Comparison of epidural and combined spinal-epidural analgesia in the management of labour without pain

The effects of combined spinal-epidural analgesia (CSEA) and epidural analgesia (EA) were studied in 50 healthy parturients randomly allocated to receive bupivacaine plus fentanyl either epidurally, or intrathecally and epidurally. Significant differences from baseline values were seen in systolic blood pressure at all time-points except for 4 h in the EA group and at 3 and 4 h in the CSEA group. Significant differences from baseline values were seen in diastolic blood pressure at 1, 2, 3 and 4 h in the EA group, whereas no significant differences from baseline were seen in the CSEA group. Pain scores in both groups were significantly decreased compared with baseline and all scores, except at 2h, were significantly lower in the CSEA group compared with the EA group. The duration of labour and total amount of drugs used were significantly decreased and cervical dilatation was faster with CSEA compared with EA. In conclusion, CSEA was associated with more rapid onset of analgesia and faster progress in cervical dilatation compared with EA, and can be used safely for labour analgesia.     

Preemptive analgesia with epidural bupivacaine plus fentanyl in gynaecological surgery—effects on serum interleukin-6 concentrations

Purpose: The aim of this study was to evaluate preemptive analgesia and its influence on interleukin-6 (IL-6) levels.Methods: Thirty patients scheduled for hysterectomy were randomised in two groups to receive 13 ml bupivacaine 0.25% plus fentanyl (100 μg) before incision and 15 ml of saline after incision (group I, GI), or 15 ml of saline before incision and 13 ml bupivacaine 0.25% plus fentanyl (100 μg) after incision (group II, GII). General anaesthesia was performed using propofol/pancuronium/O₂/isoflurane. Postoperative analgesia consisted of epidural bolus doses of 4 ml bupivacaine 0.25% plus fentanyl (50 μg) or dipyrone i.v. on demand. Pain was assessed by visual analogue scale (VAS). IL-6 levels were quantified during the study.Results: Patients in group I had significantly less pain only at arrival in recovery room. The requirements for rescue analgesia were similar in both groups and there were no significant differences in IL-6 concentrations.Conclusions: This study showed no preemptive effect of epidural fentanyl plus bupivacaine on postoperative pain and stress response as measured by IL-6 concentrations.     

Epidural analgesia in thoracic trauma: effects of lumbar morphine and thoracic bupivacaine on pulmonary function

Changes in pulmonary function tests were compared in 14 thoracic trauma patients, of whom seven received thoracic epidural bupivacaine for analgesia and seven received lumbar epidural morphine. In both groups epidural analgesia decreased subjective pain levels when compared to parenteral narcotics which the patients received before epidural catheter placement. Patients in the bupivacaine group had statistically significant improvements in vital capacity and forced expiratory volume, and a decreased respiratory rate. Patients in the morphine group had no significant change in pulmonary function. The use of thoracic epidural bupivacaine for analgesia in post-traumatic chest injuries produced superior improvement in pulmonary function when compared to lumbar epidural morphine.     

Low dose fentanyl improves continuous bupivacaine epidural analgesia following orthopaedic, urological or general surgery

This retrospective study assessed the clinical efficacy of the addition of low concentrations of fentanyl to bupivacaine 0.125% when infused epidurally for postoperative analgesia. Three patient groups received bupivacaine 0.125% alone (n=70), bupivacaine 0.125% with 1 μg/ml fentanyl (n=100), and bupivacaine 0.125% with 2 μg/ml fentanyl (n=70). The percentage of patients with adequate analgesia (pain score ≤3) was higher in both fentanyl groups compared to the plain bupivacaine group on each of the three study days (p<0.05). Those receiving plain bupivacaine had a greater incidence of patchy or unilateral blocks compared to both fentanyl groups (p<0.05). The higher dose of fentanyl was associated with a greatly increased length of stable analgesia (p<0.01). Patient satisfaction scores were highest in the 2 μg/ml fentanyl group and lowest in the plain bupivacaine group, with significant differences between all groups (p<0.01). The incidence of nausea was significantly greater in the plain bupivacaine group compared to both fentanyl groups (p<0.001); other side effects were similar between the groups. We conclude that the addition of fentanyl 1–2 μg/ml to bupivacaine 0.125% for continuous epidural infusion significantly improved all indicators of analgesic quality, without an attendant increase in side effects in a routine clinical setting and is therefore to be recommended.     

'Balanced analgesia' in the perioperative period: is there a place for ketamine?

We investigated whether intraoperative 'subanesthetic doses' of ketamine have a postoperative anti-hyperalgesic and an analgesic effect and which is the preferential route of administration, either systemic (intravenous, i.v.) or epidural. One hundred patients scheduled for rectal adenocarcinoma surgery under combined epidural/general anesthesia were included. Before skin incision all the patients received an epidural bolus followed by an infusion of continuous bupivacaine/sufentanil/clonidine mixture. They were randomly assigned to receive no ketamine (group 1), i.v. ketamine at the bolus dose of 0.25 mg/kg followed by an infusion of 0.125 mg/kg per h (group 2), 0.5 mg/kg and 0.25 mg/kg per h (group 3), epidural ketamine 0.25 mg/kg and 0.125 mg/kg per h (group 4), or 0.5 mg/kg and 0.25 mg/kg per h (group 5). All i.v. and epidural analgesics were stopped at the end of surgery and patients were connected to an i.v. morphine patient-controlled analgesia (PCA) device. Short-term postoperative analgesia (72 h) was assessed by pain visual analog scale scores at rest, cough, and movements as well as by PCA requirements. Wound mechanical hyperalgesia was evaluated and residual pain was assessed by asking the patients at 2 weeks, and 1, 6, and 12 months. The area of hyperalgesia and morphine PCA requirements were significantly reduced in group 3. These patients reported significantly less residual pain until the sixth postoperative month. These observations support the theory that subanesthetic doses of i.v. ketamine (0.5 mg/kg bolus followed by 0.25 mg/kg per h) given during anesthesia reduce wound hyperalgesia and are a useful adjuvant in perioperative balanced analgesia. Moreover, they show that the systemic route clearly is the preferential route.     

Efficacy of thoracic epidural analgesia for laparoscopic cholecystectomy

Introduction Postoperative pain is a commonly observed phenomenon after laparoscopic procedures. The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with them is not sufficiently known. Optimally, analgesic therapy should be started in sufficient time as to be effective at the point of emergence from anaesthesia. We compared the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period. Methods Thirty adult patients with American Society of Anesthesiologists (ASA) physical status I–II, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the intravenous group (n=15) received general anaesthesia with sevoflurane and intravenous infusion of 1.5 μg/ml/kg/h fentanyl analgesia followed by postoperative intravenous infusion of 1.0 μg/ml/kg/h fentanyl, supplied by a programmed continuous analgesia pump. The patients in the epidural group (n=15) had combined epidural analgesia with 0.125% bupivacaine plus 50 μg fentanyl and general anaesthesia with sevoflurane, followed by continuous epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. Visual analogue scores and the patients’ needs for analgesics and were recorded.     

Fentanyl: clinical use as postoperative analgesic--epidural/intrathecal route.

The administration of epidural and intrathecal opioids for the management of postoperative pain is well established. Fentanyl, because of its greater lipophilicity, offers a number of advantages over morphine for epidural analgesia, including a lower incidence of side effects and reduced risk of delayed-onset respiratory depression. The relatively short duration of action of epidural fentanyl makes this agent more ideally suited for continuous infusion or patient-controlled epidural analgesia (PCEA). The effective doses and adverse effects profile of epidural fentanyl are reasonably well understood. Because of the lack of spread through the cerebrospinal fluid (CSF) and hence the segmental nature of the analgesia achieved, location of epidural catheter placement is of paramount importance when this agent is used. Prolonged epidural infusion of fentanyl may result in high systemic concentrations not dissimilar to IV infusion, and, therefore, the greatest efficacy of epidural fentanyl administration may be in combination with low concentrations of bupivacaine, an approach that achieves a synergistic effect. 2-Chloroprocaine has been shown to antagonize epidural fentanyl analgesia. Intrathecal fentanyl for postoperative analgesia is limited by its short duration of action with single-bolus administration. The widespread international increase in the use of epidural fentanyl for postoperative analgesia promises further improvements and refinement in techniques.     

Pediatric analgesia with epidural fentanyl citrate administered by nursing staff.

Even though epidural analgesia is effective and has advantages over conventional postoperative analgesia, it is also labor intensive, requiring 24-hour supervision by an anesthesiologist. In an effort to decrease the manpower requirements, some hospitals allow the nursing staff to administer epidural narcotics to adult patients. In children, however, this practice has been limited. We retrospectively reviewed our experience over 12 months with this procedure. Epidural catheters (caudal, lumbar, or thoracic) were placed in 43 pediatric patients for acute and chronic pain management. All patients received a continuous epidural infusion of bupivacaine hydrochloride with fentanyl citrate. Eleven (26%) of the 43 patients required supplemental analgesia and were given 45 doses of epidural fentanyl. Adequate analgesia was achieved in all patients. No intravascular or intrathecal injections were noted, nor did any inadvertent epidural injections of medications occur. No patient had respiratory depression (respiratory rate less than 10% for age). We believe epidural administration of fentanyl by a carefully educated nursing staff is safe and effective in children.     

Addition of ketamine to propofol–fentanyl anaesthesia can reduce post-operative pain and epidural analgesic consumption in upper abdominal surgery

The aim of this study was to confirm whether intravenous anaesthesia supplemented with the N-methyl- -aspartate (NMDA) antagonist ketamine could reduce post-operative pain after elective open cholecystectomy. Fifty patients were randomised double-blind to one of the following two groups: PF Group received propofol and fentanyl supplemented with saline infusion; PFK Group received propofol and fentanyl supplemented with ketamine (total dose 2 mg/kg). During the first 48 post-operative hours, epidural analgesia was provided for all patients with patient-controlled epidural analgesia (PCEA) using 0.125% bupivacaine and morphine (0.05 mg/ml). Pain assessments at rest and movement, and cumulative PCEA volume consumed, were recorded at 5, 24 and 48 h post-operatively. The visual analogue scale (VAS) scores at rest were significantly less in the PFK Group than in the PF Group at 5, 24 and 48 h (P<0.001, P<0.001 and P=0.02, respectively). The VAS score at movement were also significantly (P<0.001) less throughout this study than in the PF Group. The difference in PCEA analgesic consumption at 0–5 and 5–24 h reached statistical significance (P<0.001 and P=0.008, respectively). Our results show that an intra-operative ketamine dose provides advantages for post-operative analgesia beyond its duration of action after an open cholecystectomy.     

腰椎手术病人连续硬膜外镇痛的不同用药方案比较

Lumbarintervertebraldiscextirpationorvertebralcanaldecom－pressionisonecommonoperation，andepiduralanesthesiaorgeneralanesthesiahavereplacedpreviouslocalanesthesia．Toobservetheeffectsandsideeffectsofdifferentepiduralanalgesiaandfindthemostfavorableformula．１Objectsandmethods１．１TheselectingandgroupingofobjectsThe１５０caseswithASAⅠ～Ⅱgrade，lumbarintervertebraldiscextirpationand／orver－tebralcanaldecompression，７８malesand７２femalesaged２０～７６years，weredividedinto５groups．There…     

Epidural opiates and local anesthetics for the management of cancer pain.

The role of epidural morphine in chronic cancer pain treatment is unresolved. In a population of 1205 cancer patients, the aggressive use of systemic opiates limited the trial of epidural analgesia to 16 cases. Successful analgesia was achieved with epidural morphine alone in 6 of these 16 cases following systemic opiate failure. The addition of bupivacaine produced analgesia in all of the 10 remaining cases and was successful chronically in 6 cases. Complications occurred in 11 of the 16 cases of epidural analgesia and included dislodged or broken catheters, pain on injection, hyperesthesia from epidural morphine and bleeding or infection related to the epidural catheter. Epidural morphine is indicated only in selected cancer pain patients and, although bupivacaine extends the efficacy of epidural analgesia, these methods are accompanied by problems and limitations.     

心外科术后吗啡与芬太尼患者自控镇痛效果观察

目的观察吗啡和芬太尼患者自控镇痛 (PCIA)用于心外科术后疼痛康复的疗效和安全性。方法将 70例心脏手术患者随机分为吗啡组和芬太尼组 ,术后在ICU病房用PCIA进行疼痛康复 ,观察镇痛起效时间、效果及满意率 ,以及 2 4h、48h和 72h生命体征及恶心、呕吐等副作用。结果两组患者的镇痛效果及满意率无显著性差异 ,生命体征均平稳 ,但芬太尼组的起效时间明显短于吗啡组 (P <0 .0 5 ) ,患者的恶心、呕吐次数明显少于吗啡组 (P <0 .0 5 )。结论吗啡和芬太尼PCIA均能安全地用于心外科术后患者急性疼痛的康复治疗 ,但芬太尼PCIA明显比吗啡PCIA起效快 ,恶心、呕吐副作用少。     

Pain score documentation and analgesia: A comparison of children and adults with appendicitis

Objective: There is a growing body of evidence suggesting that administration of analgesia in paediatric ED is inadequate. The present study was designed to assess pain score documentation and provision of opioid analgesia to children and adults with confirmed appendicitis in a mixed Australian ED. Method: A retrospective chart review of all adults and children with histologically confirmed appendicitis diagnosed in the Townsville ED during 2006 was performed. Data collected included pain score documentation, weight, opioid dose, oral analgesia, time of presentation, level of doctor and prehospital analgesia. Results: Data were collected for 106 adults and 39 children. Among them, 13 (33%) children compared with 79 (75%) adults had a pain score documented (OR 0.16, 95% CI 0.07–0.37, P < 0.001). And 11 (28%) children compared with 79 (75%) adults received i.v. morphine (OR 0.13, 95% CI 0.06–0.31, P < 0.001). Administration of oral analgesia lowered the likelihood and pain score documentation increased the likelihood of receiving morphine in both children and adults. Conclusion: Documentation of pain scores and provision of i.v. morphine is generally poor. Children are less likely than adults to have a pain score documented, or receive i.v. morphine when presenting with appendicitis.     

Combined spinal and epidural anaesthesia in elderly patients

The study was designed to investigate the effects of simultaneously combined spinal-epidural anaesthesia in elderly patients and to evaluate the problems encountered during and after performing spinal block following epidural blockade. Nineteen ASA grade III elderly patients (mean age 75.8 years) were included in the study. The first 10 patients (group 1) were given 0.5% hyperbaric bupivacaine 2 ml (10 mg) and fentanyl 0.25 ml (12.5 microg) intrathecally. The remaining nine patients (group 2) received 0.5% hyperbaric bupivacaine 1 ml (5 mg) intrathecally; following the spinal block fixation (about 15 min), fentanyl 1 ml (50 microg) in saline 10 ml was injected into the epidural catheter. The highest sensory block was achieved at T6 and T9 in groups 1 and 2, respectively. None of the patients experienced respiratory depression, sedation, vomiting, shivering or headache. In conclusion, simultaneous combination of subarachnoid and epidural blockade may provide sufficient anaesthesia with fewer complications.     

Dexmedetomidine as an adjunct to epidural analgesia after abdominal surgery in elderly intensive care patients: A prospective, double-blind, clinical trial

Background: The ideal postoperative analgesia management of elderly surgical patients in intensive care units (ICUs) is continually being investigated.Objective: The purpose of this study was to assess the effectiveness and tolerability of IV administration of dexmedetomidine as an adjunct to a low-dose epidural bupivacaine infusion for postoperative analgesia after abdominal surgery in elderly patients in the ICU.Methods: ICU patients aged >70 years undergoing abdominal surgery were eligible for the study. A lumbar epidural catheter was inserted at the beginning of the surgery with no medication. On arrival at the ICU, the catheter was loaded with 0.25% bupivacaine 25 mg at the T8 to T10 sensory level, and a continuous infusion of 0.125% bupivacaine was started at 4 to 6 mL/h in combination with patient-controlled epidural analgesia (PCEA) of fentanyl (4 μg/bolus) for pain treatment. Patients in the treatment group received dexmedetomidine as an IV loading dose of 0.6 pg/kg for 30 minutes followed by continuous infusion at 0.2 μg/kg · h^-1. Patients in the control group were not administered dexmedetomidine. The effectiveness of the pain relief was determined using a visual analog scale (VAS) (0 = no pain to 10 = worst pain imaginable) at rest. VAS score, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and arterial blood gases were monitored periodically for 24 hours after surgery. If required, tenoxicam (20-mg IV bolus) was used to ensure a VAS score of ≤3. The number of times PCEA and tenoxicam were administered and the occurrence of adverse events (AEs) were also recorded.Results: Sixty patients (34 men, 26 women; mean [SD] age, 75.96 [4.25] years; mean [SD] weight, 74.13 [10.62] kg) were included in the study. VAS scores were significantly lower in the dexmedetomidine group compared with the control group at hours 1, 2, and 12 (VAS [hour 1]: 2.8 [0.4], P < 0.001; VAS [hour 2]: 2.7 [0.5], P < 0.001; and VAS [hour 12]: 0.9 [0.7], P 0.044). The mean number of administrations of fentanyl via PCEA was significantly greater in the control group compared with the dexmedetomidine group (2.20 vs 6.63 times; P < 0.001). The mean number of administrations of tenoxicam was significantly lower in the treatment group than the control group (0.27 vs 1.07 times; P < 0.001). In the control group, the decreases in sedation at 0, 8, 12, 16, and 20 hours were significant compared with baseline (P = 0.024, P = 0.001, P = 0.020, P < 0.001, and P = 0.005, respectively). Mean HR, SBR and AEs (eg, bradycardia [HR <60 beats/min], respiratory depression [respiratory rate <8 breaths/min], hypotension \SBP <90 mm Hg], oversedation, hypoxia, and hypercapnia) decreased significantly in the dexmedetomidine group (all, P < 0.05). Significantly more patients in the dexmedetomidine group rated their satisfaction with postoperative pain control as excellent compared with the control group (12 vs 6 patients; P = 0.014).Conclusion: Intravenous dexmedetomidine was effective and generally well tolerated as an analgesic adjunct to epidural low-dose bupivacaine infusion for pain treatment, with lower need for opioids after abdominal surgery in these elderly intensive care patients than in the control group.     

Evaluation of the factors affecting the efficacy and safety of postoperative epidural analgesia using morphine

Subjective and objective methods were used to assess pain in 390 surgical patients. The quality and duration of postoperative epidural analgesia (EA) with morphine was studied with regard to the analgesic concentration and volume of the solution, segment of its administration into the epidural space and its storage period. It has been shown that the degree of an antinociceptive effect does not depend on the segment of opiate administration into the epidural space, whereas the duration of analgesia increases when EA is performed into spinal segments innervating the source of pain. The effect of the first morphine dose was more durable with the increase in the analgesic concentration and decrease in the volume of the solution. Parallel enhancement of respiratory depression effect was observed. The incidence of side effects became greater towards the end of the storage period. Possible mechanisms of changes observed in EA pharmacodynamics are reviewed in terms of increased efficacy and safety of the procedure.     

Mode of delivery following labor epidural analgesia: influence of ropivacaine and bupivacaine.

Epidural analgesia is a popular and effective method for pain relief during labor. Bupivacaine is a commonly used local anesthetic for labor epidural analgesia. Ropivacaine is an amino acid local anesthetic that is structurally related to bupivacaine with a similar potency and duration, but ropivacaine has less cardiac toxicity than bupivacaine and produces less motor blockade. These properties make ropivacaine a desirable local anesthetic agent for obstetrical analgesia. The purpose of the present study was to compare the cesarean section and instrumental delivery rates for patients receiving labor epidural analgesia using bupivacaine and ropivacaine. The medical records of 500 consecutive patients receiving bupivacaine for labor epidural analgesia were reviewed. After a 3-month familiarization period for ropivacaine, the records of 500 consecutive patients receiving ropivacaine for labor epidural analgesia similarly were reviewed. The groups did not differ demographically. The instrumental delivery rate was 14.2% for the bupivacaine group and 9.8% for the ropivacaine group. The cesarean section rate was 14% for the bupivacaine group and 10.2% for the ropivacaine group. At our facility, the use of ropivacaine decreased both cesarean section and instrumental delivery rates when compared with bupivacaine in the population studied.     

硬膜外自控镇痛用于剖宫产术后的疗效观察

目的探讨硬膜外自控镇痛（PCEA）用于剖宫产术后的临床效果。方法回顾性分析2006年1月至2008年12月在我院住院分娩的436例剖宫产产妇的临床资料,比较PCEA与肌肉注射盐酸哌替啶镇痛（对照组）的临床效果。结果与对照组相比,PCEA组产妇（24h,48h）镇痛效果明显升高（P〈0．01）,肛门排气时间及开奶时间明显缩短（P〈0．05）。结论剖宫产术后自控镇痛泵镇痛,有良好的镇痛效果,不良反应少。     

硬膜外盐酸氯普鲁卡因复合吗啡应用于妇科术后镇痛的观察

目的比较硬膜外盐酸氯普鲁卡因与布比卡因复合吗啡用于妇科术镇痛的临床效果和安全性。方法90例择期在硬膜外麻醉经腹子宫全切或子宫肌瘤摘除手术患者，随机分成三组。观察组：C1组（n=30）采用1．2％盐酸氯普鲁卡因＋0．002％吗啡；C2组（n：30）采用0．6％盐酸氯普鲁卡因＋0．002％吗啡。对照组：B组（n=30）采用0．225％布比卡因＋0．002％吗啡。观察术后1h、6h、12h、24h、48h三组患者的视觉模拟评分（VAS），运动神经阻滞程度评分（MBS）及不良反应的发生率。结果三组在镇痛效果方面和不良反应发生率均无显著性差异，在下肢运动神经阻滞方面三组差异有显著性，下肢麻木感C1组高于C2组，但都明显低于B组。结论0．6％盐酸氯普鲁卡因复合吗啡应用于妇科硬膜外术后镇痛效果可靠，不良反应少，下肢活动影响较轻微。     

Postoperative pain and gastro-intestinal recovery after colonic resection with epidural analgesia and multimodal rehabilitation

The aim of the study was to evaluate initial postoperative pain intensity and the association with recovery of gastrointestinal function and length of stay (LOS) in a multimodal programme with epidural analgesia, early oral nutrition and mobilisation with a 48 h planned hospital stay. One hundred and ten consecutive patients scheduled for elective open colonic resection under general anaesthesia with combined thoracic epidural analgesia were prospectively studied. Postoperative epidural analgesia was maintained for 48 h with bupivacaine 2.5 mg/ml and morphine 50 μg/ml, 4 ml/h. Postoperative pain scores were assessed during cough on a categorical scale (0: no pain, 1: slight pain, 2: moderate pain, 3: severe pain) 24 and 48 h after surgery. Sum of pain scores (24 + 48 h assessments) was compared with time to first postoperative defaecation and LOS. Data from 19 patients were excluded because of change in the surgical procedures (2), surgical morbidity (6), medical factors (4) and psychosocial or other factors (5) all independent of pain. Pain data were incomplete in two patients and therefore excluded. In the remaining 91 patients, median time to defaecation and LOS were 24 and 48 h, respectively. Gastrointestinal recovery and LOS did not differ between patients with high (3–6) versus low (0–2) dynamic pain scores (P > 0.4 and P > 0.1, respectively). It is concluded that a multimodal rehabilitation program including continuous thoracic epidural analgesia leads to early recovery of gastrointestinal function and sufficient analgesia allowing discharge within 2–3 days in most patients after colonic resection.