The dose-response relationship for clonidine added to a postoperative continuous epidural infusion of ropivacaine in children.

Epidurally administered clonidine enhances the quality and duration of postoperative analgesia when it is used as an adjunct to local anesthetics in children. We investigated the dose-response relationship for epidural clonidine when added to a continuous postoperative epidural infusion of ropivacaine. By use of an observer-blinded design, 55 pediatric patients (1-4 yr old) were randomly given a postoperative epidural infusion of plain ropivacaine 0.1% 0.2 mg. kg(-1). h(-1) (Group R), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.04 microg. kg(-1). h(-1) (Group RC1), ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.08 microg. kg(-1). h(-1) (Group RC2), or ropivacaine 0.08% 0.16 mg. kg(-1). h(-1) plus clonidine 0.12 microg. kg(-1). h(-1) (Group RC3). A clear dose-response relationship could be identified for a continuous infusion of epidural clonidine, with clonidine dosages in the 0.08-0.12 microg. kg(-1). h(-1) range providing improved postoperative analgesia (reduced Children's Hospital of Eastern Ontario pain score, increased time to first supplemental analgesic demand, and a reduced total number of doses of supplemental analgesics during the first 48 h after surgery). Analgesia was improved without any signs of increased sedation or other side effects. The adjunct use of epidural clonidine in the dosage range of 0.08-0.12 microg. kg(-1). h(-1) appears effective and safe for use in children. Implications: The addition of clonidine (0.08-0.12 microg.kg(-1).h(-1))to a continuous epidural infusion of ropivacaine was found to improve postoperative pain relief in children. No clinically significant signs of sedation or other side effects were observed.     

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.     

Oral clonidine premedication enhances postoperative analgesia by epidural morphine

This study was designed to evaluate the effects of oral clonidine premedication on postoperative analgesia by epidural morphine in a prospective, randomized, double-blinded design. Sixty consenting patients, scheduled for total abdominal hysterectomy, were randomly assigned to one of three groups (n = 20 each); the clonidine-morphine group received oral clonidine 5 microg/kg 90 min before arriving in the operating room and epidural morphine 2 mg before induction of general anesthesia, the clonidine-placebo group received oral clonidine 5 microg/kg and no epidural morphine, and the placebo-morphine group received no clonidine and epidural morphine 2 mg. An epidural catheter was placed at the L1-2 or L2-3 interspace, and 1.5% lidocaine was used for surgical anesthesia in all patients. General anesthesia was then induced with propofol, and maintained with a continuous infusion of propofol and 67% nitrous oxide in oxygen during surgery. Four patients were subsequently withdrawn from the study. After surgery, patient-controlled analgesia using IV morphine was used to assess analgesic requirement. Morphine consumptions determined every 6 h after surgery in the clonidine-morphine and placebo-morphine groups were significantly less than the clonidine-placebo group until 12 h after surgery, whereas those of the clonidine-morphine group were significantly less than the placebo-morphine group from 13 to 42 h after surgery. Visual analog (pain) scale (VAS) scores in the clonidine-morphine group were significantly lower than the placebo-morphine group at 48 h at rest, and at 1, 24, 36, and 48 h with movement. Similarly, VAS scores in the clonidine-morphine group were significantly lower than the clonidine-placebo group at 1 and 6 h both at rest and with movement, whereas VAS scores in the clonidine-placebo group were significantly lower than the placebo-morphine group at 24, 36, and 48 h at rest and with movement. The incidence of nausea and pruritus was similar between groups. We conclude that the combination of oral clonidine and epidural morphine produces more potent and longer lasting postoperative analgesia than either drug alone without increasing the incidence of adverse effects after major gynecologic surgeries. IMPLICATIONS: A small dose of epidural morphine is often used for postoperative analgesia. We found that oral clonidine premedication 5 microg/kg improves the analgesic efficacy of epidural morphine without increasing the incidence of adverse side effects.     

Adding clonidine to the induction bolus and postoperative infusion during continuous femoral nerve block delays recovery of motor function after total knee arthroplasty

We evaluated the effects of adding clonidine for continuous peripheral nerve infusions. Sixty patients undergoing total knee arthroplasty under combined single-injection sciatic block and continuous femoral infusion were randomly allocated to three groups: block induction with 0.75% ropivacaine followed by 0.2% ropivacaine (group control; n = 20); block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine (group cloni-bolus; n = 20), and block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine with 1 microg/mL clonidine (group cloni-infusion; n = 20). After surgery, continuous femoral infusion was provided with a patient-controlled infusion pump (basal infusion rate, 6 mL/h; incremental dose, 2 mL; lockout time, 15 min). The median (range) onset time of surgical block was 15 min (5-30 min) in group control, 10 min (5-35 min) in group cloni-bolus, and 10 min (5-30 min) in group cloni-infusion (P = 0.07). No differences were reported among groups in the degree of pain measured with the visual analog scale. The total consumption of local anesthetic solution after a 24-h infusion was 170 mL (144-220 mL) in group control, 169 mL (144-260 mL) in group cloni-bolus, and 164 mL (144-248 mL) in group cloni-infusion (P = 0.51); after the second day of infusion, total consumption was 168 mL (144-200 mL) in group control, 156 mL (144-288 mL) in group cloni-bolus, and 150 mL (144-210 mL) in group cloni-infusion (P = 0.48). Hemodynamic profiles and sedation were similar in the three groups. Motor function impairment after 48 h of infusion was observed in 27% of cloni-infusion patients but in only 6% of both the control and cloni-bolus groups (P = 0.05). We conclude that adding clonidine 1 microg/mL to local anesthetic for continuous femoral nerve block does not improve the quality of pain relief but has the potential for delaying recovery of motor function.     

Pre- and intraoperative epidural ropivacaine have no early preemptive analgesic effect in major gynecological tumour surgery

PURPOSE: Thoracic epidural analgesia (TEA) is an established technique for postoperative pain relief after major abdominal surgery. However it is still under discussion whether pre-incisional TEA can reduce postoperative pain perception or postoperative analgesic consumption. METHODS: The present prospective, randomized, double-blind study was performed to investigate the effects of intra- and postoperative TEA vs only postoperative TEA using ropivacaine 0.375% in 30 women scheduled for major abdominal tumour surgery. Prior to induction of general anesthesia patients received an epidural bolus of 10 mL saline in Group I (GI) and 10 mL ropivacaine 0.375% in Group II (GII) followed by an infusion of 6 mL x hr(-1) of the respective solution during surgery. Postoperatively all patients received an epidural infusion of 6 mL x hr(-1) ropivacaine 0.375% during 24 hr followed by patient controlled epidural analgesia for the next 72 hr. Operative data, dynamic pain scores, consumption of local anesthetics and standardized supplemental analgesics were analyzed. RESULTS: No difference was seen between groups with respect to the amount of required postoperative local anesthetics and supplemental analgesics, pain scores and side effects during the first 96 hr following surgery except a reduction of intraoperative sufentanil consumption (GI: 143.2 +/- 52.6 vs GII: 73.3 +/- 32.6 microg, P < 0.001). CONCLUSION: Intraoperative TEA with ropivacaine 0.375% did not significantly reduce the amount of analgesics required after major abdominal gynecological tumour surgery.     

Analgesic effect of clonidine added to bupivacaine 0.125% in paediatric caudal blockade

BACKGROUND: Caudals are a common method of providing pain relief in children undergoing surgery. Clonidine, an alpha(2) agonist, exhibits significant analgesic properties. The current investigation sought to determine whether caudal clonidine added to caudal bupivacaine would decrease pain in paediatric patients undergoing surgery. METHODS: Thirty-six children undergoing elective surgery were studied. Following anaesthetic induction, a caudal was placed (1 mg.kg(-1) bupivacaine 0.125%) with an equal volume of either clonidine (2 microg.kg(-1)) or saline. Perioperative analgesic requirements in the postanaesthesia care unit (PACU) and at home following hospital discharge, and parental pain scores were evaluated. RESULTS: There were no significant demographic, haemodynamic, or pain score differences between the groups. There was no difference in analgesic duration between groups. There were significantly more children who vomited during the first 24 postoperative hours in the clonidine group than in the saline group (eight in clonidine, two in saline; P < 0.05). CONCLUSION: We do not recommend adding clonidine (2 microg.kg(-1)) to a bupivacaine (0.125%) caudal block in children undergoing surgery.     

The effect of clonidine on the minimum local analgesic concentration of epidural ropivacaine during labor

On the basis of the determination of minimum local analgesic concentration (MLAC), ropivacaine has been demonstrated to be less potent than bupivacaine during the first stage of labor. In this study we assessed the effect of clonidine on the MLAC of ropivacaine. Seventy-seven parturients of mixed parity requesting epidural analgesia for labor (cervical dilation, 3-7 cm) were included in the study. They received an epidural bolus of either ropivacaine (n = 30), ropivacaine plus clonidine 30 microg (n = 28), or ropivacaine plus clonidine 60 microg (n = 19) in the second part of the study. The concentration of the ropivacaine solution was determined by the response of the previous parturient in that group by using an up-down sequential allocation. A visual analog pain score of < or =10 mm within 30 min after the epidural bolus (20 mL) was considered an effective response. An effective result directed a 0.01% wt/vol decrement for the next patient. An ineffective result directed a 0.01% wt/vol increment. The MLAC of ropivacaine was 0.097% wt/vol (95% confidence interval, 0.085%-0.108%). It was unaffected by a 30-microg dose of epidural clonidine (0.081% [0.045%-0.117%]) but was significantly decreased by a 60-microg clonidine dose (0.035% [0.024%-0.046%]) (P < 0.001). This study documents a decrease in the MLAC of ropivacaine by clonidine, significant for a 60- microg dose. IMPLICATIONS: Epidural ropivacaine potency in labor can be increased by the addition of epidural clonidine. This study demonstrates that 60 microg of epidural clonidine significantly decreases the minimum local analgesic concentration of ropivacaine during the first stage of labor but is associated with sedation.     

The effect of intravenous ketoprofen on postoperative epidural sufentanil analgesia in children.

We compared the effect of IV ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia after major surgery. We used a prospective, randomized, double-blinded, placebo-controlled, parallel-group study design in 54 children aged 1-15 yr who received a standardized anesthetic. Either IV ketoprofen or saline was administered in addition to an epidural sufentanil infusion, which was adjusted as required clinically. The study drug infusions were discontinued when pain scores were <3 on 0-10 scale for 6 h at a sufentanil infusion rate of 0.03 microg x kg(-1) x h(-1). Children in the ketoprofen group had a better analgesic effect, as shown by decreased need for sufentanil (mean [10th-90th percentiles] 8.3 [3.1-15.1] microg/kg vs 12.5 [6.2-18.9] microg/kg; P = 0.002) and earlier possibility to discontinuation of the epidural sufentanil (11 [46%] vs 3 [13%]; P = 0.014) before the end of the 72-h study period. In the ketoprofen group, median (range) pain scores were lower during activity at 24 h (2 [0-5] vs 5 [0-7]; P = 0.01) and at 72 h (0 [0-3] vs 2 [0-6]; P = 0.033), and fewer children had inadequate pain relief during activity at 24 h (0 vs 5; P = 0.037). Children who received ketoprofen required fewer infusion rate adjustments (12 [4-20] vs 17 [6-42]; P = 0.016). In the ketoprofen group, the incidence of desaturation (1 [4%] vs 6 [26%]; P = 0.035) and fever (3 [12%] vs 11 [48%]; P = 0.008) was less than that in the placebo group. We conclude that ketoprofen improved postoperative pain in children. IMPLICATIONS: We compared the effect of the IV nonsteroidal antiinflammatory drug ketoprofen versus placebo as adjuvants to epidural opioid analgesia with sufentanil. The continuous IV nonsteroidal antiinflammatory drug improved pain after major surgery in children receiving an epidural opioid. Although ketoprofen reduced epidural sufentanil requirements, the incidence of opioid-related adverse effects was not changed.     

Comparison of the effects of clonidine and ketamine added to ropivacaine on stress hormone levels and the duration of caudal analgesia

BACKGROUND: The purpose of this study was to compare the analgesic quality and duration of ropivacaine 0.2% with the addition of clonidine (1 microg.kg(-1)) with that of ropivacaine 0.2% and the addition of ketamine (0.5 mg.kg(-1)) to that of ropivacaine 0.2% and also compare the postoperative cortisol, insulin and glucose concentrations, sampled after induction and 1 h later following caudal administration in children. METHODS: According to the randomization, patients in the ropivacaine group (R; n = 25) received ropivacaine 0.2%, 0.75 ml.kg(-1); those in the clonidine group (RC; n = 25) received ropivacaine 0.2% 0.75 ml.kg(-1) plus clonidine 1 microg.kg(-1) and those in the ketamine/ropivacaine group (RK; n = 25) ropivacaine 0.2% 0.75 ml.kg(-1) plus ketamine 0.5 mg.kg(-1) (10 mg.ml(-1) concentration). Drugs were diluted in 0.9% saline (0.75 ml.kg(-1)) and prepared by a staff anesthesiologist not otherwise involved in the study. In all groups, the duration of analgesia, analgesic requirements, sedation and insulin, glucose, cortisol concentrations were recorded and statistically compared. RESULTS: There were no significant differences among the three study groups with respect to age, weight or duration of surgery. Caudal administration of clonidine 1 microg.kg(-1) or ketamine 0.5 mg.kg(-1) induced a longer duration of analgesia (P < 0.05) compared with ropivacaine alone. Insulin levels were increased and cortisol reduced in all groups. Glucose concentration was increased in all groups and statistically significant (P < 0.05). CONCLUSIONS: Addition of ketamine and clonidine to ropivacaine 0.2% 0.75 ml.kg(-1), when administered caudally in children, prolongs the duration of postoperative analgesia. The need for subsequent postoperative analgesic is also reduced. Caudal analgesia attenuates or allows partial changes to postoperative cortisol, insulin or blood glucose responses to surgery.     

Pre-incisional epidural ropivacaine, sufentanil, clonidine, and (S)+-ketamine does not provide pre-emptive analgesia in patients undergoing major pancreatic surgery

BACKGROUND: The concept of pre-emptive analgesia remains controversial. This prospective, randomized, and double-blind study compared epidural administration of ropivacaine 2 mg ml(-1), sufentanil 0.5 microg ml(-1), clonidine 3 microg ml(-1), and S(+)-ketamine 0.25 mg ml(-1) (study solution) given before incision with the same combination started at the end of the operation. METHODS: After testing the stability of the solution using high performance liquid chromatography (HPLC) and examining 12 patients for possible side-effects in comparison with the epidural infusion of ropivacaine 2 mg ml(-1) and sufentanil 0.5 microg ml(-1), 30 patients undergoing major pancreatic surgery were recruited into the study. Before induction of anaesthesia, an epidural catheter was inserted (TH6-8). Patients in Group 1 received a bolus of 8 ml followed by a continuous infusion (8 ml h(-1)) of the study solution before induction of anaesthesia. In Group 2, patients received the same volume of saline before operation, the study solution was started at the end of surgery. After operation, the infusion was maintained for at least 96 h using a patient-controlled epidural analgesia (PCEA) pump in both groups. Patients were evaluated up to the seventh postoperative day for pain and side-effects. RESULTS: Visual analogue scale (VAS) values at rest were as follows: G1 vs G2: 24 h, 19 (sd 23) vs 6 (13); 48 h, 4 (10) vs 11 (21); and 72 h, 12 (22) vs 13 (21). VAS values during coughing and mobilization were also comparable. Total volume of epidural infusion was 904 (114) ml in G1 vs 892 (154) ml in G2. The incidence of side-effects (nausea, vomiting, and motor block) was low and not different between the groups. CONCLUSIONS: Pre-incisional epidural analgesic infusion did not provide pre-emptive analgesia compared with administration started at the end of surgery, but both groups had low pain scores.     

Side-effects of postoperative epidural analgesia in children: a randomized study comparing morphine and clonidine

BACKGROUND: Morphine is widely used in association with local anaesthetics for postoperative epidural analgesia. There are no data on the prolonged use of clonidine for postoperative analgesia in children. The primary outcome of this randomized, double-blind trial was to compare the incidence of side-effects after epidural infusion of clonidine or morphine, in association with ropivacaine in children. METHODS: After institutional approval, 26 children, aged 3-12 years, who were scheduled for abdominal surgery, had an epidural catheter placed after induction of general anaesthesia. Patients were then randomized to two different groups. After an initial bolus of 2.5 mg x kg-1 0.25% ropivacaine with either 40 micro g x kg-1 morphine (group M, n = 14) or 1 micro g x kg-1 clonidine (group C, n = 12), an epidural infusion was started at a rate of 0.4 ml x kg-1 x h-1. The patients in the M group received an infusion of 0.08% ropivacaine with 10 micro g.ml-1 morphine, those in the group C an infusion of 0.08% ropivacaine with 0.6 micro g.ml-1 clonidine. RESULTS: The two groups were similar with respect to age, sex and weight. One patient in the C group was excluded for misplacement of the epidural catheter. The incidence of vomiting and pruritus was significantly higher in the M group compared with the C group (64% and 85% versus 0%, respectively). The incidence of pain was significantly higher in the C group compared with the M group (73% versus 29%) as well as the need for rescue analgesia medications. CONCLUSIONS: Epidural clonidine is followed by a significantly lower incidence of side-effects. However, its analgesic effects, at least at the doses used in this study, are less potent than those of epidural morphine.     

Continuous infraclavicular perineural infusion with clonidine and ropivacaine compared with ropivacaine alone: a randomized,double-blinded,controlled study

Although clonidine has been shown to increase the duration of local anesthetic action and prolong postoperative analgesia when included in single-injection nerve blocks, a controlled investigation of the efficacy of this practice to improve analgesia for continuous perineural local anesthetic infusion has not been reported. In this study, ambulatory patients (n = 34) undergoing moderately painful upper extremity orthopedic surgery received an infraclavicular brachial plexus block (mepivacaine 1.5%, epinephrine 2.5 micro g/mL, and bicarbonate 0.1 mEq/mL) and a perineural catheter before surgery. After surgery, patients were discharged home with a portable infusion pump delivering either ropivacaine 0.2% or ropivacaine 0.2% plus clonidine 1 micro g/mL via the catheter for 3 days (basal, 8 mL/h; patient-controlled bolus, 2 mL every 20 min). Investigators and patients were blinded to random group assignment. Daily end-points included pain scores, patient-controlled bolus doses, oral analgesic use, sleep quality, and symptoms of catheter- or infusion-related complications. Adding clonidine to ropivacaine resulted in a statistically significant decrease in the number of self-administered 2-mL bolus doses on postoperative Days 0 and 1 (P < 0.02), but this decreased actual local anesthetic consumption by an average of only 2-7 mL/d (P < 0.02). There were no statistically significant differences between the two groups for any of the other variables investigated, including sleep quality or oral analgesic requirements. We conclude that adding 1 micro g/mL of clonidine to a ropivacaine infraclavicular perineural infusion does not provide clinically relevant improvements in analgesia, sleep quality, or oral analgesic requirements for ambulatory patients having moderately painful upper extremity surgery.     

Analgesia for paediatric tonsillectomy and adenoidectomy with intramuscular clonidine

BACKGROUND: After undergoing tonsillectomy and adenoidectomy (T&A), children may experience significant pain. Clonidine, an alpha2 agonist, exhibits significant analgesic properties. The current investigation sought to determine whether intramuscular (I.M.) clonidine would decrease pain in paediatric patients undergoing T&A. METHODS: Thirty-nine children undergoing elective T&A were studied. Following inhalational anaesthetic induction, fentanyl (2 microg x kg(-1)) was given intravenously, acetaminophen (paracetamol) (30 mg.kg-1) was given rectally and the children then randomly received an i.m. injection of either normal saline or clonidine (2 microg x kg(-1)). Perioperative analgesic requirements in the postanaesthesia care unit and at home following hospital discharge were evaluated. RESULTS: There were no significant demographic, analgesic consumption, haemodynamic or pain score differences between the groups. CONCLUSIONS: We do not recommend adding i.m. clonidine (2 microg x kg(-1)) to the analgesic regimen of children undergoing tonsillectomy and adenoidectomy.     

Epidural combination of ropivacaine with sufentanil for postoperative analgesia after total knee replacement: a pilot study

BACKGROUND AND OBJECTIVE: We assessed the analgesic efficacy of postoperative epidural infusions of ropivacaine 0.1 and 0.2% combined with sufentanil 1 microg mL(-1) in a prospective, randomized, double-blinded study. METHODS: Twenty-two ASA I-III patients undergoing elective total-knee replacement were included. Lumbar epidural blockade using ropivacaine 0.75% was combined with either propofol sedation or general anaesthesia for surgery. After surgery, the epidural infusion was commenced. Eleven patients in each group received either an epidural infusion of ropivacaine 0.1% with 1 microg mL(-1) sufentanil (Group 1) or ropivacaine 0.2% with 1 microg mL(-1) sufentanil (Group 2) at a rate of 5-9 mL h(-1). All patients had access to intravenous pirinatrimide (piritramide) via a patient-controlled analgesia (PCA) device. RESULTS: Motor block was negligible for the study duration in both groups. There was no significant difference with the 100 mm visual analogue scale (VAS) scores, with the consumption of rescue analgesia or with patient satisfaction. Patients in Group 1 experienced significantly less nausea (P < 0.05) than those in Group 2. Both treatment regimens provided effective postoperative analgesia with only a minimal use of supplemental opioid PCA. CONCLUSIONS: We recommend the use of ropivacaine 0.1% with 1 microg mL(-1) sufentanil for postoperative analgesia after total knee replacement as it provides efficient pain relief with no motor block of the lower limbs. In addition, compared with 0.2% ropivacaine with sufentanil, the mixture reduces local anaesthetic consumption without compromise in patient satisfaction or VAS scores. Patients even experience less nausea.     

Patient-controlled epidural analgesia versus continuous epidural infusion with ropivacaine for postoperative analgesia in children

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 +/- 0.08 mg x kg(-1) x h(-1) versus 0.40 +/- 0.08 mg x kg(-1) x h(-1); P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA. IMPLICATIONS: We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.     

Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine,fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized,double-blinded crossover study with and without epinephrine

We have shown that epinephrine markedly improves the analgesic effect of a thoracic epidural infusion of bupivacaine and fentanyl. Ropivacaine has an intrinsic vasoconstrictive effect, and epinephrine may therefore not have the same pharmacokinetic interaction in a ropivacaine-fentanyl infusion; but a possible spinal cord alpha(2)-agonist effect of epinephrine would give the same positive pharmacodynamic interaction with ropivacaine and fentanyl during epidural analgesia. In a prospective, randomized, crossover study, a thoracic epidural infusion of ropivacaine 1 mg/mL and fentanyl 2 microg/mL with or without epinephrine 2 microg/mL was given to 12 patients in a double-blinded manner after major thoracic or upper abdominal surgery. Main outcome measures were pain intensity at rest and when coughing, evaluated on a visual analog scale. Extent of sensory blockade was evaluated by determining dermatomal hypoesthesia to cold. Pain increased (P < 0.001) and hypoesthetic dermatomal segments decreased (P < 0.001) when epinephrine was omitted from the triple epidural infusion. After 3 h without epinephrine, pain intensity when coughing was unacceptable despite rescue analgesia. After restarting the triple epidural mixture with epinephrine, pain was again reduced to mild pain when coughing, and the sensory blockade was restored. The mixture with epinephrine caused less nausea and facilitated mobilization. We conclude that epinephrine improves the pain relief and reduces the side effects of a thoracic epidural infusion of ropivacaine and fentanyl after major thoracic or upper abdominal surgery. IMPLICATIONS: Epidural epinephrine markedly improves the pain relief and sensory blockade of a small-dose thoracic epidural infusion of ropivacaine and fentanyl. Nausea was reduced, and mobilization of the patients was facilitated.     

The addition of droperidol or clonidine to epidural tramadol shortens onset time and increases duration of postoperative analgesia

PURPOSE: To compare tramadol alone and the combinations of either tramadol-clonidine or tramadol-droperidol with regard to analgesic and adverse effects. METHODS: After Ethic's Committee approval and patient informed consent were obtained, epidural catheters were inserted preoperatively at the L(3-4) interspace in 90 ASA physical status I-II adult patients undergoing lower abdominal surgery. Anesthesia was standardized. Patients were randomly assigned to one of three groups. Group I (T) patients received tramadol 75 mg, Group II (TD) patients received tramadol 75 mg plus droperidol 2.5 mg, and Group III (TC) patients received tramadol 75 mg plus clonidine 150 microg in a total volume of 10 mL administered as a single epidural injection in the postanesthesia care unit. The onset time of analgesia and duration of analgesia, visual analogue pain scores, sedation, nausea scores, vital signs and side effects were recorded. RESULTS: Duration of analgesia was similar in both the TD and TC groups, and significantly longer than in the T group (P < 0.001). Group TC patients displayed a significant increase in sedation scores and decrease in blood pressure and heart rate when compared with other groups (P < 0.001). No adverse effects were observed in Group TD, while nausea scores were high in both the T and TC groups (P < 0.001). Pain score, respiration rate, and SpO(2) values were similar in all study groups. CONCLUSION: We conclude that epidural tramadol in combination with droperidol or clonidine prolongs the duration of analgesia; however, droperidol appears to be a better alternative when adverse effects and antiemetic properties are taken into consideration.     

The dose-sparing effect of clonidine added to ropivacaine for labor epidural analgesia

To determine the effects of clonidine with ropivacaine during epidural labor analgesia, we studied 66 nulliparous women in early active labor. Women were randomized to receive ropivacaine 0.1% 8 mL plus 75 microg of clonidine (Group 1), ropivacaine 0.2% 8 mL plus 0.5 mL of NaCl 0.9% (Group 2), or ropivacaine 0.2% 8 mL plus 75 microg of clonidine (Group 3) 5 min after a bupivacaine 7.5 mg with epinephrine 15 microg test dose. Upon request, additional analgesia with ropivacaine 0.1% 8 mL followed by ropivacaine 0.2% 8 mL/h was administered. With clonidine, duration of analgesia was increased (132 +/- 48 min [Group 1] and 154 +/- 42 min [Group 3] versus 91 +/- 44 min [Group 2]; P < 0.05), and total ropivacaine dose over the first 4 h was significantly reduced (40.5 +/- 15 mg [Group 1] and 47.0 +/- 16 mg [Group 3] versus 72.5 +/- 18 mg [Group 2]; P < 0.01). The incidence of more profound motor block was more frequent in Group 2 (P < 0.05). Although there was a trend for more women receiving clonidine to require ephedrine for treatment of hypotension, this did not seem to have an impact on fetal outcome or incidence of cesarean deliveries for nonreassuring fetal heart rate tracings. This study demonstrates the dose-sparing effect of clonidine when added to ropivacaine. IMPLICATIONS: The effect of adding 75 microg of clonidine to ropivacaine for epidural labor analgesia was studied. Clonidine increased analgesia duration and produced dose sparing compared with ropivacaine alone. Despite a tendency for hypotension in women receiving clonidine, there was no apparent effect on delivery mode or neonatal outcome.     

A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl. Implications: Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.     

Analgesia for circumcision in a paediatric population: comparison of caudal bupivacaine alone with bupivacaine plus two doses of clonidine

BACKGROUND: Clonidine is often used to improve the duration and quality of analgesia produced by caudal epidural blockade, although the optimum dose of clonidine with bupivacaine remains uncertain. Methods: We compared the effect of clonidine, 1 and 2 microg x kg(-1), added to bupivacaine (1.25 mg x kg(-1)) with that of bupivacaine alone in 75 male children undergoing elective circumcision. RESULTS: There was a trend towards increasing duration of analgesia with increasing dose of clonidine [group B (bupivacaine) 280.7 (171.6) min, C1 (bupivacaine + clonidine 1 microg x kg(-1)) 327.8 (188.3) min and C2 (bupivacaine + clonidine 2 microg x kg(-1)) 382.0 (200.6) min], although this difference was not statistically significant. Mean time to arousal from anaesthesia was significantly prolonged with clonidine 2 microg kg(-1) (group C2 21.3 (13-36) min, group C1 14.0 (6-25) min and group B 14.4 (2-32) min. Supplementary analgesic requirements and incidence of adverse effects were low, with no differences between the groups. Conclusions: For paediatric circumcision, under general anaesthesia, the addition of clonidine 2 microg x kg(-1) to low volume (0.5 ml x kg(-1)) caudal anaesthetics has a limited clinical benefit for children undergoing circumcision.