A double-blind comparison of lidocaine and mepivacaine during epidural anaesthesia

The effects of epidural anaesthesia with plain 2% lidocaine or mepivacaine were compared in 200 patients undergoing extracorporeal shock wave lithotripsy in a double-blind manner. The onset, spread, duration and quality of analgesia were similar in both groups. The numbers of patients who needed vasoconstrictor or atropine were almost equal in both the lidocaine and the mepivacaine groups. Mild but significant hypotension continued for a longer period in the mepivacaine group than in the lidocaine group. A transient decrease in arterial oxygen saturation was seen in two patients receiving lidocaine and in three patients receiving mepivacaine. Mild systemic toxicity was observed in eight patients in both groups, although serious complications such as convulsions did not occur. It is concluded that both drugs can be used equally safely for epidural anaesthesia, although the maximum recommended doses differ.     

Pediatric caudal block with mepivacaine, bupivacaine or a mixture of both drugs: requirement for postoperative analgesia and plasma concentration of local anesthetics

STUDY OBJECTIVES: To assess the effects of pediatric caudal block using mepivacaine, bupivacaine, or a mixture of both drugs on postoperative analgesia, and to examine plasma concentrations of the local anesthetics after caudal injection. DESIGN: Prospective, randomized, double-blind study. SETTING: Operating room and pediatric surgical ward. PATIENTS: 60 ASA physical status I children weighing 10 to 20 kg (26 females, 34 males), and scheduled for inguinal herniorrhaphy. INTERVENTIONS: Patients randomly received caudal block with 1 mL/kg of mepivacaine 1% (Group M, n = 20), 1 mL/kg of bupivacaine 0.25% (Group B, n = 20), or a mixture of 0.5 mL/kg of mepivacaine 1% and 0.5 mL/kg of bupivacaine 0.25% (Group MB, n = 20) after induction of anesthesia with sevoflurane in 50% oxygen (O2). Anesthesia was maintained with 66% nitrous oxide in O2 supplemented with sevoflurane at an end-tidal concentration of less than 1%. MEASUREMENTS AND MAIN RESULTS: Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured. In Group M, four patients required postoperative analgesics within the first 24 hours. However, no patients required postoperative analgesics in Groups B and MB. In Group M, the plasma concentration of mepivacaine of two patients exceeded 5 microg/kg of the level of toxicity. However, these patients did not show any toxic symptoms. Because a mixture of two local anesthetics halves the concentration of each local anesthetic, the plasma concentrations of mepivacaine and bupivacaine in Group MB were significantly lower than those of Groups M and B. CONCLUSIONS: Pediatric caudal block with a mixture of mepivacaine and bupivacaine is effective for intraoperative and postoperative analgesia.     

Some Pharmacological and Toxicological Properties of a New Long-Acting Local Analgesic, Lac-43 (Marcaine®), in Comparison With Mepivacaine and Tetracaine

The toxicological and pharmacological properties of mepivacaine, LAC-43 (Marcain®)—a new local analgesic—and tetracaine were studied in experiments on animals and man using "classical" test methods. The experiments were performed by the "blind" technique; whenever possible, the results were subjected to statistical analysis and compared with those published by other investigators.
LAC-43, which is chemically closely related to mepivacaine, is more similar to tetracaine as regards its local analgesic and toxicological potencies. Thus, the acute toxicity in mice, guinea pigs and rabbits in different routes of application is about the same for LAC-43 and tetracaine and roughly 4 times higher than that of mepivacaine. Furthermore, LAC-43 and tetracaine have the same tissue toxicity—about 6 times higher than that of mepivacaine, but LAC-43 has a lower cumulative and infusion toxicity relatively to mepivacaine and absolutely to tetracaine. In infiltration and conduction analgesia, LAC-43 and tetracaine are about 3 times more potent than mepivacaine, and in surface analgesia both drugs are still more potent than mepivacaine, tetracaine being the most active.
In spite of being an amide, LAC-43 has shown evidence of being rapidly metabolised, and as the clinical experiments so far published have given promising results, it should be worth while to subject this new local analgesic drug to thorough investigations.     

Lateral approach to the sciatic nerve in the popliteal fossa: a comparison between 1.5% mepivacaine and 0.75% ropivacaine

BACKGROUND AND OBJECTIVES: Ropivacaine and mepivacaine are commonly used local anesthetics for peripheral nerve blockade. The purpose of the present study was to compare onset time, quality of anesthesia, and duration of analgesia with ropivacaine 0.75% and mepivacaine 1.5% for lateral popliteal nerve block. METHODS: Fifty American Society of Anesthesiologists (ASA) physical status I or II patients scheduled for foot and ankle surgery with calf tourniquet under lateral popliteal sciatic nerve block were randomly assigned to receive 30 mL of either ropivacaine 0.75% or mepivacaine 1.5%. Time required for onset of sensory and motor block, resolution of motor blockade, onset of postsurgical pain, and time of first analgesic medication were recorded. RESULTS: The 2 groups were similar with regard to demographic variables and duration of surgery. Onset of sensory and motor block was significantly shorter in the mepivacaine group (9.9 +/- 3.3 min and 14.7 +/- 3.6 min, respectively) than in the ropivacaine group (18.1 +/- 6.1 min and 23.6 +/- 5.5 min, respectively) (P < 0.001). Resolution of motor block occurred later in the ropivacaine group than in the mepivacaine group (P < 0.001), and duration of postoperative analgesia was significantly longer in the ropivacaine group (19 +/- 3.4 h) compared with the mepivacaine group (5.9 +/- 1.1 h) (P < 0.001). Analgesic requirements were higher in mepivacaine group than in the ropivacaine group (P < 0.001). There were 2 failed blocks, one in each group. CONCLUSIONS: Both ropivacaine and mepivacaine provided effective sciatic nerve blockade. Mepivacaine 1.5% displayed a significantly shorter onset time than ropivacaine 0.75%. Postoperatively, ropivacaine 0.75% resulted in longer-lasting analgesia and less need for oral pain medication.     

Sympathetic blockade during extradural analgesia with mepivacaine or bupivacaine

The extent of sympathetic blockade in 36 patients, who had been given extradural analgesia, was studied by means of the skin conductance response (SCR). The SCR was also studied in six healthy volunteers who received, in a cross-over fashion, infusions of physiological saline (placebo) and saline containing mepivacaine. Two more volunteers were given saline containing bupivacaine. Extradural analgesia caused a partial blockade of sympathetic activity. The higher the level of analgesia the greater the degree of inhibition of the SCR. Complete blockade of the SCR or only a weak response in the foot was obtained in the majority of cases when the level of analgesia reached a dermatome level of T4 or higher. There was no significant relationship between the degree of motor blockade of the lower extremities and the intensity of blockade of the SCR. Extradural injection of 2% mepivacaine had a greater effect on the SCR than did 0.5% bupivacaine. There was no indication that infusion of mepivacaine or bupivacaine in volunteers, whose blood levels were as high as or higher than those likely to be produced during extradural analgesia, affected the SCR.     

Local infiltration anaesthesia with ropivacaine 0.5% for excision of benign naevi

Ropivacaine is a new type of long-acting local anaesthetic of less systemic toxicity than bupivacaine. The objective of this double-blind study was to compare the efficacy and safety of ropivacaine 0.5% and mepivacaine 1% for infiltration anaesthesia in dermatologic surgery. Sixty out-patients aged 18–65 years, scheduled for excision of a benign naevus on the back, were randomly assigned to infiltration anaesthesia with either ropivacaine or mepivacaine. Both agents had a fast onset, and provided reliable anaesthesia and painfree surgery which could be carried out without the use of vasoconstrictive adjuncts or diathermy. Ropivacaine resulted in a longer duration of analgesia than mepivacaine, and both treatments were well tolerated.     

Clonidine-mepivacaine mixture vs plain mepivacaine in paediatric surgery

In a double-blind study, 42 children, aged 1–10, undergoing general subumbilical surgery, were randomly allocated to two groups; they received, via caudal extradural, 1% mepivacaine 7 mg·kg^?1 and normal saline 1 ml (Group 1) and a mixture of 1% mepivacaine 7 mg·kg^?1 plus clonidine 2 μg·kg^?1 and normal saline up to 1 ml (Group 2) respectively. No significant difference was noticed in age, weight, duration of surgery and onset time of anaesthesia, blood pressure, heart rate and oxygen saturation. Mean duration of analgesia (evaluated with ‘Broadman objective pain scale') was 143 min for Group 1 and 218 min for Group 2 (P < 0.05); the time of sedation (evaluated with a sedation score) was statistically longer in Group 2 (172 min vs 89 min in Group 1). This longer sedation is due both to the longer analgesia and partially to a side effect of clonidine. In conclusion the addition of 2 μg·kg^?1 of clonidine to mepivacaine prolongs the duration of caudal analgesia in children.     

Does pregnancy alter the systemic toxicity of local anesthetics?

The toxicity of mepivacaine in chronically instrumented nonpregnant and pregnant sheep was evaluated, and compared with data from previous studies of the toxicity of other local anesthetics. Thirteen preparations were studied, seven nonpregnant (NP) and six pregnant (P). Mepivacaine 2 mg.kg-1.min-1 was infused at a constant rate into the femoral vein until toxic manifestations occurred, in the following sequence: convulsions, hypotension, respiratory arrest, and circulatory collapse. The doses and plasma concentrations of mepivacaine necessary to produce toxic symptoms were similar in NP and P animals, whereas, in a previous study, pregnancy enhanced the cardiotoxicity of bupivacaine. No malignant ventricular arrhythmias were observed throughout the study. Protein binding of mepivacaine was also determined in sera from nonpregnant and pregnant ewes and compared with that for bupivacaine. Serum protein binding of mepivacaine was not reduced in pregnancy at the drug concentrations associated with toxic symptoms; at circulatory collapse, it was approximately 22% in NP and P. In contrast, the proportion of bound bupivacaine was 73% in NP and 51% in P, a significant difference. These protein binding data suggest that, although lethal concentrations of bupivacaine, determined in the previous study, were higher in NP than in P animals, concentrations of free drug were similar. Thus, the difference between the two drugs may be related to gestational increases in the availability of free drug in the case of bupivacaine.     

Alterations in the pharmacokinetic properties of amide local anaesthetics following local anaesthetic induced convulsions

The comparative pharmacokinetic properties of lidocaine, bupivacaine, etidocaine and mepivacaine were investigated in convulsing and non-convulsing dogs. The same dose of a given local anaesthetic was administered as either a 30-s intravenous (IV) bolus to produce convulsions or as a 15-min IV infusion producing no convulsions. Derived pharmacokinetic data were found to be different in convulsing and non-convulsing animals. Total body clearance was found to be significantly reduced for lidocaine (29%, P less than 0.05), bupivacaine (31%, P less than 0.05), etidocaine (60%, P less than 0.01) and mepivacaine (68%, P less than 0.01) in convulsing animals. Increases in elimination half-life only achieved statistical significance in mepivacaine-treated animals (non-convulsing 45.2 min, convulsing 105.4 min, P less than 0.01). Overall, the most profound effects of convulsions on pharmacokinetic data were seen with mepivacaine. Convulsions were associated with increases in heart rate ranging from 117% (lidocaine, P less than 0.05) to 129% (mepivacaine, P less than 0.05), increases in cardiac output ranging from 78% (mepivacaine) to 232% (bupivacaine, P less than 0.05) and increases in mean arterial pressure ranging from 45% (lidocaine, P less than 0.05) to 80% (bupivacaine, P less than 0.05). The results suggest that when local anaesthetic-induced seizures occur in man, it cannot be assumed that these drugs will be distributed and eliminated as predicted by intravenous infusion of non-toxic doses.     

Regional anesthesia for hand surgery

Several regional anesthetic techniques for hand and wrist surgery are mentioned. Of these techniques, the axillarybrachial plexus block offers several advantages, such as ease of administration, prolongation of analgesia, and very few potential complications. Three conditions must be met to provide effective regional anesthesia: (1) patient instruction, (2) a surgeon comfortable with the technique, and (3) a prepared anesthesiologist. The axillary brachial plexus block is performed aseptically in a manner that promotes proximal spread of local anesthetic, giving the opportunity to block the musculocutaneous nerve before its exit from the sheath. In our institution, we favor 1.5% mepivacaine versus 0.5 bupivacaine because of its inherent safety factor. However, all local anesthetics have the potential for systemic toxicity with either inadvertent intra-arterial injection or use of excessive amounts of drug. Toxic symptoms range from mild, such as as tinnitus, to more severe, such as convulsions, and further progression to cardiovascular collapse. This toxicity must be anticipated and treated appropriately. Our own institutional study showed an 89% success rate with axillary brachial plexus blocks used for hand and wrist procedures. However, the success rate dropped to 60% for surgery involving the elbow. These results were improved by the use of local anesthetic supplementation or intravenous sedation.     

Continuous brachial plexus infusion of butorphanol-mepivacaine mixtures for analgesia after upper extremity surgery

We have recently reported that continuous administration of butorphanol into the brachial plexus neurovascular sheath provided superior analgesia compared with that obtained with continuous i.v. administration. Furthermore, we found that analgesia was most pronounced when a mixture of mepivacaine and butorphanol was given and that butorphanol alone ranked next. In this study, we increased the dose of butorphanol, compared with that used in our previous reports, and an initial bolus dose of butorphanol was administered into the brachial plexus neurovascular sheath just after surgery had ended. Thereafter, postoperative pain relief was estimated. In patients undergoing upper extremity surgery with continuous axillary brachial plexus block, group A received a bolus of 1 ml of physiological saline with 1.5% mepivacaine, 10 ml into the brachial plexus sheath followed by a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/ 72 h. Group B was given a bolus of butorphanol 1 mg (1 ml) with 1.5% mepivacaine, 10 ml into the brachial plexus sheath and a continuous brachial plexus infusion of 0.5% mepivacaine with butorphanol 6 mg at a rate of 144 ml/72 h. After operation, VAS scores did not differ between the two groups. The time to first use of supplementary analgesia did not differ significantly between the two groups and there were no significant differences in the number of patients who required supplementary analgesia. These results indicate that continuous butorphanol 2 mg day-1 with 0.5% mepivacaine provided sufficient postoperative analgesia after upper limb surgery.      

A comparison of 0.5% ropivacaine and 1% mepivacaine for sciatic nerve block in the popliteal fossa

BACKGROUND: The purpose of this study was to compare anesthetic efficacy and postoperative analgesia of 0.5% ropivacaine and 1% mepivacaine for sciatic nerve block in the popliteal fossa (popliteal block). METHODS: A prospective, double-blind study was carried out in 58 adult patients scheduled for outpatient foot or ankle surgery. They were randomized to receive popliteal block with 40 ml of either 0.5% ropivacaine (group R) or 1% mepivacaine (group M). An atraumatic, Teflon-coated needle connected to a neurostimulator was used to make a single puncture using a posterior approach. The times to onset of sensory and motor block, and the need for intraoperative sedation were recorded. Before discharge, patients were asked to document the time to first analgesic use, time to return of full sensation in the foot, and their evaluation of the technique. RESULTS: Onset time (mean+/-standard deviation, 95% confidence interval) of both sensory block (6.5+/-5.1 min, 4.47-8.49, in group R and 6.2+/-3.7 min, 4.83-7.69, in group M) and motor block (6.6+/-4.4 min, 4.81-8.23, in group R and 7.9+/-4.1 min, 6.29-9.53, in group M) was similar in both groups. Postoperative analgesia lasted longer in group R (15.2+/-5.1 h, 13.25-17.21) than in group M (5.7+/-1.8 h, 5.01-6.41; P<0.001). Duration of sensory block was longer in group R (20.7+/-6.2 h, 18.51-23.01) than in group M (6.5+/-1.7 h, 5.86-7.16; P<0.001). Acceptance of the anesthetic procedure was similar in both groups. CONCLUSION: In this study we demonstrated that both 0.5% ropivacaine and 1% mepivacaine for popliteal block produced rapid, effective and safe anesthesia but postoperative analgesia was more long-lasting with ropivacaine.     

Systemic, but not pulmonary, hemodynamics are depressed during combined high thoraco-cervical epidural and general anesthesia in dogs

PURPOSE: An epidural block is frequently combined with general anesthesia. Both systemic and pulmonary hemodynamics may be affected by high epidural anesthesia and the combined general anesthetic. These effects were investigated in a canine model. METHODS: Systemic and pulmonary hemodynamics during a combined high thoraco-cervical epidural and general anesthesia were studied in dogs; the animals were anesthetized with propofol, 10 mg.kg(-1).hr(-1), or 2% sevoflurane, and then 1% mepivacaine, 5 mL, was injected epidurally between T1 and T2. Cardiac output (CO), pulmonary capillary wedge pressure (PCWP), pulmonary arterial pressure (PAP), mean arterial pressure (MAP), central venous pressure (CVP), electrocardiogram, and arterial and mixed venous gases were monitored for over 90 min after epidural mepivacaine. The interval between sevoflurane and propofol studies was two hours. RESULTS: Baseline measurement of MAP with sevoflurane anesthesia was significantly lower (P < 0.05-0.01) at every time point than with propofol anesthesia. After epidural mepivacaine (C1)-T7/8 blockade), MAP (P < 0.05-0.01), CO (P < 0.05-0.01), and heart rate (P < 0.05-0.01) decreased significantly during both propofol and sevoflurane anesthesia. In the sevoflurane group, stroke volume decreased significantly (P < 0.05-0.01) but recovered; however, MAP (P < 0.01) and CO (P < 0.05) did not recover 90 min after the injection. Mean CVP and systemic vascular resistance were not altered. There were no changes in mean PAP, mean PCWP, and pulmonary vascular resistance. CONCLUSION: A combined high thoracic/general anesthesia depressed systemic hemodynamics, whereas the pulmonary circulation was not affected. The extent of the depression varied with the general anesthetics used, sevoflurane and propofol.     

Epidural fentanyl improves the onset and spread of epidural mepivacaine analgesia

Purpose

To determine the extent of enhanced blockade by the combined use of epidural fentanyl and mepivacaine. We compared the onset of hypoalgesia, analgesia and the threshold of pressure pain.

Methods

Thirty patients were randomly divided into three groups. The fentanyl group received 10 ml saline containing 0.1 mg fentanyl, mepivacaine group received 10 ml mepivacaine 1% and a mixed group received 10 ml mepivacaine 1% with 0.1 mg fentanyl. All solutions, without epinephrine, were injected through an epidural catheter at T_5–6 to T_6–7. The change in sensation, loss of pin-prick and pain threshold sensation, measured by pressure algometer, were assessed at 2.5-min intervals for 15 min at the T₄ dermatome. Spread of analgesia was determined at 15 min.

Results

Loss of pinprick was more rapid in the mixed, 11.0 ± 2.7 (SD) min, than in the mepivacaine group, 15.0 ± 2.9 min, (P < 0.05), although there was no difference in change of sensation. Pressure pain threshold increased with time in the mepivacaine (P < 0.05) and mixed (P < 0.05) groups. It was higher in the mixed than in the fentanyl and mepivacaine groups at 5, 7.5 and 10 min (P < 0.05). The lower level of analgesia was lower in the mixed than in the mepivacaine groups (P < 0.05). Blood pressure was unchanged in the three groups, but heart rate decreased at 7.5, 10, 12.5, and 15 min in the mepivacaine and mixed groups (P < 0.05).

Conclusions

The addition of fentanyl to mepivacaine accelerates the onset of analgesia and enhances the analgesic effect of epidural block.     

One-day surgery for acquired forefoot deformity: sciatic nerve blockade with mepivacaine vs mepivacaine+ropivacaine: a prospective, randomized study

AIM: The aim of the study was to determine the doses of ropivacaine combined with mepivacaine for sciatic nerve blockade to enable the extension of analgesia without prolonged motor blockade, for the management of very painful operations in one-day surgery. METHODS: After obtaining approval by the ethics committee and written informed consent, we recruited 30 ASA I-III patients undergoing corrective orthopedic surgery of the forefoot in one-day surgery with sciatic nerve blockade. The patients were randomly divided into 3 groups: one control group, treated by 1.5% mepivacaine (300 mg), and two groups differentiated by the dose of 0.5% ropivacaine (25 and 40 mg) used in combination with 1.5% mepivacaine (225 mg). The offset data of the blockade were obtained by a self-assessment form filled in by the patients, and a direct check on discharge by a blinded observer. RESULTS: There was no significant difference in the duration of the blockade among the 3 groups; the extension of analgesia was significant (P<0.003) in the group treated by mepivacaine+ropivacaine 40 mg (mean 477+/-255 min). CONCLUSION: Adequate doses of ropivacaine added to mepivacaine for peripheral blockade produce and increase the duration of analgesia without influencing the criteria for discharge after Day Surgery.     

Alkalinization of mepivacaine for axillary block.

We examined the onset and distribution of sensory blockade, the onset of motor blockade, and venous mepivacaine concentrations after axillary block with 1.25% mepivacaine with and without bicarbonate. There were no statistically significant differences between the alkalinized and placebo groups with respect to distribution of analgesia or anesthesia, time to onset of analgesia, or time to onset of paresis. However, alkalinization significantly decreased the time to onset of anesthesia in the medial cutaneous nerve of the forearm, the median nerve, and the ulnar nerve, as well as the time to onset of paralysis. Concentrations of mepivacaine in venous blood did not differ significantly. We conclude that alkalinized mepivacaine offers the advantage of quicker onset of more profound blockade in several terminal nerve distributions.     

Dose Response Studies in Elderly Patients Subjected to Epidural Analgesia

In 51 men, aged 60–87 years, subjected to lumbar epidural analgesia for transurethral resection of the prostate gland, the relationship between doses of 10, 15 and 20 ml mepivacaine 1.5% with adrenaline 1:200,000 and the extension of analgesia was studied. Three different postures during application of epidural analgesia were investigated (left lateral position, sitting position with the patient turned supine immediately after injection, and the sitting position with the patient turned supine 5 min after injection). The results indicate that posture did not significantly influence the extension of analgesia, which was found to be positively correlated to the volume of mepivacaine, and the segmental dose requirement was positively correlated to the volume injected. It is concluded that transurethral resection of the prostate gland in patients over 60 years old can be performed using mepivacaine 1.5% with adrenaline 1:200,000 injected in the lumbar epidural space. In some cases, doses of 15 and 20 ml provoked an unwanted extension of analgesia, reaching the upper thoracic segments.     

Refractory generalized convulsions in a patient undergoing brain tumor resection during propofol anesthesia

Propofol has been used to treat convulsions, while the drug is known to induce convulsions. We described a case of generalized convulsions during brain tumor resection under propofol anesthesia. A 24-year-old man was scheduled to undergo brain tumor resection. He had no history of epilepsy. Anesthesia was induced and maintained with propofol and fentanyl. During the craniotomy, the patient developed generalized convulsions. Diazepam, thiamylal, and phenytoin were given intravenously and the seizure activity resolved. Generalized convulsions recurred three times during the operation. Postoperative course was uneventful. On the 16 th postoperative day, the patient underwent ventriculoperitoneal shunt under general anesthesia using sevoflurane, nitrous oxide and oxygen. Convulsions were not noted intra- and postoperatively. Because convulsions did not occur during sevoflurane anesthesia and the patient had no history of epilepsy, propofol may have induced a generalized convulsions on the first operation.     

Comparison of lidocaine hydrocarbonate,lidocaine hydrochloride and mepivacaine in the axillary block

Axillary block was performed on 60 patients undergoing various types of surgical procedures on the upper limb. The patients were divided randomly into three equal groups of 20 and received lidocaine hydrocarbonate 1% or lidocaine hydrochloride 1% or mepivacaine 1%, each solution containing epinephrine 1/400,000. A double-blind design was used. Lidocaine hydrocarbonate and lidocaine hydrochloride were both found to have a shorter latency of analgesia than mepivacaine. Duration of analgesia, quality of the sensory and motor block were not found to be statistically different between the three groups.     

Patient-controlled epidural analgesia combined with patient-controlled intravenous analgesia for postoperative analgesia after Miles' operation for rectal cancer

A 69-year-old woman (156 cm, 53 kg) underwent a Miles' operation, total hysterectomy, resection of vagina, and thigh flap to vulva for rectal cancer. Before general anesthesia, an epidural catheter was inserted at T11-12 interspace, and 1.5% mepivacaine 7ml was administered. Sensory block level spread from T4 to L1. Anesthesia was induced with propofol and maintained with sevoflurane in air oxygen mixture. Operation was performed uneventfully. After the operation, postoperative analgesia was achieved with patient-controlled epidural analgesia (PCEA). The epidural solution of 0.06% ropivacaine with 4 microg x ml(-1) fentanyl and 20 microg x ml(-1) was connected to a PCA pump (i-Fuser, JMS, Japan) that was programmed as an 8 ml initial bolus, 4 ml x hr(-1) basal infusion, 2 ml bolus dose, and 10-min lockout interval. Although abdominal pain was well controlled by PCEA, intractable pain in the pelvic nerve region existed. Patient-controlled intravenous analgesia (IV-PCA) with fentanyl, ketamine, and lidocaine was added to PCEA. Then excellent pain relief was obtained without any side effects such as nausea, vomiting, drowsiness, and respiratory depression. It could be useful to use IV-PCA together with PCEA when wide spread postoperative analgesia is necessary.