Intrathecal morphine and clonidine for coronary artery bypass grafting

Background. After cardiac surgery adequate postoperative analgesiais necessary. We assessed analgesia using intrathecal morphineand clonidine. Methods. In a double-blind randomized study, 45 patients havingcoronary artery bypass graft surgery were allocated randomlyto receive i.v. patient-controlled analgesia (PCA) morphine(bolus, 1 mg; lock-out interval, 7 min) (control group), eitheralone or combined with intrathecal morphine 4 µg kg^–1or with both intrathecal morphine 4 µg kg^–1and clonidine 1 µg kg^–1. Intrathecal injectionswere performed before the induction of general anaesthesia.Pain was measured after surgery using a visual analogue scale(VAS). We recorded i.v. PCA morphine consumption during the24 h after operation. Results. Morphine dosage [median (25th–75th percentiles)]was less in the first 24 h in the patients who were given intrathecalmorphine + clonidine [7 (0–37) mg] than in other patients[40.5 (15–61.5) mg in the intrathecal morphine group and37 (30.5–51) mg in the i.v. morphine group]. VAS scoreswere lower after intrathecal morphine + clonidine compared withthe control group. Time to extubation was less after intrathecalmorphine + clonidine compared with the i.v. morphine group [225(195–330) vs 330 (300–360) min, P<0.05]. Conclusion. Intrathecal morphine and clonidine provide effectiveanalgesia after coronary artery bypass graft surgery and allowearlier extubation. Br J Anaesth 2003; 90: 300–3     

Orally administered clonidine significantly reduces pain during injection of propofol

We examined the analgesic effects of orally administered clonidineon pain induced by injection of propofol (Diprivan; 2,6-diisopropylphenol). Female patients (n=81) were randomly allocated to oneof two groups: oral clonidine (5.5 µg kg^–1)followed by i.v. propofol and a control group given placebofollowed by i.v. propofol. The median pain score in the groupreceiving clonidine, using a four-point scale (0=no pain, 1=minimalpain, 2=moderate pain, 3=severe pain) was 1 (0–2), significantlylower than in the control group [2 (1–3), median (25–75percentiles), P<0.001]. Br J Anaesth 2001; 86: 874–6     

The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain and morphine requirements after Caesarean section: a randomized controlled trial

Background. Intrathecal clonidine prolongs spinal anaesthesia.We investigated the effect of the addition of clonidine (75µg) to hyperbaric bupivacaine on postoperative morphineconsumption after Caesarean section in a randomized controlleddouble-blind trial. Methods. A group of 106 women received spinal anaesthesia usingeither bupivacaine 0.5% (2.2 ml) heavy with 0.5 ml normal saline0.9% (B) or bupivacaine 0.5% (2.2 ml) heavy with clonidine (75µg) in 0.5 ml normal saline 0.9% (BC). The primary outcomewas the total morphine consumption in the first 24 h after surgery.Secondary outcomes were the duration of postoperative analgesia,postoperative pain scores, the need for alfentanil during surgery,block regression, clonidine side-effects and morphine side-effects. Results. Total morphine consumption was similar in both studygroups. The mean time to the first analgesic request in theBC group was 129 (SD 13.8) min, compared with 55 (14.2) minin the B group [mean difference (95% CI) –75 (–106to –44) min]. In the BC group 22 (42%) patients had acomplete motor block 1 h after surgery compared with 4 (8%)patients in the B group [RR (95% CI) 0.18 (0.07–0.49)].Side-effects of intrathecal clonidine were not detected. Conclusions. The addition of clonidine (75 µg) to hyperbaricbupivacaine prolongs spinal anaesthesia after Caesarean sectionand improves early analgesia, but does not reduce the postoperativemorphine consumption during the first 24 h. No clinically relevantmaternal or neonatal side-effects were detected.     

Sedation caused by clonidine in patients with spinal cord injury

Background. In patients with spinal cord injury, cephalad spreadof intrathecal (i.t.) medication could be delayed. Methods. We used bispectral index and an observer scale to assesssedation after two different doses of i.t. clonidine in patientswith or without spinal cord injury. Twelve patients with neurologicaldeficit caused by trauma (Spinal Cord Injury, SCI) were comparedwith patients without neurological disease. They received 10mg of i.t. bupivacaine with clonidine, with either 50 µg(low dose, n=6) or 150 µg (high dose, n=6) at L₂–L₃.A further 12 patients, six with spinal trauma lesion and sixhealthy, received i.t. bupivacaine and 150 µg of i.m.clonidine. Results. Sedation and a decrease in BIS occurred only in patientsreceiving 150 µg of clonidine. Onset of sedation and thedecrease in BIS was delayed in most spinal cord injured patientswhatever the route of administration (P<0.001). Durationof sedation was not different between the groups. Delayed sedationand decrease of BIS after i.t. clonidine in patients with spinalcord injury are similar than those observed after i.m. clonidine. Conclusion. A systemic effect is likely to be the main reasonfor sedation. Br J Anaesth 2003; 90: 742–5     

Recovery after remifentanil and sufentanil for analgesia and sedation of mechanically ventilated patients after trauma or major surgery

We investigated the analgesic effect and the neurological recoverytime after administration of remifentanil in mechanically ventilatedpatients in an intensive care unit. Twenty patients, after traumaor major surgery with no intracranial pathology, were randomizedto receive either remifentanil/propofol (n=10) or sufentanil/propofol(n=10). A sedation score and a simplified pain score were usedto assess adequate sedation and analgesia. Medication was temporarilystopped after 24 h. Immediately before and 10 and 30 min after,the degree of sedation and pain score were evaluated. Adequateanalgesia and sedation was achieved with remifentanil 10.6 µgkg^–1 h^–1 and propofol 2.1 mg kg^–1 h^–1,or sufentanil 0.5 µg kg^–1 h^–1 and propofol1.3 mg kg^–1 h^–1. The difference in propofol dosebetween groups was significant. Ten minutes after terminatingthe medication, the degree of sedation decreased significantlyafter remifentanil and all patients could follow simple commands.During the following 20 min, all patients with remifentanilemerged from sedation and complained of considerable pain. Bycontrast, in the sufentanil group, only six (7) responded tocommands after 10 (30) min and their pain score remained essentiallyunchanged during the 30-min observation period. We concludethat, in contrast to sufentanil, remifentanil facilitates rapidemergence from analgesia and sedation, allowing a clinical neurologicalexamination within 10–30 min in mechanically ventilatedpatients with no intracranial pathology. Br J Anaesth 2001; 86: 763–8     

Role of beta-blockade in anaesthesia and postoperative pain management after hysterectomy

Background. Perioperative use of ß-blockers has beenadvocated as a strategy to prevent cardiac sequelae. This studyevaluated the influence of perioperative esmolol administrationupon anaesthesia and postoperative pain management amongst patientsundergoing hysterectomy. Methods. Ninety-seven ASA I–II patients, undergoing abdominaltotal hysterectomy, were randomly divided into one of two groups.Patients in the Esmolol group received an i.v. loading doseof esmolol 0.5 mg kg^–1 followed by infusion of 0.05 mgkg^–1 min^–1 before anaesthesia induction. The infusionwas documented at the completion of surgery. The Control groupreceived a volume of normal saline. After surgery, all patientswere treated with patient-controlled i.v. analgesia (PCA), whichwas programmed to deliver 1 mg of morphine on demand for 3 consecutivedays. Pain intensity on movement and at rest, sedation score,and side effects were recorded. Results. The two groups were comparable with respect to theircharacteristics. Patients in the esmolol group received significantlylower end-tidal isoflurane concentrations (1.0 (0.3) vs 1.4(0.5)%, respectively; P<0.001) and fentanyl (0.9 (0.2) vs1.2 (0.5) µg kg^–1, respectively; P=0.006) duringanaesthesia. They also showed a reduced heart rate and arterialpressure response to tracheal intubation, skin incision, andtracheal extubation. The Esmolol group consumed less PCA morphinein 3 days (37.3 (8.4) vs 54.7 (11.2) mg, respectively; P=0.005).Pain intensity and medication side effects were similar in thetwo groups. Conclusion. The results suggest that perioperative esmolol administrationduring anaesthesia reduces the intraoperative use of inhalationanaesthetic and fentanyl, decreases haemodynamic responses,and reduced morphine consumption for the first 3 postoperativedays.     

Intrathecal sufentanil and morphine for post-thoracotomy pain relief

In this double-blind randomized study we compared a group of15 patients undergoing thoracotomy who received a spinal injectionof sufentanil 20 µg combined with morphine (200 µg)after induction of general anaesthesia with a control groupof the same size. Post-operative pain was rated on a visualanalogue scale (VAS) and a verbal rating scale at rest and witha VAS on coughing. In the recovery room, patients received titratedi.v. morphine until the VAS score was <30, and were followedby patient-controlled analgesia (PCA) for 72 h. The intrathecalsufentanil and morphine group had a lower intra-operative requirementfor i.v. sufentanil and needed less i.v. morphine for titrationin the recovery room. I.v. PCA morphine consumption and painscores were lower in the active group than in the control groupduring the first 24 h. There were no differences afterthis time. Spirometric data (peak expiratory flow, forced vitalcapacity and forced expiratory volume in 1 s) were similarin the two groups. We conclude that the combination of intrathecalsufentanil and morphine produces analgesia of rapid onset andwith a duration of 24 h. Br J Anaesth 2001; 86: 236–40.     

Epidural analgesia with 0.15% ropivacaine plus sufentanil 0.5 microgram ml-1 versus 0.10% bupivacaine plus sufentanil 0.5 microgram ml-1: a double-blind comparison during labour

Background. Ropivacaine has been claimed to produce less motorblock than bupivacaine during epidural analgesia. However, thisadvantage has not been clearly confirmed in obstetric studiesusing low analgesic concentrations in a ratio close to thatsuggested to be equianalgesic. Methods. This double-blind, randomized, prospective study wasperformed in 140 parturients who requested epidural analgesia.After a lumbar epidural catheter had been placed, patients receivedeither 0.10% bupivacaine plus sufentanil 0.5 µg ml^–1or 0.15% ropivacaine plus sufentanil 0.5 µg ml^–1followed by a continuous infusion. Additional boluses were usedfor inadequate levels of analgesia. Visual analogue pain scores,motor block, level of sensory block, supplementary boluses andmain characteristics of labour were recorded. Results. No differences were observed between the two groupsfor pain scores, total volume of anaesthetic solution used [59(23) and 57 (24) ml in the bupivacaine and ropivacaine groupsrespectively], duration of labour, mode of delivery, side-effectsor satisfaction score. The incidence of motor block was notstatistically different between the groups (54 and 69% in thebupivacaine and ropivacaine groups respectively, P=0.07). However,when motor block occurred, survival analysis showed that itoccurred sooner in the course of labour with ropivacaine comparedwith bupivacaine (log rank test, P=0.012). Conclusion. Combined with sufentanil 0.5 µg ml^–1,0.10% bupivacaine and 0.15% ropivacaine produce effective andequivalent analgesia during labour, with similar incidencesof motor block. Br J Anaesth 2002; 88: 809–13     

Comparison of phenylephrine infusion regimens for maintaining maternal blood pressure during spinal anaesthesia for Caesarean section

Background. During spinal anaesthesia for Caesarean section,the optimal phenylephrine regimen and the optimal blood pressure(BP) to which it should be titrated are undetermined. The idealregimen would balance efficacy for maintaining uteroplacentalperfusion pressure against potential for uteroplacental vasoconstriction,both of which may affect fetal acid–base status. We comparedphenylephrine infusion regimens based on three different BPthresholds. Methods. After intrathecal injection, we infused phenylephrine100 µg min^–1 for 2 min. Then, until delivery,we infused phenylephrine whenever systolic BP (SBP), measuredevery 1 min, was below a randomly assigned percentage of baseline:100% (Group 100, n=25), 90% (Group 90, n=25) or 80% (Group 80,n=24). We compared umbilical blood gases, Apgar scores and maternalhaemodynamics and symptoms. Results. Patients in Group 100 had fewer episodes [median 0(range 0–8)] of hypotension (SBP <80% baseline) comparedwith Group 80 [5 (0–18)] and Group 90 [2 (0–7)](P<0.001 in each instance). Total dose of phenylephrine wasgreater in Group 100 [median 1520 µg (interquartile range1250–2130 µg)] compared with Group 90 [1070 (890–1360)µg] and Group 80 [790 (590–950) µg]. Umbilicalarterial pH was greater in Group 100 [mean 7.32 (95% confidenceinterval 7.31–7.34)] than in Group 80 [7.30 (7.28–7.31)](P=0.034). No patient had umbilical arterial pH <7.2. InGroup 100, 1/24 (4%) patients had nausea or vomiting comparedwith 4/25 (16%) in Group 90 and 10/25 (40%) in Group 80 (P=0.006). Conclusions. For optimal management, phenylephrine should betitrated to maintain maternal BP at near-baseline values. Br J Anaesth 2004; 92: 469–74     

Emetic effects of morphine and piritramide

Background. Successful management of postoperative pain requiresthat adequate analgesia is achieved without excessive adverseeffects. Opioid-induced nausea and vomiting is known to impairpatients’ satisfaction, but there are no studies providingsufficient power to test the hypothesis that the incidence ofopioid-induced nausea and vomiting differs between µ-opioidreceptor agonists. Thus, we tested the hypothesis that the incidenceof vomiting and nausea differs between morphine and piritramide. Methods. In a prospective, randomized, double-blind fashion,we administered either morphine (n=250) or piritramide (n=250)by patient-controlled analgesia (PCA) for postoperative painrelief. We used a bolus dose of 1.5 mg with a lockout time of10 min. Incidence and intensity (numerical rating scale) ofpostoperative nausea, vomiting, pain, patient satisfaction (score0–10), side-effects (score 0–3) and drug consumptionwere measured. Results. Mean drug consumption did not differ between the piritramideand morphine groups (30.8 (SD 22.4) mg day^–1 vs 28.4 (21.8)mg day^–1) during the first postoperative day and therewere no significant differences in the overall incidence ofnausea (30% vs 27%) and vomiting (19% vs 15%). Intensity ofnausea correlated inversely (P=0.01) with morphine consumptionbut not with piritramide consumption. Pain scores both at rest(2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9(2.3)) were slightly but significantly less with morphine. Conclusions. Opioid-induced emesis was observed in about one-thirdof the patients using morphine and piritramide for PCA and theincidence of vomiting was one-half of that. Potential differencesin the incidence of vomiting during PCA therapy between theseµ-opioid receptor agonists can be excluded. Br J Anaesth 2003; 91: 218–23     

Influence of peroperative opioid on postoperative pain after major abdominal surgery: sufentanil TCI versus remifentanil TCI. A randomized, controlled study

Background. Sufentanil and remifentanil are characterized bytwo different pharmacokinetic profiles. The aim of this studywas to compare the effects of sufentanil and remifentanil administeredusing target-controlled infusion (TCI) on recovery and postoperativeanalgesia after major abdominal surgery. Methods. Thirty adult patients scheduled for open colorectalsurgery were included in a prospective, randomized study. SufentanilTCI (sufentanil group) or remifentanil TCI (remifentanil group)was administered during surgery. In the remifentanil group,30 min before the anticipated end of surgery, morphine 0.15mg kg^–1 was administered i.v. In the sufentanil group,an effect-site concentration of 0.25 ng ml^–1 wastargeted at extubation. In both groups, postoperative pain wascontrolled by titration of i.v. morphine and then patient-controlledanalgesia with morphine. Results. The extubation time was similar in the two groups (mean(SD) 13 (6) and 14 (6) min in the sufentanil and remifentanilgroups respectively). Visual analogue scale scores were significantlygreater during the first 2 h after tracheal extubation in theremifentanil group than in the sufentanil group. The time tofirst analgesic request in the postanaesthesia care unit wassignificantly longer in the sufentanil group than in the remifentanilgroup (55 (64) (range 2–240) vs 11 (7) (1–29) min;P<0.001). The cumulative morphine dose for titration wassignificantly greater in the remifentanil group (P<0.01).The cumulative morphine dose used during titration and patient-controlledanalgesia was significantly greater in the remifentanil group4, 12 and 24 h after extubation (P<0.05). Conclusion. TCI sufentanil (0.25 ng ml^–1 effect-siteconcentration at extubation) is more effective than the intraoperativecombination of remifentanil TCI infusion with morphine bolus(0.15 mg kg^–1) for postoperative pain relief aftermajor abdominal surgery and does not compromise extubation andrecovery. Br J Anaesth 2003; 91: 842–9     

Efficacy of augmentation of epidural analgesia for Caesarean section

Background. Extension of a labour epidural for Caesarean deliveryis thought to be successful in most cases and avoids the useof general anaesthesia. However, most previous studies thathave estimated the failure rate of pre-existing epidural catheterswere performed in small numbers of patients. Methods. Therefore, we undertook to retrospectively measurethe failure rate of indwelling epidural catheters in a largenumber of patients. Results. The anaesthetic team was available at all times andwas permanently led by a senior anaesthetist specialized inobstetrics. Extension was performed using lidocaine 2% withepinephrine (mean 18 (SD 6) ml), combined in most patients withsufentanil (9 (2.2) µg) and/or clonidine (75 µg).Among 194 consecutive extensions performed in a 1-yr period,general anaesthesia was required in five patients (2.6%) whilesedation and/or i.v. analgesia were used in 27 patients (13.9%).In three cases where general anaesthesia was required, the intervalbetween decision to incision was <10 min. No factorassociated with failure could be identified. Addition of a lipophilicopioid or of clonidine did not modify the efficacy of the block(i.e. general anaesthesia or supplementation were required ina similar proportion). Conclusions. The augmentation of labour epidurals for Caesareansection using lidocaine 2% plus epinephrine is a reliable andeffective technique. No factor associated with failure couldbe identified. Br J Anaesth 2003; 91: 532–5     

Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study

Background. Clonidine is used increasingly in paediatric anaestheticpractice to prolong the duration of action of caudal block witha local anaesthetic agent. Which route of administration ofclonidine is the most beneficial remains unknown. We comparedthe effects of caudal and i.v. clonidine on postoperative analgesiaproduced by caudal bupivacaine after hypospadias repair. Methods. Forty-six children (ASA I or II) aged 24–104months received standardized premedication with midazolam, ageneral anaesthetic and a caudal block with bupivacaine 0.25%,0.5 ml kg^–1. The children were randomized in a double-blindfashion to two groups: the i.v. group received clonidine 2 µg kg^–1i.v. and simultaneously the same volume of saline caudally.The caudal group received clonidine 2 µg kg^–1caudally and a similar volume of saline i.v. After surgery,all children received acetaminophen 20 mg kg^–1 rectallyor orally 6-hourly and were given a patient-controlled or nurse-controlledanalgesia (PCA/NCA) pump with i.v. morphine (bolus of 25 µg kg^–1and an 8-min lockout period with no background infusion). Monitoringof scores for pain, sedation, motor block, and postoperativenausea and vomiting was performed by nurses blinded to the studyallocations. Time to first activation of the PCA/NCA pump and0–24 h and 24–48 h morphine consumption were alsorecorded. Results. Forty-four children completed the study. Age, weightand duration of anaesthesia and surgery were similar in thetwo groups. The median (range) time to first activation of thePCA/NCA pump was similar in the two groups: 425 (150–1440)min in the i.v. group and 450 (130–1440) min in the caudalgroup. The number of children not requiring postoperative morphinewas four and seven respectively. Morphine consumption during0–24 h and 24–48 h was similar between groups. Conclusions. The analgesic effect of clonidine 2 µg kg^–1as an adjunct to caudal block with bupivacaine 0.25%, 0.5 ml kg^–1is similar whether administered i.v. or caudally. Br J Anaesth 2004; 92: 223–7     

Relationship of the functional recovery after hip arthroplasty to the neuroendocrine and inflammatory responses

We studied the relationship between the neuroendocrine and inflammatoryresponses to hip arthroplasty and functional recovery in 102patients undergoing elective arthroplasty for osteoarthritis.Blood samples were collected for up to 7 days after surgeryand analysed for concentrations of norepinephrine, epinephrine,cortisol, interleukin-6 and C-reactive protein. The primaryoutcome measures were milestones in hospital, times to walk10 and 25 m, pain on discharge from hospital, and function1 and 6 months after surgery. Walking distances in hospitalwere significantly delayed in patients with greater interleukin 6and C-reactive protein concentrations, but few neuroendocrinemeasures had significant correlations with functional recoveryin hospital. Multivariate analysis showed that the interleukin 6concentration on day 1 was the unique predictor of time to walk10 and 25 m, and that the day 2 concentration of C-reactiveprotein was the unique predictor of pain on discharge from hospital.No significant correlations were found between the inflammatoryand neuroendocrine variables and recovery at 1 and 6 months.We conclude that the inflammatory response affects immediatefunctional recovery after hip arthroplasty. Br J Anaesth 2001; 87: 537–42     

Influence of thoracic epidural analgesia on cardiovascular autonomic control after thoracic surgery

Background. Thoracic epidural analgesia (TEA) is effective inalleviating pain after major thoracoabdominal surgery and mayalso reduce postoperative mortality and morbidity. This studyinvestigated cardiovascular autonomic control in patients undergoingelective thoracic surgery and its modulation by continuous TEA. Methods. Thirty-eight patients were randomly assigned to receivepatient-controlled analgesia (PCA group) or thoracic epiduralanalgesia (TEA group) with doses of bupivacaine (0.25% duringoperation, 0.125% after operation) and fentanyl (2 µg ml^–1).Heart rate variability (HRV), baroreflex function and pressureresponse to nitroglycerine and phenylephrine were assessed beforeoperation, 4 h after the end of surgery (POD 0) and on the firstand second postoperative days (POD 1 and POD 2). Results. Early after surgery, all HRV variables and baroreflexsensitivities were markedly decreased in both groups. In theTEA group, total HRV and its high-frequency components (HF)increased towards preoperative values at POD 1 and POD 2,whereas the ratio of low to high frequencies (LF/HF) was significantlyreduced (mean (SD), –44 (15)% at POD 0, –38 (17)%at POD 1, –37 (18%) at POD 2) and associatedwith blunting of the postoperative increase in heart rate andblood pressure. In the PCA group, the ratio of LF/HF remainedunchanged and the decrements in HRV variables persisted untilPOD 2. In the two groups, baroreflex sensitivities andpressure responses recovered preoperative values at POD 2. Conclusions. In contrast with PCA management, TEA using lowconcentrations of bupivacaine and fentanyl blunted cardiac sympatheticneural drive, resulting in vagal predominance, while HRV variableswere better restored after surgery. Br J Anaesth 2003; 91: 525–31     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

Comparison of hyperbaric and plain ropivacaine 15 mg in spinal anaesthesia for lower limb surgery

Background. Previously, plain ropivacaine 15 mg given intrathecallyhas been shown to be feasible for ambulatory surgery of lower-extremities.Hypothetically, hyperbaric solution could improve and shortenthe block. Methods. This prospective, randomized, double-blind study included56 patients undergoing surgery of lower extremities. They receivedintrathecally either 1.5 ml of ropivacaine 10 mg ml^–1and 0.5 ml of glucose 300 mg ml^–1 (HYP) or 2 ml of ropivacaine7.5 mg ml^–1 (PL). Results. All patients in Group HYP achieved T₁₀ dermatome analgesiabut only 64% (18/28) of Group PL. T₁₀ analgesia was reachedin 5 min (median, range 5–20 min) in the HYP group vs10 min (5–45 min) in the PL group (P=0.022), and fullmotor block in 10 min (5–45 min) vs 20 min (5–60min) (P=0.003), respectively. Group HYP had a longer durationof analgesia at T₁₀; 83 min (5–145 min) vs 33 min (0–140min) (P=0.004). Duration of sensory block from injection ofthe anesthetic to complete recovery was shorter in Group HYPthan in Group PL, 210 min (120–270 min) vs 270 min (210–360min) (P<0.001), as was duration of motor block, 120 min (5–150min) vs 210 min (120–330 min) (P<0.001). Patients ofGroup HYP attained discharge criteria earlier than those ofGroup PL (P=0.009). Conclusion. In comparison with the plain solution, 15 mg ofintrathecal hyperbaric ropivacaine produced a faster onset,greater success rate of analgesia at the level of T₁₀ dermatome,and faster recovery of the block.     

Patient-controlled cervical epidural fentanyl compared with patient-controlled i.v. fentanyl for pain after pharyngolaryngeal surgery

Background. Analgesia after pharyngolaryngeal surgery is commonlyprovided through the i.v. route. The aim of the study was tocompare cervical epidural administration of fentanyl with thei.v. route for postoperative analgesia after pharyngolaryngealsurgery. Methods. In a randomized double-blind study 42 patients receivedfentanyl via patient-controlled analgesia (PCA) either throughthe i.v. route (PCA-IV group, n=22) or through the cervicalepidural route (PCA-Epid group, n=20). Identical PCA settingswere used in the two groups (bolus dose: 1.5 µg kg^–1,bolus: 25 µg, lockout interval: 10 min, maximum cumulativedose: 400 µg per 4 h). Analgesia at rest and during swallowingwas evaluated using a visual analogue scale. Results. Analgesia at rest was better in the PCA-Epid groupthan in the PCA-IV group but only 2 and 6 h after surgery (P<0.02).There was no difference in analgesia during swallowing. Cumulativedoses of fentanyl were similar {PCA-Epid group: 1412 µg(912), PCA-IV group: 1287 µg (1200) [median (IQR)]}. ThePa_O2 showed a significant decrease between the preoperativeand postoperative period, but this decrease was identical inthe two groups [PCA-IV-group: 11.47 (2.4) kPa vs 8.27 (0.9)kPa; PCA-Epid group: 11.33 (1.9) kPa vs 9.20 (2.4) kPa for preoperativeand postoperative period respectively]. Conclusions. The study results show that cervical epidural analgesiaprovides marginally better pain relief at rest with no decreasein the fentanyl consumption. The use of the cervical epiduraladministration of fentanyl is questionable because of the possiblecomplications of the technique.     

Analgesic efficacy of bilateral superficial cervical plexus block administered before thyroid surgery under general anaesthesia

Background: The use of regional anaesthesia in thyroid surgery remains controversial.This double-blind, randomized controlled study was conductedto evaluate the analgesic efficacy of bilateral superficialcervical plexus block (BSCPB) performed under general anaesthesiain patients undergoing total thyroidectomy. Methods: Eighty-seven consecutive consenting patients were randomizedto receive a BSCPB with saline (Group P, n = 29), ropivacaine0.487% (Group R, n = 29), or ropivacaine 0.487% plus clonidine5 µg ml^–1 (Group RC, n = 29). Sufentanil was givenduring the intraoperative period for a 20% increase in arterialmean pressure or heart rate in a patient with a bispectral indexbetween 40 and 60. All patients received 4 g of acetaminophenduring the first 24 h after operation. The pain score was checkedevery 4 h and nefopam was given for pain score >4 on a numericpain scale. Results: During surgery, the median sufentanil requirements were significantlyreduced in Group RC compared with Groups R and P (0.32 vs 0.47and 0.62 µg kg^–1; P < 0.0001). After surgery,the number of patients requiring nefopam within 24 h of surgerywas significantly lower in Groups R and RC than in Group P (16and 19 vs 25; P = 0.03). At post-anaesthetic care unit admission,median (range) pain scores were significantly lower in GroupsR [3 (0–10)] and RC [3 (0–8)] than in Group P [5(0–8), P = 0.03]. No major complications of BSCPB occurredduring study. Conclusions: BSCPB with ropivacaine and clonidine improved intraoperativeanalgesia. BSCPB with ropivacaine or ropivaciane and clonidinewas effective in reducing analgesic requirements after thyroidsurgery.     

Choice of opioid for initiation of combined spinal epidural analgesia in labour--fentanyl or diamorphine

Sixty-two women requesting regional analgesia in labour wereallocated to receive a 1.5 ml intrathecal injection aspart of a combined spinal–epidural (CSE) analgesic technique.This contained either bupivacaine 2.5 mg plus fentanyl25 µg (group F) or bupivacaine 2.5 mg plus diamorphine250 µg (group D). Times of analgesic onset and offsetwere recorded, motor and proprioceptive assessments made andside-effects noted. Analgesic onset was not significantly differentbetween the groups (group F, 8.0 min; group D, 9.5 min; P=0.3)but time to first top-up request was significantly longer inthe diamorphine group (group F, 73 min; group D, 101 min; P=0.003).Motor loss, assessed by the modified Bromage score, was statisticallybut not clinically greater in the fentanyl group (P=0.01). Maternalhypotension, pruritis, proprioceptive loss, nausea and fetalbradycardia were rare and not severe, and their incidences didnot differ between groups. No respiratory depression was observedafter CSE. This use of diamorphine was not associated with increasedside-effects compared with fentanyl/bupivacaine, and it hasa longer duration of action. Br J Anaesth 2001; 86: 567–9