A prospective, double-blind, randomized trial of caudal block using ropivacaine 0.2% with or without fentanyl 1 microg kg-1 in children

Background. It has been reported that ropivacaine produces vasoconstrictionin contrast to vasodilation produced by bupivacaine. It is possiblethat additives to ropivacaine can provide further analgesicadvantages compared with bupivacaine. We thus evaluated whetherthe addition of fentanyl to ropivacaine prolonged the durationof analgesia after a single shot caudal block. Methods. A total of 36 children undergoing surgical proceduresbelow the umbilicus were randomly allocated to one of two groups:Group F received ropivacaine 0.2%, 1 ml kg^–1 with fentanyl1 µg kg^–1 and Group S received ropivacaine 0.2%,1 ml kg^–1 with saline. The analgesic effect of the caudalblock was evaluated using the Children's Hospital of EasternOntario Pain Scale (CHEOPS) and sedation was assessed usingthe Steward score at 30 min after extubation and at 1, 2, 4,6, 12 and 24 h. The first analgesic requirement time and side-effectsin a 24 h period were also recorded. Results. There were no differences in characteristics betweenthe groups. The end-tidal concentration of sevoflurane at extubationin Group F was significantly lower than in Group S. However,there was no significant difference in time from discontinuationof the volatile anaesthetics to tracheal extubation. No statisticaldifferences were found in the CHEOPS and Steward score, andthe time to first analgesia. The incidence of postoperativevomiting was not significantly different. Conclusion. We found that the addition of fentanyl 1 µgkg^–1 to ropivacaine 0.2% for caudal analgesia providesno further analgesic advantages over ropivacaine 0.2% alone.     

Obstetric outcome following epidural analgesia with bupivacaine-adrenaline 0.25% or bupivacaine 0.125% with sufentanil - a prospective randomized controlled study in 1000 parturients

Background: Epidural analgesia (EDA) is the most efficient method for pain relief during labour, but there is still a debate as to whether it interferes with the normal process of delivery. Some authors argue that the incidence of instrumental deliveries, Caesarean section, malrotation and protracted labour is increased in parturients receiving EDA.
Methods: 1000 parturients were prospectively randomized to receive EDA either with a high dose of local anaesthetic (0.25% bupivacaine with adrenaline=HD) or with a low dose (0.125% bupivacaine with sufentanil 10 μg=LD).
Results: The incidence of instrumental delivery and Caesarean section and the need for oxytocin was reduced in the LD compared to HD group. The delivery time was similar with HD and LD among primiparous, but decreased significantly among multiparous in the LD group. The incidence of malrotation was low in both groups. The quality of analgesia was equal during the first stage in the 2 groups, but was lower in the LD group during the second stage. More parturients in the LD group ambulated, but this did not affect the incidence of instrumental delivery.
Conclusion: It is concluded that a lower dosage of bupivacaine combined with sufentanil in epidural analgesia significantly improves the obstetric outcome as compared to a higher dosage of bupivacaine with adrenaline using intermittent bolus technique.     

Caudal anesthesia for minor pediatric surgery: a prospective randomized comparison of ropivacaine 0.2% vs levobupivacaine 0.2%

BACKGROUND: Previous published data comparing ropivacaine 0.2% with levobupivacaine 0.25% have suggested that ropivacaine might be associated with less early postoperative motor blockade compared with levobupivacaine. The aim of the present study was to further investigate this issue comparing equal concentrations (0.2%) of ropivacaine and levobupivacaine in children undergoing minor subumbilical surgery. METHODS: Following induction of a standardized anesthetic, patients (1-7 years) were randomized in a double-blind manner to receive a caudal block with either ropivacaine 0.2% (group R, n=30) or levobupivacaine 0.2% (group L, n=30), total volume 1 ml.kg-1. Motor blockade (modified Bromage scale; primary end-point) and analgesia [Children and Infants Postoperative Pain Scale (CHIPPS) score] were assessed at predetermined time points during the first 24-postoperative hours. RESULTS: Motor blockade was only registered during the first postoperative hour with no significant differences between the groups (group R n=5, group L n=8). Postoperative CHIPPS scores were almost identical in both groups with only seven and six patients requiring supplemental analgesia (CHIPPS score>or=4) in the R and L groups, respectively. CONCLUSIONS: A 0.2% concentrations of ropivacaine or levobupivacaine are clinically very similar with regard to postoperative analgesia and unwanted postoperative motor blockade in children undergoing minor subumbilical surgery.     

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

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

Postoperative epidural analgesia after total knee arthroplasty with sufentanil 1 microg/ml combined with ropivacaine 0.2%, ropivacaine 0.125%, or levobupivacaine 0.125%: a randomized, double-blind comparison

BACKGROUND AND OBJECTIVES: Total knee replacement is associated with severe postoperative pain that, if treated insufficiently, interferes with early rehabilitation. The purpose of the present study is to compare the efficacy of ropivacaine (0.2% and 0.125%) and levobupivacaine (0.125%), all in combination with sufentanil 1 microg/mL with regard to postoperative pain relief and absence of motor block in a patient-controlled epidural analgesia setting. METHODS: The study design was randomized and double-blind. Sixty-three patients scheduled for total knee replacement under combined spinal-epidural anesthesia were randomly allocated to receive ropivacaine 0.2%/sufentanil 1 microg/mL (group 1), ropivacaine 0.125%/sufentanil 1 microg/mL (group 2), or levobupivacaine 0.125%/sufentanil 1 microg/mL (group 3) for postoperative epidural pain relief. Primary endpoints were numerical rating scores for pain and patient satisfaction, motor block scores, time to first demand of the patient-controlled epidural analgesia device and average hourly consumption of local anesthetic and sufentanil. RESULTS: There were no significant differences between the 3 groups regarding numerical rating scores for pain, patient satisfaction, and motor block scores at any of the time intervals; time to first demand and average hourly sufentanil consumption were similar. Patients in group 1 used significantly more local anesthetic than patients in groups 2 and 3. CONCLUSIONS: All 3 solutions provided adequate analgesia and minimal motor block. The higher concentration of ropivacaine 0.2% was associated with a higher consumption of local anesthetic and did not result in a decrease in the consumption of sufentanil. Under the conditions of this study, patient-controlled epidural analgesia consumption of the epidural mixture was predominantly determined by sufentanil.     

Improved analgesia with clonidine when added to local anesthetic during combined spinal-epidural anesthesia for hip arthroplasty: a double-blind, randomized and placebo-controlled study

Background: The perioperative effects of intrathecal and epidural clonidine combined with local anesthetic were evaluated in 60 patients undergoing hip arthroplasty. Methods: This was a double‐blinded study and the patients were randomized into three groups, with 20 patients in each group. All patients received spinal anesthesia with 17.5 mg of plain bupivacaine with 15 µg of clonidine (Group BC‐RC) or without clonidine (Groups B‐R and B‐RC). Postoperatively, epidural infusion was administered in the following way: Group B‐R – ropivacaine 4 mg h^?1; Groups B‐RC and BC‐RC: ropivacaine 4 mg h^?1 and clonidine 40 µg h^?1. Sensory block was assessed with light touch, pinprick, transcutaneous electrical stimulation at T12 and L2 dermatomes, and perception of thermal stimuli. Results: The maximal upper level of sensory block measured by pin‐prick (T6–T7) did not differ between the groups while the partial sensory block for cold and warmth were increased two dermatomes above pin‐prick level in the group with intrathecal clonidine compared to the other two groups (P < 0.05). Duration of anesthesia, analgesia and motor block were longer in Group BC‐RC compared to Groups B‐R and B‐RC (P < 0.02). Postoperatively, both VAS score on movement and PCA‐morphine consumption were higher in Group B‐R than in Groups B‐RC and BC‐RC (P < 0.01). The arterial pressure and heart rate in Groups B‐RC and BC‐RC were significantly lower than in Group B‐R at 10–24 and 15–24 h, respectively, after spinal injection. Conclusion: Low‐dose intrathecal clonidine provided a better quality of anesthesia and longer‐lasting analgesia. Epidural clonidine‐ropivacaine infusion resulted in improved postoperative analgesia but was associated with a moderate decrease in blood pressure.     

Levobupivacaine–tramadol combination for caudal block in children: a randomized,double‐blinded,prospective study1

Background: The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg·kg⁻¹ and mixture of both in children undergoing day‐case surgery. Methods: Sixty‐three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg·kg⁻¹ (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml·kg⁻¹). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children’s and Infants’ Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was ≥4. Results: No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 ± 160 min vs 322 ± 183 min and 248 ± 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. Conclusion: Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.     

The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine,fentanyl and adrenaline after major surgery. A randomized,double-blind,dose-finding study

BACKGROUND: We have documented that adrenaline 2.0 micro g.ml- 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1. Concern about possible adverse effects on spinal cord blood flow, expressed by others, prompted us to find the lowest concentration of adrenaline needed to produce effective and reliable pain relief after major surgery. METHODS: A prospective, randomized, double-blind, parallel group study was carried out in 36 patients after major thoracic or upper abdominal surgery. Patients with only mild pain when coughing during titrated thoracic epidural infusion of approximately 9 ml per hour of bupivacaine 1 mg.ml- 1, fentanyl 2 micro g.ml- 1, and adrenaline 2.0 micro g.ml- 1 were included. The study was conducted as a dose-finding study comparing three different adrenaline concentrations in the epidural mixture (0.5, 1.0, and 1.5 micro g.ml- 1) with each other and with adrenaline 2.0 micro g.ml- 1 in our standard epidural mixture. On the 1st postoperative day, the patients were randomly allocated into three equal groups of 12 patients each, and given a double-blind epidural infusion at the same rate, but with different adrenaline concentrations (0.5, 1.0, or 1.5 micro g.ml- 1). The effects were observed for 4 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections per hour (4 ml) and subsequent i.v. morphine, if necessary. All patients received rectal paracetamol 1 g, every 6th hour. Main outcome measures were pain intensity at rest and when coughing, evaluated by a visual analogue scale and an overall quality of pain relief score. The extent of sensory blockade was evaluated by determining dermatomal hypaesthesia to cold. RESULTS: Pain intensity when coughing increased (P < 0.001) and the number of hypaesthetic dermatomal segments decreased (P < 0.002) when the concentration of adrenaline was reduced below 1.5 micro g.ml- 1 in the triple epidural mixture. This change started within two hours after reducing the concentration of adrenaline below 1.5 micro g.ml- 1. The differences in pain intensities at rest were less pronounced. After 4 h with adrenaline 0.5 or 1.0 micro g.ml- 1 pain intensity when coughing was unacceptable in spite of rescue analgesia. After restarting the standard epidural mixture with adrenaline 2.0 micro g.ml- 1, pain intensity was again reduced to mild pain when coughing and the sensory blockade was restored. Occurrence of pruritus increased with a decreasing adrenaline concentration. CONCLUSIONS: Adrenaline in a dose-related manner improves the pain-relieving effect and sensory blockade and decreases the occurrence of pruritus of a low-concentration thoracic epidural analgesic infusion of bupivacaine 1 mg. ml- 1 and fentanyl 2 micro g.ml- 1 after major thoracic or upper abdominal surgery. The minimally effective concentration of adrenaline, when added to bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1, to maintain relief of dynamic pain is approximately 1.5 micro g.ml- 1. The data clearly document that dynamic, cough-provoked pain is a more sensitive outcome measure for postoperative pain relief than pain at rest.     

Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl. A randomized, double-blind crossover study with and without fentanyl

BACKGROUND: The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief, and side effects when removing fentanyl from an optimally titrated epidural infusion consisting of bupivacaine, fentanyl and adrenaline. METHODS: A prospective, randomized, double-blind, crossover study was carried out in 20 patients after major upper abdominal surgery requiring a large longitudinal incision. Patients with only mild pain when coughing during thoracic epidural infusion of about 10 ml per hour of bupivacaine 1 mg x ml(-1), fentanyl 2 microg x ml(-1), and adrenaline 2 microg x ml(-1) were included. On the 1st and 2nd postoperative days, each patient was given a double-blind epidural infusion, at the same rate, with or without fentanyl. The effects were observed for 6 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections (4 ml) per hour and intravenous morphine if necessary. RESULTS: Main outcome measures, i.e. pain intensity when coughing and at rest, increased (P<0.001) when fentanyl (19.2+/-5.2 microg x h(-1)) was omitted from the epidural infusion: after 6 h pain intensity when coughing had increased to unacceptable levels in spite of increased consumption of rescue bupivacaine and adrenaline (P<0.001). Within 15-20 min after restarting the triple epidural mixture with fentanyl, pain intensity was again reduced to mild pain when coughing. CONCLUSIONS: A low dose of epidural fentanyl (20 microg x h(-1)) markedly improved the pain-relieving effect of bupivacaine and adrenaline infused epidurally at a thoracic level after major upper abdominal surgery. This dose of fentanyl is much too small to relieve severe dynamic pain when given systemically. Therefore, this study indirectly supports the view that a low-dose thoracic epidural infusion of fentanyl has a spinal analgesic site of action.     

Epinephrine concentration (1:100,000 or 1:200,000) does not affect the clinical efficacy of 4% articaine for lower third molar removal: a double-blind, randomized, crossover study.

PURPOSE: This study compared the use of 4% articaine in association with 1:100,000 (10 mug/mL; A100) or 1:200,000 (5 mug/mL; A200) epinephrine in lower third molar removal. PATIENTS AND METHODS: Fifty healthy volunteers underwent removal of symmetrically positioned lower third molars, in 2 separate appointments, under local anesthesia with either A100 or A200, in a double-blind, randomized, and crossed manner. Latency, duration of postoperative analgesia, duration of anesthetic action on soft tissues, intraoperative bleeding, and hemodynamic parameters were evaluated. RESULTS: A100 and A200 presented very similar latency (1.64 +/- 0.08 and 1.58 +/- 0.08 minutes, respectively; P > .05). Identical volumes of both anesthetic solutions were used: 2.7 mL = 108 mg of articaine plus 27 mug (A100) or 13.5 mug (A200) of epinephrine. The 2 solutions provided similar duration of postoperative analgesia regardless of bone removal (around 200 minutes; P > .05). The 2 solutions also had a similar duration of anesthetic action on soft tissues (around 250 minutes; P > .05). The surgeon's rating of intraoperative bleeding was considered very close to minimal. Transient changes in hemodynamic parameters were observed, but these were neither clinically significant nor attributable to the type of anesthetic used (P > .05). CONCLUSIONS: An epinephrine concentration of 1:100,000 or 1:200,000 in 4% articaine solution does not affect the clinical efficacy of this local anesthetic. It is possible to successfully use the 4% articaine formulation with a lower concentration of epinephrine (1:200,000 or 5 mug/mL) for lower third molar extraction with or without bone removal.     

不同方式氟比洛芬酯复合芬太尼术后镇痛效果的比较:前瞻性、多中心、随机、双盲、对照、平行分组研究

目的 比较不同方式氟比洛芬酯复合芬太尼用于术后镇痛的效果.方法 本研究为前瞻性、多中心、随机、双盲、对照、平行分组研究.选择2010年1月至2010年10月择期行骨科、胸外科、肝胆外科等大中型手术的病人,ASA分级Ⅰ或Ⅱ级,年龄14 ～ 91岁,体重35 ～ 95 kg,采用随机数字表法,将其分为3组,A组:术毕即刻静脉注射氟比洛芬酯100 mg,然后芬太尼1.0 mg用生理盐水稀释至100 ml,进行PCIA;B组:氟比洛芬酯200 mg+芬太尼0.6 mg用生理盐水配稀释至100 ml,进行PCIA;C组:术毕即刻静脉注射氟比洛芬酯100 mg,氟比洛芬酯200 mg+芬太尼0.6 mg用生理盐水稀释至100 ml进行PCIA.3组背景输注速率2 ml/h,PCA量2 ml,锁定时间10 min.分别于术毕、术后4、8和24 h时记录静态和动态VAS评分和镇静评分.术后24 h内记录镇痛有效、过度镇静、恶心、呕吐、瘙痒、头晕、嗜睡和呼吸抑制的发生情况.术后24和48 h时随机选择一个中心B组镇痛泵内容物,取样后进行微生物培养试验.结果 共完成2596例,其中A组875例、B组946例、C组775例.与A组比较,B组术毕、术后4、8和24h时静态和动态VAS评分和各时点镇静评分均降低,C组术毕、术后4、8h时静态和动态VAS评分均降低,术后4、8h时镇静评分升高,2组镇痛有效率均升高,B组过度镇静发生率降低,C组过度镇静发生率升高,2组术后恶心和呕吐的发生率降低,C组术后头晕发生率降低(P＜0.05);与B组比较,C组各时点静态和动态VAS评分、镇痛有效率、恶心、呕吐以及瘙痒发生率差异无统计学意义(P＞0.05),术毕、术后4、8h时镇静评分升高,过度镇静发生率升高,头晕发生率降低(P＜0.05).术后24、48 h时泵内容物标本细菌和真菌培养均为阴性.结论 对于大中型手术病人,氟比洛芬200 mg复合芬太尼0.6 mg PCIA(背景输注速率2 ml/h,PCA量2 ml,锁定时间10 min)术后镇痛的效果更佳,且不良反应发生几率低.