Spinal ropivacaine or bupivacaine for cesarean delivery: a prospective, randomized, double-blind comparison

BACKGROUND AND OBJECTIVES: The aim of this prospective, randomized, double-blinded study was to compare clinical efficacy and safety of ropivacaine and bupivacaine given intrathecally in combination with morphine for cesarean delivery. METHODS: With ethical committee approval and a written informed consent, 60 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive spinal anesthesia with either 20 mg ropivacaine plus 0.1 mg morphine (n = 30) or 15 mg bupivacaine plus 0.1 mg morphine (n = 30). Profile of spinal block (onset and recovery times), cardiovascular effects, and quality of postoperative analgesia (patient-controlled morphine) were recorded by a blinded observer. RESULTS: The onset time of motor block was shorter after bupivacaine (8 +/- 2 min) than after ropivacaine (12 +/- 5 minutes) (P <.05), whereas duration of both sensory and motor blocks was longer after bupivacaine (139 +/- 37 minutes and 254 +/- 76 minutes) than after ropivacaine (112 +/- 27 minutes and 211 +/- 48 minutes) (P <.01 and P <.05, respectively). No differences in intraoperative quality of anesthesia and clinical hypotension requiring ephedrine administration were observed between the two groups. Postoperative analgesia was similarly effective in both groups; however median consumption of patient-controlled morphine during the first 24 hours after surgery was higher in patients of group Ropivacaine (5 mg; range, 0 to 18 mg) than in patients of group Bupivacaine (2 mg; range, 0 to 7 mg) (P <.01). CONCLUSION: Spinal anesthesia produced with 20 mg ropivacaine plus 0.1 mg morphine is as effective and safe as that provided by 15 mg bupivacaine plus 0.1 mg morphine, with an earlier recovery of sensory and motor functions after surgery.     

Comparison between extradural infusion of ropivacaine or bupivacaine for the prevention of postoperative pain after total knee arthroplasty

We have compared the analgesia and motor block produced by extradural infusions of ropivacaine and bupivacaine after total knee arthroplasty. Fifty-two patients received 8 ml h1 of either 0.2% ropivacaine or 0.2% bupivacaine by extradural infusion for 24 h after operation. Analgesia was assessed by postoperative visual analogue scale (VAS) and morphine consumption. At rest these were low in both groups; median VAS was 0- 13.3 mm for the ropivacaine group and 0-0.5 mm for the bupivacaine group. Over the 24 h of the infusion, the estimated (ropivacaine bupivacaine) difference in wound pain at rest was 5.6 mm (P = 0.017) and on passive movement 11.6 mm (P = 0.016). Median morphine consumption was 30.7 mg in the ropivacaine group and 20.5 mg in the bupivacaine group. In the ropivacaine group, 50% of patients compared with 19% in the bupivacaine group had no motor block 2 h after operation, increasing to 88% for ropivacaine and 56% for bupivacaine by 24 h. Bupivacaine produced significantly more frequent and intense motor block over the 24 h (P = 0.015).      

Postoperative analgesia using caudal morphine in pediatric surgery: randomized double-blind study compared with bupivacaine

Morphine and bupivacaine have been administered caudal via to 28 children between 2 and 12 years old for the postoperative pain treatment. All of them were submitted to general anesthesia and randomly divided into 3 groups depending on the drug administered caudal via. a) Morphine group (n = 10): morphine chlorhydrate 50 micrograms/kg (0.5 ml/kg of morphine solution 100 micrograms/ml). b) Bupivacaine group (n = 10): bupivacaine 0.5%, 2.5 mg/kg. c) Control group (n = 8): no drug administered. Pain evaluation was made on the basis of physiological and clinical data. In the morphine group, the postoperative time until analgesia was required 20 +/- 5 hours and analgesia has been significantly better (p less than 0.001) than bupivacaine and control group. The number of analgesic drug needed during the postoperative 24 first hours was also less in morphine group. No differences on postoperative complications were seen among the 3 groups and no case of respiratory depression was observed. It is concluded that epiduro-caudal morphine provides effective and prolonged analgesia and can be safely used for postoperative pain treatment in pediatric urologic surgery. However, we believe, that larger series of patients will provide better information of its efficacy and other side effects.     

Postoperative analgesia using continuous lumbar epidural infusion of ropivacaine in comparison with bupivacaine

BACKGROUND: Epidural bupivacaine infusion is a commonly used technique for postoperative analgesia because of its motor-sparing properties. Recently a new long acting local anesthetic, ropivacaine, has become available. The aim of this study was to investigate the efficacy of ropivacaine and bupivacaine with regard to postoperative analgesia when administered continuously into the lumbar epidural space. METHODS: All patients were ASA I II and undergoing ipsi-lateral leg orthopedic surgery with epidural or combined spinal-epidural anesthesia. Patients were randomly assigned to following three groups: 0.1% ropivacaine (0.1 R); 0.2% ropivacaine (0.2 R); 0.125% bupivacaine (0.125 B). At the end of surgery, continuous infusion was begun at a rate of 6 ml.hr 1 after a bolus epidural administration of 5 ml of 0.2% ropivacaine in R groups and 0.25% bupivacaine in B group. Sensory and motor block, blood pressure, pulse rate, verbal pain score (VPS), analgesic consumption were assessed at 20 min, 1, 3, 10-20 hrs following the beginning of continuous infusion. RESULTS: Vital signs were stable at every measuring point in all groups. In 0.1 R group (n = 20), the spread of sensory block at 3 hrs after infusion was lower than 0.2 R group (n = 19), and VPS during the study was higher than 0.125 B group (n = 17). Bromage scale after 3 hrs was higher in 0.2 R group compared with 0.125 B group. The degree of sensory and motor block gradually decreased, resulting in little difference between the groups. When epidural anesthesia was spread over the surgical area throughout the study, 0.2 R or 0.125 B was sufficiently relieved from postoperative pain. CONCLUSIONS: After leg orthopedic surgery, 6 ml.hr-1 of 0.2 R or 0.125 B provided enough postoperative analgesia when the spread of anesthesia covered the operated area. 0.2 R would be better compared to 0.125 B in continuous epidural infusion for postoperative analgesia due to less systemic toxicity, even though it accompanies a little more intense motor block.     

Comparison of low-dose intrathecal and epidural morphine and bupivacaine infiltration for postoperative pain control after surgery for lumbar disc disease

This prospective, blinded, placebo-controlled study was performed to compare the postoperative analgesic efficacy of low-dose intrathecal and epidural morphine with paraspinal muscle infiltration of bupivacaine in lumbar discectomy cases. Eighty ASA I-III adult patients undergoing elective surgery for lumbar disc disease were enrolled in the study. Patients were randomized to four groups by envelopes. Study groups were as follows: group 1 (n = 20), intrathecal morphine 0.1 mg; group 2 (n = 20), epidural morphine 2 mg; group 3 (n = 20), 30 mL of bupivacaine 0.25% paraspinal muscle infiltration; group 4 (n = 20), 30 mL of saline paraspinal muscle infiltration before wound closure. Recorded parameters were time to response to painful and verbal stimuli and postoperative pain assessed at 30 minutes and 2, 4, 6, 8, 12, and 24 hours by Visual Analog Scale (VAS) and Numeric Pain Scale (NPS). Hemodynamic data, sedation scores, and side effects were also recorded. Meperidine and naproxen sodium were used for postoperative analgesia. Follow-up was performed by a blinded investigator. Mean VAS scores were lower in groups 1 and 2 at 30 minutes (P < 0.05). Mean VAS score of group 2 was lower than that of group 4 at 4 hours postoperatively (P < 0.05). Mean NPS scores were lower in groups 1 and 2 at 2, 4, and 6 hours (P < 0.05) and in group 2 at 8 hours compared with the other groups. The number of patients requiring meperidine at early postoperative phase (0-6 hours) was less in groups 1 and 2 compared with groups 3 and 4 (P < 0.05).There were no statistically significant differences in the late postoperative analgesic requirements, after correction for multiple testing. In conclusion, low-dose intrathecal and epidural morphine provide lower postoperative pain scores and a reduction in early postoperative analgesic requirement with insignificant side effects compared with paraspinal bupivacaine or saline infiltration.     

Epidural levobupivacaine 0.1% or ropivacaine 0.1% combined with morphine provides comparable analgesia after abdominal surgery

Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 +/- 178 mg levobupivacaine versus 347 +/- 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects. IMPLICATIONS: Small concentrations (0.1%) of epidural levobupivacaine and ropivacaine combined with morphine (0.1 mg/h) produce comparable analgesia and have similar side effects for similar dose requirements.     

Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty

The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intraarticular administration of morphine or bupivacaine in patients undergoing TKA.     

Intraoperative single-shot “3-in-1” femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement

PURPOSE: To compare analgesia after intraoperative single shot "3-in-1" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR). METHODS: We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: "3-in-1" FNB using 30 mL of ropivacaine 0.25%, R2: "3-in-1" FNB using 30 mL of ropivacaine 0.5%, B: "3-in-1" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared. RESULTS: There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B. CONCLUSION: "3-in-1" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of "3-in-1" FNB.     

Evaluation of the effect of perineuronal morphine on the quality of postoperative analgesia after axillary plexus block: a randomized double-blind study

A randomized, double-blind study was performed on 50 patients scheduled for elective hand and forearm surgery under axillary plexus block to evaluate the effect of perineuronal morphine on the quality of postoperative analgesia. Patients were divided into two groups. In group A (n = 25) 5 mg of preservative-free morphine in 1.0 mL of 0.9% saline was added to the local anesthetic solution (20 mL of 1% plain lignocaine, 20 mL of 0.5% plain bupivacaine). They also received an intramuscular placebo injection of 1.0 mL of 0.9% saline in the upper thigh. In group B (n = 25), 1.0 mL of 0.9% saline was added to the local anesthetic solution and patients received an intramuscular injection of 5 mg of preservative-free morphine in 1.0 mL of 0.9% saline in the thigh. The addition of morphine to the local anesthetic solution for the axillary block did not shorten the onset time of the block, improve the quality of postoperative pain relief, or provide longer lasting analgesia than that obtained with intramuscular morphine.     

Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia

N-methyl-D-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.     

A randomized,double-blinded comparison of thoracic epidural ropivacaine,ropivacaine/fentanyl,or bupivacaine/fentanyl for postthoracotomy analgesia

Epidural ropivacaine has not been compared with bupivacaine for postthoracotomy analgesia. Eighty patients undergoing elective lung surgery were randomized in a double-blinded manner to receive one of three solutions for high thoracic epidural analgesia. A continuous epidural infusion of 0.1 mL. kg(-1). h(-1) of either 0.2% ropivacaine, 0.15% ropivacaine/fentanyl 5 micro g/mL, or 0.1% bupivacaine/fentanyl 5 micro g/mL was started at admission to the intensive care unit. We assessed pain scores (rest and spirometry), IV morphine consumption, spirometry, hand grip strength, PaCO(2), heart rate, blood pressure, respiratory rate, and side effects (sedation, nausea, vomiting, and pruritus) for 48 h. Thoracic epidural ropivacaine/fentanyl provided adequate pain relief similar to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. The use of plain 0.2% ropivacaine was associated with worse pain control during spirometry, larger consumption of IV morphine, and increased incidence of postoperative nausea and vomiting. Morphine requirements were larger in the ropivacaine group, with no differences between bupivacaine/fentanyl and ropivacaine/fentanyl groups. Patients in the ropivacaine group experienced more pain and performed worse in spirometry than patients who received epidural fentanyl. There was no significant difference in motor block. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia. IMPLICATIONS: Thoracic epidural ropivacaine/fentanyl provided adequate pain relief and similar analgesia to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. Plain 0.2% ropivacaine was associated with worse pain control and an increased incidence of postoperative nausea and vomiting. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia.     

布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛安全性探讨

目的探讨布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛的效果、并发症及安全陛。方法1600例行连续术后硬膜外镇痛的患者,按所用镇痛药物配伍不同分为：0．1％布比卡因＋5μg／ml芬太尼组（B组,n=920）和0．2％罗哌卡因＋2μg／ml芬太尼组（R组,n=680）。对两组镇痛效果（视觉模拟评分及患者对镇痛效果的满意度）、并发症和处理措施进行总结分析。结果视觉模拟评分两组无差异（P〉0．05）。患者对镇痛的满意度R组明显高于B组（P〉0．05）。并发症的发生率B组高于R组（P〉0．05）。两组内年龄≥60岁的患者低血压的发生率高于年龄〈60岁者（P〈0．05）;女性患者恶心呕吐的发生率高于男性（P〈0．05）;腰段硬膜外镇痛患者下肢乏力或麻木的发生率明显高于胸段硬膜外镇痛患者（P〈0．05）。结论布比卡因、罗哌卡因与芬太尼不同配伍均可安全有效地用于连续术后硬膜外镇痛,罗哌卡因组并发症较少,并发症的发生与镇痛药物、年龄、性别及硬膜外置管部位有关。     

Comparison between bupivacaine 0.125% and ropivacaine 0.2% for epidural administration to outpatients with chronic low back pain

BACKGROUND AND OBJECTIVE: Epidural blocks should provide good analgesia for the treatment of chronic low back pain without any motor block to allow active physiotherapy. Epidural ropivacaine is known to produce less motor block compared to bupivacaine at anaesthetic concentrations. This prospective, randomized double blind study compares the analgesic, motor block, and haemodynamic effects of single shot epidural injections of ropivacaine 0.2% 10 mL with bupivacaine 0.125% in outpatients suffering from chronic low back pain. METHODS: Forty patients were assigned to receive either ropivacaine 0.2% (n = 20) or bupivacaine 0.125% (n = 20) within a series of eight single shot epidural blocks. RESULTS: Thirty-six patients received either ropivacaine 0.2% (n = 18) or bupivacaine 0.125% (n = 18) within a series of eight single shot epidural blocks. Both groups showed no significant differences either in analgesia, or in motor blockade or haemodynamic changes. Thus ropivacaine 0.2% did not reduce the incidence of motor block (9.0% of patients with motor block Bromage scores 1, 2 or 3 in ropivacaine or bupivacaine). The combination of repeated epidural analgesia and physiotherapy reduced the median pain-scores (visual analogu scale, 0-10) from 7 (SD +/- 1.6) at the beginning of the study to 4.1 (SD +/- 1.7) at the end of the series. CONCLUSIONS: Both bupivacaine 0.125% and ropivacaine 0.29% appear suitable for epidural administration to outpatients with chronic low back pain attending for epidural analgesia associated with physiotherapy (physical therapy).     

A prospective trial of analgesia following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty

BACKGROUND: The extraperitoneal instillation of bupivacaine has been shown to be superior to the use of a placebo for postoperative analgesia following endoscopic extraperitoneal inguinal hernioplasty. The objective of the present study was to compare the efficacy of postoperative analgesia by local wound infiltration to instillation of the extraperitoneal space with bupivacaine. METHODS: Between 1 September 1999 and 2 June 2000, a total of 100 patients who underwent unilateral endoscopic extraperitoneal inguinal hernioplasties were recruited to receive either local wound infiltration with 10 ml of 0.5% bupivacaine (group I, n = 50) or instillation of the extraperitoneal space with 40 ml of 0.25% bupivacaine after mesh placement (group II, n = 50). Daily postoperative pain was assessed by visual analogue pain score on a scale from 0 to 10 at rest and upon coughing. Total amount of oral analgesic consumed and clinical outcomes of the two groups were compared. RESULTS: A comparison of daily pain scores of the two groups at rest and upon coughing showed no significant difference (p = ns). The mean number of oral analgesic tablets consumed were 3.2 +/- 0.5 (SEM) and 3.3 +/- 0.5 (SEM) in groups I and II, respectively (p = ns). During follow-up, asympatomatic groin collections were more common in group II (n = 4) than group I (n = 2) (p = ns). CONCLUSIONS: Compared to local wound infiltration with bupivacaine, the extraperitoneal instillation of bupivacaine did not bestow any additional analgesic benefits. Therefore, the routine infiltration of skin incisions with bupivacaine is recommended after endoscopic extraperitoneal inguinal hernioplasty.     

The effect of epidural vs intravenous analgesia for posterior spinal fusion surgery

BACKGROUND: The study objective was to compare epidural vs intravenous postoperative analgesia in posterior spinal fusion surgery patients. METHODS: This prospective, double-blinded, randomized study was performed in a tertiary care teaching hospital involving 31 American Society of Anesthesiologists physical status I and II adolescent/young adult patients scheduled for elective posterior spinal fusion surgery for idiopathic scoliosis. Patients were divided into three treatment groups according to the epidural solution infused: group 1 (n = 10) 0.1% bupivacaine + 5 microg x ml(-1) fentanyl; group 2 (n = 12) 0.0625% bupivacaine + 5 microg x ml(-1) fentanyl; group 3 (n = 9) 0.9% sodium chloride (placebo). During general anesthesia all patients received a directly placed midthoracic epidural catheter with a set infusion rate followed by morphine sulfate intravenous patient-controlled analgesic device postoperatively. Morphine sulfate usage and visual analog scores were evaluated at 4 h intervals postoperatively for up to 96 h. Postoperative time to liquids, solid food, ambulation, length of stay, discontinuation of Foley catheter, and side effects were recorded. RESULTS: No consistent difference was detected on intravenous morphine dose usage, visual analog scores, or estimated pain scale over the whole follow-up period. No difference was observed in the epidural groups in time to oral intake of liquids or solids, ambulation, bowel sounds, or length of stay when compared with placebo. CONCLUSIONS: By evaluating morphine sulfate usage between groups, the analgesic effectiveness of continuous thoracic epidural analgesia bupivacaine and fentanyl doses used revealed no significant improvement over intravenous morphine sulfate analgesia alone in patients after posterior spinal fusion surgery.     

The bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not prevent postoperative pain after total thyroidectomy

BACKGROUND AND OBJECTIVES: Patients undergoing thyroid surgery need postoperative pain management. Bilateral superficial cervical plexus block by administration of 0.25% bupivacaine with 1:200000 epinephrine at the end of surgery has been shown to improve postoperative analgesia. The objective of this study was to assess the analgesic efficacy in the first 36 postoperative hours after total thyroidectomy of bilateral superficial cervical plexus block with 0.75% ropivacaine administered before the incision or on completion of the surgical procedure. METHODS: We performed a prospective double-blinded, randomized controlled trial that compared 3 parallel groups: the CONT group did not receive any block, the PRE group received bilateral superficial cervical plexus block before surgery while under general anesthesia, and the POST group received bilateral superficial cervical plexus block after surgery while under general anesthesia. The study included 111 patients (37 in each group). Postoperative pain was assessed every 4 hours by use of a 0 to 10 numeric rating scale. All patients received paracetamol every 6 hours. Morphine was administered following a standardized protocol if the numeric rating scale was 4 or higher. The main outcome variables were the proportion of patients given morphine during the 36 hours period, pain intensity scores, and morphine consumption. RESULTS: No intergroup differences were observed in terms of percentage of patients who required morphine, morphine delivery, pain scores, and intraoperative opioid consumption. CONCLUSIONS: Bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not improve postoperative analgesia after total thyroidectomy.     

Preoperative infiltration of bupivacaine - effects on pain relief and trauma response (cortisol and interleukin-6)

Hypothesis: Subcutaneous infiltration of bupivacaine before skin incision can reduce postoperative pain and modulate the stress response.
Methods: In a randomized study on pain relief after hysterectomy 29 patients were referred into one of three groups, receiving 30 ml of bupivacaine 0.25% with adrenaline, 30 ml of saline or no infiltration along the line of the proposed incision 10 min before start of surgery. A Visual Analogue Scale was used for repeated pain ratings. Postoperative pain relief was provided with patient-controlled analgesia with intravenous morphine 0.04 mg/kg. Lockout time was 10 min. The immuno-logical and endocrine stress response to trauma was reflected by blood interleukin-6 (IL-6) and cortisol concentrations measured during 72 h following skin incision.
Results: There were large individual variations in the accumulated postoperative consumption of morphine at 20 h after start of surgery. It was significantly reduced in patients receiving infiltration of bupivacaine. They used 39 mg (9–62) median (range) of intravenous morphine whereas the patients in the saline group used 65 mg (47–120) and patients in the control group used 54 mg (36–130) ( P <0.05). Significant elevation of plasma IL-6 and serum cortisol levels appeared in all groups with peak values at 3 h. There were no differences between the groups. There was a correlation between cortisol and IL-6. Six of the 29 patients had a postoperative infection which was reflected in increased IL-6 levels.
Conclusion: Preoperative subcutaneous infiltration of bupivacaine significantly reduced the postoperative consumption of intravenous morphine.     

Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine

BACKGROUND AND OBJECTIVE: No clinical trials comparing the characteristics of sensory blockade caused by various local anaesthetics in thoracic paravertebral blockade have been published. The aim of this prospective study was a clinical assessment of sensory blockade after paravertebral injection of ropivacaine or bupivacaine in patients undergoing modified radical mastectomy. METHODS: Seventy ASA I-II patients were randomized to receive a single injection of ropivacaine 0.5% (n = 35) or bupivacaine 0.5% (n = 35) at the T4 level. General anaesthesia with propofol and fentanyl was provided during the procedure and patients were not intubated. The following parameters were analysed: duration and dynamics of the sensory blockade and the patient's and surgeon's assessment. RESULTS: Both ropivacaine and bupivacaine provided a similar level of analgesia. Ropivacaine was characterized by more rapid onset - after only 5 min 53% of patients in this group had the extent of sensory blockade wide enough to perform modified radical mastectomy in comparison to only 20% after bupivacaine (P 9 segments blocked) was noted more often in the ropivacaine group (88% vs. 65%, P < 0.05), lasted longer and appeared to be wider than sensory blockade produced by bupivacaine. Regression of sensory blockade was initially similar, but after 24 h sensory blockade in the ropivacaine group still had a potential to provide analgesia for modified radical mastectomy in 81% of patients in comparison to only 50% of such patients in the bupivacaine group (P < 0.05). Degree of postoperative pain, performance of the cardiovascular system, consumption of medications and complications were all similar between the study groups. CONCLUSIONS: Both agents provide satisfactory conditions for mastectomy, but ropivacaine seems to be superior to bupivacaine for thoracic paravertebral blockade during breast cancer surgery.     

Peripheral opioid analgesia in laparoscopic cholecystectomy

BACKGROUND: Recent research has revealed that opioids can act directly on the peripheral terminals of afferent nerves to mediate antinociception. The aim of this study was to assess the influence of peripheral morphine administration on the nociception process in the postoperative period. METHODS: One hundred fifty patients for laparoscopic cholecystectomy were randomly divided into 5 groups. Group M patients (n=30) received local infiltration at trocar insertion points with 2 mg morphine in 20 mL of 0.9% NaCl solution (5 mL of solution per point) 10 minutes before the operation. For group B patients (n=30), the solution used for infiltration was 20 mL of 0.25% bupivacaine; for group M+B patients (n=30), the solution was 2 mg morphine in 20 mL of 0.25% bupivacaine; and for group S patients (n=30), the solution was 20 mL 0.9% NaCl. For group S+M patients (n=30), trocar insertion points were infiltrated with 20 mL of 0.9% NaCl, and patients in this group were given 2 mg of subcutaneous morphine 10 minutes before the surgery. Postoperative analgesic therapy was provided by on-demand analgesia with tramadol. After surgery, the following were measured: pain intensity scored on the visual analog scale, total tramadol requirement, time from the end of the surgical procedure to the administration of the first dose of tramadol, and the frequency of undesirable side effects (sedation, nausea, and vomiting). RESULTS: Pain intensity and total tramadol requirement after surgery were lower in groups M, B, and M+B compared with groups S and S+M, but these differences were not statistically significant. The time from the completion of the operation to the administration of the first dose of tramadol was significantly longer in groups M, B, and M+B compared with groups S and S+M. CONCLUSION: Results of the study confirm the possibility of modifying the nociception process in the postoperative period through peripheral opioid administration.