Levobupivacaine patient controlled analgesia: Epidural versus blind fascia iliaca compartment analgesia – A comparative study

This study was designed to compare the analgesic efficacy of levobupivacaine patient controlled analgesia epidural versus patient controlled analgesia with fascia lliaca compartment block. In patients undergoing fixation of fracture neck femur.MethodsSixty patients ASA II&III undergoing fixation of fracture neck femur were randomly allocated into two groups (n = 30).Group EEpidural group given levobupivacaine 0.25% 15 ml before induction of general anesthesia, followed by postoperative PCEA with levobupivacaine (0.125%).Group FFascia iliaca block group given levobupivacaine 0.25% 30 ml through the catheter before induction of general anesthesia, followed by postoperative patient controlled fascia illiaca analgesia with levobupivacaine (0.125%).Severity of postoperative pain at rest in 24 h using VAS, number of patients required additional analgesia (tramadol) in 24 h, doses of postoperative 24 h tramadol consumed, postoperative mean arterial blood pressure and heart rate were recorded.ResultsThe severity of postoperative pain was statistically significantly less in E group, number of patients required tramadol in 24 h were statistically significantly less in E group than F group, postoperative tramadol consumed was statistically significantly less in E group than F group.ConclusionPCEA with levobupivacaine (0.125%) was associated with satisfactory analgesia than patient controlled analgesia with fascia iliaca block in patients undergoing fixation of fracture neck femur.     

Dexamethasone bupivacaine versus bupivacaine for peribulbar block in posterior segment eye surgery

AimThe study conducted aims to assess the efficacy, time to first analgesic request, and postoperative inflammatory response after adding dexamethasone to local anesthetic mixture for a peribulbar block in posterior segment eye surgery.Patients and methodsA double-blind randomized study was carried out on 50 ASA I and II patients scheduled for elective posterior segment surgery (vitreoretinal). Patients were allocated randomly into two groups, 25 patients in each group. Group I received equal volumes of 10 ml of a l:1 mixture of bupivacaine 0.5% and saline, supplemented with 4 mg dexamethasone in 1 ml saline and group II received the same local anesthetic mixture (total volume 10 ml) without adding dexamethasone. The duration and onset of motor block, time to first analgesic request, postoperative inflammatory response, and other side effects such as nausea and vomiting were assessed.ResultsPatients receiving peribulbar block were significantly pain free by end of surgery (0 h) (P < 0.05) and throughout the postoperative period in the dexamethasone group at 2 and 6 h postoperatively. The number of patients requiring rescue analgesics was significantly lower with dexamethasone bupivacaine block (P < 0.05). The incidence of postoperative nausea and vomiting was significantly less in the first group (I) in comparison to the other group (II) (P < 0.05) and lastly the level of C reactive protein postoperatively was found to be significantly less in the dexamethasone group than the other one (P < 0.0001).ConclusionAdding dexamethasone to bupivacaine in peribulbar block appears to be a safe and clinically superior adjuvant with less postoperative pain, inflammatory response in patients undergoing posterior segment eye surgery.     

A comparison of epidural magnesium and/or morphine with bupivacaine for postoperative analgesia after cesarean section

BackgroundMagnesium can potentiate the antinociceptive effect of morphine. This prospective randomized double-blinded study was undertaken to establish the analgesic effect of adding magnesium to epidural morphine during cesarean section.MethodsTwo hundred patients undergoing cesarean section under combined spinal–epidural anesthesia were recruited. After administration of intrathecal bupivacaine 10 mg, patients were randomly assigned to receive one of four epidural study solutions: 0.1% bupivacaine 10 mL (Group B); 0.1% bupivacaine 10 mL and morphine 1.5 mg (Group B+Mor); 0.1% bupivacaine 10 mL and magnesium 500 mg (Group B+Mg); or 0.1% bupivacaine 10 mL morphine 1.5 mg and magnesium 500 mg (Group B+Mor+Mg). The primary outcome was the area under the curve for visual analog scale pain scores during 36 h postoperatively. Secondary outcomes included time to the use of rescue analgesics, patient satisfaction and side effects.ResultsPatients in Group B+Mor+Mg had lower for pain scores and area under the curve pain scores both at rest and on movement, increased time for first analgesic request, and increased satisfaction score at 24 h after surgery.ConclusionAddition of magnesium 500 mg and morphine 1.5 mg to epidural 0.1% bupivacaine 10 mL reduced postoperative pain compared with addition of morphine or magnesium alone or no additive.     

Effect of intra-articular injection of midazolam and/or bupivacaine on postoperative analgesia after arthroscopic knee surgery

BackgroundA variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. We investigated the hypothesis that intra-articular midazolam would result in lower pain score and reduced analgesic requirements.MethodsOne-hundred patients undergoing arthroscopic meniscectomy were allocated randomly to receive intra-articular 20 mL of isotonic saline containing 50 μg/kg midazolam (midazolam group (group M),the bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, and the midazolam with bupivacaine group (group MB) received bupivacaine 0.25% and 50 μg/kg of midazolam in 20 mL. The postoperative analgesia was assessed using visual analog score at rest and during movement at 1/2 h, 1 h, 2 h, 6 h, 12 h, and 24 h.ResultsPatients in group MB showed significantly lower visual analog scores, both at rest and during movement, long time to first postoperative analgesic request, as well as reduced total analgesic consumption than the other two groups.ConclusionIntraarticular administration of midazolam in combination with bupivacaine improves the quality of postoperative analgesia after arthroscopic meniscectomy.     

Sequential higher epidural catheter re-insertion after accidental dural puncture ameliorates the frequency and severity of post-dural puncture headache

ObjectivesThis cohort study aimed to evaluate the outcome of a hypothesis to use higher level for epidural catheter insertion and activation when an epidural tap was encountered at a lower level during epidural analgesia for labor pain.MethodsEpidural analgesia for labor pain was conducted using a mixture of 0.125% bupivacaine and fentanyl 5 μg/ml (10–15 ml) in 5-ml increments and maintained using continuous epidural infusion of 0.125% bupivacaine and fentanyl 2 μg/ml at rate of (5–15 ml/h), subsequently adjusted according to the patients needs. All cases had accidental dural puncture (ADP) were managed immediately with re-insertion of the needle at a higher level and completion of the procedure and maintained using continuous epidural infusion of 0.0625% bupivacaine and fentanyl 2 μg/ml at rate of (6–12 ml/h) for 24 h after delivery. Postpartum follow-up was conducted for 30 days to comment on the occurrence and severity of post-dural puncture headache (PDPH). All patients developed PDPH were followed daily until resolution of their headache.ResultsAbout 4800 parturient were enrolled in the study, ADP occurred in 24 patients with a frequency of 0.5%. All cases were immediately managed by re-insertion of the needle at a higher level and the procedure was successfully completed without new dural puncture, with 100% re-insertion success rate, and patients were maintained on continuous epidural infusion for 24 h. Throughout 30-day follow-up; only six of 24 patients developed PDPH with a success rate of re-insertion procedure as a prophylactic modality for PDPH after ADP of 75%. PDPH was relieved with bed rest, liberal fluids and paracetamol for 4 days in four patients, while the 5th patient continued to complain but the patient refused to undergo epidural blood patch (EBP) and headache started to subside and patient stopped to complain by the 10th day, and the last patient agreed to undergo EBP; and headache was relived immediately after 2 h.ConclusionIt could be concluded that re-insertion of epidural catheter at higher level of accidental dural puncture with epidural continuous infusion for 24 h could be considered as an efficient prophylactic modality to safe guard against PDPH with success rate of 75% and minimizes its severity if occurred.     

Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study

IntroductionBurn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72 h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.MethodsA retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.ResultsFifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p < 0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p < 0.0001).ConclusionPatients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.     

The effect of adding magnesium sulphate to epidural bupivacaine and fentanyl in elective caesarean section using combined spinal–epidural anaesthesia: a prospective double blind randomised study

BackgroundCombined spinal–epidural anaesthesia is commonly used for elective caesarean section. Intrathecal injection produces rapid onset with minimal doses of local anaesthetic and epidural administration can be used to prolong the block. Our study examined the effects of adding magnesium sulphate to epidural bupivacaine and fentanyl in patients undergoing elective caesarean section using combined spinal–epidural anaesthesia.MethodsWomen ASA physical status I or II at term were recruited. All received 2 mL intrathecal 0.5% hyperbaric bupivacaine, 10 mL epidural 0.25% plain bupivacaine with fentanyl 100 μg, and were randomly allocated to receive either 10 mL of epidural 0.9% sodium chloride or 10 mL epidural 5% magnesium sulphate. The quality of surgical anaesthesia, incidence of hypotension, Apgar scores, intraoperative pain assessment, onset of postoperative pain, sedation scores and side effects were recorded in the postoperative period.ResultsNinety women were recruited. There was no difference in the time taken for the block to reach T4 sensory level, time to reach the highest level of sensory block, time interval between first neuraxial injection and onset of surgery between the groups. Women who received magnesium had greater motor block and muscle relaxation (P < 0.05). Apgar scores were 7 or more in almost all neonates in both groups. There was no significant difference in the incidence of hypotension, nausea and vomiting and duration of motor blockade between the groups. Women who received magnesium showed less shivering and later onset of post operative pain (P < 0.05).ConclusionThe addition of magnesium to epidural bupivacaine and fentanyl in women undergoing elective caesarean section with combined spinal–epidural anaesthesia improved intraoperative conditions and the quality of postoperative analgesia.     

The value of epidural magnesium sulfate as an adjuvant to bupivacaine and fentanyl for labor analgesia

ObjectiveWe conducted this clinical study to assess the adjuvant effects of single dose magnesium sulfate (Mg) when administered epidurally during labor with fentanyl and bupivacaine.MethodsEighty healthy nulliparous women in labor requesting epidural analgesia were divided into two groups. Group 1 received bupivacaine 0.125% with magnesium sulfate 50 mg and fentanyl 50 μg as a loading dose; group 2, received bupivacaine 0.125% and fentanyl 50 μg only. Hemodynamic parameters, motor and sensory evaluation, cervical dilation at time of consenting, the progress of labor, the visual analog pain score (VAS), Apgar score, cord blood acid base status, side effects as nausea, vomiting, itching and respiratory depression were recorded. Fetal heart rate tracings were also documented.ResultsEpidural single dose magnesium sulfate added to bupivacaine and fentanyl in labor resulted in significantly faster onset and longer duration of epidural analgesia (169 ± 50 min) in comparison to those patients who received bupivacaine and fentanyl only (105 ± 41 min), also there was a significant reduction in the number of women requiring additional boluses of bupivacaine when Mg was added (P = 0.016). The two groups had no significant differences as regards maternal satisfaction score, maternal and neonatal adverse effects.ConclusionMagnesium sulfate added to bupivacaine and fentanyl for labor epidural analgesia resulted in faster onset, longer duration of action and reduced the break through pain.     

Postoperative analgesia after major abdominal surgery: Fentanyl–bupivacaine patient controlled epidural analgesia versus fentanyl patient controlled intravenous analgesia

BackgroundMajor abdominal surgeries induce neurohumoral changes responsible for postoperative pain, various organ dysfunctions and prolonged hospitalization. Inadequate pain control is harmful and costly to patients thus an appropriate pain therapy to those patients must be applicated.MethodsOne hundred patients (ASA I or II) of either sex aged from 20 to 60 years were scheduled for elective major abdominal surgery. Patients were allocated randomly into two groups (fifty patients each) to receive: patient-controlled epidural analgesia with bupivacaine 0.125% and fentanyl (PCEA group), or patient controlled intravenous analgesia with fentanyl (PCIA group). Postoperative pain was assessed over 24 h using Numerical Pain Rating scale (NPRS). The frequency of rescue analgesia, sedation score and overall patient satisfaction were recorded. Any concomitant events like nausea; vomiting, shivering, pruritus or respiratory complications were recorded postoperatively.ResultsThere was a significant less pain in PCEA group at 2, 8 and 12 h. postoperative but PCIA group had less pain at immediate postoperative time. As regard sedation scale, patients of the PCEA group were significantly less sedated than PCIA group at immediate postoperative only. Overall patient satisfaction was significantly more in PCEA group.ConclusionThis study concluded that both PCEA and PCIA were effective in pain relief after major abdominal surgery but PCEA was much better in pain relief, less sedating effect and overall patient satisfaction.     

Preemptive use of epidural magnesium sulphate to reduce narcotic requirements in orthopedic surgery

Background and objectivesAs pain is one of the most common problems challenging the anesthetist, and as regional anesthesia is a safe, inexpensive technique with the advantage of prolonged postoperative analgesia. Also, we all know that Magnesium is the fourth most plentiful cation in the body with antinociceptive properties arising from being the natural physiological calcium antagonist and the antagonism to N-methyl-d-aspartate (NMDA) receptor. Thus, the study is a prospective, randomized, double-blind study designed to evaluate analgesic efficacy of magnesium sulphate when added to epidural bupivacaine in patients undergoing orthopedic surgery in the lower limb.MethodsAfter approval of the ethical committee and informed written consent 60 patients ASA I and II, undergoing orthopedic surgery in the lower limb were enrolled to receive either bupivacaine 0.5% or bupivacaine 0.5% plus magnesium sulphate 50 mg as an initial bolus dose followed by a continuous infusion of 10 mg/h as intraoperative epidural analgesia. Postoperatively, all patients were equipped with a patient-controlled epidural analgesia device. Heart rate, mean arterial pressure, oxygen saturation, respiratory rate, pain assessment using a visual analogue scale (VAS), sedation score, the first time patient ask for analgesics and postoperative fentanyl consumption were recorded.ResultsVAS was significantly less in the magnesium group during 15 and 30 min intra-operatively and in the first and third hour post-operatively. The postoperative rescue analgesia, as well as the PCEA fentanyl consumption, was significantly reduced in the magnesium group.ConclusionCo-administration of epidural magnesium provides better intraoperative analgesia as well as the analgesic-sparing effect on PCEA consumption without increasing the incidence of side-effects.     

Is the combination of epidural clonidine–levobupivacaine has same analgesic efficacy and safety as the combination fentanyl–levobupivacaine after radical cystectomy?

ObjectiveThis study was conducted to compare the efficacy and safety of addition of two drugs; clonidine versus fentanyl to epidural levobupivacaine to control postoperative pain after radical cystectomy surgery.Patients and MethodsAll urinary bladder cancer patients of both sex, ASA I and II, 40–70 years undergoing radical cystectomy surgery in National Cancer Institute (NCI) from November 2011 till May 2012 are the target group of which 50 patients accepted to share in the study, they are randomly classified by permuted block technique into two groups; group C (clonidine) who received 6 ml of levobupivacaine 0.25% + clonidine 75 μg epidural bolus dose followed by continuous epidural infusion of levobupivacaine 0.125% + clonidine 2 μg/ml at a total rate of 6–10 ml/h, and group F (fentanyl) who received 6 ml of levobupivacaine 0.25% + fentanyl 50 μg bolus dose followed by continuous epidural infusion of levobupivacaine 0.125% + fentanyl 2 μg/ml at a total rate of 6–10 ml/h. Paracetamol 1 g IV infusion was used as a rescue pain treatment. In both groups epidural activation is done after complete recovery from balanced general anesthesia. In both groups we measured vital signs (HR, MBP, RR), 0–10 visual analogue scale (VAS) and Sedation using the four-point Ramsay Sedation Scale are assessed for first 24 h postoperatively. In addition we recorded the total 24 h rescue paracetamol dose needed and side effects of both drugs were also observed.ResultsWe found that there is no statistical significant difference between both groups in the vital signs (HR, MBP, and RR), analgesic efficacy (VAS), and Sedation effects (Sedation Scale), and all data were within clinically accepted range. There was no statistically significant difference in total 24 h paracetamol rescue dose needed in both groups with the same range (1–3 g/24 h) and same median value (2 g/24 h). Recorded side effects were minimal and insignificant in both groups.ConclusionWe concluded that both clonidine and fentanyl can be used as effective additive to epidural levobubivacaine for postoperative analgesia after radical cystectomy with no significant difference between them in vital signs, analgesic, sedative effects and safety profile on adding each of them in doses not exceeding 20 μg/h to epidural continuous levobupivacaine infusion.     

Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery

BackgroundDexamethasone has anti-inflammatory properties that can affect postoperative analgesia when added to caudal bupivacaine.MethodsSeventy-two geriatric patients scheduled for elective total hip replacement under ultrasound guided caudal anesthesia were randomized blindly into two groups: Group BD received caudal isobaric bupivacaine 0.25% (20 ml) and dexamethasone 8 mg (2 ml) and Group BS received caudal isobaric bupivacaine 0.25% (20 ml) and normal saline (2 ml). Postoperative analgesia was assessed by recording time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively as a primary outcome. Secondary outcomes were the time taken to the onset of sensory analgesia at T10, time to the onset of complete motor block, VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12 and 24 h, and postoperative adverse events.ResultsGroup BD had a significantly longer time to first rescue analgesia [402 (63) vs 213 (53)] min and significantly lower doses of paracetamol [3389 (728) vs 2833 (697)] mg meperidine hydrochloride [78 (30) vs 142 (28)] mg than Group BS. VAS scores were significantly lower in Group BD than Group BS both at rest and on movement respectively at 4, 6, 8, 12 and 24 h.ConclusionAdding dexamethasone with isobaric bupivacaine caudal anesthesia prolongs the duration of postoperative analgesia and decreased postoperative analgesic requirement in geriatric patients undergoing total hip replacement surgery in comparison isobaric bupivacaine alone.     

Post-thoracotomy pain relief: Thoracic paravertebral block compared with systemic opioids

BackgroundWe evaluated the safety and efficacy of thoracic paravertebral block as a method of pain relief after thoracotomy in comparison with systemic opioids.Study designRandomized controlled trial.MethodsWe scheduled 40 patients divided into two groups to receive either 20 ml bupivacaine (0.5%) incremental injections for intra and postoperative analgesia via a catheter inserted in the thoracic paravertebral space. The other 20 patients received systemic morphine for postoperative analgesia. We recorded postoperative Visual Analog Scale pain score, total morphine consumption, time to first analgesic request, changes in pulmonary functions and side effects.ResultsVisual analogue scale (VAS) at rest was lower in the paravertebral group at all measurement points except at 16, 20 and 24 h postoperatively. Pain on coughing showed significant difference (P value < 0.05) at 8 and 16 h but not at 24 h. Post-operative consumption of morphine was 36 (22–42) mg in the control group versus 9 (2–22) mg in the paravertebral block group (PVB) (P value = 0.003). Total bupivacaine dose used in the PVB group in the first 24 h was 300–420 mg. For time to first analgesic request it was significantly longer in the morphine group than the paravertebral block group. VAS at first analgesic request was not statistically different between the two groups.There was no significant difference between the two groups as regards to peak expiratory flow rate (PEFR) preoperatively, after 12 h or 24 h.There was a significant reduction in the incidence of side effects in the TPVB group compared to morphine group concerning vomiting and pruritus.no local anesthetic toxicity was reported.ConclusionWe conclude that thoracic PVB provides effective post thoracotomy analgesia supported by lower VAS pain scores at rest and on coughing compared to intravenous morphine with significant less incidence of side effects.     

Evaluation of levobupivacaine passage to breast milk following epidural anesthesia for cesarean delivery

BackgroundFollowing maternal administration, local anesthetics pass into breast milk. In the present study, we aimed to compare the passage of levobupivacaine and bupivacaine into breast milk following epidural anesthesia for cesarean delivery.MethodsA total of 20 women undergoing elective cesarean delivery under epidural anesthesia were randomized to receive either 0.5% levobupivacaine or 0.5% racemic bupivacaine via an epidural catheter. Immediately before and 30 min, 1 h, 2 h, 6 h, 12 h and 24 h after administration of epidural local anesthetic, maternal blood and breast milk samples were taken simultaneously. Drug concentrations in plasma and milk were determined via high-performance liquid chromatography. The infant’s drug exposure was determined by calculating milk/plasma ratios of levobupivacaine and bupivacaine.ResultsBoth levobupivacaine and bupivacaine were detected in breast milk 30 min after epidural administration. Concentrations of both agents showed constant and similar decreases in milk and plasma and were nearly undetectable at 24 h. The milk/plasma ratios were 0.34 ± 0.13 for levobupivacaine and 0.37 ± 0.14 for bupivacaine.ConclusionsBoth levobupivacaine and bupivacaine pass into breast milk following epidural administration. The concentration of both drugs was approximately three times lower in breast milk than in maternal plasma.     

Dexmedetomidine improves intraoperative conditions and quality of postoperative analgesia when added to epidural in elective cesarean section

IntroductionThis study was designed to evaluate the effect of adding dexmedetomidine to regular mixture of epidural drugs for pregnant women undergoing elective caesarian section with special emphasis on their sedative properties, ability to improve quality of intraoperative, postoperative analgesia and neonatal outcome.MethodsFifty women of ASA physical status I or II at term pregnancy were enrolled randomly to receive either plain bupivacaine plus fentanyl (BF group) or plain bupivacaine plus mixture of fentanyl and dexmedetomidine (DBF group). Incidence of hypotension, bradycardia, Apgar scores, intraoperative pain assessment, onset of postoperative pain, sedation scores and side effects were recorded.ResultsNo difference in the times taken for block to reach T4 sensory level, to reach the highest level of sensory block and interval between first neuraxial injection and onset of surgery between the groups. Onset of postoperative pain was significantly delayed in the DBF group (P = 0.001), the need for supplementary fentanyl was significantly less in DBF group (P = 0.03), and no significant difference was obtained between both groups regarding neonatal Apgar scores as well as the incidence of hypotension, bradycardia, nausea, vomiting and duration of motor blockade between the groups. DBF group had significantly less incidence of shivering (P = 0.03).ConclusionAdding dexmedetomidine to regular mixture of epidural anesthetics in women undergoing elective cesarean section improved intraoperative conditions and quality of postoperative analgesia without maternal or neonatal significant side effects.     

Portal track infiltration versus Interscalene brachial plexus block for Pain control following shoulder arthroscopy

Arthroscopic shoulder surgery is often associated with severe postoperative pain that can be difficult to manage without large-dose opioids 1, 2.Local anaesthetics can also be injected into joint spaces to provide analgesia during and after arthroscopic surgery [3].The goal of the present study was to assess the efficacy of the portal track infiltration versus interscalene block on adequacy of pain control, and possible side effects.MethodsSixty patients of ASA I or II patients, presenting for arthroscopic subacromial decompression, were included in this comparative randomized study.Group I received preincisional 30 ml of bupivacaine 0.5% using spinal needle 22G at the site of insertion of the trocars, 10 ml at each trocars site. Group II received interscalene block using the same equal amount of 30 ml bupivacaine 0.5% at the start of the procedure before general anaesthesia using electric nerve stimulator. Visual analogue scale (VAS), time to first need of analgesia in each group, total amount of analgesia and the occurrence of side effects necessitating overnight hospital stay were recorded.ResultsThere was significant reduction of heart rate and mean blood pressure in group II compared to group I from 15 min onwards.VAS readings were insignificant between the two groups in the first 9 h postoperatively.As regards the timing of first requirement of analgesics and total amount of analgesia required in the first 24 h, and the complications necessitating overnight stay, the readings were insignificant in both groups.ConclusionThis denotes that pre-emptive analgesia offered using portal track infiltration not only gives equipotent analgesia to that of the interscalene, but lacks significant risks and can be easily to give by the surgeon.     

Intravenous dexamethasone as an adjunct to improve labor analgesia: A randomized,double-blinded,placebo controlled clinical trial

ObjectiveTo study the role of intravenous (i.v.) dexamethasone as an analgesic adjunct in labor analgesia.DesignDouble-blinded randomized controlled trial.SettingLabor analgesia in a tertiary-care teaching hospital.PatientsEighty consenting ASA I-II parturients, age > 18 year, nulliparous, single gestation, cephalic presentation at ≥ 36 wk. of gestation, in early spontaneous labor (cervical dilatation ≤ 5 cm) requesting epidural analgesia.InterventionsThe patients were randomized to two groups. The Dexa group received 8 mg of dexamethasone i.v. in 50 ml normal saline approximately 45 min before the procedure. Placebo group patients received 50 ml normal saline only. All patients underwent epidural labor analgesia per hospital protocol. After an initial bolus, they received continuous background infusion of 5 ml/h of 0.1% of levobupivacaine with 2 μg/ml of fentanyl, with the provision of patient controlled boluses of 5 ml of the same drug combination with a lockout interval of 12 min if needed.MeasurementsPrimary outcome measure: hourly average consumption of neuraxially administered levobupivacaine-fentanyl combination. Secondary outcomes and observations: pain score, maternal satisfaction, sensory and motor block characteristics, hemodynamic parameters of mother, fetal heart rate, duration of second stage of labor, mode of delivery, Apgar scores at 1 and 5 min, and adverse effects.Main resultsAverage hourly drug consumption was significantly lower in Dexa group as compared to Placebo group (10.34 ± 1.79 ml/h vs. 11.34 ± 1.83 ml/h; mean difference 1.007, 95% CI 0.199–1.815; P = 0.015). The median number of bolus doses was 4 (interquartile-range [IQR] 3–5.75) and 5 (IQR 3–6) in the Dexa and Placebo groups, respectively (P = 0.162). There was no significant difference between groups with regard to pain scores, maternal satisfaction and hemodynamics, mode of delivery, and adverse effects.ConclusionsI.v. dexamethasone significantly decreased hourly average drug consumption of levobupivacaine-fentanyl combination through the epidural route, demonstrating the epidural drug dose sparing effect during labor analgesia.     

Comparison of caudal epidural block and ultrasonography-guided transversus abdominis plane block for pain relief in children undergoing lower abdominal surgery

Study objectiveWe conducted this study to compare the efficacy of caudal epidural block (CEB) vs ultrasonography-guided transversus abdominis plane (TAP) block for providing postoperative pain relief in children scheduled for lower abdominal surgery. Whereas the primary objective was to compare the duration of postoperative analgesia, the secondary objectives included comparative assessment (TAP vs CEB) of quality of pain relief in the first 24 hours postoperatively and rescue analgesia requirements.DesignRandomized-control, prospective, observer-blinded, 2-arm, single-center comparison.SettingOperating room, postoperative recovery area.PatientsEighty-children, aged 2-6 years, of American Society of Anesthesiologists physical status I/II scheduled to undergo unilateral lower abdominal surgery under general anesthesia.InterventionsThe recruited children were randomly allocated to receive under general anesthesia either CEB (group C, 0.75 mL/kg of 0.25% bupivacaine) or ultrasonography-guided administration of TAP block (group T, 0.5 mL/kg of 0.25% bupivacaine).MeasurementsIntraoperative: heart rate and noninvasive blood pressure; postoperative: pain profile, including duration of postoperative analgesia, quality of pain relief, and rescue analgesia requirements.Main resultsThe median duration of postoperative analgesia was significantly greater in children who received CEB than those who were administered TAP block (group C: 362.5 minutes [172.5-693.75] vs group T: 210 minutes [108.75-362.5]; P < .05). No difference was found in the incidence of postoperative pain up to 6 hours from the point of initiation of assessment (group C: 47.2% vs group T: 55.9%; P > .05). The children who received CEB experienced greater incidence of pain in the 6- to 24-hour postoperative interval than those administered TAP block (group C: 75% vs group T: 44.1%; P < .05). Although there was no difference in the rescue analgesia requirements, the number of children not requiring any rescue analgesia in the first 24 hours postoperatively was significantly higher in the TAP group (group C: n = 2 vs group T: n = 8; P < .05).ConclusionsIn children undergoing lower abdominal surgery, CEB provides a significantly prolonged duration of postoperative analgesia when compared with ultrasonography-guided TAP block.     

Efficacy of dexmedetomidine addition to bupivacaine on the quality of blind fascia iliaca compartment block in children undergoing femur fracture surgery

Efficacy of dexmedetomidine addition to bupivacaine on the quality of blind fascia iliaca compartment block in children undergoing femur fracture surgery.ObjectivesThe objectives of this study were designed to detect the effects of addition of dexmedetomidine to bupivacaine on the quality of blind fascia iliaca compartment block and its possible side effects in children undergoing fracture femur surgery.MethodsThis study was conducted on 28 children (2–6 years of age), scheduled for fracture femur surgery. Children were randomly allocated to receive either 0.25% bupivacaine 1 ml kg^?1 (B group), or 0.25% bupivacaine 1 ml kg^?1 with dexmedetomidine 2 μg kg^?1 (BD group). Anesthesia was maintained with sevoflurane 1–1.5 minimum alveolar concentration. Intraoperative sevoflurane concentration, hemodynamic, postoperative emergence delirium, sedation scores and pain scores were recorded. Duration of surgery and emergence time were recorded. Postoperative complications such as (nausea and vomiting, respiratory depression, purities, hypotension and bradycardia) were reported.ResultsCompared to the group B, patients received bupivacaine–dexmedetomidine for fascia iliaca compartment block had lower intraoperative sevoflurane concentration, higher sedation score, longer duration of postoperative analgesia, less use of rectal paracetamol for the first 24 h postoperatively and less number with postoperative agitation. No patients developed postoperative respiratory depression, purities, hypotension or bradycardia.ConclusionThe present study concluded that the combined use of bupivacaine–dexmedetomidine for fascia iliaca compartment block in children provided significant reduction of end-tidal sevoflurane concentration, remarkable hemodynamic stability, significant postoperative analgesia with lower postoperative analgesics requirements without any undesirable complications.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.