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.     

Continuous spinal microcatheter (28 gauge) technique for arterial bypass surgery of the lower extremities and comparison of ropivacaine with or without morphine for postoperative analgesia

Background. The aim of this study was to evaluate a microcathetertechnique for continuous spinal anaesthesia (CSA) and continuousspinal postoperative analgesia (CSPA) in vascular surgery. Methods. A total of 47 patients (range 51–95 yr, ASA II–IV)undergoing peripheral bypass surgery of the lower extremitiesreceived a spinal microcatheter (28 gauge) at L3–L4 orL2–L3. For CSA, ropivacaine 7.5 mg ml^–1 was givenin small increments. Central venous pressure was maintained3 mm Hg. Of 47 patients, 44 received CSPA, either using ropivacainealone 2 mg h^–1 (group R, n=22) or ropivacaine 1 mg h^–1with morphine 8 µg h^–1 (group RM, n=22) for 24 hafter surgery (randomized, double-blinded). Results. Intraoperative haemodynamic control was good; duringthe initial 60 min only four patients received phenylephrinei.v. for hypotension. Up to 30% of the patients felt mild painat incision but surgery [mean duration 173 min (range 66–327)]was successfully completed under CSA in 45 patients. In fourinstances of acute revision surgery, a new block was administeredutilizing the spinal catheter in place. Postoperative pain reliefwas comparably adequate in both groups with no difference inrescue pain medication. Four patients (three in R, one in RM)had weak motor blockade in the first postoperative morning. Conclusions. The described CSA technique offered good haemodynamiccontrol, ease of maintaining spinal anaesthesia, and ease ofproviding a new spinal block for revision. The combination oflow-dose ropivacaine and morphine for CSPA did not offer anybenefit compared with the higher ropivacaine dose alone. Presented in part at the 28th Congress of the Scandinavian Societyof Anaesthesiology and Intensive Care Medicine, Reykjavik, Iceland,June 29–July 3, 2005     

Analgesia for day-case shoulder surgery

Background. Single-shot nerve blocks provide excellent postoperativeanalgesia for a limited period and are increasingly used inday-case units. They allow early patient discharge followingpainful operative procedures that would otherwise require overnighthospitalization. We investigated the adequacy of analgesia athome after the block had worn off. Methods. A prospective audit by telephone 1 week after surgeryof 50 consecutive patients who had had a single-shot interscaleneblock for day-case shoulder arthroscopic surgery. Results. The mean length of adequate sensory block was 22.5h (9–48 h) after which 20% of patients had a maximum visualanalogue scale (VAS) score of 5/5. Most patients did not takeanalgesics as prescribed and two patients (5.4%) required additionalanalgesia from their family doctor or accident and emergencydepartment. Conclusions. We conclude that analgesia at home is often inadequateafter painful day-case surgical procedures if single-shot localanaesthetic blockade is used. Br J Anaesth 2004; 92: 414–15     

Comparison of ropivacaine 2 mg ml(-1) and prilocaine 5 mg ml(-1) for i.v. regional anaesthesia in outpatient surgery

Background. Ropivacaine 2 mg ml^–1 (0.2%) provides longer-lastinganalgesia after deflation of the tourniquet cuff, with fewerside-effects, than lidocaine 5 mg ml^–1 (0.5%) after i.v.regional anaesthesia (IVRA). Whether ropivacaine 2 mg ml^–1also exerts this advantage over prilocaine 5 mg ml^–1,the local anaesthetic of choice in IVRA in most European countrieswas investigated in this study. Methods. Sixty outpatients scheduled for forearm or hand surgeryreceived IVRA with 40 ml of ropivacaine 2 mg ml^–1 (Ropi)or prilocaine 5 mg ml^–1 (Prilo) in a randomized, double-blindedfashion. The development and recovery of pin-prick analgesiaand motor power of the hand, as well as ropivacaine and prilocaineplasma concentrations (n=30), were assessed during and afteroperation. Results. Anaesthesia for surgery was adequate in both groups.Pin-prick analgesia was achieved at a similar rate, except inthe radial nerve distribution area where at 10 min 60% of Ropiand 90% of Prilo patients had analgesia (P=0.017). At 10 min100 and 97% had motor block of the hand in the Ropi and Prilogroups, respectively. Recovery of the sensory block in all innervationareas was already observed 2 min after the tourniquet cuff release.At 10 min after releasing the tourniquet cuff 31% of the Ropipatients and none of the Prilo patients still had analgesiain the median nerve distribution (P=0.004). At 12 min, 42% inthe Ropi group and none in the Prilo group had decreased gripstrength. After the release of the tourniquet, mean plasma concentrationsof ropivacaine were higher than those of prilocaine. The highestindividual concentration of ropivacaine was 1.65 µg ml^–1and that of prilocaine 0.6 µg ml^–1. None of theRopi patients experienced any symptoms of local anaesthetictoxicity. Conclusions. Compared with prilocaine 5 mg ml^–1, analgesiain IVRA with ropivacaine 2 mg ml^–1 developed slightlymore slowly, while motor block developed at a similar rate.After the release of the tourniquet, sensation recovered quicklyand at a similar rate in the two groups, except for a slightlyslower recovery after ropivacaine in the innervation area ofthe median nerve, but no surgically useful extended analgesiaafter the cuff deflation was observed. Despite a 60% lower milligram-dose,ropivacaine plasma concentrations were markedly higher thanthose of prilocaine.     

Intermittent vs continuous administration of epidural ropivacaine with fentanyl for analgesia during labour

Background. Many years ago regular intermittent bolus administrationof epidural local anaesthetic solution was recognized to producemore effective analgesia than continuous infusion, but onlyrecently has the development of suitable pumps allowed the formertechnique's wider evaluation. Methods. In this randomized, double-blind trial, 40 primigravidpatients had a lumbar epidural catheter inserted, and plainropivacaine 0.2% 15–20 ml was titrated until analgesiaand bilateral sensory block to T10 were produced (time zero).Patients were then given either an infusion of ropivacaine 2mg ml^–1 with fentanyl 2 µg ml^–1 at 10 ml h^–1,or hourly boluses of 10 ml of the same solution. Pain, sensoryblock and motor block were measured frequently. If requested,additional 10 ml boluses of the study mixture were given foranalgesia. Results. There were no differences between the two groups inpatient characteristics, obstetric/neonatal outcome, or in sensoryor motor block. A total of 12 (60%) patients in the continuousgroup required one or more additional boluses compared with4 (20%) patients in the intermittent group (95% CI 9.6–61.7%,P=0.02). Therefore the intermittent group received a lower totaldrug dose than the infusion group (P=0.02). Duration of uninterruptedanalgesia (time to first rescue bolus) was longer in the intermittentgroup (P<0.02). Conclusions. The intermittent group required fewer supplementaryinjections and less drug to maintain similar pain scores, sensoryand motor block compared with the continuous group. This representsa more efficacious mode of analgesia. Declaration of interest. P.D.W.F., C.S.M. and J.B.W. receivedsalaries from AstraZeneca while working as research fellowsat Ninewells Hospital, Dundee, UK.     

Review of interscalene block for postoperative analgesia after shoulder surgery in obese patients

In recent years, the prevalence of obesity has significantly increased in developed countries, a trend that has been just as apparent in France as elsewhere. Obesity may predispose to osteoarthritis, which may subject a high percentage of patients to shoulder surgery. Interscalene block remains one of the most efficient technique for postoperative analgesia after shoulder surgery. However, there are no specific guidelines or discussions in the literature about the use and management of interscalene block for obese patients. No study has yet specifically assessed obesity relative to interscalene block. Regional anesthesia offers certain advantages in obese patients: minimal airway intervention, improved postoperative analgesia, and decreased opioid consumption. In obese patients undergoing shoulder surgery, the goal of postoperative pain management is to provide comfort, early mobilization, and improved respiratory function without the worry of inadequate sedation and respiratory compromise. The ongoing debate on the relevance of obesity, for example in terms of obstructive sleep apnea syndrome, obesity hypoventilation syndrome, and other related respiratory disturbances, in relation to the choice of analgesic techniques, especially interscalene block, patient-controlled intravenous analgesia and patient monitoring, demands large-scale, well-designed studies to resolve it. Nevertheless, obesity per se should not dissuade patients from undergoing shoulder surgery under interscalene block.     

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     

Prospective evaluation of deep topical fornix nerve block versus peribulbar nerve block in patients undergoing cataract surgery using phacoemulsification

We compared the efficacy of deep topical fornix nerve blockanaesthesia (DTFNBA) versus peribulbar nerve block in patientsundergoing cataract surgery using phacoemulsification. We studied120 patients, allocated randomly to two groups. Group 1 (n=60)received peribulbar block with 5 ml of a 1:1 mixture of 0.5%plain bupivacaine and 2% lidocaine supplemented with hyaluronidase300 i.u. ml^–1. Group 2 received DTFNBA with placementof a sponge soaked with 0.5% bupivacaine deep into the conjunctivalfornices for 15 min. No sedation was given to either group.Analgesia was assessed by the reaction to insertion of the superiorrectus suture and by questioning during the procedure. A three-pointscoring system was used (no pain=0, discomfort=1, pain=2). Scoringwas repeated at keratotomy, hydrodissection and hydrodelineation,phacoemulsification, irrigation and aspiration, and at intraocularlens insertion. If the patient’s pain score was 0 or 1,no further action was taken. If the pain score at any stageof the operation was 2, intracameral injection of 1% preservative-freelidocaine was given. One patient in Group 2 needed intracamerallidocaine at the stage of phacoemulsification (P>0.05) andfour experienced discomfort at irrigation and aspiration (P=0.043).We conclude that DTFNBA may be a useful needle-free anaesthetictechnique in patients undergoing cataract surgery using phacoemulsification. Br J Anaesth 2000; 85: 314–6 Footnotes ^* Corerspondign author     

Assessment of pulse transit time to indicate cardiovascular changes during obstetric spinal anaesthesia

Background. Pulse transit time (PTT) measurement may providerapidly available beat-to-beat cardiovascular information whenconditions change quickly and routine invasive arterial pressuremeasurement is not justified, for example during obstetric spinalanaesthesia. Method. We obtained ethics approval for an observational studyof PTT during the onset of spinal anaesthesia in patients havingelective or urgent Caesarean section. PTT was measured as thedifference in time between the peak of the ECG R wave and theupstroke of the toe plethysmograph. Arterial pressure was measuredby non-invasive sphygmomanometry. Results. We analysed data from 58 normotensive patients and15 patients with pregnancy-induced hypertension (PIH). PTT increasedwith the onset of spinal anaesthesia as arterial pressure decreased.An increase of 20% in PTT was 74% sensitive and 70% specificin indicating a decrease in mean arterial pressure of more than10%. Changes in PTT were related to changes in mean arterialpressure (r²=0.55, P<0.0001). Arterial pressure changes weregreater and PTT increased significantly more quickly in thenormotensive patients than in the patients with hypertension[median, quartiles: 32 (14, 56) ms min^–1 compared with7 (6, 18) ms min^–1; P<0.01, Mann–Whitney U-test].However, the relationship between PTT and arterial pressurewas similar for the normotensive patients and the patients withPIH. Conclusion. PTT measurement gave a beat-to-beat indication ofarterial pressure during spinal anaesthesia, and could be developedto allow prediction of the onset of hypotension. Data from this study were presented in part at the ObstetricAnaesthetists Association Meeting at Nottingham, UK, on May10, 2002 and at the 13th World Congress of the InternationalSociety for the Study of Hypertension in Pregnancy at Toronto,Canada, on June 2, 2002.     

Comparison of three different volumes of mepivacaine in axillary plexus block using multiple nerve stimulation

Background. The multiple injection technique for axillary block,in which the four distal nerves of the plexus are located bya nerve stimulator and separately injected, has been shown toprovide a high success rate and a short onset time. This randomizeddouble-blind study was conducted to compare the effectivenessof three different volumes of mepivacaine 10 mg ml^–1 inpatients undergoing elective distal upper limb surgery underaxillary brachial plexus block with the four-nerve approach.The number of complete sensory blocks was the primary efficacyvariable. Methods. A total of 114 adult patients were randomly allocatedto receive 36 (n=38), 28 (n=38), and 20 ml (n=38) of mepivacaine10 mg ml^–1. In each group, volumes were equally distributedin the four nerve territories. In all patients, performancetime, latency time, block characteristics, need of supplementaryblocks, tourniquet tolerance, duration of analgesia, and complicationswere recorded. Results. Complete sensory block was obtained in 97% of patientsreceiving a volume of 36 ml, 97% of those receiving 28 ml, and94% of those receiving 20 ml. One patient in the group of 28ml and five patients in the group of 20 ml experienced painon inflation of the tourniquet. Two months after surgery, nocase of postoperative neurological dysfunction was observed. Conclusions. The three volumes (38, 28, and 20 ml) of mepivacaine10 mg ml^–1 ensured a similar and high percentage of completesensory blocks in axillary brachial plexus anaesthesia withnerve stimulation involving the location of four motor responses. Br J Anaesth 2003; 91: 519–24     

Comparison of ropivacaine 0.5% (in glucose 5%) with bupivacaine 0.5% (in glucose 8%) for spinal anaesthesia for elective surgery

Background. Hyperbaric solutions of ropivacaine have been usedsuccessfully to provide spinal anaesthesia. This study was designedto compare the clinical efficacy of hyperbaric ropivacaine withthat of the commercially available hyperbaric preparation ofbupivacaine. Methods. Forty ASA grade I–II patients undergoing lower-abdominal,perineal or lower-limb surgery under spinal anaesthesia wererecruited and randomized to receive ropivacaine 5 mg ml^–1(with glucose 50 mg ml^–1), 3 ml or bupivacaine 5 mg ml^–1(with glucose 80 mg ml^–1), 3 ml. The level and durationof sensory block, intensity and duration of motor block, andtime to mobilize and micturate were recorded. Patients wereinterviewed at 24 h and at 1 week to identify any residual problems. Results. All blocks were adequate for the proposed surgery,but there were significant differences between the two groupsin mean time to onset of sensory block at T10 (ropivacaine 5min; bupivacaine 2 min; P<0.005), median maximum extent (ropivacaineT7; bupivacaine T5; P<0.005) and mean duration of sensoryblock at T10 (ropivacaine 56.5 min; bupivacaine 118 min; P=0.001).Patients receiving ropivacaine mobilized sooner (ropivacainemean 253.5 min; bupivacaine 331 min; P=0.002) and passed urinesooner (ropivacaine mean 276 min; bupivacaine 340.5 min; P=0.01)than those receiving bupivacaine. More patients in the bupivacainegroup required treatment for hypotension (>30% decrease insystolic pressure; P=0.001). Conclusions. Ropivacaine 15 mg in glucose 50 mg ml^–1 providesreliable spinal anaesthesia of shorter duration and with lesshypotension than bupivacaine. The recovery profile for ropivacainemay be of interest given that more surgery is being performedin the day-case setting. Br J Anaesth 2003; 90: 304–8     

Efficacy of three doses of tramadol with bupivacaine for caudal analgesia in paediatric inguinal herniotomy

Background. This study was designed to evaluate the analgesicefficacy of three doses of tramadol, administered caudally withbupivacaine, in providing postoperative pain relief in children. Methods. Eighty children, aged between 2 and 8 yr, undergoinginguinal herniotomy were randomly allocated to receive bupivacaine0.25% 0.75 ml kg^–1 (Group B; n=20), bupivacaine 0.25%0.75 ml kg^–1 with tramadol 1 mg kg^–1 (Group BT1;n=20), bupivacaine 0.25% 0.75 ml kg^–1 with tramadol 1.5mg kg^–1 (Group BT1.5; n=20), or bupivacaine 0.25% 0.75ml kg^–1 with tramadol 2 mg kg^–1 (Group BT2; n=20)by the caudal route immediately after induction of general anaesthesia.Heart rate, arterial pressure and oxygen saturation were monitored.Postoperative pain was assessed at regular intervals for 24h using All India Institute of Medical Sciences pain score.Analgesia was supplemented whenever pain score was 4. Durationof analgesia and requirement for additional analgesics was noted. Results. Duration of analgesia was longer in Group BT2 [(mean(SD) 12 (0.9) h] compared with Group B [4 (1) h], Group BT1[8 (0.9) h], or Group BT1.5 [11 (1) h]; all P<0.001. Totalconsumption of rescue analgesic was significantly lower in groupBT2 compared with other groups (P<0.001). There were no significantchanges in heart rate, arterial pressure and oxygen saturationbetween groups. Adverse effects were not observed. Conclusions. Caudal tramadol 2 mg kg^–1, combined withbupivacaine 0.25% 0.75 ml kg^–1, provided longer durationof postoperative analgesia and reduced requirement for rescueanalgesic compared with tramadol 1 mg kg^–1 or 1.5 mg kg^–1in children undergoing inguinal herniotomy.     

Effects of mid-line thoracotomy on the interaction between mechanical ventilation and cardiac filling during cardiac surgery

Background. Mid-line thoracotomy is a standard approach forcardiac surgery. However, little is known how this surgicalapproach affects the interaction between the circulation andmechanical ventilation. We studied how mid-line thoracotomyaffects cardiac filling volumes and cardiovascular haemodynamics,particularly variations in stroke volume and pulse pressurecaused by mechanical ventilation. Methods. We studied 19 patients during elective coronary arterybypass surgery. Before and after mid-line thoracotomy, we measuredarterial pressure, cardiac index (CI) and global end-diastolicvolume index (GEDVI) by thermodilution, left ventricular end-diastolicarea index (LVEDAI) by transoesophageal echocardiography andthe variations in left ventricular stroke volume and pulse pressureduring ventilation by arterial pulse contour analysis. Results. After thoracotomy, CI increased from 2.3 (0.4) to 2.9(0.6) litre min^–1 m^–2, GEDVI increased from 605(110) to 640 (94) litre min^–1 m^–2, and LVEDAI increasedfrom 9.2 (3.7) to 11.2 (4.1) cm² m^–2. All these changeswere significant. In contrast, stroke volume variation (SVV)decreased from 10 (3) to 6 (2)% and pulse pressure variation(PPV) decreased from 11 (3) to 5 (3)%. Before thoracotomy, SVVand PPV significantly correlated with GEDVI (both P<0.01).When the chest was open, similar significant correlations ofSVV (P<0.001) and PPV (P<0.01) were found with GEDVI. Conclusion. Thoracotomy increases cardiac filling and preload.Further, thoracotomy reduces the effect of mechanical ventilationon left ventricular stroke volume. However, also under openchest conditions, SVV and PPV are preload-dependent. Br J Anaesth 2004; 92: 808–13     

Effect of adding dopexamine to intraoperative volume expansion in patients undergoing major elective abdominal surgery

Background. The contribution of low-dose dopexamine to outcome,when given to increase cardiac output in patients already treatedwith fluids during major abdominal surgery, is not yet known. Method. We carried out a randomized double-blind placebo-controlledtrial. All 100 patients studied were given fluid infusions duringsurgery guided by stroke volume measurements made with an oesophagealDoppler probe. Patients were randomized to receive dopexamineat the rate of 0.25 µg kg^–1 min^–1or saline 0.9% (control) for the first 24 h after the startof surgery. The primary outcome measure was the incidence ofpostoperative morbidity. Results. There were no statistically significant differencesbetween groups in the incidence of postoperative complications,the length of hospital stay, the incidence of morbidity andthe use of critical care facilities. The patients randomizedto receive dopexamine had significantly more pre-existing diseasethan the control patients. Mortality in both groups was significantlyless than predicted by the POSSUM (Physiological and OperativeSeverity Score for the enUmeration of Mortality and morbidity)risk prediction score. Conclusion. We could not demonstrate an advantage to using low-dosedopexamine in high-risk patients during major abdominal surgery. Br J Anaesth 2003; 91: 619–24     

Ultrasonography-guided rectus sheath block in paediatric anaesthesia--a new approach to an old technique

Background. The purpose of this study was an anatomical andclinical evaluation of ultrasonography-guided rectus sheathblocks in children. Method. A total of 30 children were included in the sono-anatomicalpart of the study. The depth of the anterior and posterior rectussheath was evaluated with a portable SonSite 180 plus ultrasoundmachine and a 5–10 MHz linear probe. In total, 20 consecutivechildren undergoing umbilical hernia repair were included inthe clinical part of this study. After induction of generalanaesthesia children received a rectus sheath block under real-timeultrasonographic guidance by placing 0.1 ml kg^–1 bilaterallyin the space between the posterior aspect of the sheath andthe rectus abdominis muscle. Results. Ultrasonographic visualization of the posterior rectussheath was possible in all children. The correlation betweenthe depth of the posterior rectus sheath and weight (adjustedr²=0.175), height (adjusted r²=0.314) and body surface area(adjusted r²=0.241) was poor. The ultrasound-guided rectus sheathblockade provided sufficient analgesia in all children withno need for additional analgesia in the perioperative period. Conclusion. The bilateral placement of levobupivacaine 0.25%0.1 ml kg^–1 in the space between the posterior aspectof the rectus sheath and the rectus abdominis muscle under real-timeultrasonographic guidance provides sufficient analgesia forumbilical hernia repair. The unpredictable depth of the posteriorrectus sheath in children is a good argument for the use ofultrasonography in this regional anaesthetic technique in children.      

Comparison of three different epidural solutions in off-pump cardiac surgery: pilot study

Background. Immediate extubation using thoracic epidural analgesia(TEA) has become more popular after off-pump coronary arterybypass grafting (OPCAB). In this randomized prospective double-blindstudy, we present the first comparison of preoperative and postoperativehaemodynamics during different regimens of TEA for immediateextubation after cardiac surgery. Methods. Sixty patients undergoing OPCAB were enrolled in thisstudy. TEA was installed >1 h before application of heparinat levels T2–T4. Analgesia was provided by bupivacaine0.25%, 8 ml, 15 min before surgery and extubation, and at 10ml h^–1 during surgery and up to 72 h afterwards usingone of the following regimens: bupivacaine 0.125% alone, bupivacaine0.125% with fentanyl 3 µg ml^–1 or bupivacaine 0.125%with clonidine 0.6 µg ml^–1. Patients were block-randomizedfor one of the three treatments. Pain scores and infusion ratesof TEA were assessed up to 48 h after surgery. Respiratory functionwas assessed by Pa_O2 and Pa_O2 immediately after surgery, andhaemodynamic stability was recorded in the form of heart rateand diastolic and systolic blood pressure. Results. Patient characteristics, respiratory function and haemodynamicstability did not vary between the three groups. Pain controlwas very good and was not significantly different between thegroups using similar infusion rates after surgery. Paraesthesiain dermatomes T1 or C8 occurred equally in all three groups.There was no neurological complication related to TEA in thisstudy. Conclusions. We conclude that immediate extubation after OPCABusing TEA is feasible with different TEA regimens. Respiratoryfunction, haemodynamic stability and pain control are not differentbetween TEA with bupivacaine alone, bupivacaine with fentanylor bupivacaine with clonidine.     

Remifentanil or propofol for sedation during carotid endarterectomy under cervical plexus block

Background. During carotid endarterectomy under regional anaesthesia,patients often require medication to control haemodynamic instabilityand to provide sedation and analgesia. Propofol and remifentanilare used for this purpose. However, the benefits, side-effects,and optimal dose of these drugs in such patients are unclear. Methods. Sixty patients were included in a prospective, randomized,single blinded study. All patients received a deep cervicalplexus block with 30 ml ropivacaine 0.75% and were randomizedto receive either remifentanil 3 µg kg^–1 h^–1or propofol 1 mg kg^–1 h^–1. The infusions were startedafter performing the regional block and were stopped at theend of surgery. Arterial pressure, ECG, ventilatory rate, andPa_CO2 were measured continuously and recorded at predeterminedtimes. Twenty-four hours after surgery, patient comfort, andsatisfaction were also evaluated. Results. In three patients, the infusion of remifentanil hadto be stopped because of severe respiratory depression or bradycardia.No significant differences were found between the two groupsin haemodynamic variables or sedative effects, but there wasa significantly greater decrease in ventilatory frequency andincrease in Pa_CO2 in the remifentanil group. The patient’ssubjective impressions and pain control were excellent in bothgroups. Conclusion. As a result of the higher incidence of adverse respiratoryeffects with remifentanil and similar sedative effects, propofolis preferable for sedation during cervical plexus block in elderlypatients with comorbid disease at the dosage used. Br J Anaesth 2002; 89: 637–40     

Anaesthesia-related diplopia after cataract surgery

Background. We studied the incidence and clinical characteristicsof persistent diplopia related to anaesthesia for cataract surgeryin a general hospital. Methods. This was a retrospective review of anaesthesia for3587 cataract surgeries. Of all the cases of diplopia referredto the ocular motility clinic after cataract surgery, thoseinvolving anaesthesia-related diplopia lasting longer than 1month were studied. Results. During the study period, 3450 cataract surgeries wereperformed by phacoemulsification and 137 by extracapsular extraction.Retrobulbar block was used in 2024 cases, peribulbar block in98, topical anaesthesia in 1420 and general anaesthesia in 43.Twenty-six cases of persistent diplopia were found (0.72% incidence),nine of which (0.25%) were considered to be related to anaestheticfactors; five of the latter involved the left eye. Five werecaused by paresis of the inferior rectus muscle and three byfibrosis. In one patient, the inferior oblique muscle was affected.Anaesthesia was by retrobulbar block in eight cases (0.39%)and by peribulbar block in one. No diplopia was found in patientswho had topical or general anaesthesia. Treatment was with surgeryin two patients and with prisms in six. One patient continuesto be studied. Conclusions. Persistent diplopia can occur after cataract surgeryusing retrobulbar block predominantly through direct damageto the inferior rectus muscle. The overall incidence of anaesthesia-relateddiplopia in this series was 0.25%. Br J Anaesth 2003; 90: 189–92     

Propofol 1% versus propofol 2% in children undergoing minor ENT surgery

Background. The induction characteristics of propofol 1% and2% were compared in children undergoing ENT surgery, in a prospective,randomized, double-blind study. Methods. One hundred and eight children received propofol 1%(n=55) or 2% (n=53) for induction and maintenance of anaesthesia.For induction, propofol 4 mg kg^–1 was injectedat a constant rate (1200 ml h^–1), supplementedwith alfentanil. Intubating conditions without the use of aneuromuscular blocking agent were scored. Results. Pain on injection occurred in 9% and 21% of patientsafter propofol 1% and 2%, respectively (P=0.09). Loss of consciousnesswas more rapid with propofol 2% compared with propofol 1% (47 svs 54 s; P=0.02). Spontaneous movements during inductionoccurred in 22% and 34% (P=0.18), and intubating conditionswere satisfactory in 87% and 96% (P=0.19) of children receivingpropofol 1% or 2%, respectively. There were no differences betweenthe two groups in respect of haemodynamic changes or adverseevents. Conclusions. For the end-points tested, propofol 1% and propofol2% are similar for induction of anaesthesia in children undergoingminor ENT surgery. Br J Anaesth 2003: 90: 375–7