Nausea and vomiting after major arthroplasty with spinal anaesthesia including morphine: a randomised trial of subhypnotic propofol infusion as prophylaxis

Background : Postoperative nausea and vomiting (PONV) following major arthroplasty with spinal anaesthesia and intrathecal morphine is reported in 45–74% of patients. This randomised, double-blind, placebo-controlled trial was undertaken to determine whether a subhypnotic infusion of propofol has a prophylactic antiemetic effect in this patient population.
Methods : 82 patients undergoing hip or knee replacement under subarachnoid bupivacaine anaesthesia plus morphine 0.25 mg were randomised at the end of surgery to receive either propofol 30 mg · h^-1 or fat emulsion (Intralipid®) 3 ml · h^-1 for 20 h postoperatively. Blinded observers recorded episodes of nausea, vorniting and pruritus.
Results : PONV in the intervention group was 40% vs 59% in the controls (P=0.1, not significant). Pruritus occurred in 34%, with a similar rate in both groups.
Conclusion : These results suggest that routine use of postoperative, subhypnotic propofol infusion as PONV prophylaxis is not justified in this patient population.     

The effects of wound infiltration with bupivacaine versus saline on postoperative pain and opioid requirements after herniorrhaphy

In a prospective, double-blind, placebo-controlled study, twenty-eight healthy, male patients, aged 20–69 years, scheduled for unilateral elective inguinal herniorrhaphy ad modum Bassini were randomized to receive postoperative infiltration of the surgical wound with either bupivacaine 0.25%, or isotonic saline. General anaesthesia was induced with thiopentone 3–5 mg·kg^-1 and alfentanyl 10 μg·kg^-1, and maintained with alfentanyl 5 μg·kg^-1 15 min and N₂O/O₂. After herniorrhaphy, the internal fascia was infiltrated with bupivacaine 0.25% or saline, 10 ml. After closure of the external fascia, the subcutaneous tissue was infiltrated with bupivacaine 0.25% or saline, 15 ml on both sides of the surgical wound. Pain at rest, during mobilisation and during cough was significantly decreased in patients receiving bupivacaine compared to placebo. Median time to first request for morphine was increased from 25 min to 135 min, and the consumption of supplementary morphine during the 24 h study period reduced from four to two doses of 0.1 mg·kg^-1 iv or 0.125 mg·kg^-1 im, in patients who received bupivacaine compared to placebo.     

Preoperative infiltration of the surgical area enhances postoperative analgesia of a combined low–dose epidural bupivacaine and morphine regimen after upper abdominal surgery

In a randomized, blinded trial we assessed the value of adding preoperative infiltration of the surgical area with bupivacaine to a low dose epidural regimen for postoperative pain treatment. Forty–nine patients scheduled for major upper abdominal surgery during combined thoracic epidural (bupivacaine + morphine) and general anaesthesia were studied. Postoperative analgesia was epidural bupivacaine 10 mg hr^-1 + morphine 0.2 mg hr^-1 for 72 h. The patients randomly received preoperative infiltration of the surgical area with bupivacaine 0.25%, 40 ml (group I); or no infiltration (group II). Pain was evaluated at rest, during cough and during mobilization six and eight h after start of surgery, and at 8 a.m. and 4 p.m. on the following days until 72 h after start of surgery. The sensory level of analgesia was evaluated by pin prick. We found no difference between the two groups during rest and cough. However, during mobilization group I had lower pain scores compared to group II ( P < 0.05). There was a significant reduction in the need for supplemental intramuscular morphine in the treatment group compared to the control group ( P <0.05). Thus an enhanced analgesic effect was demonstrated by adding preoperative infiltration of the surgical area with local anaesthetic to a low dose epidural bupivacaine/morphine regimen after upper abdominal surgery.     

Interpleural or thoracic epidural analgesia for pain after thoracotomy. A double blind study

The analgetic effect of bupivacaine given epidurally or interpleurally after thoracotomy was investigated in a randomized, double blind, placebo controlled study. 32 patients with both an epidural and an interpleural catheter, were randomized to receive either interpleural or epidural analgesia. The interpleural group was given bupivacaine 5 mg ml^-1 with 5 microgram epinephrine as a 30 ml interpleural bolus, followed by a continuous infusion starting at a rate of 7 ml per hour and epidurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The epidural group was given bupivacaine 3.75 mg–ml^-1 with 5 microgram epinephrine as a 5 ml epidural bolus, followed by a continuous infusion starting at a rate of 5 ml per hour and interpleurally a bolus of 0.9% NaCl followed by a continuous infusion of 0.9% NaCl. The draining tubes were clamped during the injection of the interpleural bolus and 15 min afterwards. Adequacy of pain relief was evaluated with the Prins–Henry pain scale. Morphine requirement was registered, there was no difference between the groups in painscores or need for additional morphine.     

Epidural bupivacaine for aortic surgery The effect of dilution on the quality of analgesia

Twenty patients undergoing elective abdominal aortic aneurysm repair were randomly allocated to two groups and studied for 24 h following surgery. Postoperative analgesia was provided by epidural bupivacaine infusion and intravenous patient-controlled 0.05 mg boluses of alfentanil. One treatment group received 7 ml.h^-1 of a 0.25% solution of bupivacaine, the other 25 ml.h^-1 of a 0.07% solution. The rate of infusion was thus 17.5 mg.h^-1 in both groups. Patients receiving 7 ml.h^-1 of epidural infusate required more doses of alfentanil (median 26.5, range 0-50) than the group receiving 25 ml.h^-1 of the dilute infusion (median 3.0, range 0–16). It is concluded that 17.5 mg.h^-1 of bupivacaine infused into the epidural space produces better analgesia when infused in a volume of 25 ml.h^-1 (0.07%) than when given in a volume of 7ml.h^-1 of solution (0.25%).     

The effect of epidural bupivacaine on vecuronium–induced neuromuscular blockade in children

The efTect of epidural bupivacaine on potency and duration of action of vecuronium–induced neuromuscular blockade (NMB) was evaluated in 30 general surgical paediatric patients (ASA I–II) of three to ten years of age. Premedication was midazolam 0.5 μg kg^-1 orally (max 15 mg). In addition to general anaesthesia, 15 of the children received a lumbar epidural block with 0.5% bupivacaine 2.5 mg kg^-1. Anaesthesia was induced and maintained with N₂O:o₂ (2:1), propofol and alfentanil. NMB was monitored by adductor pollicis EMG with the train–of–four stimulus every 20 sec. Thirty minutes following the epidural bupivacaine injection (mean plasma concentration 0.86 μg ml^-1) or induction of anaesthesia a cumulative dose–response curve of vecuronium was established to achieve a 95% depression of the twitch response. Thereafter, NMB was allowed to recover spontaneously. ED doses of vecuronium were 19–22% greater in the control group than in the epidural group. ED^ doses were 33.8 (s.e.mean 1.3) μg kg"¹ and 28.4 (2.2) μg kg"', respectively ( P <0.05). There were no differences in recovery times from NMB between control and epidural group, the recovery index (time of twitch height to recover from 25 to 75%) being 6.4 (0.4) min and 7.0 (0.9) min, respectively. However, a negative correlation was found between bupivacaine plasma concentration and an ED₅₀ dose of vecuronium ( P =0.01). Our results indicate that vecuronium is slightly more potent in children with bupivacaine epidural block than in children without it.     

Thoracic epidural analgesia in aortocoronary bypass surgery II: effects on the endocrine metabolic response

Thoracic epidural analgesia (TEA) may offer haemodynamic benefits for patients with coronary heart disease going through major surgery. This may – in part – be secondary to an effect on the endocrine and metabolic response to surgery. We therefore investigated the effect of TEA on the endocrine metabolic response to aortocoronary bypass surgery (ACBS).
Thirty male patients (age < 65 years, ejection fraction > 0.5) were randomized into 3 groups; the HF group receiving a high dose fentanyl (55 μg–kg^-1) anaesthesia, the HF + TEA group with the same fentanyl dose + TEA with 10 ml bupivacain 5 mg ml^-1, followed by 4 ml every hour, and the LF + TEA group receiving fentanyl 15 μg kg^-1 + TEA. Adrenalin, noradrenalin, systemic vascular resistance (SVR), glucose, Cortisol, lactate and free fatty acids were followed during the operation and for 20 h postoperatively.
A significant increase in adrenalin, noradrenalin and SVR was found in the HF group whereas this increase was blocked in both epidural groups. An increase in glucose and Cortisol was noticed in all groups, but the increase was delayed in the epidural groups.
Our results suggest that a more effective blockade of the stress response during ACBS is obtained when TEA is added to general anaesthesia than with high dose fentanyl anaesthesia alone.     

Comparison of continuous epidural infusion of morphine/bupivacaine with fentanyl/ bupivacaine for postoperative pain relief

The efficacy and safety of postoperative analgesia with continuous epidural infusion of either morphine or fentanyl in combination with bupivacaine were evaluated in 85 patients, ASA physical status I or II, undergoing thoracic and/or upper abdominal surgery. Patients were treated with one of the combinations for 48 h after surgery. The morphine/bupivacaine group (MB; n = 45) received morphine at the rate of 0.2 mg h^-1, and bupivacaine at the rate of 10 mg h^-1 for the first 24 h or 5 mg h^-1 for the second 24 h; the fentanyl/bupivacaine group (FB; n = 40) received fentanyl at the rate of 20 μg–h^-1, and bupivacaine at the rate of 10 mg h^-1 for the first 24 h or 5 mg h^-1 for the second 24 h. The degree of pain relief assessed by the visual pain scale and the modified Prince Henry pain scale was satisfactory in most patients in both groups. In group MB 74% and in group FB 76% of patients did not need any supplementary analgesics. No significant differences were observed between the groups in assessment of pain. The incidence of hypotension ( P < 0.05) and pruritus ( P < 0.05) was higher in group MB than in group FB. None of the patients developed respiratory depression in either group.     

Effect of piroxicam in addition to continuous thoracic epidural bupivacaine and morphine on postoperative pain and lung function after thoracotomy

Twenty-eight patients scheduled for lung resection with lateral thoracotomy and postoperative chest drains during combined thoracic epidural bupivacaine plus morphine and general anaesthesia were studied. Postoperative pain treatment was continuous epidural infusion of bupivacaine 0.25% 5 ml h-1 plus morphine 0.2 mg h-1 for 48 h and, in addition, the patients received rectal piroxicam 40 mg randomly and double-blind 12 h and 1 h before surgery and 20 mg 24 h-1 postoperatively or placebo. Pain was evaluated at rest, during cough and mobilisation, together with pulmonary function (FEV1, FVC, PEFR) and sensory level of analgesia repeatedly for 48 h. The results showed efficient pain relief, but without differences in pain scores or need for supplementary analgesics between the two groups. Pulmonary function decreased similarly in the two groups. Thus we were unable to show enhanced analgesia by supplementing an otherwise effective low-dose epidural bupivacaine and morphine treatment with piroxicam after thoracic surgery with chest drains.     

Effect of intraperitoneal bupivacaine on pain after laparoscopic cholecystectomy

The effect of intraperitoneal bupivacaine on postoperative pain was studied in 60 ASA 1–2 patients undergoing elective laparoscopic cholecystectomy. The patients were randomly selected (20 patients in each group) to receive in double-blind fashion 100 ml of either plain 0.15% bupivacaine {150 mg · 100 ml^-1) or the same solution with adrenaline (1.5 μg ml^-l), or the same volume of saline into the right subdiaphragmatic space at the end of surgery. The patients were kept in the Trendelenburg's position for 20 min after the instillation. Venous blood samples for the determination of bupivacaine plasma concentrations were drawn up to 180 min. Plasma bupivacaine concentrations peaked at 30 min (highest individual value 2.6 μg ml^-1) after instillation. Bupivacaine concentrations were significantly lower in the bupivacaine-adrenaline group. During the follow-up no difference between the groups occurred as to the time to first demand of analgesia, severity of postoperative pain, amount of consumed analgesics during 7 days, and length of hospitalization. In all groups, 30–45% of the patients complained of right shoulder pain. After the first 24 hours, pain at rest and during moving was reported as mild and was managed with oral ketoprofen.
It is concluded that postsurgical intraperitoneal instillation of 150 mg bupivacaine in 100 ml of saline had no effect on pain after laparoscopic cholecystectomy.     

Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post–dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n=17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n= 13) patients had an immediate conversion to spinal anaesthesia and received post–caesarean section continuous intrathecal patient–controlled analgesia consisting of fentanyl 5 (ig'ml^-1 with bupivacaine 0.25 mg·ml^-1 and epinephrine 2 μg·ml^-1 with catheterization lasting >24 h. No parturient in group III developed a PDPH. This was substantially lower ( P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.     

Continuous epidural infusion of bupivacaine and morphine for postoperative analgesia after hysterectomy

The analgesic efficacy and side-effects of combined epidural infusion of bupivacaine and morphine, in comparison with these drugs alone, for postoperative analgesia after hysterectomy (60 patients) were evaluated. Before general anaesthesia, all patients had an epidural catheter placed (Th11-12) and 20 ml of 0.5%, bupivacaine was injected. In random order, epidural infusion was continued for 24 h with either 0.25% bupivacaine 4 ml.h-1 (BUPI-group), a bolus of 2 mg of morphine followed by morphine 0.2 mg.h-1 (MO-group), or a combination of the two drugs (COMB-group). A urinary bladder catheter was kept for 24 h. Supplementary postoperative pain medications were i.m. morphine 0.1 mg.kg-1 or rectal indomethacin 50 mg, on request. Immediately after awakening from general anaesthesia and transfer to the recovery room, 18/20 of the BUPI-group patients, 17/20 of the MO-group patients and 19/20 of the COMB-group patients were pain-free. In the postoperative evening and the first postoperative morning, the corresponding figures were 7/20 and 10/20 in the BUPI-group, 15/20 and 15/20 in the MO-group, and 18/20 and 15/20 in the COMB-group (postop, evening; P less than 0.01 BUPI vs. others). The number of patients requiring supplementary analgesics (morphine and indomethacin during the first 24 h was greatest in the BUPI-group P less than 0.01). The number of patients who vomited during the 24-h period was 3 in the BUPI-group, 9 in the MO-group and 5 in the COMB-group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of bupivacaine and fentanyl as an adjuvant of epidural morphine for postoperative analgesia

We conducted a retrospective study to determine whether bupivacaine or fentanyl is a better adjuvant to epidural morphine for postoperative analgesia using 108 patients. Following epidural lidocaine anesthesia with or without light general anesthesia for major gynecological surgeries, 59 patients received epidural morphine (EPM) 2 mg (group M), 21 patients received morphine 2 mg plus 0.25% plain bupivacaine 6–10 ml epidurally (group B), and 28 patients received morphine 2 mg plus fentanyl 100 μg epidurally (group F). The analgesic interval, defined as the duration from EPM injection to the first request of analgesics for incisional pain, was significantly longer in group F than in group M (29±11vs 19±17 h,P<0.05), but similar to group B (22±14 h). Group F patients required the least amount of analgesics for incisional pain of the three groups during the first 24 h postoperatively (P<0.01). The incidence of adverse effects was similar among all three groups. In conclusion, fentanyl appears to be a better adjuvant to epidural morphine than bupivacaine.     

The effect of balanced analgesia on early convalescence after major orthopaedic surgery

Forty–two patients scheduled for total knee arthroplasty (n = 20) or hip arthroplasty (n = 22) were randomly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam, or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen. Patients undergoing knee– or hip arthroplasty treated with epidural analgesia had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment, while no important differences were observed after cessation of the epidural regimen. However, the achieved pain relief had no impact on postoperative convalescence parameters, such as ambulation, patient activity including need for nursing care, fatigue or hospital stay. Late postoperative pain, fatigue and conservative attitudes and routines in the postoperative care, were the most important reasons limiting mobilization and activity. We conclude that effective early (48 h) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay.     

Subcutaneous blood flow in man during sleep with continuous epidural anaesthesia

Background: Subcutaneous blood flow increases during sleep and we evaluated if this increase is affected by epidural anaesthesia.
Methods: Lower leg subcutaneous blood flow was determined by ¹³³Xenon clearance in ten subjects during continuous epidural anaesthesia at L₂-L₃ including eight hours of sleep, while the upper abdominal subcutaneous blood flow served as control.
Results: Epidural anaesthesia to the level of the umbilicus was followed by an increase in the lower leg subcutaneous blood flow from 3.4 (1.8-6.3) to 7.8 (3.6–16.9) ml min^-1 100 g^-1 (median and range; P <0.001) and returned to 3.5 (2.4–7.6) ml min^-1 100 g^-1 after 88 (45–123) min. In contrast, until the period of sleep the upper abdominal region blood flow remained at 5.2 (3.2–6.4) ml min^-1 100 g^-1. During sleep, lower leg subcutaneous blood flow did not change significantly, but the upper abdominal flow increased to 6.2 (5.2–7.2) ml min^-1 100 g^-1 after 34 (29–70) min ( P <0.01), and it remained elevated for 125 (100–164) min.
Conclusions: The results indicate that although epidural anaesthesia induced only a temporary increase in lower leg subcutaneous blood flow, it hindered the rise in subcutaneous blood flow normally manifest during early sleep.     

Intraarticular morphine for pain relief after knee arthroscopy performed under regional anaesthesia

Eighty patients scheduled to undergo knee arthroscopy were studied in random and double blind fashion. Spinal anaesthesia with hyperbaric 0.5% bupivacaine was selected for 40 overnight–in–patients. At the end of arthroscopy, 1 mg morphine or saline was injected intraarticularly. Local anaesthesia with 1% lidocaine plus adrenaline, was selected for another 40 out–patients. At the end of the arthroscopy either 1 mg morphine or saline was injected intraarticularly. As a rescue medication the spinal anaesthesia patients received oxycodone 0.14 mg kg^-1 i.m. or ketoprofen 100 mg p.o. and the local anaesthesia patients received ketoprofen 100 mg p.o. The need for additional postoperative analgesic was almost similar in both spinal anaesthesia groups. The patients having local anaesthesia and given intraarticular morphine needed fewer doses of ketoprofen (22 doses) postoperatively than the control group (39 doses) ( P < 0.05). Duration of analgesia was slightly longer after morphine than in the control group (ns). There was no difference between the morphine patients and the control patients in the two studies regarding the incidence of side effects. We conclude that postoperative analgesia in patients undergoing knee arthroscopy under local anaesthesia, but not under bupivacaine spinal anaesthesia, can be improved with a single intraarticular injection of 1 mg morphine.     

Effects of five amino–amide local anaesthetic agents on human polymorphonuclear leukocytes measured by chemiluminescence

The aim of this study was to assess the influence of five amino–amide local anaesthetic agents on the production of oxygen metabolites in the human polymorphonuclear leukocyte (PMNL), both intra– and extracellularly.
Ropivacaine, a new long–acting amino–amide local anaesthetic agent, bupivacaine, lidocaine, mepivacaine and prilocaine in concentrations 1–5 μg–ml^-1 up to 500–1000 μg–ml^-1 were compared to an untreated control. PMNLs were isolated from heparinized blood (healthy adult volunteers). Cells were incubated with the various local anaesthetics (37C, 30 min), then placed in a Biolumat (luminol–amplified chemiluminescence) and stimulated by formyl–methionyl–leucyl–phenylalanine (FMLP), phorbol myristate acetate (PMA) or ionomycin. Horseradish peroxidase (HRP) was added to discriminate between an intra– or extracellular response.
In general, a decrease in chemiluminescence–response was seen with higher concentrations (500–1000 μg–ml^-1) of the various local anaesthetics. Lidocaine showed a decrease even at lower concentrations. A marked increase in intracellular response for prilocaine 1000 μg–ml^-1 (3894 μmol–1^-1) accompanied by a reduction in extracellular response, using FMLP HRP as a stimuli, was noted. Ropivacaine 1000 μg ml^-1 (3216 umol–1^-1) showed a decrease both intra– and extracellularly that was similar to, and even somewhat more pronounced than lidocaine 1000 μg–ml^-1 (3692 μmol'l^-1), when using PMA with or without HRP as the stimuli.     

The optimal dose of ketamine for caudal epidural blockade in children

Sixty boys aged up to 9 years undergoing orchidopexy were randomly allocated to receive one of three solutions for caudal epidural injection: group A received 1 ml. kg⁻¹ of 0.25% bupivacaine with 0.25 mg. kg⁻¹of preservative-free ketamine, group B received 1 ml. kg⁻¹ of 0.25% bupivacaine with ketamine 0.5mg. kg⁻¹ and group C received 1 ml. kg⁻¹ of 0.25% bupivacaine with 1 mg. kg⁻¹ of ketamine. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this score exceeded four. The median duration of caudal analgesia was 7.9h in group A, 11 h in group B and 16.5 h in group C. There were no differences between the groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Group C had a significantly higher incidence of behavioural side effects, including slightly odd behaviour, vacant stares and abnormal effect than groups A and B.     

A comparison of opioid solutions for patient-controlled epidural analgesia

Sixty patients took part in a randomised, double-blind study to compare the analgesic and side effects of three opioid-containing solutions for patient-controlled epidural analgesia following abdominal surgery. Patients in group 1 received a solution containing bupivacaine 0.125% with fentanyl 10μg. ml⁻¹, group 2 bupivacaine 0.125% with diamorphine 125μg. ml⁻¹, group 3 pethidine 2.5 mg. ml⁻¹. All groups received 4 ml.h⁻¹ background infusion and 3 ml boluses every 20 min if necessary. There were no significant differences between the groups in visual analogue scale pain scores (p = 0.537) or volumes of solution used at 24 h (p = 0.351) or 48 h (p = 0.105). Motor block was significantly higher in group 2 (p < 0.004) and pruritis occurred significantly less in group 3 (p < 0.05). We conclude that these three solutions produce equivalent analgesia but that pethidine 2.5 mg. ml⁻¹ may be associated with fewer side effects.     

Respiratory depression following epidural morphine in an infant of three months of age

Epidural administration of combinations of opioids and a local anaesthetic provides prompt and effective analgesia and is increasingly used in paediatric anaesthesia. However, respiratory depression by rostral spread of opioid in the CSF is by far the greatest concern after epidural morphine. An infant of three months of age underwent portoenterostomy (Kasai's operation) for extrahepatic biliary duct atresia. A median approach at the L₃–L₄ epidural interspace was used and a dose of 1 ml·kg^–1 of 0.125% bupivacaine with adrenaline 1:400 000 mixed with 50 μg·kg^–1 morphine was injected using a 19 gauge Tuohy needle. Six h after epidural morphine, the infant developed respiratory depression with an increase in drowsiness, miosis and decreased respiratory rate. Low arterial saturation ( S pO₂) was detected by pulse oximetry and confirmed by blood gas analysis. An intravenous bolus of 5 μg·kg^–1 naloxone followed by a 3-h infusion of 2 μg·kg^–1·h^–1 resulted in complete reversal of signs and symptoms of respiratory depression. Epidural opioids should be limited to paediatric patients admitted to specialized recovery units for the first postoperative day.