Effect of continuous postoperative analgesia with peridural bupivacaine on intestinal motility following colorectal resection]

In a prospective randomized trial the effects of continuous peridural analgesia on gastrointestinal motility and the postoperative course was studied in 48 consecutive patients with elective colorectal resections. 24 patients had peridural analgesia (PDA) with bupivacaine while 24 patients received intravenous analgesia (IVA) with pentazocine. With PDA the first passage of flatus and faeces was significantly accelerated. PDA was not associated with an increased rate of anastomotic breakdown and there were no respiratory complications in the PDA group.     

Effect of continuous epidural infusion of morphine for postoperative analgesia on pituitary-adrenocortical function

Plasma levels of cortisol, ACTH and beta-endorphin like immunoreactivity (beta-ELI) were measured to evaluate postoperative pain relief with epidural morphine and systemic analgesics in conjunction with endocrine functions in 16 patients who underwent gastrectomy. Eight of these patients (epidural morphine group) obtained postoperative analgesia with continuous epidural infusion of morphine with a pump as in our previous report. A bolus of epidural morphine was administered through an indwelling thoracic (Th8,9) catheter at 3 hrs prior to the proposed end of the surgery, which was followed with continuous epidural infusion of morphine at a rate of 0.167-0.042 mg.hr-1 with a pump (CADD-PCA, Model 5200P, Pharmacia) during and after anesthesia and surgery with gradual decrease in dose until the third postoperative day. The remaining eight patients (systemic analgesics group) repeatedly received systemic pentazocine and buprenorphine when needed. Plasma cortisol levels increased significantly at the end of surgery and after in both groups. However plasma concentrations of cortisol in the epidural morphine group were significantly lower than those in the systemic analgesics group on the first and second postoperative days. Plasma levels of ACTH and beta-ELI increased significantly at the end of surgery but returned to levels of the previous day in both groups postoperatively. Our study suggests that continuous epidural infusion of morphine is adequate for postoperative pain relief and has suppressing effect on plasma cortisol levels as compared with systemic analgesics regimen.     

Plasma bupivacaine concentrations during postoperative continuous epidural analgesia

Postoperative analgesia and plasma concentrations of bupivacaine were evaluated in six patients receiving intermittent epidural bupivacaine for a period of 72 hours following large bowel surgery. Repeated doses were administered every hour by a new automatic, specially designed pump. Venous plasma bupivacaine concentrations showed accumulation for up to 48-60 hours during administration and were mostly less than 2 micrograms/ml except in an elderly, frail patient in whom a peak of 3.9 micrograms/ml was observed. This convenient, low-dose, pulsed technique provided excellent analgesia although special care may be necessary in the elderly and frail patient if potentially toxic levels are to be avoided.     

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.     

Effects of postoperative continuous epidural analgesia after laparoscopy-assisted colectomy

BACKGROUND: This study was conducted to evaluate the effects of continuous epidural analgesia on the postoperative pain and the early recovery after laparoscopy-assisted colectomy (LAC). METHODS: A total of 50 patients undergoing elective LAC were investigated for postoperative pain score and other variables retrospectively. RESULTS: Thirty patients who had received epidural analgesia (E group) showed significantly lower pain scores for 2 and 24 hours after surgery, compared with twenty patients who had received analgesics intramuscularly or transrectally (C group). The patients in the E group needed significantly less supplemental analgesics than those in C group for 12 to 24 hours after the operation. The incidence of postoperative complications and the early recovery were not significantly different between the two groups. CONCLUSIONS: These results show that postoperative continuous epidural analgesia is effective for postoperative pain relief in patients after laparoscopy-assisted colectomy.     

硬膜外吗啡持续注入用于小儿术后镇痛的研究

目的　评价硬膜外吗啡 5μg· kg- 1 · h- 1 复合 0 .12 5 %丁哌卡因持续注入对儿童术后镇痛的效果及安全性。方法　选 ASA ( ～ )级择期腹部或下肢手术的患儿 2 3例 ,行硬膜外复合全麻 ,术毕以 0 .12 5 %丁哌卡因及吗啡 5μg· kg- 1 · h- 1 按 0 .5 ml· h- 1 的速率硬膜外腔持续注入 ,观察镇痛效果及副作用 ,监测血压、心率、呼吸频率及脉搏氧饱和度。结果　术后无痛及轻微痛的患儿 2 2 /2 3(95 .6 5 % ) ,中度痛 1/ 2 3(4.35 % ) ,血压、心率、呼吸频率稳定 ,无明显呼吸抑制 ,恶心、呕吐发生率较低 (分别为 17.39%、8.70 % )。结论　吗啡 5μg· kg- 1 · h- 1 复合 0 .12 5 %丁哌卡因硬膜外持续注入是儿童较为安全有效的术后镇痛方法之一。     

Effect of oral gabapentin on postoperative epidural analgesia

Background. Gabapentin has been used successfully as a non-opioidanalgesic adjuvant for postoperative pain management. We hypothesizedthat gabapentin might be a useful adjuvant for postoperativeanalgesia provided with patient-controlled epidural analgesia(PCEA). Methods. Forty patients undergoing lower extremity surgery procedureswere randomly assigned to receive (i) placebo capsules (control)or (ii) gabapentin (1.2 g day^–1) before and for 2 daysafter surgery. Anaesthetic technique was standardized. Postoperativeassessments included verbal rating scale scoring for pain andsedation, PCEA usage, quality of recovery assessment, timesof GI function recovery, and patient satisfaction scoring forpain management. Results. Pain scores at 1, 4, 8, 12, and 16 h (P<0.001),PCEA bolus requirements (n) at 24 [21 (3), 14 (2)], 48 [15 (4),10 (3)] and 72 [8 (5), 2 (3)] (P<0.05) and paracetamol (mg)consumption [700 (523), 350 (400)]; P<0.05), were significantlylower in the gabapentin-treated patients than in the controlgroup. Patient satisfaction with postoperative pain managementat 24 h was better in gabapentin-treated patients [85.5 (7.5),66.5 (15)]; P<0.001). Gabapentin-treated patients had lessmotor block when compared with control group. Times of returnof bowel function, hospitalization, and resumption of dietaryintake were similar in the groups. However, the incidence ofdizziness was higher in the gabapentin group (35% vs 5%; P<0.05). Conclusions. Oral gabapentin (1.2 g day^–1) as an adjunctto epidural analgesia decreased pain and analgesic consumption.Despite an increased incidence of dizziness it also increasedpatient satisfaction.      

术后镇痛对红细胞免疫功能的影响

目的 探讨术后镇痛对红细胞免疫功能的影响。方法 择期胆囊切除术患者,ＡＳＡⅠ～Ⅱ级,随机分为镇痛组（以ＶＡＳ≤３分者为试验对象,ｎ＝１５）,与对照组,分别在术前、术后３ｄ、术后７ｄ采静脉血样检测红细胞Ｃ３ｂ受体花环率（ＲＣＲ）、红细胞免疫复合花环率（ＣＩＣＲ）、自然肿瘤红细胞花环率（ＮＴＥＲＴ）、红细胞免疫粘附促进因子（ＲＦＥＲ）及红细胞免疫粘附抑制因子（ＲＦＩＲ）。结果 与对照组相比,镇痛组术前     

Effect of postoperative epidural analgesia on patient outcomes

The overall benefits of perioperative epidural anesthesia and analgesia for decreasing morbidity and mortality is controversial. However, perioperative epidural anesthesia and analgesia will attenuate detrimental perioperative pathophysiology, which, in turn, may diminish the incidence of adverse patient outcomes. There are increasing experimental and clinical data to support the use of perioperative epidural anesthesia and analgesia for decreasing postoperative pulmonary, gastrointestinal, and cardiovascular complications. One of the primary reasons that the “regional versus general anesthesia” question has not been answered is due to the significant methodological issues present in every available trial, which affect the interpretation and limit the applicability of the trial results. A major issue in the overall interpretation of results from trials examining the effect of postoperative epidural analgesia on patient outcomes is that “epidural analgesia” is commonly viewed as a generic term. There are clinical and outcome implications for various inputs into what constitutes “epidural analgesia,” including the duration of epidural analgesia, analgesic contents (eg, local anesthetics versus opioids), and location of catheter placement. We will examine these issues along with the role of epidural analgesia in the multimodal approach for patient recovery.     

Effect of postoperative epidural analgesia on surgical outcome

Pain relief allowing sufficient mobilization after major surgical procedures can only be achieved by continuous epidural analgesia with local anesthetics, which also reduces the stress response to surgery. However, the role of postoperative epidural analgesia on postoperative morbidity is controversial. We therefore update the effects of postoperative analgesia on surgical outcome. After major abdominal surgery, postoperative epidural analgesia with local anesthetics significantly reduces postoperative ileus and pulmonary complications while effects on cardiac morbidity are debatable. Continuous epidural analgesia significantly lowers the risk of thromboembolic complications after lower body procedures, while no effect is seen after major abdominal surgery. Unfortunately, many studies have inadequate study design, with use of lumbar epidural analgesia for abdominal procedures, or the epidural regimen does not contain a sufficient amount of local anesthetics. Future evaluation of the effects of epidural analgesia on postoperative outcome also requires integration of epidural analgesia within a multimodal rehabilitation programme.     

Complications of continuous epidural infusions for postoperative analgesia in children

To determine the incidences of side effects and complications associated with the use of epidural analgesia for infants and children at the Alberta Children’s Hospital, we reviewed our experience over a two-year period. A database was established for recording management, side effects and complications of each epidural, and this is a retrospective review ofthat database. Problems were identified as complications if there was a need for medical intervention related to the patient complaint, and if the intervention was documented in the patient record. Continuous epidural analgesia with bupivacaine 0.125% or bupivacaine 0.1% with epinephrine was used for managing postoperative pain in 190 children with mean age 5.6 yr (range 1 mo to 18 yr) and the mean weight 22 kg (range 4–88 kg). Mean duration of the epidural infusions was 4.7 days (range 1–16 d). In 127 patients, 203 complications were recorded. Complications, in order of frequency, were nausea and vomiting (23% of patients), motor blockade (15.8% of patients), oversedation (6.3% of patients), and pruritus (5.2% of patients). Four patients had complications which were potentially related to toxic effects of, or resistance to, bupivacaine, and serum levels of bupivacaine were measured at 3.86, 5.5, 2.1 and 2.34 μg · ml^?1. Early discontinuation of the epidural occurred in 41 cases, technical problems with the epidural catheter being the commonest reason (21 cases). Although three potentially serious complications were identified (one catheter site infection, one seizure, one respiratory depression) none was associated with lasting consequences. The majority of complications associated with the use of epidurals were minor and easily remedied. With increased experience using continuous epidurals, technical problems should diminish and consistency and reliability of the technique should improve.     

胆道术后镇痛对病人胃肠动力的影响研究

目的　探讨胆道术后镇痛对病人胃肠动力的影响。方法　选择 2 0 0 1年 1月～ 2 0 0 2年 7月胆道手术病人 2 18例 ,分为镇痛组 (A组 )和非镇痛组 (B组 ) ,统计两组病人术后胃瘫发生率、肛门排气时间、恢复进食时间、胃肠减压管留置时间长短。结果　①A组病人术后胃瘫发生率为 5 .0 % ,B组 0 .8% ,两组间差异无统计学意义。②A组病人术后肛门排气、恢复进食时间较B组显著延长 ,超过 3d病例数为 3 8例 ,B组 18例 ,P <0 .0 1。③A组病人术后胃肠减压管留置时间较B组延长 ,超过 3d病例数为 16例 ,B组 11例 ,P <0 .0 1,差异有显著性。结论　术后镇痛能有效地改善疼痛 ,但会导致胃肠功能恢复的延迟 ;对老年病人 (≥ 60岁 ) ,更会导致胃瘫的发生 ,所以在病人的选择方面应慎重。     

Midazolam improves postoperative epidural analgesia with continuous infusion of local anaesthetics

Purpose

Midazolam has been shown to have an analgesic effect by single shot epidural administration. In this study, the effect of midazolam on continuous epidural infusion of bupivacaine was investigated to find a better combination for postoperative analgesia.

Methods

Sixty patients scheduled for gastrectomy were divided into three groups of 20. The following mixtures, in 40 ml, were infused continuously over 12 hr after surgery; 40 ml bupivacaine 0.5% in Group C, bupivacaine 0.5% 38 ml + 10 mg midazolam in Group M10, and bupivacaine 0.5% 36 ml + 20 mg midazolam in Group M20. If necessary, 50 mg indomethacin suppository was administered. Blood pressure, heart rate, respiratory rate, analgesia score, and sedation score were monitored for 12 hr after surgery. Amnesia and frequency of the administration of indomethacin suppository were also noted.

Results

Blood pressure, heart rate and respiratory rate showed no differences among the groups. Greater sedation was seen in Groups M10 and M20 compared with Group C during first 120 min (P < 0.05). The number of patients with memory was larger in Group C (18) than in Group M10 (10,P = 0.006) and Group M20 (6,P < 0.001). Better analgesia was obtained in patients receiving midazolam than in Group C (P < 0.05). The frequency of the indomethacin administration was 2.0 ± 1.1 (SD) in Group C, which was larger than in Group M10 (1. 1 ± 0.9,P = 0.035) and Group M20 (1.2 ± 0.7,P = 0.039).

Conclusion

Adding midazolam to a continuous epidural infusion of bupivacaine provides better analgesia, amnesia and sedation than bupivacaine alone without side effects in patients undergoing laparotomy.     

The effects of postoperative continuous epidural analgesia after laparoscopy-assisted distal gastrectomy

BACKGROUND: This study was conducted to evaluate the effects of continuous epidural analgesia on the postoperative pain and the early recovery after laparoscopy-assisted gastrectomy (LAG). METHODS: A total of 66 patients undergoing elective LAG were investigated for postoperative pain score and other variables retrospectively. RESULTS: Forty-four patients who had received epidural analgesia (E group) showed significantly lower pain scores for 2, 12 and 48 hours after surgery, compared with 22 patients who had received analgesics intramuscularly or transrectally (C group). The patients in the E group needed significantly less supplemental analgesics than those in C group for 2 and 12 hours after the operation. The early recovery and the incidence of postoperative complications were not significantly different between the two groups. CONCLUSIONS: These results show that postoperative continuous epidural analgesia is effective for postoperative pain relief in patients after laparoscopy-assisted gastrectomy.     

Effects of dopamine on intestinal hemodynamics and motility during epidural analgesia in the cat

The effects of dopamine on intestinal blood flow (IBF) and intestinal contraction rate (ICR), and on mean arterial pressure (MAP) and heart rate (HR) were studied in eight cats before and during epidural analgesia (EDA). Before EDA, dopamine 5 and 10 micrograms.kg-1.min-1 had no effect on IBF, MAP and HR, but the higher infusion rate decreased ICR by 71 +/- 19% (mean +/- 1 s.e.mean) (P less than 0.01). EDA significantly increased IBF when intestinal arterial pressure was maintained at an unchanged level by means of a pump, and transiently increased ICR and intestinal tone, but reduced MAP by 46 +/- 8% (139 +/- 11 to 75 +/- 9 mmHg, P less than 0.01) and HR by 26 +/- 3% (248 +/- 7 to 184 +/- 8 beats.min-1, P less than 0.01). During EDA, dopamine increased IBF further, the response being similar at both infusion rates. 5 micrograms.kg-1.min-1 increased HR by 26 +/- 7 beats.min-1 (P less than 0.01) and MAP by 19 +/- 9 mmHg (ns). The corresponding values at 10 micrograms.kg-1.min-1 were 65 +/- 14 beats.min-1 (P less than 0.01) and 35 +/- 8 mmHg (P less than 0.01), respectively, Vascular autoregulation appeared to be unaffected by dopamine and EDA. The effect of dopamine on ICR was not significantly different to what was seen before EDA. It is concluded that the effects of dopamine on IBF, MAP and HR were markedly different during EDA as compared to before the block and that ICR was reduced by dopamine, while it was transiently increased by EDA.(ABSTRACT TRUNCATED AT 250 WORDS)     

不含局麻药单用吗啡行术后硬膜外持续镇痛的可行性

吗啡配伍局麻药行术后硬膜外持续镇痛已广泛应用于临床,目前一般认为,配伍局麻药可以减少吗啡的用量,从而降低吗啡的不良反应（如呼吸抑制、恶心呕吐、皮肤瘙痒、尿潴留等）,3年来我们在术后硬膜外镇痛病人中,观察和探讨较低剂量的吗啡不含局麻醉药是否也可达到良好的镇痛效果,同时针对性地应用一些药物如恩丹西酮、苯海拉明、胃复安、地塞米松等,试图降低吗啡不良反应的发生率。     

Comparison of continuous epidural bupivacaine infusion plus either continuous epidural infusion or patient-controlled epidural injection of fentanyl for postoperative analgesia.

We compared the postoperative epidural analgesia provided by the continuous epidural infusion of bupivacaine supplemented with patient-controlled injection (PCA) of epidural fentanyl with that provided by a continuous infusion of bupivacaine supplemented with a continuous epidural infusion of fentanyl. Our patient population comprised 16 ASA physical status I or II patients undergoing laparotomy with a midline incision under general anesthesia combined with bupivacaine epidural analgesia. Post-operatively, a continuous epidural infusion of bupivacaine (0.1 mg.kg-1.h-1) was combined with epidural fentanyl given by either (a) PCA (15-micrograms bolus with a lockout interval of 12 min, n = 8) or (b) continuous infusion (1 microgram.kg-1.h-1, n = 8). In the case of inadequate pain relief in the latter group, the fentanyl infusion rate was increased by 10 micrograms/h. Analgesia evaluated by a visual analogue pain score and by a verbal pain score was similarly effective in both groups. The sedation score was also similar in both groups. The total dose of epidural fentanyl administered during the first 24 h was significantly lower in the PCA group than in the continuous infusion group (405 +/- 110 micrograms vs 1600 +/- 245 micrograms, P less than 0.001). The dose of fentanyl given during each 4-h interval ranged between 40 and 160 micrograms in the PCA group and 251 and 292 micrograms in the continuous infusion group. Clinically detectable respiratory depression was not observed in either group. In conclusion, epidural administration of 0.1 mg.kg-1.h-1 bupivacaine combined with fentanyl provides effective postoperative analgesia with a total dose of fentanyl required that is lower when fentanyl is administered by epidural PCA rather than by continuous epidural infusion.     

Effect of epidural clonidine on analgesia and pharmacokinetics of epidural fentanyl in postoperative patients

Epidural clonidine produces postoperative analgesia in patients and potentiates opioid analgesia in animals. The aim of the current study was to assess the effect of epidural clonidine on the plasma concentrations and analgesic effect of fentanyl after epidural administration. Twenty ASA physical status 2 or 3 patients recovering from abdominal surgery were allocated randomly to receive either epidural fentanyl (100 micrograms in 10 ml isotonic saline; EF group) or epidural fentanyl (same dose) plus epidural clonidine (150 micrograms; EF + C group) in isotonic saline solution. Analgesia was assessed over a period of 12 h after epidural injection. Venous samples were obtained until 360 min after epidural injection for radioimmunoassay determination of plasma fentanyl concentration. Onset of analgesia was similar in the two groups of patients (13 +/- 6 and 13 +/- 3 min, respectively, after injection), but duration was more than doubled in the patients receiving clonidine (543 +/- 183 vs. 250 +/- 64 min). Peak plasma fentanyl concentrations (Fmax) and the time to reach Cmax (Tmax) were comparable in the two groups (0.29 +/- 0.15 ng.ml-1 at 16.2 +/- 14.8 min in the EF group and 0.27 +/- 0.11 ng.ml-1 at 8.3 +/- 5.5 min in the EF + C group), as were plasma concentrations at each definite time of measurement. Drowsiness and hypotension were noticed in the EF + C group. Thus, epidural clonidine appears to prolong epidural fentanyl analgesia without affecting its plasma concentration.