Combined intrathecal and epidural magnesium sulfate supplementation of spinal anesthesia to reduce post-operative analgesic requirements: a prospective, randomized, double-blind, controlled trial in patients undergoing major orthopedic surgery

BACKGROUND: New ways of decreasing post-operative analgesic drug requirements are of special interest after major surgery. Magnesium sulfate (MgSO(4)) alters pain processing and reduces the induction and maintenance of central sensitization by blocking the N-methyl-D-aspartate (NMDA) receptor in the spinal cord. We investigated whether supplementation of spinal anesthesia with combined intrathecally and epidurally infused MgSO(4) reduced patients' post-operative analgesia requirements. METHODS: In a randomized, prospective, double-blind, placebo-controlled trial, we enrolled 120 consecutive patients undergoing orthopedic surgery during spinal anesthesia (levobupivacaine and sufentanil). Patients were randomly assigned to receive intrathecal MgSO(4) (94.5 mg, 6.3%), epidural MgSO(4) (2%, 100 mg/h), intrathecal and epidural MgSO(4) combined or spinal anesthesia alone (controls). Post-operative morphine consumption was assessed in all groups by patient-controlled analgesia (PCA). RESULTS: Of the 120 patients enrolled, 103 (86%) completed the study. Morphine consumption at 36 h after surgery was 38% lower in patients receiving spinal anesthesia plus epidural MgSO(4) [- 14.963 mg; 95% confidence interval (CI), - 1.44 to - 28.49 mg], 49% lower in those receiving spinal anesthesia plus intrathecal MgSO(4) (- 18.963 mg; 95% CI, - 5.27 to - 32.65 mg) and 69% lower in the intrathecal-epidural combined group (- 26.963 mg; 95% CI, - 13.73 to - 40.19 mg) relative to control patients receiving spinal anesthesia alone. No complications developed during the post-operative course or at 1 month after surgery. CONCLUSION: In patients undergoing orthopedic surgery, supplementation of spinal anesthesia with combined intrathecal and epidural MgSO(4) significantly reduces patients' post-operative analgesic requirements.     

Spinal anesthesia and postoperative analgesia with intrathecal morphine for orthopedic surgery]

The aim of this study was to evaluate the analgesic efficacy and side effects of intrathecal morphine in the dose range 0.2-0.5 mg. One-hundred patients scheduled for elective lower limb orthopedic operation under spinal anesthesia using hyperbaric or isobaric bupivacaine 0.5% with morphine in dose from 0.2 to 0.5 mg. Pain score, duration of analgesia and the incidence of adverse effects like nausea, vomiting, pruritus, urinary retention and respiratory depression were assessed for 48 hr postoperatively. There were significant differences in the duration and efficacy analgesia and the incidence of pruritus the morphine dose-related. We did not observe the increased frequency of nausea and vomiting with increased dose. The respiratory depression not observed in connection with intrathecal morphine. The evidence from this current study suggests that spinal anesthesia with combination of local anesthetic and morphine can be employed to provide safe and efficacious analgesia in patients undergoing orthopedic operations. The adverse effects which developed due to intrathecal morphine were able to treat with success.     

Combined spinal epidural vs epidural labour analgesia: does initial intrathecal analgesia reduce the subsequent minimum local analgesic concentration of epidural bupivacaine?

Labour analgesia initiated using a combined spinal-epidural (CSE) technique may reduce subsequent epidural bupivacaine requirements compared with an epidural-only technique. We compared the minimum local analgesic concentrations (MLAC) of epidural bupivacaine following initial intrathecal or epidural injection. In a prospective, double-blind study, 115 women requesting epidural analgesia were randomly assigned to receive either an epidural with bupivacaine 20 mg and fentanyl 40 μg or a CSE with intrathecal bupivacaine 2.5 mg and fentanyl 5 μg. Analgesia was assessed using a visual analogue pain score. When further analgesia was requested, bupivacaine 20 ml was given, and the concentration was determined using the technique of up-down sequential allocation. The MLAC of bupivacaine in the epidural group was 0.032% wt/vol (95% CI 0.020-0.044) compared with 0.047% wt/vol (95% CI 0.042-0.052) in the CSE group. Bupivacaine requirements for the second injection were increased following intrathecal analgesia by a factor of 1.45 (p = 0.026) compared with epidural analgesia.     

An evaluation of intrathecal bupivacaine combined with intrathecal or intravenous clonidine in children undergoing orthopedic surgery: a randomized double-blinded study

Background: Propofol is a popular agent for providing intraoperative sedation in pediatric population during lumbar puncture and spinal anesthesia. Adjuvant‐like clonidine is used increasingly in pediatric anesthesia to provide postoperative analgesia with a local anesthetic agent. The aim of this study was to assess the effects of intrathecal and intravenous clonidine on postoperative analgesia/sedation and intraoperative requirements of propofol after intrathecal bupivacaine for orthopedic surgery in children. Methods: Fifty‐nine ASA I and II children aged 6–8 year undergoing orthopedic surgery were randomized to receive intrathecal 0.5% bupivacaine 0.2–0.4 mg·kg^?1 and intravenous 2 ml saline (Group B), intrathecal 0.5% bupivacaine 0.2–0.4 mg·kg^?1 plus 1 μg·kg^?1 clonidine and intravenous 2 ml saline (Group BCit), and 0.5% bupivacaine 0.2–0.4 mg·kg^?1 and intravenous 1 μg·kg^?1 clonidine in 2 ml of saline (Group BCiv). Intraoperative sedation was maintained with 20–50 μg·kg^?1·min^?1 of propofol infusion. The requirements of propofol, time to first rescue analgesia, and postoperative pain or sedation scores were assessed. The duration of motor and sensory blocks and perioperative adverse events were determined. Results: Clonidine significantly prolonged the time to first rescue analgesia and reduced the requirements of propofol sedation whether administered intravenously or intrathecally. The mean Children and Infants Postoperative Pain Scale scores of children were significantly lower in groups BCit and BCiv than in group B. Postoperative sedation scores were higher in groups BCit and BCiv than in group B. Intrathecal clonidine significantly prolonged the time to regression of the sensory block and recovery of motor block. There were no significant differences among the three groups regarding the incidence of perioperative adverse events. Conclusion: Intrathecal or intravenous clonidine similarly provided better postoperative analgesia and sedation and reduced the requirements of propofol. Only intrathecal clonidine prolonged the duration of sensory and motor blocks.     

Combined spinal and epidural anesthesia for cesarean section: a retrospective study with 0.5% hyperbaric bupivacaine

BACKGROUND: We investigated retrospectively the relationship between the intrathecal dose of 0.5% hyperbaric bupivacaine and the use of 2% mepivacaine through an epidural catheter. METHODS: Forty-nine patients undergoing cesarean section with combined spinal and epidural anesthesia (CSEA) were analyzed. They were divided into two groups; with (CSEA group) and without additional epidural injection group (spinal group). RESULTS: In the CSEA group (24 patients received 1.2 +/- 0.4 ml of 0.5% hyperbaric bupivacaine), 5-10 ml of 2% mepivacaine were required to achieve the adequate surgical anesthesia. In the spinal group (25 patients received 1.6 +/- 0.3 ml of 0.5% hyperbaric bupivacaine), cesarean section was performed without additional mepivacaine before delivery. The analgesic level and the amount of fluid infusion were similar in the two groups. However, 20% of patients in the spinal group showed hypotension (systolic blood pressure below 80 mmHg), although no patients in the CSEA group developed hypotension. The amount of ephedrine used before delivery was significantly larger in the spinal group (8.9 +/- 7.7 mg) than in the CSEA group (3.9 +/- 4.3 mg). CONCLUSIONS: Spinal anesthesia induced by 1.2 ml of 0.5% hyperbaric bupivacaine with sequential epidural block induced by 5-10 ml of 2% mepivacaine caused no hypotension during cesarean section.     

Fentanyl shows different effects by administration routes on bispectral index during spinal anesthesia in patients undergoing cesarean section

BACKGROUND: Spinal anesthesia using a local anesthetic with fentanyl has been reported to induce sedation. We previously reported that the bispectral index (BIS) value was significantly decreased by spinal anesthesia using only bupivacaine and fetanyl after cesarean delivery. In the present study, we studied the effect of different fentanyl administration routes on BIS values during spinal anesthesia for cesarean section. METHODS: Forty-six women scheduled for cesarean section were allocated into five-groups according to the route of fentanyl administration and amount of local anesthetic: intrathecal 0.5% isobaric bupivacaine 2.5 ml plus fentanyl 20 microg (n = 11), intrathecal 0.5% isobaric bupivacaine 2.5 ml plus intravenous fentanyl 100 microg (n = 12), intrathecal 0.5% isobaric bupivacaine 2.5 ml plus epidural fentanyl 100 microg (n = 8), intrathecal 0.5% isobaric bupivacaine 2.5 ml (n = 8), and intrathecal 0.5% isobaric bupivacaine 3.0 ml (n = 7). BIS values were recorded during anesthesia. RESULTS: BIS values in intrathecal fentanyl group were lower than those of other groups (P = 0.03). The cumulative duration of BIS values 80 and below 80 was longer in the intrathecal fentanyl group than those of other groups (P = 0.004). CONCLUSION: The BIS value was significantly decreased only by intrathecal fentanyl for cesarean section.     

Intrathecal clonidine does not reduce post-spinal shivering

BACKGROUND: After general or epidural anesthesia, clonidine is known to be effective in suppressing established shivering. The aim of this study was to assess the preventive effect of intrathecal clonidine on post-spinal shivering compared with intravenous (i.v.) clonidine. METHODS: One hundred and fifty patients scheduled for orthopedic surgery were randomly allocated into three groups to receive either 1 microg/kg clonidine i.v. (IV group) or the same volume of isotonic saline (control and IT groups) at 5 min before spinal anesthesia. Spinal anesthesia was performed with 12-15 mg hyperbaric bupivacaine 0.5% plus either 1 ml of saline (control and IV groups) or 150 microg clonidine (IT group). Shivering was evaluated for a period of 90 min and graded as none, mild, moderate, and severe. RESULTS: Twenty patients (40%) in the control group and 17 patients (34%) in the IT group showed shivering compared with four (8%) in the IV group. Patients with moderate-to-severe shivering were only seen in the control and IT group, and the maximal intensity of shivering was not different between the two groups. Patients in the IV group were significantly more sedated than the other groups. CONCLUSIONS: The intrathecal administration of clonidine 150 microg fails to prevent post-spinal shivering; by contrast, we have confirmed that i.v. clonidine 1 microg/kg is an effective method to prevent shivering in patients undergoing spinal anesthesia for orthopedic surgery.     

Patient supplemented epidural analgesia after major abdominal surgery with bupivacaine/fentanyl or ropivacaine/fentanyl

PURPOSE: To compare analgesic efficacy and occurrence of motor block and other side effects during patient supplemented epidural analgesia (PSEA) with either ropivacaine/fentanyl or bupivacaine/fentanyl mixtures. METHODS: In a prospective, randomized, double-blind study, 32 ASAI-III patients undergoing major abdominal surgery received an epidural catheter at the T8- T10, followed by integrated general epidural anesthesia. Postoperative epidural analgesia was provided using a patient controlled pump with either ropivacaine 0.2%/2 microg x ml(-1) fentanyl (group Ropivacaine, n = 16) or bupivacaine 0.125%/2 microg x ml(-1) fentanyl (group Bupivacaine, n = 16) [background infusion 4-6 ml x hr(-1), 1.5 ml Incremental Doses and 20 min lock out]. Verbal pain rating score, number of incremental doses, consumption of epidural analgesic solution and rescue analgesics, sedation (four-point scale), and pulse oximetry were recorded by a blind observer for 48 hr after surgery. RESULTS: No differences in pain relief, motor block, degree of sedation, pulse oximetry and other side effects were observed between the two groups. The number of incremental doses and the volume of analgesic solution infused epidurally were higher in patients receiving the bupivacaine/fentanyl mixture (10 [0-52] I.D. and 236 [204-340] ml) than in patients receiving the ropivacaine/fentanyl solution (5 [0-50] I.D. and 208 [148-260] ml) (P = 0.03 and P = 0.05, respectively). CONCLUSION: Using a ropivacaine 0.2%/2 microg x ml(-1) fentanyl mixture for patient supplemented epidural analgesia after major abdominal surgery provided similar successful pain relief as bupivacaine 0.125%/2 microg x ml(-1) fentanyl, but patients receiving bupivacaine/fentanyl requested more supplemental.     

The Effect of Transdermal Nitroglycerin on Spinal S(+)-Ketamine Antinociception Following Orthopedic Surgery

STUDY OBJECTIVES: To determine whether combination of transdermal nitroglycerine (a nitric oxide generator) would enhance analgesia from epidural S(+)-ketamine (a N-methyl-D-aspartate antagonist) in patients undergoing orthopedic surgery with combined spinal anesthesia. DESIGN: Randomized, double-blind study. SETTING: Orthopedic surgery unit of a teaching hospital. PATIENTS: 60 ASA physical status I and II patients scheduled for minor orthopedic knee surgery. INTERVENTIONS: Patients were randomized to one of five groups (n = 12) to receive combined epidural/intrathecal anesthesia. A 10-mL epidural injection was first administered to all patients (study drug or normal saline). Intrathecal anesthesia consisted of 15 mg bupivacaine. Twenty to 30 minutes after the spinal puncture, a transdermal patch of either nitroglycerin 5 mg or placebo was applied. The control group (CG) received epidural saline and transdermal placebo. The nitroglycerin group (NG) received epidural saline and transdermal nitroglycerine patch. The 0.1 mg/kg S(+)-ketamine epidural group (1 KG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal placebo. The 0.2 mg/kg S(+)-ketamine epidural group (2 KG) received 0.2 mg/kg epidural S(+)-ketamine and transdermal placebo. Finally, the nitroglycerin/0.1 mg/kg S(+)-ketamine epidural group (1 NKG) received 0.1 mg/kg epidural S(+)-ketamine and transdermal nitroglycerin. Pain and adverse effects were evaluated using a 10-cm visual analog scale (VAS). MEASUREMENTS AND MAIN RESULTS: The groups were demographically the same. Sensory anesthetic level and VAS score for pain at the time of first rescue medication were similar among groups. The time to first rescue analgesic (min) was less in both the CG and the NG groups compared with the other groups (p < 0.05). Epidural S(+)-ketamine resulted in analgesia to both groups (1 KG < 2 KG; p < 0.05). The 1 NKG and the 2 KG displayed similar analgesia (p > 0.05). The CG required more rescue analgesics in 24 hours compared with the patients who received epidural S(+)-ketamine (p < 0.02). CONCLUSIONS: Epidural S(+)-ketamine resulted in antinociception, which was enhanced by transdermal nitroglycerin.     

Epidural morphine improves pain relief and maintains sensory analgesia during continuous epidural bupivacaine after abdominal surgery

Twenty patients scheduled for elective major abdominal surgery were matched into two groups with regard to age, sex, height, body weight, and surgical procedure. Both groups received general anesthesia plus lumbar epidural analgesia with similar loading doses of bupivacaine 0.5% (23.1 +/- 1.0 and 23.3 +/- 0.8 ml) (mean +/- SEM) followed by continuous infusion of plain bupivacaine 0.5% (8 ml/hr) plus, in one group, epidural morphine (0.5 mg/hr). Pain score on a 5-point scale and sensory analgesia (pin prick) were assessed hourly for 16 hours after skin incision. If sensory analgesia decreased more than 5 segments from preoperative levels or if pain scores reached 2 (moderate pain), the patients were removed from the study, and pain was treated with other methods. Preoperative mean (+/- SEM) sensory levels of analgesia were similar in the bupivacaine and the bupivacaine-morphine groups (T3.4 +/- 0.5 and T3.3 +/- 0.4, respectively). In the group receiving only bupivacaine, sensory analgesia regressed over time with a simultaneous increase in pain score. Thus, within 10 hr after skin incision, seven patients in this group were discharged from the study, and 16 hr after incision only one patient maintained initial level of sensory analgesia. In contrast, each patient receiving bupivacaine plus morphine had stable sensory analgesia and was completely free of pain as indicated by a mean pain score of zero during the 16-hr observation period. Thus epidural morphine may improve pain relief and maintain analgesia during continuous epidural bupivacaine administration after abdominal surgery.     

Low-dose sufentanil dœs not potentiate intra-thecal morphine for perioperative analgesia after major colorectal surgery

PURPOSE: Both intrathecal sufentanil (ITS) and intrathecal morphine (ITM) improve analgesia in obstetrical or cardiac procedures. From a pharmacokinetic standpoint, combining these two opioids may improve perioperative analgesia. We performed a prospective randomized double-blind study to compare the analgesic efficacy of ITM alone vs a mixture of a low dose of ITS plus ITM for perioperative pain relief in colorectal surgery. METHODS: Eighty adult patients undergoing colorectal surgery were randomly allocated to receive either 0.4 mg ITM alone or 10 microg ITS plus 0.4 mg ITM before general anesthesia. Intraoperative intravenous sufentanil consumption, postoperative morphine consumption delivered with a patient controlled analgesia device, pain scores, patient satisfaction and adverse effects were recorded for the first 48 hr postoperatively. RESULTS: No differences were observed between groups with respect to intraoperative sufentanil consumption (39 +/- 23 microg in group ITM and 40 +/- 25 microg in group ITS plus ITM, P = 0.85) and in postoperative morphine consumption in postanesthesia care unit (6 +/- 5 mg vs 6 +/- 5 mg, P = 0.59), at 24 hr (26 +/- 17 vs 24 +/- 15 mg, P = 0.59) and at 48 hr (47 +/- 31 vs 44 +/- 22 mg, P = 0.58). Similarly, no differences were observed in regards to pain relief, patient satisfaction and incidence of adverse effects. CONCLUSIONS: These results do not support the addition of 10 microg ITS to 0.4 mg ITM for colorectal surgery, as low dose sufentanil does not improve intraoperative and postoperative analgesia in this setting.     

A double-blind randomized controlled trial of patient-controlled epidural analgesia with or without a background infusion following initial spinal analgesia for labor pain

BackgroundPatient-controlled epidural analgesia (PCEA) combined with spinal analgesia is an option for pain relief in labor. However, the effect of a CBI on the analgesic requirements of laboring women is still debated. This double-blind study investigated the effect of CBI with PCEA following spinal analgesia on the local anesthetic requirements of parturients during labor.MethodsSixty-six nulliparous women were randomly assigned to a standard PCEA protocol (5-mL demand bolus, 10-min lockout) with or without a CBI of 6 mL/h. The epidural solution consisted of 0.1% ropivacaine with fentanyl 2 μg/mL. Labor analgesia was initiated in both groups with intrathecal bupivacaine 2.5 mg plus fentanyl 25 μg. The number of demands per hour and the hourly dose of ropivacaine were calculated for both groups.ResultsThe median [range] number of analgesic boluses per hour in the PCEA group that were demanded: 2.4 [0.8–12.2] and delivered: 1.6 [0.8–2.6], were significantly greater than those in the PCEA+CBI group: 0.7 [0.4–4.2] and 0.6 [0.2–1.3] (P 0.05). However, the hourly ropivacaine dose in the PCEA group (7.9 [3.9–13.2] mg/h) was not significantly different from that in the PCEA+CBI group (8.4 [6.0–12.5] mg/h).ConclusionIn laboring nulliparous patients provided initial labor analgesia with spinal anesthesia, the use of a continuous background infusion decreases PCEA demand dosing, but not the total hourly amount of ropivacaine and fentanyl used.     

Epidural infusion of low dose bupivacaine after combined spinal-epidural anesthesia using needle through needle method provided no analgesic effect on postoperative pain after caesarian section

BACKGROUND: In order to evaluate the analgesic efficacy of low dose epidural bupivacaine infusion with and without morphine after caesarean section we performed combined spinal-epidural anesthesia (CSEA) using needle through needle method. Three different epidural analgesic regimens were compared retrospectively. METHODS: The number of analgesic use during 24 hours after operation was compared. Patients were categorized into three groups; group N : intraoperative bolus epidural morphine (2.5 mg) alone, group L : bolus morphine (2.5 mg) plus epidural bupivacaine infusion (32 ml of 0.2% bupivacaine) at a rate of 2.1 ml x hr(-1), group M : bolus morphine (2.4 mg) plus epidural bupivacaine-morphine (33 ml of 0.2% bupivacaine containing morphine 2.3 mg) infusion at a rate of 2.1 ml x hr(-1). Used analgesics included pentazocine 15 mg i.m., diclofenac 25 mg suppo. and loxoprofen 60 mg p.o.. RESULTS: The mean number of analgesic use during the first 24 hours in group M (0.29 +/- 0.46) was significantly smaller than those of group N (0.97 +/- 0.91) and group L (0.84 +/- 0.95). Percentage of patients requiring no analgesic during the first 24 hours was significantly less in group M (70.8%) than in group N (33.4%) and group L (42.1%). CONCLUSIONS: A 2.1 ml x hr(-1) infusion of epidural bupivacaine has no analgesic effect after caesarean section under CSEA using NTN method.     

A comparison between post-operative analgesia after intrathecal nalbuphine with bupivacaine and intrathecal fentanyl with bupivacaine after cesarean section

BackgroundAdding intrathecal opioids to intrathecal local anesthetics to decrease their doses and provide hemodynamic stability are major goals during spinal anesthesia in cesarean section. Different opioids were used to select the one with the longest duration of analgesia and the least side effects. In this study, intrathecal nalbuphine was compared with intrathecal fentanyl as an adjuvant to hyperbaric bupivacaine in cesarean section.Patients and methodsSixty female patients of ASA grades I and II presented for elective cesarean deliveries with spinal anesthesia were randomly allocated to 2 equal groups; Group F: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml fentanyl (25 μg); Group N: 30 patients received intrathecal injection of 2 ml of 0.5% hyperbaric bupivacaine plus 0.5 ml nalbuphine (0.8 mg). The onset of sensory and complete motor blockade, time of sensory blockade, duration of analgesia and motor blockade, fetal Apgar score, visual analog scale score, oxygen saturation, adverse effects and hemodynamic parameters were recorded intra-operatively and up to 4 h post-operatively. The effective analgesic time was recorded.ResultsThe onset of complete motor block was significantly more rapid in fentanyl group than in nalbuphine group. The duration of post-operative analgesia was more prolonged in nalbuphine group but the difference was insignificant. No significant difference was found between both groups as regards the duration of sensory block, motor block, duration of analgesia, fetal Apgar score, visual analog scale score, hemodynamic parameters and oxygen saturation. Adverse effects were less common in nalbuphine group but the difference was insignificant.ConclusionEither intrathecal nalbuphine 0.8 mg or intrathecal fentanyl 25 μg combined with 10 mg bupivacaine provides good intra-operative and early post-operative analgesia in cesarean section.     

Median effective local anesthetic doses of plain bupivacaine and ropivacaine for spinal anesthesia administered via a spinal catheter for brachytherapy of the lower abdomen

BACKGROUND AND OBJECTIVES: Continuous spinal anesthesia via a spinal catheter allows adjusting the duration and extent of anesthesia to surgical needs, maintenance of hemodynamic stability, and good postoperative analgesia. This study was designed to determine the median effective local anesthetic dose of plain ropivacaine and bupivacaine administered intrathecally for interstitial brachytherapy of the lower abdomen using the Dixon up-and-down method. METHODS: Forty patients were randomly allocated to receive either intrathecal bupivacaine 5 mg per mL or ropivacaine 10 mg per mL via a 24-gauge spinal catheter at the L3-4 interspace. The initial dose was 10 mg of bupivacaine or 20 mg of ropivacaine; the dosing intervals were 1 mg and 2 mg, respectively. Doses for subsequent patients were determined by the response of the previous patient in that group. Successful anesthesia was defined as a loss of sensation to a cold stimulus at the T6 level and full motor blockade within 20 minutes after administration of the local anesthetic. RESULTS: The median effective local anesthetic dose for intrathecal bupivacaine was 11.2 mg (95% confidence interval [CI], 10.3-12.1) and 22.6 mg for ropivacaine (95% CI, 20.5-24.6). A relative analgesic potency ratio of 0.50 (95% CI, 0.44-0.56) was calculated between the median effective local anesthetic dose of intrathecal bupivacaine and ropivacaine. CONCLUSIONS: Bupivacaine and ropivacaine are appropriate for continuous spinal anesthesia for interstitial radiation therapy procedures of the lower abdomen. In the dose-ranges investigated, intrathecal ropivacaine is approximately half as potent as bupivacaine.     

Intrathecal but not systemic sufentanil reduces the consumption of propofol for bispectral index-guided sedation

OBJECTIVE: The addition of opioids to local anesthetics in spinal anesthesia modulates some aspects of anesthesia and analgesia. We evaluate the effect of adding different doses of intrathecal and subcutaneous sufentanil on propofol requirements for sedation during spinal anesthesia. MATERIAL AND METHODS: Prospective clinical trial randomizing patients undergoing knee arthroscopy to 4 groups. Group 1 received 12.5 mg of 0.75% hyperbaric bupivacaine (HBB); Group 2, 12.5 mg of HBB plus 2.5 microg of intrathecal sufentanil; Group 3, 12.5 mg of HBB plus 5 microg of intrathecal sufentanil; and Group 4, 12.5 mg of HBB plus 5 microg of subcutaneous sufentanil. When spinal anesthesia had been induced, a bispectral index (BIS) monitor was connected and baseline values were recorded for each patient. Sedation was then initiated with propofol at a dose of 2.5 microg/ml, using an effect-site target-controlled infusion system to maintain a BIS value between 60 and 75. BIS, vital signs, total propofol dose (TPD), mean infusion dose (MID), and awakening time were recorded. RESULTS: One hundred patients were included in the study. MID and TPD were lower in Groups 2 and 3 than in Groups 1 and 4 (P = .009). Consumption of propofol was 35.23% less in Group 2 and 37.50% less in Group 3 than in Group 1 (P = .001). CONCLUSIONS: The addition of 2.5 microg or 5 microg of intrathecal sufentanil to HBB reduces MID, TPD, and consumption of propofol in patients undergoing spinal anesthesia; the addition of 5 microg of subcutaneous sufentanil does not produce this effect.     

Postoperative analgesia with minidose intrathecal morphine for bipolar hip prosthesis in extremely elderly patients

Purpose

It is known that an optimal dose of intrathecal morphine for analgesia after total hip arthroplasty in older patients is 0.1 mg. On the other hand, minidose intrathecal morphine (0.05 mg) is useful for analgesia after the transurethral resection of the prostate in elderly patients. We evaluated the postoperative analgesic effect of minidose intrathecal morphine after bipolar hip prosthesis in seniors (age 85 years or more) undergoing spinal anesthesia.

Methods

Twenty seniors undergoing bipolar hip prosthesis under spinal anesthesia were randomly allocated to one of two groups. Group A (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, and group B (n = 10) received intrathecal injection of 0.5% isobaric bupivacaine, 2.8 ml, plus morphine, 0.05 mg. Pain, nausea, and itching were evaluated using a numerical rating scale, ranging from 0 to 10, at 0, 4, 8, 12, and 24 h after the operation.

Results

The values on the numerical rating scale for pain in group B were significantly lower than those in group A at 4, 8, and 12 h after the operation. There were no significant differences between the groups in the values on the numerical rating scale for nausea or itching throughout the time course of the study. No patient in either group showed hypoxemia or respiratory depression throughout the time course.

Conclusion

The results show that minidose intrathecal morphine provides a good analgesic effect without side effects, and it would be an effective and safe procedure for bipolar hip prosthesis in seniors.     

Epidural buprenorphine--a double-blind study of postoperative analgesia and side effects

Epidural buprenorphine was investigated as a postoperative analgesic in a randomized double-blind study of 158 patients given epidural analgesia with mepivacaine or bupivacaine for orthopedic surgery of the lower extremity. At the end of surgery, patients were given either 0.15 mg of epidural buprenorphine (n = 38), 0.3 mg (n = 37) in 15-ml saline, or no further epidural injections (n = 47, control group) after 2% mepivacaine for intraoperative anesthesia. A fourth group (n = 36) received 0.3 mg of buprenorphine in 15-ml saline, after the intraoperative use of 0.5% bupivacaine. The patients rated postoperative pain. The need for additional analgesics as well as side effects were recorded. Analgesia after 0.15 mg buprenorphine was superior to that after no reinjection for 6 hr after surgery (P less than 0.05). Buprenorphine (0.3 mg) was superior both to no reinjection and to 0.15 mg of buprenorphine until the twelfth hour (P less than 0.05). Analgesia after bupivacaine followed by 0.3 mg of buprenorphine was not significantly different than analgesia seen after mepivacaine followed by 0.3 mg of buprenorphine. There was an increase of PaCO2 of 2-5 mm Hg between 1.5-3.5 hr after 0.3 mg of buprenorphine without any evidence for late respiratory depression. Other side effects, e.g., disturbances of micturition, pruritus, nausea, vomiting, fatigue, and headache, were comparably common in all groups. The epidural administration of 0.3 mg buprenorphine may be recommended for postoperative analgesia following orthopedic surgery of the lower extremity.     

Small-dose intrathecal clonidine and isobaric bupivacaine for orthopedic surgery: a dose-response study

We examined the dose-response relationship of intrathecal clonidine at small doses (相似文献   

Investigation of 121 cases of spinal anesthesia with plain 0.5% bupivacaine

Bupivacaine has been used for spinal anesthesia since 1982 in our department. We performed a retrograde investigation of 121 cases who had lower limb surgery and anesthetized with plain 0.5% bupivacaine solution during the year of 1987. Doses of bupivacaine, maximum spread of analgesia and spinal tap level were analyzed. We chose the bupivacaine doses from 2.5 ml to 4.0 ml depending on the condition of the patient and the specificity of the surgery. The patients were divided into 3 groups by the dose of bupivacaine: i.e. 3.0, 3.5, 4.0 ml of plain 0.5% bupivacaine. Seventy percent of all patients had a spinal tap on L3/4 interspace. The average upper level of analgesia was T7 in each group and no patient had analgesia above T2 level. There was no correlation between the site of injection and volume of local anesthetics. However patient's physical status and surgical procedure are more important to obtain the good analgesic level. There was no significant respiratory depression nor hypotension during and after the surgery. It is concluded that 3-4 ml of 0.5% bupivacaine provided satisfactory spinal anesthesia for the lower limb surgery.