Efficacy of the fascia iliaca compartment block vs continuous epidural infusion for analgesia following total knee replacement surgery

Background and objective: Total knee replacement causes moderate to severe postoperative pain. The aim of this trial was to compare postoperative analgesia from a fascia iliaca compartment block to continuous epidural analgesia following knee arthroplasty. Patients and Methods: Clinical trial enrolling patients in American Society of Anesthesiologists (ASA) classes 1 to 3 randomized to 2 groups. One group received spinal anesthesia plus a fascia iliaca compartment block with 0.1% bupivacaine at a rate of 10 mL/h. The second group received combined spinal-epidural anesthesia plus epidural analgesia with 0.1% bupivacaine in continuous infusion at a rate of 8 mL/h. Postoperative pain on a visual analog scale (VAS) at rest and on movement was recorded every 3 hours for the first 24 hours. Use of intravenous morphine and the adverse events were also recorded. Results: Forty patients (20 for each group) were enrolled. The distribution of age, weight, body mass index, sex, ASA class, duration of surgery, use of morphine, and the incidence of adverse effects were similar in the 2 groups. Postoperative VAS scores at rest and on movement were also similar. The incidence of arterial hypotension was higher in the epidural analgesia group. Conclusions: The fascia iliaca compartment block and continuous epidural infusion are similarly efficient in providing postoperative analgesia for patients after total knee replacement. The fascia iliaca compartment block is associated with a lower incidence of postoperative hemodynamic complications. Early, safe rehabilitation is facilitated by both analgesic techniques.     

Patient-controlled regional analgesia is effective in children: a preliminary report

PURPOSE: To report a preliminary analysis of prospectively recorded data in 27 children in whom patient-controlled regional analgesia (PCRA) was used for postoperative pain control following lower limb surgery. METHODS: Under general anesthesia, perineural catheters (popliteal and fascia iliaca compartment block) were inserted and infused with ropivacaine 0.2% (0.02 mL.kg(-1).hr(-1)). Additional demand doses were left to the child's discretion (0.1 mL.kg(-1)and a 30-min lockout interval). RESULTS: The average total dose of ropivacaine administered was 4.9 +/- 2 mg.kg(-1)over 48 hr. Visual analogue scale and Children's Hospital of Eastern Ontario Pain Scale scores were always inferior to 5/10 and 6/13, respectively. Motor block was observed in two children and two children needed rescue analgesia. CONCLUSIONS: Our preliminary observations indicate that PCRA in children provides satisfactory postoperative pain relief following lower limb surgery.     

Comparison of continuous 3-in-1 and fascia Iliaca compartment blocks for postoperative analgesia: feasibility,catheter migration,distribution of sensory block,and analgesic efficacy

BACKGROUND AND OBJECTIVES: Efficacy and technical aspects of continuous 3-in-1 and fascia iliaca compartment blocks were compared. METHODS: Forty-four patients scheduled for cruciate ligament repair or femur surgery were randomly divided into 2 groups. After surgery with the patient anesthetized, catheters were placed for continuous 3-in-1 blocks by means of a nerve stimulator (group 1). In group 2, the catheter was inserted for continuous fascia iliaca compartment block without the use of a nerve stimulator. In both groups, a 5-mg/kg bolus of 0.5% ropivacaine was administered followed by continuous infusion of 0.1 mL/kg/h of 0.2% ropivacaine for 48 hours. In the postoperative period, all the patients received parenteral propacetamol (6 g daily) and ketoprofen (200 mg daily) and 0.1 mg/kg of subcutaneous morphine as rescue analgesia if the visual analog scale (VAS) pain values were greater than 30 mm. We evaluated the technical difficulties relative to catheter placement, the location of the catheter, the analgesic efficacy, and the distribution of the sensory block at 1 hour, 24 hours, and 48 hours. RESULTS: Catheter placement was faster in group 2, and the absence of nerve stimulation decreased material costs (P <.05). No significant difference was observed between groups concerning location of the catheter tip under the fascia iliaca. In both groups, the distribution of the sensory block and its course were similar except for those of the obturator nerve (more sensory blocks in group 1, P <.05). No significant difference was noted between the groups regarding median VAS pain values and consumption of morphine during the 48-hour period. No major side effect was observed. CONCLUSIONS: The authors conclude that a catheter for continuous lumbar plexus block can be placed more quickly and at lesser cost using the fascia iliaca technique than the perivascular technique with equivalent postoperative analgesic efficacy.     

Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty.

We prospectively studied the continuous "modified" femoral three-in-one block for postoperative pain after total knee arthroplasty. Sixty-two patients undergoing elective knee arthroplasty under spinal anesthesia with bupivacaine (B) and fentanyl were randomized to receive 0.2% B, 0.1% B, or placebo at 10 mL/h for 48 h after an initial bolus of 30 mL of the same solution via the femoral block catheter. The catheters were inserted under the fascia iliaca using a "double pop" technique and a peripheral nerve stimulator and were advanced 15-20 cm cranially. Venous plasma levels of B, desbutylbupivacaine, and 4-hydroxy B were measured daily for 3 days. All patients received patient-controlled analgesia with morphine and indomethacin suppositories for 48 h. Using computed tomography, we evaluated the catheter location for 20 patients. The catheter tips, located superior to the upper third of the sacroiliac joint in the psoas sheath, were labeled as ideally located. The group receiving 0.2% B had a larger block success rate, smaller morphine consumption in the immediate postoperative period (15 vs 22 mg) and during the first postoperative day (9 vs 18 mg), and achieved a greater range of motion in the immediate postoperative period (91 degrees +/- 10 degrees vs 80 degrees + 13 degrees ). Visual analog scores for pain during both rest and activity were low but similar between the groups. Forty percent of the catheters evaluated were ideally located. Ideal location and use of 0.2% B resulted in 100% success of blockade of all three nerves. The S1 root was blocked in up to 76% of patients. The plasma levels of B, 4-hydroxy B, and desbutylbupivacaine were below the toxic range during the infusion. We conclude that continuous fascia iliaca block with 0.2% B results in opioid-sparing and improved range of motion during the immediate postoperative period. Larger doses of bupivacaine may safely be used in the immediate postoperative period if needed. IMPLICATIONS: Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.     

Analgesia before a spinal block for femoral neck fracture: fascia iliaca compartment block

Background: In this prospective randomized study, the authors compared the analgesic effect of a fascia iliaca compartment (FIC) block with that of intravenous (i.v.) alfentanil when administered to facilitate positioning for spinal anaesthesia in elderly patients undergoing surgery for a femoral neck fracture.
Methods: The 40 patients were randomly assigned to one of two groups, namely, the FIC group (fascia iliaca compartment block, n =20) and the IVA group (intravenous analgesia with alfentanil, n =20). Group IVA patients received a bolus dose of i.v. alfentanil 10 μg/kg, followed by a continuous infusion of alfentanil 0.25 μg/kg/min starting 2 min before the spinal block, and group FIC patients received a FIC block with 30 ml of ropivacaine 3.75 mg/ml (112.5 mg) 20 min before the spinal block. Visual analogue pain scale (VAS) scores, time to achieve spinal anaesthesia, quality of patient positioning, and patient acceptance were compared.
Results: VAS scores during positioning (mean and range) were lower in the FIC group than in the IVA group [2.0 (1–4) vs. 3.5 (2–6), P =0.001], and the mean (± SD) time to achieve spinal anaesthesia was shorter in the FIC group (6.9 ± 2.7 min vs. 10.8 ± 5.6 min; P =0.009). Patient acceptance (yes/no) was also better in the FIC group (19/1) than in the IVA group (12/8)( P =0.008).
Conclusions: An FIC block is more efficacious than i.v. alfentanil in terms of facilitating the lateral position for spinal anaesthesia in elderly patients undergoing surgery for femoral neck fractures.     

The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures

Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% +/- 13% (mean +/- SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffé's method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 +/- 20 versus 88 +/- 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words) IMPLICATIONS:Postoperative pain at the split skin donor sites is often more intense than the pain at the grafted site. This prospective, randomized, double-blind study assessed the efficacy of a continuous fascia iliaca compartment block in reducing the pain at the thigh donor site.     

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.     

Plasma bupivacaine levels after fascia iliaca compartment block with and without adrenaline

Twenty children undergoing unilateral surgery on the thigh received a fascia iliaca compartment block using 2 mg·kg⁻¹ of bupivacaine with (Group A) or without (Group P) adrenaline 1/200 000. Venous blood samples were taken as 5, 10, 15, 20, 25, 30, 40, 50 and 60 min after injection and assayed for concentrations of bupivacaine. In all subjects an adequate block was produced. Plasma concentrations of bupivacaine in Group P were significantly higher than those in Group A ( P <0.05). The median maximum plasma concentration (C_max) was 1.1 μg·ml⁻¹ (range 0.54–1.29 μg·ml⁻¹) in Group P and 0.35 μg·ml⁻¹ (range 0.17–0.96 μg·ml⁻¹) in Group A. The median time taken to attain C_max (T_max) was 20 min (range 10–25 min) in Group P and 45 min (range 5–50 min) in Group A. The median time to first analgesia was 9.75 h (range 3–15 h) in Group P and 10.5 h (range 2.5–21 h) in Group A. The study confirmed the efficacy of the fascia iliaca compartment block in children and showed that when performed with 2 mg·kg⁻¹ of bupivacaine it is associated with plasma concentrations of bupivacaine well within acceptable limits. The addition of adrenaline 1/200 000 to the local anaesthetic solution reduces the maximum plasma concentration reached.     

A comparison of pre‐operative nerve stimulator‐guided femoral nerve block and fascia iliaca compartment block in patients with a femoral neck fracture

We undertook a randomised, controlled trial to compare the analgesic efficacy and opioid sparing effect of nerve stimulator‐guided femoral nerve block with fascia iliaca compartment block in patients awaiting surgery for fractured neck of femur. Ten‐centimetre visual analogue pain scores were measured before and 2 h after the block and opioid consumption was recorded in the 12‐h period after the block. One hundred and ten patients were randomly assigned. Femoral nerve block provided superior pre‐operative analgesia for fractured neck of femur compared with fascia iliaca compartment block. The difference in the mean reduction of pain score after the block was 0.9 (95% CI 0–1.8); p = 0.047. Patients receiving a femoral nerve block required less morphine after the block than those receiving fascia iliaca compartment block (p = 0.041).     

A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty

We assessed whether a modified fascia iliaca compartment block in unilateral total hip arthroplasty provides a morphine-sparing effect in the first 24 hours. This involved a randomised, double blind study of 44 patients. Both groups received a modified fascia iliaca block with the trial group receiving 30 ml 0.5% bupivacaine with 1:200,000 adrenaline, 150 microg clonidine and 9 ml 0.9% saline and the control group receiving 40 ml 0.9% saline. Otherwise both groups received identical care with a subarachnoid block for operative anaesthesia. Patient-controlled morphine analgesia was commenced postoperatively and data were collected at three, six, 12 and 24 hours post commencement of surgery. We found that the trial group used less morphine at 12 and 24 hours (P < 0.001). The median morphine usage at 24 hours was 37.5 mg in the control patients and 22 mg in the trial patients. Pain scores were similar between groups. We conclude that a modified fascia iliaca compartment block has a significant morphine-sparing effect in unilateral total hip arthroplasty.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

Systematic review of the effects of fascia iliaca compartment block on hip fracture patients before operation

Background

Fascia iliaca compartment block is used for hip fractures in order to reduce pain, the need for systemic analgesia, and prevent delirium, on this basis. This systematic review was conducted to investigate the analgesic and adverse effects of fascia iliaca block on hip fracture in adults when applied before operation.

Fascia iliaca compartment block for femoral bone fractures in prehospital care

BACKGROUND AND OBJECTIVES: The fascia iliaca compartment block provides a faster and more consistent simultaneous blockade of the lateral cutaneous and femoral nerves than the "3 in 1" block. We studied the effectiveness of this technique for analgesia after a femoral bone fracture in pre-hospital care. METHODS: Patients with an isolated femoral shaft fracture were included. A fascia iliaca compartment block was performed on all of them. Twenty milliliters of lidocaine 1.5 % with epinephrine were injected under the fascia iliaca. The intensity of pain was measured using a simplified verbal scale (SVS) from 0 (no pain) to 4 (extreme pain). The SVS was noted before the block was performed, 10 minutes later, and then on admission to the trauma care center. Sensory blockade was evaluated using cold perception in the lateral, medial, and internal part of the thigh 10 minutes after block performance and on arrival at the trauma care center. RESULTS: Twenty-seven patients were enrolled in this study. The SVS was 3 (3-4) before the block, 1 (0-2) 10 minutes after the block, and 0 (0-1) when arriving at the trauma care center (P <.05). The SVS was lower when the internal part of the thigh was blocked. CONCLUSION: The fascia iliaca compartment block is a simple, inexpensive, and effective method of prehospital analgesia for femoral shaft fracture. A sensory block of the internal part of the thigh is an early predictive sign of optimal pain relief.     

Postoperative continuous intrathecal pain treatment in children after selective dorsal rhizotomy with bupivacaine and two different morphine doses

BACKGROUND: Children undergoing selective dorsal rhizotomy (SDR) experience severe pain postoperatively; a pain related to both the extensive surgical exposure with multilevel laminectomy and nerve root manipulation. We sought to define an optimal dose of continuous intrathecal (IT) morphine and bupivacaine to treat this severe pain. The aim of this study was to compare two different concentrations of morphine in a fixed dose of bupivacaine with regard to the analgesic effect and survey if they differed in side effects. METHODS: Twenty-six children, aged 2.7-7.4 years undergoing SDR were included in this study. Postoperatively 11 children received a continuous infusion of morphine 0.4 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (low-dose group) and 15, a continuous infusion of morphine 0.6 microg x kg(-1) x h(-1) and bupivacaine 40 microg x kg(-1) x h(-1) (high-dose group). The Behavioral Observational Pain Scale (BOPS) was used to evaluate pain. RESULTS: Better pain relief was obtained in the high-dose group seen in lower BOPS score compared with the low-dose group [P = 0.03, Fisher's permutation test and P = 0.06 Wilcoxon-Mann-Whitney (WMW) test]. The low-dose group received seven times as much ketobemidone 0.43 +/- 0.54 mg x kg(-1) 48 h(-1) compared with 0.06 +/- 0.09 mg x kg(-1) 48 h(-1) in the high-dose group (P = 0.0005 Fisher's permutation test, P = 0.0017 WMW test). There was no statistical difference in pruritus and postoperative nausea and vomiting between the groups. Respiratory and hemodynamic depression was not found. CONCLUSION: This study shows that, compared with low-dose, the higher dose of continuous IT morphine combined with bupivacaine, significantly reduce pain score and postoperative intravenous analgesic requirements without increasing adverse effects.     

Postoperative analgesia in infants and children: new developments

Nowadays, postoperative pain control in infants and children is a big challenge. The only effective solution is a multidisciplinary work with accurate guidelines, starting from the preoperative period throughout the surgery and arriving at the postoperative period. The approach must be scientific, based on the recent studies and research. In recent years, there has been a renaissance in regional anesthesia in children, in part because of a greater concern about postoperative pain management in young patients, and in part because of technical advances in equipment to perform the blocks. In fact several techniques and routes can be used for pain treatment but all have side effects. We await data from the use of COX2 inhibitors, surely the future of NSAIDs, with valid anti-inflammatory action and fewer side effects in children. When possible/not controindicated, regional analgesia is often the best choice. Recently continuous peripheral infusion is successfully applied in infants and children, due to its safety, efficacy and well limited localisation of analgesia. All the variety of peripheral nerve blocks used in adults can be used in pediatrics. The indications to place a catheter for a continouos peripheral nerve blocks are the followings: major orthopedic procedures; the procedure is scheduled to last more than two hours; congenital malformation of foot or hand; fracture reduction; traction of femur fracture; when postoperative pain therapy is necessary for several days; painful physical therapy. The commonly performed continuous peripheral blocks in children are the brachial plexus block (parascalene or axillary), the femoral nerve block, the fascia iliaca block, the sciatic nerve block with the lateral or with the popliteal approach. In these last two years also our group performed several continuous peripheral nerve blocks particularly axillary, femoral and sciatic for major orthopedic surgery and trauma. In our institution, we use a bolus dose of 0.5-1 ml/kg (depending on the nerve to be blocked) of ropivacaine 0.2% or levobupivacaine 0.25% with clonidine 2 microg/kg and then in infants older than 6 months and children we use a continuous infusion of 0.1-0.3 ml/kg/h of 0.2% ropivacaine or 0.25% levobupivacaine with clonidine 3 microg/kg/24h for 48-72 hours. For older children doses and concentrations are usually the same used in adults.     

Continuous subacromial bupivacaine infusion for postoperative analgesia after open acromioplasty and rotator cuff repair: preliminary results

Shoulder surgery is often associated with severe postoperative pain. Previous results in which single or continuous subacromial infiltration of local anesthetics was used as a method of postoperative pain relief have been contradictory. This study was initiated to evaluate the postoperative analgesic effect of a subacromial continuous 0.25% bupivacaine infusion at a rate of 6 mL/h after elective open shoulder surgery. We hypothesized that this procedure would improve postoperative analgesia while reducing morphine requirements. By use of a prospective, double-blind, randomized study design, 50 consecutive patients undergoing acromioplasty and rotator cuff repair surgery received a multiorifice catheter placed in the subacromial space. Twenty patients received 0.25% bupivacaine (group 1), and twenty-two patients received saline solution (group 2). The primary endpoints in the two groups were total morphine consumption administered by patient-controlled analgesia and the patient's subjective pain level evaluated by a visual analog scale during the first 48 postoperative hours. No major technical or pharmacologic side effects were noticed, and the indwelling pain catheter was well tolerated by all patients. There was no statistically significant difference (P < .05) either in total cumulative morphine consumption microg/48 h (73.2 +/- 43.1 vs 60.9 +/- 35.9) or in subjective pain perception 10-point visual analog scale (3.2 +/- 1.4 vs 3.1 +/- 1.5) between the two study groups. The continuous subacromial infiltration of 0.25% bupivacaine at a rate of 6 mL/h is concluded to be ineffective in providing pain relief supplementary to patient-controlled analgesia after open rotator cuff repair and acromioplasty surgery.     

Intraarticular bupivacaine-clonidine-morphine versus femoral-sciatic nerve block in pediatric patients undergoing anterior cruciate ligament reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.     

超声引导髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞在老年患者髋关节置换术术后镇痛中的作用

目的 观察超声引导下髂筋膜腔隙与髂腹下/髂腹股沟神经联合阻滞在老年患者全髋关节置换术术后镇痛的作用. 方法 选择2015年1月～2015年11月全身麻醉下行单侧前外侧入路全髋关节置换术的患者50例,年龄61～75岁,ASA分级Ⅱ、Ⅲ级,采用随机数字表法将患者分为两组(每组25例):单纯髂筋膜间隙阻滞组(单纯组)和髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞组(复合组).手术结束后即刻行患侧超声引导下神经阻滞.单纯组于髂筋膜腔隙注射0.3％罗哌卡因30 ml;复合组分别于髂筋膜腔隙与髂腹下/髂腹股沟注射0.3％罗哌卡因15 ml.记录患者一般情况,术后6、12、18、24 h患者静息及运动VAS评分,超声成像时间,穿刺注药时间,患者自控镇痛(patient controlled analgesia,PCA)芬太尼累计用量及术后镇痛相关副作用的发生情况. 结果 两组患者一般情况差异无统计学意义(P＞0.05).两组患者术后各时点静息VAS评分差异均无统计学意义(P＞0.05).复合组运动VAS评分在术后6 h [(3.8±0.9)分]和12 h[(3.6±1.3)分]时点较单纯组[(5.5±11)分和(5.3±1.0)分]降低(P＜0.05);在术后18h和24 h时点,2组运动VAS评分差异均无统计学意义(P＞0.05).两组患者超声成像时间和穿刺注药时间差异均无统计学意义(P＞0.05).复合组PCA芬太尼累计用量[(0.54±0.03) mg]较单纯组[(0.69±0.05) mg]降低(P＜0.05).两组患者术后镇痛相关副作用发生率差异无统计学意义(P＞0.05). 结论 在老年患者髋关节置换术后,超声引导髂筋膜腔隙与髂腹下/髂腹股沟神经复合阻滞可安全、有效地用于术后镇痛,显著缓解患者甲早期的运动疼痛同时减少芬太尼用量.     

Cumulation of bupivacaine, desbutylbupivacaine and 4-hydroxybupivacaine during and after continuous interscalene brachial plexus block

Desbutylbupivacaine (DBB) and 4-hydroxybupivacaine (4-OHB) are major metabolites of bupivacaine. They may cumulate during continuous infusion blocks. In the present study, all patients received an interscalene brachial plexus block with 20-28 ml of 0.75% bupivacaine plus adrenaline. A catheter was introduced into the interscalene space, and an infusion of 0.25% bupivacaine (5-9 ml/h) was started and continued with ten patients for 24 h and with another ten for 48 h. An infiltration block of the suprascapular and intercostobrachial nerves was performed using 0.5% bupivacaine. Before surgery, light general anaesthesia was induced. For measurement of plasma concentrations of bupivacaine, DBB and 4-OHB blood samples were taken before the block and 30 min, 3 h, 24 h and 48 h after the blocks as well as 30 min, 1 h, 2 h, 4 h and 6 h after the termination of the infusions. The highest plasma concentrations of bupivacaine, mean 1.84 micrograms/ml, were measured 30 min after the block. There was a slight but statistically significant rise in the bupivacaine concentrations between 24 and 48 h. The bupivacaine concentration decreased by 54% and 45%, on average, during the first 6 h following the 24- and 48-h infusions, respectively. On average, the highest DBB concentrations were measured 2 h after the 24-h infusion (0.31 +/- 0.18 micrograms/ml) and 30 min after the 48-h infusion (0.33 +/- 0.13 micrograms/ml). The highest 4-OHB concentrations were measured 1 h (0.18 +/- 0.09 micrograms/ml) and 30 min (0.20 +/- 0.05 micrograms/ml) after the 24- and 48-h infusions, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Morphine with or without a local anaesthetic for postoperative intrathecal pain treatment after selective dorsal rhizotomy in children

Selective dorsal rhizotomy is a surgical procedure with a selective division of posterior spinal nerve rootlets to treat spasticity in children. The extensive surgical procedure with multilevel laminectomies and the nerve root manipulation result in intense pain postoperatively. Two intrathecal (IT) regimes of pain treatment were compared in these children, concerning their pain relief and possible side-effects. In a prospective study, 12 children (3-6 years of age) with six in each group, received either intermittent IT morphine (5 microg x kg(-1) four times a day) or continuous infusion of a mixture of bupivacaine (40 microg x kg(-1) x h(-1)) and morphine (0.6 microg x kg(-1) x h(-1)). Pain score was lower in the bupivacaine/morphine group (0.2 +/- 1.1) compared to intermittent morphine (2 +/- 2.4) on a scale from 0 to 6 (P less than or = 0.0001). Bupivacaine/morphine resulted in a lower, but not significant, difference in pruritus and lower muscle spasm. Haemodynamic and ventilatory parameters did not differ between the groups. Intrathecal continuous infusion of bupivacaine and morphine was superior to intermittent morphine in the treatment of pain after selective dorsal rhizotomy operations.