Effect of postoperative epidural analgesia on surgical outcome

Pain relief allowing sufficient mobilization after major surgical procedures can only be achieved by continuous epidural analgesia with local anesthetics, which also reduces the stress response to surgery. However, the role of postoperative epidural analgesia on postoperative morbidity is controversial. We therefore update the effects of postoperative analgesia on surgical outcome. After major abdominal surgery, postoperative epidural analgesia with local anesthetics significantly reduces postoperative ileus and pulmonary complications while effects on cardiac morbidity are debatable. Continuous epidural analgesia significantly lowers the risk of thromboembolic complications after lower body procedures, while no effect is seen after major abdominal surgery. Unfortunately, many studies have inadequate study design, with use of lumbar epidural analgesia for abdominal procedures, or the epidural regimen does not contain a sufficient amount of local anesthetics. Future evaluation of the effects of epidural analgesia on postoperative outcome also requires integration of epidural analgesia within a multimodal rehabilitation programme.     

Patient-controlled epidural analgesia (PCEA) for postoperative pain control after lumbar spine surgery

Spine surgery remains one of the most common procedures for patients with a wide variety of spine disorders. Postoperative pain after major spine surgery is moderate to severe. We retrospectively reviewed 245 medical records of adult patients undergoing major spine surgery who received either patient-controlled epidural analgesia based on local anesthetics and opioids or patient-controlled intravenous analgesia as postoperative pain management. Several outcomes were analyzed including pain intensity, opioid consumption, time to endotracheal extubation, the incidence of deep venous thrombosis, and length of stay in the hospital. We found that the use of patient-controlled epidural analgesia provided better postoperative analgesia [median (quartiles) verbal analog scale score of 4 (3, 5) vs. 5 (3, 6)] and decreased the amount of opioid consumption postoperatively [median of 0 mg (0, 3) vs. 35 mg (0, 150)] compared with patient-controlled intravenous analgesia. Also, a substantially higher number of patients in the patient-controlled intravenous group required opioids as rescue analgesia. Incidences of deep venous thrombosis, operating room extubation, and length of stay in the hospital were not associated with the analgesic technique. The results of this study suggest that the use of neuroaxial analgesia for the management of postoperative pain associated with major spine surgery may have some beneficial properties over intravenous analgesia. The use of a reduced amount of opioids by patients with epidural analgesia may be relevant because of potential fewer side effects mainly in elderly patients. Several limitations related to the retrospective nature of the study are described. Prospective randomized-controlled trials are needed to understand and elucidate the optimum regimen of postoperative pain management after major spine surgery.     

Lower extremity blocks for analgesia

A large proportion of patients undergoing surgery do not receive adequate postoperative analgesia.[1] Postoperative pain is the leading cause of unplanned hospital admissions after ambulatory surgery and a major source of dissatisfaction with perioperative outcome. [2] The establishment of acute pain services in major institutions both in the United States and overseas has had a major effect on postoperative comfort and patient satisfaction. [3 and 4] Most acute pain services primarily use intravenous patient-controlled analgesia (PCA) or patient-controlled epidural infusion; however, advances in neuronal blockade offer an unprecedented range of effective and surgery site–specific analgesic options. Using long-acting local anesthetics, peripheral nerve blocks can be used to provide an excellent anesthesia and postoperative analgesia. Additionally, a catheter for continuous infusion of local anesthetics can be inserted perineurally to extend the analgesia beyond the duration of the single-shot blocks. This review will discuss the advantages and limitations of various nerve block techniques when used for postoperative pain management for several common surgical indications. Copyright 2002, Elsevier Science (USA). All rights reserved.     

Effects of continuous epidural infusion of local anesthetics on endocrine-metabolic responses to hysterectomy]

The plasma concentrations of glucose, insulin, epinephrine, norepinephrine and cortisol were measured in 18 women before, during and after abdominal hysterectomy. Nine patients received continuous epidural analgesia with intermittent injections of 10 ml of mepivacaine solution (intermittent group), and 9 others received epidural analgesia with continuous infusion of 10 ml.h-1 of 2% mepivacaine (continuous group). Plasma glucose and insulin concentrations remained unchanged during and after surgery in the two groups. Plasma epinephrine and norepinephrine concentrations increased after surgery, and cortisol concentration increased during and after surgery in the two groups. Plasma concentration of glucose during surgery was significantly lower in the continuous group than in the intermittent group. The methods of epidural administration of local anesthetics exert little influence on endocrine-metabolic responses to stress associated with lower abdominal surgery.     

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.     

Analgesia de parto no neuroeixo: uma revisão da literatura

The use of analgesia techniques for labor has become increasingly frequent, with neuraxial techniques being the most commonly used and most effective. Labor pain entails a number of physiological consequences that may be negative for the mother and fetus, and therefore must be treated. This literature review was performed through a search in the PubMed database, from July to November 2016, and included articles in English or Portuguese, published between 2011 and 2016 or anteriorly, if relevant to the topic. The techniques were divided into the following topics: induction (epidural, combined epidural‐spinal, continuous spinal, and epidural with dural puncture) and maintenance of analgesia (continuous epidural infusion, patient‐controlled epidural analgesia, and intermittent epidural bolus). Epidural analgesia does not alter the incidence of cesarean sections or fetal prognosis, and maternal request is a sufficient indication for its initiation. The combined technique has the advantage of a faster onset of analgesia; however, patients are subject to a higher incidence of pruritus resulting from the intrathecal administration of opioids. Patient‐controlled analgesia seems to be an excellent technique, reducing the consumption of local anesthetics, the number of anesthesiologist interventions, and increasing maternal satisfaction.     

Spinal mechanisms contribute to analgesia produced by epidural sufentanil combined with bupivacaine for postoperative analgesia

When used alone, lipid-soluble epidural opioids are thought to produce analgesia supraspinally via systemic absorption. However, spinal opioids and local anesthetics have been shown to act synergistically at the spinal level in animal studies. We, therefore, tested the hypothesis that sufentanil requirements will be less when given epidurally than IV in patients simultaneously given epidural bupivacaine after major abdominal surgery. Forty patients were anesthetized with isoflurane and epidural bupivacaine for major abdominal surgery. After surgery, each was given a continuous epidural infusion of bupivacaine at a rate of 5 mg/h and sufentanil patient-controlled analgesia (PCA). In a randomized, double-blinded fashion, the sufentanil was given either epidurally or IV. PCA settings were the same in each group. For 60 hrs after surgery, the following variables were measured: pain scores at rest, during mobilization, and during coughing; extension of sensory block; side effects; and sufentanil consumption. Pain scores, extension of sensory block, and the incidence of side effects did not differ between the two groups. Consumption of sufentanil in the epidural group was half that of the IV group (48 h after surgery: 107 +/- 57 microg versus 207 +/- 100 microg for the epidural and IV groups, respectively; P < 0.05). We conclude that spinal mechanisms contribute to the analgesia produced by epidural sufentanil in combination with a local anesthetic. IMPLICATIONS: When combined with epidural bupivacaine, the sufentanil requirement was 50% less when given epidurally than IV. Epidural sufentanil thus appears to have a spinal mechanism of action.     

Pre- and intraoperative epidural ropivacaine have no early preemptive analgesic effect in major gynecological tumour surgery

PURPOSE: Thoracic epidural analgesia (TEA) is an established technique for postoperative pain relief after major abdominal surgery. However it is still under discussion whether pre-incisional TEA can reduce postoperative pain perception or postoperative analgesic consumption. METHODS: The present prospective, randomized, double-blind study was performed to investigate the effects of intra- and postoperative TEA vs only postoperative TEA using ropivacaine 0.375% in 30 women scheduled for major abdominal tumour surgery. Prior to induction of general anesthesia patients received an epidural bolus of 10 mL saline in Group I (GI) and 10 mL ropivacaine 0.375% in Group II (GII) followed by an infusion of 6 mL x hr(-1) of the respective solution during surgery. Postoperatively all patients received an epidural infusion of 6 mL x hr(-1) ropivacaine 0.375% during 24 hr followed by patient controlled epidural analgesia for the next 72 hr. Operative data, dynamic pain scores, consumption of local anesthetics and standardized supplemental analgesics were analyzed. RESULTS: No difference was seen between groups with respect to the amount of required postoperative local anesthetics and supplemental analgesics, pain scores and side effects during the first 96 hr following surgery except a reduction of intraoperative sufentanil consumption (GI: 143.2 +/- 52.6 vs GII: 73.3 +/- 32.6 microg, P < 0.001). CONCLUSION: Intraoperative TEA with ropivacaine 0.375% did not significantly reduce the amount of analgesics required after major abdominal gynecological tumour surgery.     

Perioperative thoracic epidural analgesia in aortic surgery: role of levobupivacaine

AIM: Perioperative pain management in patients undergoing surgery is an essential target in order to improve intraoperative outcome and reduce postoperative complications occurrence. The combination of a local anesthetic with an opiate for epidural administration can ensure both analgesic effect (opiate) and neuroendocrine protection (local anesthetic). Levobupivacaine, S(-)-enantiomer form of bupivacaine, produces a sensitive-motor blockade similar to the racemate, with less cardiotoxicity; also ropivacaine is not cardiotoxic, but it has less anesthetic efficacy than levobupivacaine; both anesthetics could be administered through the epidural catheter in order to ensure adequate analgesia without any hemodynamic effects. Aim of our study was to evaluate a thoracic epidural analgesia for abdominal aortic surgery. METHODS: Through a randomized mono-blind study, involving 28 patients undergoing aortic surgery, we performed a clinical evaluation of 2 different perioperative thoracic epidural analgesic techniques; 2 different local anesthetics (levobupivacaine versus ropivacaine) in combination with the same opiate (fentanyl) were compared. RESULTS: The results obtained show that both techniques ensure an excellent perioperative analgesia without any cardiotoxicity, with only moderate adverse effects due to opiate; the absence of postoperative mortality (within 30 days from operation) and the modest perioperative morbidity underline the qualities of this analgesic technique. CONCLUSION: The combination of fentanyl with levobupivacaine or ropivacaine for use in thoracic epidural administration ensured both analgesic and neuroendocrine effect; significative differences between the 2 local anesthetics cannot be demonstrated, even if levobupivacaine, which presents a higher anesthetic efficacy, requires lower dosages.     

A review of intrathecal and epidural analgesia after spinal surgery in children

In view of the overall experience regarding regional anesthetic techniques to control postoperative pain in infants and children, it is feasible that a similar efficacy and safety profile can be obtained when using such techniques after major orthopedic procedures such as anterior or posterior spinal fusion. I reviewed previous reports regarding the use of neuraxial techniques to provide analgesia after spine surgery in the pediatric population. Variations in both the surgical procedure and the analgesic technique may make the comparison among studies somewhat impractical. Variations of the analgesic technique include 1). the dose of the medications used; 2). the route of delivery (intrathecal or epidural); 3). the mode of delivery (single dose, intermittent bolus dosing, and continuous infusion); 4). the number of epidural catheters used (one versus two); 5). the medications infused (opioids, local anesthetics, or both); 6). the opioid used (morphine, fentanyl, hydromorphone); and 7). the analgesic regimen of the control group (intermittent "as needed" morphine or patient-controlled analgesia). Although limited data are available to document the analgesic superiority of these techniques over parenteral opioids, clinical data offer evidence of other benefits, including decreased intraoperative blood loss and quicker return of gastrointestinal function.     

Reduction of pain inhibition on voluntary muscle activation by epidural analgesia

The influence of postoperative pain on muscle function, and the possible effect of local anesthetics on the normal muscle function are discussed. The integrated EMG (IEMG) during maximum voluntary contraction of the quadriceps muscle was registered in ten patients the day after undergoing reconstruction of the anterior cruciate ligament. Recordings were taken before, 5, 12, and 20 min to 25 min after epidural injection of 20 ml of 0.25% lidocaine with adrenaline (2.5 micrograms/ml). As pain gradually subsided, IEMG increased a mean of 2,728% 20 min to 25 min after injection (range 425% to 10,068%), compared to initial recordings before anesthesia. This indicates that pain relief plays a significant role in the ability to normally activate the quadriceps muscle after open knee surgery. Neither the Hoffman (H-)reflex, nor maximum voluntary isokinetic muscle torque was appreciably affected by epidural injection of dilute local anesthetics, as tested on two healthy volunteers. Infiltrations of local anesthetics into the distal part of the quadriceps muscle did not affect maximum voluntary isokinetic knee extension torque. From the experiments performed we conclude that it is possible to selectively block pain by injections of local anesthetics into the epidural space, without interfering with normal muscle function. It might thus be possible to prevent some of the postoperative muscle atrophy by using a continuous epidural analgesia for two to three days following surgery, and starting an early active physical therapy program.     

Effect of epidural analgesia on postoperative paralytic ileus in chronic schizophrenia

BACKGROUND AND OBJECTIVES: Postoperative paralytic ileus is frequently encountered in chronic schizophrenic patients who undergo abdominal surgery. We investigated whether epidural analgesia with local anesthetics minimizes postoperative ileus in schizophrenic patients who are treated long term with antipsychotic drugs. METHODS: We measured the VAS pain after surgery and the time that elapsed before the first passage of flatus and/or feces after the end of surgery in schizophrenic patients provided analgesia with systemic buprenorphine (group A) and schizophrenic patients receiving epidural analgesia with local anesthetics (group B). RESULTS: The frequency of patients who did not pass flatus and/or feces for more than 120 hours postoperatively was significantly higher in group A. Postoperative pain scores of group A at 8 and 24 hours after the end of anesthesia were 36.0 +/- 12.8 and 31.7 +/- 10.7 (0 to 100 mm scale), which were significantly higher than 25.4 +/- 13.2 and 20.5 +/- 9.4 scores in group B. CONCLUSIONS: Epidural analgesia with local anesthetics in chronic schizophrenic patients undergoing abdominal surgery minimizes postoperative ileus compared to patients receiving systemic buprenorphine.     

Use of peridural catheters in the treatment of postoperative pain after spinal instrumentated fusion--an experience report

AIM: In a prospective randomized clinical study we investigated in a group of 20 patients after spinal instrumentation surgery the analgesic efficacy and the safety of epidural analgesia. Intraoperatively an epidural catheter was placed by the orthopedic surgeons for postoperative pain control. METHOD: For epidural catheter analgesia a mixture of the local anesthetic ropivacaine and the opioid sufentanil was used with an initial bolus, followed by a continuous infusion and the possibility of patient-controlled bolus administration (PCEA). Pain-scores (VAS) were measured pre- and postoperatively at rest, and during active mobilization maneuvers like turning around in bed and standing. The neurological status, side effects, and complications were evaluated. RESULTS: Mean pain-scores (VAS) were 3.8 pre-operatively at rest, after initiation of epidural analgesia 0.3 at rest, 1.6 at turning around in bed and 0.8 at standing (6.8 pre-operatively). Transient sensible or motoric deficits, due to the local anesthetics' effect, occurred in 8 respectively in 3 of the patients. Drug-induced typical side-effects were pruritus, nausea and emesis. No cardiopulmonary complications happened. CONCLUSION: The epidural lumbal analgesia is an effective and safe method to control postoperative pain after spinal instrumentation surgery. Precondition is the knowledge about the safe and standardized technique of intraoperative catheter placement by the orthopedic surgeon, the choice of the appropriate analgesic drugs and a good cooperation between the departments of anesthesiology and orthopedic surgery and nursing staff.     

Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery

BACKGROUND: Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. METHODS: Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. RESULTS: Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. CONCLUSION: After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.     

Insertion of an epidural catheter from the surgical wound for postoperative analgesia--a case report

A 62-year-old male was scheduled for discectomy for lumbar disc herniation. He had bronchial asthma, and his asthma was induced by nonsteroidal anti-inflammatory drugs. We decided to use continuous epidural block for postoperative analgesia. However, he was frightened of insertion of an epidural catheter. Therefore, we planned to insert the epidural catheter before the end of surgery under general anesthesia. It was easily placed at L 5-S 1 interspace using a Tuohy needle from the surgical wound, and the contrast medium 5 ml was injected through the epidural catheter to confirm the placement. After the surgery, continuous epidural block with local anesthetics was used for two days. He did not complain of severe pain postoperatively.     

Combined general and epidural anesthesia for abdominal aortic aneurysm surgery

Management of the patient with an abdominal aortic aneurysm (AAA) is based on the size of the aneurysm and the presence of a coexisting medical disease. Anesthesia for AAA repair requires an understanding of the major physiological changes occurring during aortic cross-clamping and unclamping so that fluid and vasodilator/vasopressor requirements can be anticipated, especially with supraceliac clamping. The goals are to provide hemodynamic stability and to preserve end-organ function-notably cardiac, renal, and spinal cord function. A combination of general and thoracic epidural anesthesia is commonly used for AAA surgery. The advantages of intraoperative use of epidural local anesthetics are (1) a reduced need for intraoperative inhalational and intravenous (opioid) anesthetics, which allows for early extubation of the trachea; (2) reduced requirements for vasodilating agents before and during cross-clamping of the aorta; and (3) excellent postoperative analgesia, which allows for earlier recovery of pulmonary and gastrointestinal functions. Disadvantages include the close attention to intravascular volume status that is necessary during unclamping of the aorta. Although much literature has been published suggesting benefits of thoracic epidural anesthesia and analgesia on the cardiac, respiratory, and immune systems as well as on the surgical stress response, most currently published studies lack the power to provide definitive answers to the question, “Does intraoperative use of epidural local anesthetics improve outcome?” Copyright © 2000 by W.B. Saunders Company     

Patient-controlled thoracic epidural infusion with ropivacaine 0.375% provides comparable pain relief as bupivacaine 0.125% plus sufentanil after major abdominal gynecologic tumor surgery

BACKGROUND AND OBJECTIVES: We tested the hypothesis that an opioid-free local anesthetic alone is able to provide comparable analgesia to the opioid supplemented epidural application of local anesthetics using thoracic epidural catheters after major abdominal surgery. METHODS: In a prospective, randomized, and double-blind study, we have compared the analgesic efficacy and side effects of ropivacaine 0.375% (group R) versus bupivacaine 0.125% in combination with sufentanil 0.5 microg/mL(-1) (group B/S) via a thoracic epidural catheter for a duration of 96 hours after major abdominal surgery in 30 gynecologic tumor patients. Piritramide was given for breakthrough pain. Assessments were performed every 12 hours after start of the epidural infusion using continuous (first 24 hours) and patient-controlled epidural analgesia (PCEA) (24 to 96 hours). RESULTS: No differences were seen in demographic and perioperative data. Dynamic pain scores (visual analog scale [VAS] values) were comparable between groups during mobilization (group R v group B/S: 24 hours: 40 +/- 30 v 36 +/- 14, P =.9; 48 hours: 46 +/- 33 v 42 +/- 25, P =.93; 72 hours: 42 +/- 24 v 48 +/- 26, P =.78; 96 hours: 42 +/- 25 v 29 +/- 28, P =.49) and on coughing during the whole study period. Hemodynamics, intensity of motor block (Bromage scale), and side effects like nausea, vomiting, pruritus, and bladder disfunction also did not differ between groups. CONCLUSION: The present study shows that thoracic epidural infusion of ropivacaine 0.375% provides comparable pain relief and incidence of side effects after major abdominal gynecologic surgery as bupivacaine 0.125% in combination with 0.5 microg/mL(-1) sufentanil and may therefore represent an alternative in epidural pain management.     

Advances in neuraxial blocks for labor analgesia: new techniques, new systems

Neuraxial block for labor analgesia is widely accepted and highly effective. Much progress has been achieved in terms of providing safer and more efficacious analgesia. Emphasis has been placed on maternal autonomy and individualization of therapy. The introduction of the combined spinal-epidural technique in the labor ward has afforded excellent rapid onset analgesia and minimal impediment to maternal mobility. Newer enantiopure amide local anesthetics, like ropivacaine and levobupivacaine, have also been introduced to enhance the safety of epidural analgesia with respect to cardiotoxicity. The introduction of the computer-assisted approach to provide a more interactive background infusion could potentially refine the delivery of patient-controlled epidural analgesia. The enhanced effectiveness of synchronized basal automated boluses has also been exploited for patient-controlled epidural analgesic systems. The quest to provide seamless analgesia that empowers the laboring parturient in a cost effective way continues to be a developing area of research.     

A review of clinical evidence supporting techniques to prevent chronic postoperative pain syndromes

OBJECTIVE: To conduct a systematic review to evaluate the level of evidence for using acute postoperative pain management techniques with a view to pre-empting the later development of chronic pain syndromes. MATERIAL AND METHODS: Systematic review of the literature on the treatment of acute postoperative pain and its usefulness in preventing postoperative chronic pain syndromes. RESULTS: Fifteen studies focusing on 3 conditions were examined: chronic postmastectomy pain syndrome, chronic postthoracotomy pain syndrome, and chronic phantom limb pain. Four clinical trials provided no clear evidence of benefit from preoperative injections of local anesthetic in decreasing the incidence of chronic postmastectomy pain. Continuous thoracic epidural analgesia started before surgery has been shown to have a clearly beneficial effect in preventing chronic pain 3, 6, and 12 months after thoracotomy. Chronic phantom limb pain syndromes have not been found to be prevented by the use of continuous epidural analgesia started before or after surgery in comparison with the injection of local anesthetics through a perineural catheter or the oral or intramuscular administration of morphine-like drugs. CONCLUSIONS: Only chronic pain following thoracotomy has been found to be preempted by acute pain management and only by continuous thoracic epidural analgesia started before surgery. There is no solid evidence demonstrating that other techniques used to relieve acute postoperative pain have a beneficial effect in preempting chronic postoperative pain syndromes.     

Peridural anesthesia and narcosis with propofol in thoracic surgery

Twelve patients undergoing elective thoracic surgery because of lung cancer, have been studied. The anesthetic management included: continuous epidural anesthesia with bupivacaine (T6-T7), continuous infusion of propofol and vecuronium, mechanical ventilation with an oxygen/air mixture. We evaluated the perioperative analgesia and the cardiovascular side effects of two groups of patients differing for the position (supine or lateral) selected to administer the local anesthetic. We also analysed the most important characteristics of the recovery from anesthesia (degree of analgesia and consciousness, respiratory function and cooperation with physiotherapeutic manoeuvres). The authors conclude that, although the number of patients studied is limited, there are no significant differences between the two groups for intraoperative analgesia and hemodynamic imbalance; the anesthetic technique employed is a reliable alternative to classic balanced anesthesia, because seems to reply very well to the mayor purposes of thoracic surgery. Moreover it makes the operative room free from pollution caused by volatile anesthetics.