Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty

BACKGROUND: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. METHODS: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. RESULTS: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. CONCLUSION: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.     

Clonidine addition prolongs the duration of caudal analgesia

BACKGROUND: In this study, using a dose-ranging design, we examined the effects of clonidine with 0.125% bupivacaine on the duration of post-operative analgesia in caudal anaesthesia in children. METHODS: We conducted a controlled, prospective study of clonidine in caudal anaesthesia in 60 children, aged 1-10 years, undergoing elective inguinal hernia repair. Induction and maintenance of anaesthesia were performed by inhalation of sevoflurane and nitrous oxide. The children were randomized in a double-blind fashion to four groups, and were given a caudal anaesthetic with either 0.125% plain isobaric bupivacaine (1 ml/kg) or bupivacaine plus 1, 1.5 or 2 microg/kg of clonidine. The blood pressure and heart rate were recorded peri-operatively. Analgesia was evaluated by the modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) or a visual analogue scale (VAS). Paracetamol was given when the mCHEOPS score was greater than five or when the VAS score was greater than 30 mm. The monitoring of scores for pain, haemodynamic changes and post-operative nausea and vomiting was performed by nurses blind to the study allocation. RESULTS: The duration of analgesia was found to be significantly longer in the group given bupivacaine plus 2 microg/kg of clonidine (median, 650 min; range, 300-900 min). Peri-operative hypotension and bradycardia, post-operative respiratory depression and motor block were not recorded in any patient. CONCLUSIONS: The addition of clonidine to 0.125% bupivacaine prolongs the duration of post-operative analgesia without any respiratory or haemodynamic side-effects.     

Intrathecal morphine reduces breakthrough pain during labour epidural analgesia

BACKGROUND: When using the combined spinal-epidural (CSE) technique forlabour analgesia, parturients often experience breakthroughpain after the spinal medication has receded. We tested thehypothesis that a small dose of intrathecal morphine would reducebreakthrough pain. METHODS: This was a randomized, double-blind, placebo-controlled trial.Subjects were randomized to receive either 100 µgof morphine (MS) or placebo (PLCB) with the spinal injectionof bupivacaine and fentanyl. Assessments included need for supplementationduring labour analgesia, use of pain medications for 24 hafter delivery, and side-effects. The primary end-point wasthe rate of breakthrough pain. RESULTS: Sixty subjects were enrolled, 55 subjects completed the trial.The MS group had a significantly lower rate of breakthroughpain than the PLCB group [0.6 (0.6) vs 1.1 (0.8) episodes perpatient; P < 0.01], and longer time to first episode of breakthroughpain (300 vs 180 min; P = 0.03). The MS group used 75%less opioid medications during the subsequent 24 h, buthad a 17% incidence of nausea. CONCLUSIONS: The addition of small dose of morphine to the spinal componentof the CSE technique improved the effectiveness of epidurallabour analgesia and reduced the need for pain medications over24 h, but resulted in a small increase in nausea.     

Post-operative analgesia with caudal epidural sufentanil

The effectiveness of post-operative analgesia and the frequency of side effects of caudal epidural sufentanil with bupivacaine plus adrenaline was compared with bupivacaine plus adrenaline alone and morphine with bupivacaine plus adrenaline. One hundred and four children scheduled for subdiaphragmatic surgery were studied and divided in three groups. The results showed that epidural sufentanil with bupivacaine provided better analgesia than bupivacaine alone with fewer side effects compared with the group who received morphine and bupivacaine.     

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

AIM: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). METHODS: For 6 months, we prospectively studied women undergoing CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, followed by bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% as top-up according to patient request. Sixteen milliliters of lidocaine 2%, 1 ml of bicarbonate and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. RESULTS: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) score 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio, 4.39; P = 0.005). CONCLUSION: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor and having a higher VAS score in the 2 h before CS are at risk for inability to extend labor epidural analgesia to epidural anesthesia for CS.     

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

OBJECTIVE: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). METHODS: For 6 months, we prospectively studied women undergoing a CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, then bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% top-ups according to patient request. Sixteen millilitres of lidocaine 2%, 1 ml of bicarbonate, and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. RESULTS: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient's age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index (BMI) at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio 4.39, P = 0.005). CONCLUSION: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor, having a higher VAS in the 2 h before CS are at risk of inability to extend labor epidural analgesia to epidural anesthesia for CS.     

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

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

年龄对小剂量舒芬太尼硬膜外自控镇痛效应的影响

目的观察年龄对小剂量舒芬太尼硬膜外自控镇痛效应的影响。方法择期行髋关节和下肢骨科术后病人75例（ASAⅠ-Ⅱ级）,年龄22岁-85岁,根据年龄分为A组（22岁-45岁）、B组（46岁-64岁）和C组（65岁-85岁）,每组25例。术后三组均经硬膜外导管接通并开启电子镇痛泵,三组药物配伍和PCA给药模式相同：负荷剂量5μg,背景剂量1μg／h,PCA追加剂量2．5μg,锁定时间3 min。记录PCA开机给负荷量后0、4 h、8 h、20 h、24 h和48 h舒芬太尼累积用量、VAS评分和不良反应及治疗措施,并计算术后第二天舒芬太尼累积用量。结果术后4 h、8 h、20 h和24 h等时间点A组VAS评分高于B组和C组（P〈0．01）。术后8h和20h等时间点B组VAS评分显著高于C组（P〈0．05）。A组恶心等不良反应发生率高于B组和C组（P〈0．01）。结论年龄以及伴随年龄增加发生的椎管内退行性改变是影响小剂量舒芬太尼PCEA效果的重要因素,其中老年病人效果最好,不良反应少,适宜老年病人选用。     

程控间歇脉冲输注联合硬膜外分娩镇痛时产妇爆发痛的相关因素分析

目的 分析程控间歇脉冲输注联合患者自控硬膜外分娩镇痛模式下产妇发生爆发痛的相关因素.方法 选择行分娩镇痛的产妇215例,年龄20～45岁,孕期≥37周,单胎头位,ASAⅡ或Ⅲ级.行硬膜外穿刺置管后接入电子镇痛泵,参数设置:0.08％罗哌卡因+舒芬太尼0.4μg/ml,负荷剂量15 ml,脉冲剂量10 ml/h,单次追加...     

The dose of caudal epidural analgesia and duration of postoperative analgesia

BACKGROUND: Single dose caudal epidural is commonly utilized for postoperative analgesia in children. Previous studies have determined the optimal concentration of local anaesthetic, and the minimal volume to produce a desired dermatomal distribution. However, none has sought the optimal volume to administer. The specific aim of this study was to determine whether the volume of caudal epidural local anaesthetic influenced the duration of postoperative analgesia. METHODS: Fifty-four children aged 1-6 years and ASAPS I-II scheduled for elective inguinal herniorraphy were enrolled in this randomized and blinded clinical trial. They received a standardized general anaesthetic with one of three possible doses of caudal epidural analgesic: 0.7, 1.0, or 1.3 ml.kg-1 of 0.175% bupivacaine with 1 : 200 000 epinephrine. The patients were assessed by blinded observers during in-hospital recovery and by parents at home. RESULTS: The principal outcome measure of time until first postoperative analgesic requirement was similar between the groups (4.2, 3.6, and 4.8 h respectively). Other effects which might be altered by epidural analgesia, including time until first void, ambulation, and discharge readiness did not differ between groups. CONCLUSIONS: Increasing local anaesthetic dose and volume do not increase the duration of postoperative analgesia of caudal epidural in children undergoing inguinal herniorraphy.     

Safety and efficacy of patient controlled epidural analgesia following pediatric spinal surgery

BACKGROUND: Patient controlled epidural analgesia (PCEA) is uncommon in pediatric anesthesia. Because PCEA offers superior pain control compared with continuous epidural infusions in adults, we prospectively evaluated the analgesia efficacy and safety of PCEA in children and adolescents following extensive spinal surgery. METHODS: Following ethics committee approval, 100 consecutive children [age median (range) 14 (6-19) years] undergoing spinal surgery were studied until the seventh postoperative day, and 98 children received a PCEA. One or two epidural catheters were positioned under direct vision by the surgeon based on the number of vertebral segments operated upon. The epidural solution consisted of bupivacaine 0.0625%, fentanyl 1 microg.ml(-1) and clonidine 0.6 microg.ml(-1), delivered at a basal rate of 0.2 ml.kg(-1).h(-1) and a PCEA dose of 0.1 ml.kg(-1).h(-1)(max. 2 h(-1)). On the fourth postoperative day, PCEA was stopped and analgesia was continued with patient controlled analgesia (PCA) with morphine. RESULTS: During the PCEA regimen, the maximal scores of the revized facial scale were below 4 at rest with a very high satisfaction rate (>90%). Pain scores were higher during mobilization on the first postoperative day and when PCEA was switched to PCA. The overall incidence of adverse events was low and consisted primarily of technical problems and postoperative nausea and vomiting. Only two children experienced a complication requiring the discontinuation of the PCEA but there were no consequent adverse sequelae. CONCLUSIONS: The present study demonstrates that PCEA provides excellent pain relief following extensive spinal surgery and is associated with a low incidence of adverse events. The use of PCEA should be encouraged in children and adolescents following extensive spinal surgery.     

不含局麻药单用吗啡行术后硬膜外持续镇痛的可行性

吗啡配伍局麻药行术后硬膜外持续镇痛已广泛应用于临床,目前一般认为,配伍局麻药可以减少吗啡的用量,从而降低吗啡的不良反应（如呼吸抑制、恶心呕吐、皮肤瘙痒、尿潴留等）,3年来我们在术后硬膜外镇痛病人中,观察和探讨较低剂量的吗啡不含局麻醉药是否也可达到良好的镇痛效果,同时针对性地应用一些药物如恩丹西酮、苯海拉明、胃复安、地塞米松等,试图降低吗啡不良反应的发生率。     

Dexmedetomidine improves intraoperative conditions and quality of postoperative analgesia when added to epidural in elective cesarean section

IntroductionThis study was designed to evaluate the effect of adding dexmedetomidine to regular mixture of epidural drugs for pregnant women undergoing elective caesarian section with special emphasis on their sedative properties, ability to improve quality of intraoperative, postoperative analgesia and neonatal outcome.MethodsFifty women of ASA physical status I or II at term pregnancy were enrolled randomly to receive either plain bupivacaine plus fentanyl (BF group) or plain bupivacaine plus mixture of fentanyl and dexmedetomidine (DBF group). Incidence of hypotension, bradycardia, Apgar scores, intraoperative pain assessment, onset of postoperative pain, sedation scores and side effects were recorded.ResultsNo difference in the times taken for block to reach T4 sensory level, to reach the highest level of sensory block and interval between first neuraxial injection and onset of surgery between the groups. Onset of postoperative pain was significantly delayed in the DBF group (P = 0.001), the need for supplementary fentanyl was significantly less in DBF group (P = 0.03), and no significant difference was obtained between both groups regarding neonatal Apgar scores as well as the incidence of hypotension, bradycardia, nausea, vomiting and duration of motor blockade between the groups. DBF group had significantly less incidence of shivering (P = 0.03).ConclusionAdding dexmedetomidine to regular mixture of epidural anesthetics in women undergoing elective cesarean section improved intraoperative conditions and quality of postoperative analgesia without maternal or neonatal significant side effects.     

Randomized study of intravenous fluid preload before epidural analgesia during labour

We performed a randomized controlled trial of the effect ofintravenous fluid preload on maternal hypotension and fetalheart rate (FHR) changes in labour after the first epiduralinjection. Group 1 (49 women) received 1 litre of crystalloidpreload. Group 2 (46 women) received no preload. No statisticallysignificant difference was shown between the two groups foreither of the outcomes. Hypotension was found in three womenin group 1 and five in group 2 (P=0.4). Deterioration in FHRpattern was found in four women in group 1 and 11 in group 2(P=0.08). This study has not shown a significant increase inthe incidence of hypotension when intravenous preload is omittedbefore epidural analgesia using a low concentration of bupivacaineduring labour. Because of the clinical importance of the differencein the rate of FHR deterioration between the two groups, wecontinue to administer preload for high-risk cases. Br J Anaesth 2000; 85: 311–3 Footnotes ^* Correspondingauthor     

Effects of preemptive epidural analgesia on post-thoracotomy pain

OBJECTIVE: The purpose of this study was to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain and the incidence of chronic post-thoracotomy pain. METHOD: Meta-analysis of randomized controlled trials (RCTs). SEARCH STRATEGY: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were searched from 1966 to December 2004 for prospective RCTs published in all languages using the following MeSH terms: post-thoracotomy pain, epidural analgesia, chronic pain, and preemptive analgesia. SELECTION CRITERIA: All RCTs that compared thoracic epidural analgesia initiated before surgical incision (preemptive group) versus thoracic epidural analgesia initiated after completion of surgery (control group) in adult patients undergoing unilateral thoracotomy. MEASUREMENTS AND MAIN RESULTS: Three authors reviewed all citations and simultaneously extracted data on sample size, patient characteristics, surgical and analgesic interventions, methods of pain assessment, and pain scores at 24 hours, 48 hours, and 6 months postoperatively. Six studies were included with a total of 458 patients. Pooled analyses indicated that preemptive TEA was associated with a statistically significant reduction in the severity of acute pain on coughing at 24 and 48 hours (weighted mean difference -1.17 [95% confidence interval (CI) -1.50 to -0.83] and -1.08 [95% CI -1.17 to -0.99]), respectively. Acute pain was a good predictor of chronic pain. However, there was no statistically significant difference in the overall incidence of chronic pain at 6 months between the preemptive TEA group (39.6%) and the control group (48.6%). CONCLUSION: Preemptive TEA appeared to reduce the severity of acute pain but had no effect on the incidence of chronic pain.     

腰-硬联合阻滞腰麻后硬膜外镇痛时机对分娩镇痛的影响

目的观察腰-硬联合阻滞(CSEA)腰麻后硬膜外镇痛时机对分娩镇痛的影响。方法选择ASAⅠ或Ⅱ级,足月初产妇80例,于宫口开至2~3cm时实施CSEA镇痛。将入选产妇采用随机数字表法均分为E1组、E2组、E3组和E4组,分别于蛛网膜下腔给药后3、30、60和90min接受持续硬膜外给药。L3~4椎间隙行硬膜外穿刺,取25G腰麻穿刺针刺入蛛网膜下腔,见脑脊液后给予布比卡因2.5mg和芬太尼25μg,然后均采用PCEA模式。0.1%罗哌卡因与2μg/ml芬太尼混合液100ml加入电子镇痛泵,设置背景维持量为10ml/h,单次剂量为5ml,锁定时间15min。记录第一产程时间、第二产程时间、催产素使用率、分娩方式和不良反应发生情况,新生儿Apgar评分、脐动脉血气分析,以及产妇补救剂量和硬膜外用药总量。结果四组产妇产程、催产素使用率、分娩方式、新生儿Apgar评分、脐动脉血气分析差异均无统计学意义。E1、E2组需要PCA例数和次数明显少于、硬膜外罗哌卡因补救剂量明显低于E3、E4组(P<0.05)。结论蛛网膜下腔给药后30min以内开始硬膜外持续镇痛可以明显减少PCA次数和硬膜外罗哌卡因的补救剂量。     

Comparison of bupivacaine and fentanyl as an adjuvant of epidural morphine for postoperative analgesia

We conducted a retrospective study to determine whether bupivacaine or fentanyl is a better adjuvant to epidural morphine for postoperative analgesia using 108 patients. Following epidural lidocaine anesthesia with or without light general anesthesia for major gynecological surgeries, 59 patients received epidural morphine (EPM) 2 mg (group M), 21 patients received morphine 2 mg plus 0.25% plain bupivacaine 6–10 ml epidurally (group B), and 28 patients received morphine 2 mg plus fentanyl 100 μg epidurally (group F). The analgesic interval, defined as the duration from EPM injection to the first request of analgesics for incisional pain, was significantly longer in group F than in group M (29±11vs 19±17 h,P<0.05), but similar to group B (22±14 h). Group F patients required the least amount of analgesics for incisional pain of the three groups during the first 24 h postoperatively (P<0.01). The incidence of adverse effects was similar among all three groups. In conclusion, fentanyl appears to be a better adjuvant to epidural morphine than bupivacaine.     

Visceral pain during caesarean section under spinal and epidural anaesthesia with bupivacaine

In a randomized study, the incidence of visceral pain was evaluated in 46 patients undergoing elective caesarean section under spinal or epidural anaesthesia with 0.5% bupivacaine. If the patient experienced pain during the operation, a standard visual analogue scale ranging from 0 to 10 was used to assess the degree of pain. Visceral pain occurred in 12/23 patients in the spinal group and in 13/23 patients in the epidural group. In neither group was a correlation found between the cephalad level of analgesia or the intensity of cutaneous analgesia in the sacral region, and the presence of visceral pain.