Epidural buprenorphine with nitrous oxide-oxygen-enflurane anesthesia

Epidural buprenorphine (Bn) with nitrous oxide-oxygen-enflurane (GOE) anesthesia was investigated as an anesthetic method in 63 patients who underwent upper abdominal surgery over three hours. The patients were divided randomly into three groups. The first group received only GOE anesthesia (group A, n = 13), the second group was given GOE anesthesia and 0.2 mg epidural Bn every three hours during operation (group B, n = 23) and the third group was administered GOE anesthesia and 0.2 mg epidural Bn every six hours (group C, n = 27). The patients were rated according to intraoperative anesthetic dosage, awakening from anesthesia, postoperative respiratory depression and postoperative analgesia. The administered enflurane concentration declined approximately 0.4% in group B and C as compared that in group A (P less than 0.05). And there was no intra-group difference in the awakening time from anesthesia. Postoperative respiratory depression was noted in group B. The respiratory rate 18.7 +/- 1.0 (mean +/- SE) min-1 in group B was significantly lower compared with the rates 22.8 +/- 1.5 min-1 in group A and 22.1 +/- 1.1 min-1 in group C (P less than 0.05). The PaCO2 value 44.1 +/- 1.0 mmHg in group B was significantly higher compared with the values 39.8 +/- 0.8 mmHg in group A and 41.3 +/- 0.9 mmHg in group C (P less than 0.01). Postoperative analgesia was remarkably prolonged in group B and C; 542 +/- 97 minutes and 504 +/- 97 minutes, respectively, as compared with 55 +/- 20 minutes in group A (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Subarachnoid buprenorphine administered by implantable micropumps

This report concerns 23 patients, the majority of whom are suffering from low back and chest pain caused by chest, urological or gynaecological cancer. These patients were treated with subarachnoid buprenorphine, administered in a single bolus or by slow infusion from micropumps, at a daily dose adapted to patients need (0.06-0.15 mg). The painful symptomatology was successfully controlled in all the cases treated, allowing the patients to live a virtually normal life. In no cases was respiratory depression or tolerance observed.     

Epidural buprenorphine for postoperative analgesia after hip operations

Two groups of 20 patients each were given immediately after hip-operation an epidural injection of 0,15 or 0,3 mg buprenorphine. Effects and side effects are compared with those observed in two groups of patients having the same type of operation, and given either 4 mg of morphine or saline (placebo) by epidural injection. Buprenorphine in both doses produced a shorter duration of analgesia than 4 mg of morphine. In no case did respiratory depression occur. Urinary retention after buprenorphine was barely more frequent than in the placebo group. Nausea and vomiting occurred in 35-45% of patients. We do not see an advantage in replacing morphine by buprenorphine for epidural opiate-analgesia, because the same high rate of nausea/vomiting is associated with a significantly shorter duration of analgesia after buprenorphine. We are convinced that epidural opiate-analgesia is most valuable for postoperative pain relief but should be reserved for selected cases.     

Epidural buprenorphine for pain relief after spinal decompression

We report a prospective double-blind trial of the efficacy of a single epidural dose of buprenorphine on pain after spinal decompression. Postoperative pain was assessed by a linear analogue pain chart and by the additional requirement for analgesia. The patients receiving buprenorphine were significantly more comfortable (p less than 0.005) and required less analgesia in the first 12 hours after operation (p less than 0.05) than the control group. This simple procedure is recommended as an effective and safe method of reducing pain.     

Epidural buprenorphine in management of pain in multiple rib fractures

BACKGROUND: Pain from multiple rib fractures may affect pulmonary function, morbidity, and length of stay in the intensive care units. This study describes some clinical characteristics of epidural buprenorphine, a lipophilic and partial opiate agonist with a higher micro receptor affinity than morphine, in combating the pain in multiple rib fractures. METHODS: The study was conducted prospectively over a 15-month period. A total of 27 patients admitted to the hospital with multiple rib fractures were studied. Buprenorphine at a concentration of 0.3 mg in 5-10 ml normal saline was administered epidurally, twice daily the first 24 h, thereafter once daily. Ventilatory function tests (including vital capacity, tidal volume, respiratory rate, and minute volume) and assessment of pain intensity using a simple, categorical, verbal rating scale were obtained before and after institution of analgesia. Any nausea, vomiting, hypotension, urinary retention, respiratory depression or pruritis were recorded. RESULTS: We found a significant improvement in ventilatory function tests during the 1st, 2nd, and 3rd day after epidural analgesia when compared with the preanalgesia levels (P < 0.001). Changes in the verbal rating scale demonstrated that epidural buprenorphine was associated with marked improvement in pain at rest and pain during coughing and deep breathing. None of our patients developed hypotension (<10% of the baseline), urinary retention or respiratory depression. Nausea, vomiting, and mild pruritis were the only reported complications. CONCLUSIONS: Epidurally introduced narcotic, like buprenorphine in saline, has been found to be effective in our study to achieve adequate analgesia in treatment of patients with multiple rib fractures. In addition, this methodology of pain relief eliminates the costly delivery system and early discharge, and allows walking epidurals and follow-up on outpatient basis.     

Thermal care in the perioperative period

Perioperative hypothermia is, even today, 15 years after the development of active warming devices, a common complication of anesthesia and surgery.The combination of anesthetic-induced thermoregulatory impairment and exposure to cold operating room environments makes most surgical patients hypothermic. Hypothermia results initially from a core-to-peripheral redistribution of body heat, and subsequently from heat loss exceeding heat production. Patients becoming sufficiently hypothermic during general anesthesia develop a core-temperature plateau when arterio-venous shunt tone is re-established.General anesthesia produces marked and dose-dependent inhibition of thermoregulatory control, typically increasing the sweating and vasodilation thresholds by approximately 1 °C and reducing the vasoconstriction and shivering thresholds by approximately 3 °C. As a result, the inter-threshold range increases roughly 20-fold, leaving patients poikilothermic over an approximately 4 °C range of core temperatures. Regional anesthesia also impairs thermoregulatory control, producing both peripheral and central inhibition.Even mild perioperative hypothermia, which can easily be prevented, is associated with adverse outcomes including morbid cardiac events, coagulopathy, surgical wound infections, and prolonged hospitalization. Consequently, body temperature should be measured in most surgical patients. Unless hypothermia is specifically indicated (e.g. for protection against ischemia), intraoperative core temperature should be maintained above 36 °C.     

Neurological conditions in the perioperative period

The wide spectrum of neurological disorders and their effects on the function of the central and peripheral nervous system can cause an extensive array of symptoms and significant morbidity and mortality. This morbidity and mortality is often amplified in the perioperative period with an elevated risk of anaesthetic complications and adverse events. However, the number of patients with neurological disease requiring surgery is unlikely to diminish, and therefore this anaesthetic risk needs to be met and managed effectively. Here we aim to examine a range of different neurological conditions, exploring the possible complications and complexities encountered in the perioperative period, in addition to discussing strategies to minimize the risk of adverse outcomes and ensure the delivery of safe anaesthesia and good perioperative care.     

Neurological conditions in the perioperative period

The wide spectrum of neurological disorders and their effects on the function of the central and peripheral nervous system can cause an extensive array of symptoms and significant morbidity and mortality. Morbidity and mortality are often amplified in the perioperative period with an elevated risk of anaesthetic complications and adverse events. However, the number of patients with neurological disease requiring surgery is unlikely to diminish, and therefore this anaesthetic risk needs to be met and managed effectively. Here we aim to examine a range of different neurological conditions, exploring the possible complications and complexities encountered in the perioperative period, in addition to discussing strategies to minimize the risk of adverse outcomes and ensure the delivery of safe anaesthesia and good perioperative care.     

Antiplatelet therapy in the perioperative period

Antiplatelet drugs are the cornerstone treatment in the secondary prevention of arterial thrombosis. Until recently, their intake was interrupted in the perioperative period because of fear for bleeding, but new insights have challenged this old habit: In patients at high risk for atherothrombotic events who need to undergo surgery or an invasive procedure, the risk for bleeding complications because of a treatment with low-dose acetylsalicylic acid (LD ASA) needs to be balanced against the risk of atherothrombotic events after treatment discontinuation. For patients at high risk of atherothrombotic complications recent guidelines do no longer advocate to interrupt LD ASA routinely. However, the likelihood of bleeding versus atherothrombotic complications should be considered on a case-by-case basis. When continued perioperatively, the bleeding risk associated with thienopyridines (ticlopidine, clopidogrel and prasugrel) is higher than that of LD ASA. It is recommended to stop their intake 1 week before the surgical intervention, except in patients with (recent) coronary stenting.     

Hemodynamic monitoring in the perioperative period

Both, obligatory non-invasive hemodynamic monitoring and adjunctive hemodynamic monitoring need to be considered perioperatively. Patient as well as surgical requirements may contribute to the decision making process. Effectiveness and quality of the perioperative patient monitoring solely depends on the knowledge and awareness of the anesthesist with regard to the potentials and limitations of the applied monitoring.