microg/ml, respectively. CONCLUSION: A continuous infusion of bupivacaine 0.5% at 4 ml/h is effective for decreasing pain and the need for opioid analgesic medication as well as for improving patient satisfaction with their pain management after cardiac surgery. Patients in the bupivacaine-0.5% group were able to ambulate earlier, leading to a reduced length of hospital stay.     

小儿术后硬膜外自控镇痛的临床效果

目的：探讨小儿术后硬膜外自控镇痛（ＰＣＥＡ）的可行性和安全性。方法;术后５￣１１岁的小儿４０例,分成Ａ、Ｂ两组。Ａ组镇痛液配方０．０７５％布比卡因＋０．００１２％丁丙诺啡,Ｂ组配方与Ｓ组相同并加入小剂量氟哌啶,以ＬＣＰ模式实施ＰＣＥＡ。结果：Ｂ组２天用量均少于Ａ组（Ｐ〈０．０１￣０．０５）,从三种评分指标和并发症综合比较分析,提示两组均能达到满意的镇痛效果,但Ｂ组优于Ａ组。结论：小儿术后用０．０７     

Qualität der postoperativen Schmerztherapie

Background

Despite well-designed concepts of perioperative pain management, recent studies have revealed that a large number of patients still suffer from unacceptable pain after surgery. The purpose of this prospective evaluation was to critically analyze postoperative pain treatment provided by a routinely established, DIN certified acute pain service (APS) at the University Hospital Großhadern in Munich.

Materials and methods

A total of 1,000 consecutive patients received one of the following analgesic procedures: continuous epidural analgesia (EA, n?=?401), continuous and patient-controlled epidural analgesia (PCEA, n?=?305), intravenous patient-controlled analgesia with opioids (PCA, n?=?169) or continuous peripheral nerve block (CPNB, n?=?125). For EA and PCEA, ropivacaine 0.2?% and sufentanil 0.24 µg/ml were administered while peripheral regional analgesia was performed with infusion of ropivacaine 0.2?% only. Patients with PCEA were allowed a 3 mg bolus once per hour on demand. Standardized intravenous PCA was performed with piritramide 2.5 mg/ml, a bolus of 2.5 mg, a lock-out time of 15 min, a maximum of 25 mg/4 h and no background infusion. During the daily visits the APS assessed pain intensity at rest and during movement on a numerical rating scale from 0 (no pain) to 10 (maximum pain), acceptance of pain, satisfaction with the analgesic procedure, demand of additional non-opioid analgesics, the need for optimization including bolus applications and changes of the infusion rate or retraction of the epidural catheter. The duration of the procedures, side effects and complications were documented. The catheter insertion sites were inspected daily for redness and tenderness on palpation.

Results

In general, epidural and peripheral regional analgesic techniques were superior in terms of postoperative analgesia to intravenous opioid PCA and were associated with fewer side effects, such as sedation, nausea, vomiting, obstipation and sensorimotor deficits. A subgroup analysis revealed that in major upper abdominal surgery, EA provided significantly better analgesia at rest and during movement than PCA. In lower abdominal surgery PCEA induced significantly better analgesia than both PCA and EA, especially during movement. Patient satisfaction was generally high and was best with PCEA (95?%) followed by CPNB (94?%), EA (91?%) and PCA (88?%). On the first postoperative day analgesic procedures had to be optimized (e.g. by bolus administration, retraction of catheters or changes to standardized PCA) in 23?% of EA patients, 10?% of PCEA patients, 6?% of PCA patients and 12?% of CPNB patients. Major complications, such as neuraxial hematoma, infections or respiratory depression were not observed.

Conclusions

As described in many prospective studies, this evaluation revealed that for postoperative pain control, regional anesthesia is superior to intravenous patient-controlled analgesia with strong opioids in terms of analgesia and side effects. In the setting of a well-organized acute pain service with frequent education and training of all members involved, postoperative pain management is safe and effective. However, regular re-evaluation of the defined and certified procedures is necessary.     

Continuous lumbar plexus block provides improved analgesia with fewer side effects compared with systemic opioids after hip arthroplasty: a randomized controlled trial

BACKGROUND AND OBJECTIVES: A single injection lumbar plexus block for acute pain management after hip surgery is usually limited to the immediate postoperative period. We conducted a randomized controlled trial to determine the effect of a continuous lumbar plexus block on perioperative opioid requirements and pain intensity. METHODS: Adult patients undergoing elective hip arthroplasty under general anesthesia were randomized to continuous lumbar plexus block combined with patient-controlled analgesia (PCA) or PCA only for postoperative pain. Patients allocated to the lumbar plexus block had the catheter placed before surgery. Patients were followed for 36 hours. Perioperative opioid requirement was the primary outcome; secondary outcomes included assessment of pain intensity, patient and surgeon satisfaction with the analgesic technique, and occurrence of nausea and vomiting. RESULTS: Seventeen patients were randomized to each treatment group. Compared with patients in the PCA group, patients in the continuous lumbar plexus block group required less morphine (12 mg) (95% CI, -12.9 to -3.9), had on average less pain (-2.1 units on a 0 to 10 scale) (95% CI, -3.8 to -1.1), were more satisfied with their analgesic technique, and experienced less nausea and vomiting. One patient in the continuous lumbar plexus block developed a delayed paresis and 1 patient in the PCA group developed respiratory depression. CONCLUSIONS: Continuous lumbar plexus block combined with PCA is superior to PCA alone for postoperative pain management following hip replacement. It reduces opioid requirements, opioid related side effects, and enhances patient satisfaction. However, additional research is required to determine its safety in light of the neurologic injury observed.     

Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA

We have compared the efficacy of patient-controlled interscalene analgesia (PCIA) using ropivacaine with patient-controlled analgesia (PCA) using nicomorphine in 60 patients (n = 30 in each group), in a prospective, randomized study. In both groups, all patients received interscalene block with 0.75% ropivacaine before induction of anaesthesia. Six hours after interscalene block, patients in group PCIA received continuous infusion of 0.2% ropivacaine at a rate of 5 ml h-1 with a bolus dose of 3 or 4 ml and a lockout time of 20 min; patients in group PCA received continuous infusion of nicomorphine 0.5 mg h-1 and a bolus dose of 2 or 3 mg with a lockout time of 20 min. Control of pain was significantly better from 12 to 48 h after operation (except at 42 h) in group PCIA. Nausea and pruritus occurred significantly more frequently in group PCA. Patient satisfaction was greater in group PCIA. We conclude that the use of 0.2% ropivacaine using PCIA was an efficient way of managing pain after major shoulder surgery and compared favourably with PCA nicomorphine in terms of pain relief, side effects and patient satisfaction.      

Effect of patient-controlled perineural analgesia on rehabilitation and pain after ambulatory orthopedic surgery: a multicenter randomized trial

BACKGROUND: Efficacy of continuous perineural and patient-controlled ropivacaine infusion at home after orthopedic surgery was compared with patient-controlled intravenous morphine for functional recovery and postoperative analgesia in a multicenter randomized trial. METHODS: Eighty-three patients scheduled to undergo acromioplasty or hallux valgus surgery received an interscalene (n = 40) or popliteal (n = 43) peripheral nerve block with 30 ml ropivacaine, 0.5%. After randomization, patients were discharged home 24 h after surgery with a disposable infusion pump delivering either patient-controlled intravenous morphine (n = 23) or perineural 0.2% ropivacaine infusion, either continuous infusion without bolus (n = 30) or basal infusion plus bolus (n = 30). The patients recorded pain scores on movement and/or walking and were directed to take paracetamol and rescue analgesics if necessary. The time necessary to be able to walk for 10 min; daily activities on days 1, 2, and 3; adverse events; and overall satisfaction scores were noted and graded by the patient. RESULTS: Basal-bolus ropivacaine decreased the time to 10 minutes' walk, optimized daily activities (P < 0.01), and decreased the amount of ropivacaine used. The morphine group had greater pain scores and consumption of morphine and ketoprofen compared with both ropivacaine groups (P < 0.05). The incidence of nausea/vomiting, sleep disturbance, and dizziness increased, and the patient satisfaction score decreased in the morphine group (P < 0.05). CONCLUSIONS: After ambulatory orthopedic surgery, 0.2% ropivacaine delivered as a perineural infusion using a disposable elastomeric pump with patient-controlled anesthesia bolus doses optimizes functional recovery and pain relief while decreasing the consumption of rescue analgesics and ropivacaine, and the number of adverse events.