Preemptive analgesia with bupivacaine for segmental mastectomy

BACKGROUND AND OBJECTIVES: Preemptive analgesia is the concept of providing analgesia before surgical incision, resulting in less postoperative pain. The purpose of this study is to determine if preemptive and/or postoperative local anesthetic infiltration of bupivacaine in patients undergoing segmental mastectomy results in less postoperative pain compared with patients receiving placebo. METHODS: In this prospective, double-blinded study, 120 patients were randomized into 4 groups: group 1, preincisional (10 mL) and postoperative (10 mL) wound infiltration of 0.5% bupivicaine, (+Pre+Post); group 2, preincisional bupivacaine (10 mL) and postoperative infiltration (10 mL) of placebo (normal saline solution), (+Pre-Post); group 3, preincisional placebo (10 mL) and postoperative bupivacaine (10 mL), (-Pre+Post); or group 4, preincisional (10 mL) and postoperative infiltration of placebo (10 mL), (-Pre-Post). All patients received a standardized laryngeal mask general anesthetic. Data were recorded at the following time intervals: preoperative admission, postanesthesia care unit (PACU) admission, PACU stay, stepdown-unit admission, stepdown-unit stay, hospital discharge, and 24 hours post operation. RESULTS: No difference was noted with respect to preoperative pain visual analog scale (VAS, 0-100 mm), surgical duration, PACU stay time, stepdown-unit stay time, incidence of postoperative nausea, or treatment for nausea in all measured time periods. The placebo group (group 4) had significantly higher mean pain VAS scores during the early postoperative period (PACU admission and PACU stay) compared to the other groups (PACU admission: group 1 = 2 +/- 8, group 2 = 4 +/- 11, group 3 = 3 +/- 15, group 4 = 17 +/- 21, P < .01; PACU stay: group 1 = 6 +/- 13, group 2 = 6 +/- 10, group 3 = 10 +/- 21, group 4 = 20 +/- 18, P < .01). Likewise, the number of patients who reported pain (pain frequency) was significantly higher in group 4 (placebo) compared with all other groups at PACU admission, PACU stay, stepdown-unit admission, and stepdown-unit stay (P < or = .01). CONCLUSION: Preincisional and/or postoperative wound bupivacaine infiltration lacks preemptive analgesic effects for segmental mastectomy.     

Femoral nerve block with bupivacaine 0.25 per cent for postoperative analgesia after open knee surgery

An assessment was made, in a randomised double-blind fashion, of the pain relief afforded by femoral nerve block (FNB) performed at the end of ligament reconstruction of the knee, using 0.25 per cent bupivacaine in ten patients, and normal saline in ten patients. All patients commenced "continuous passive motion" (CPM) of the operated knee after arrival in the Recovery Room. The postoperative analgesic requirement, both for intravenous fentanyl in the Recovery Room, and intramuscular and oral analgesia on the ward, was then studied. The time interval between FNB and first dose of analgesia was significantly longer in the bupivacaine group than in the control group. The bupivacaine group also required significantly less intravenous fentanyl in the Recovery Room. On the ward, there was no difference between the two groups in the total dose of intramuscular meperidine given in the first 12 hours postoperatively. We conclude that femoral nerve block is a useful adjunct in pain management after ligament reconstruction of the knee, especially in the early postoperative period, but does not decrease the total intramuscular dose of analgesia in the first 12 postoperative hours.     

Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy

OBJECTIVE: To assess the effectiveness of analgesia by cranial nerve block with bupivacaine in the first 24 hours following elective supratentorial craniotomy. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed in 30 patients who underwent craniotomy for excision of a tumor. The cranial nerve block was performed using saline (control group, n=15) or 0.25% bupivacaine with epinephrine at 1:200 000 (bupivacaine group, n=15). Morphine (2 mg, intravenous bolus) was used for rescue analgesia. Pain was assessed on a visual analog scale (VAS) at 2, 4, 8, 12, 16, and 24 hours following the cranial nerve block. The following data were recorded: time elapsed until appearance of pain, use of rescue analgesia, and incidence of adverse effects. RESULTS: The use of morphine was significantly lower in the group of patients who received a cranial nerve block with bupivacaine than in the control group (mean [SD], 3.7 [1.6] mg vs 172 [2.5] mg). The mean time to the first requirement for rescue analgesia was longer in the bupivacaine group than in the control group (731 [247] minutes vs 80 [71] minutes). The VAS score during the first 16 hours was significantly lower in the bupivacaine group than in the control group. The incidence of nausea and vomiting was significantly higher in the control group (67% vs 13%). CONCLUSIONS: Cranial nerve block with 0.25% bupivacaine following supratentorial craniotomy improves postoperative analgesia, reduces the requirement for morphine, and contributes to reducing nausea and vomiting.     

Effect of pre-incision skin infiltration on post-hysterectomy pain--a double-blind randomized controlled trial

In this double-blind placebo-controlled randomized trial, we compared the analgesic effect of preoperative 0.25% bupivacaine (n = 21) skin infiltration with normal saline (n = 19) in patients undergoing abdominal hysterectomy through a lower midline incision. All patients received postoperative patient-controlled analgesia with morphine and were followed for 72 hours. The main outcome measures were morphine consumption and pain score at rest, and the contribution of different components of pain was also assessed prospectively. No statistically significant differences were found. All except one patient (n = 39) could distinguish the different characteristics of somatic and visceral pain. Visceral pain predominated in the first 48 hours. We concluded that local anaesthetic infiltration is not effective in reducing pain after abdominal hysterectomy. Effective postoperative analgesia should aim to eliminate the visceral pain component.     

Preincisional treatment to prevent pain after ambulatory hernia surgery

We designed this study as a randomized comparison of postoperative pain after inguinal hernia repair in patients treated with triple preincisional analgesic therapy versus standard care. Triple therapy consisted of a nonsteroidal antiinflammatory, a local anesthetic field block, and an N-methyl-D-aspartate inhibitor before incision. The treatment group (n = 17) received rofecoxib, 50 mg PO, a field block with 0.25% bupivacaine/0.5% lidocaine, and ketamine 0.2 mg/kg IV before incision; controls (n = 17) received a placebo PO before surgery. The anesthetic protocol was standardized. Postoperative pain was treated by fentanyl IV and oxycodone 5 mg/acetaminophen 325 mg PO as required for pain. Pain scores (0-10) and analgesic were recorded for the first 7 days after surgery. Pain scores were 47% lower in the treatment group before discharge (3.1 +/- 0.6 versus 5.9 +/- 0.6, P = 0.0026) (mean +/- SE) and 18% less in the first 24 h after discharge (5.6 +/- 0.4 versus 6.8 +/- 0.5, P = 0.05); oral analgesic use was 34% less in the treatment group (4.6 +/- 0.8 doses versus 7.1 +/- 0.7 doses, P = 0.02) in the first 24 h after surgery. We conclude that triple preincisional therapy diminishes pain and analgesic use after outpatient hernia repair, and encourage further evaluation of this technique. IMPLICATIONS: Outpatients undergoing inguinal hernia repair under general anesthesia report moderate-to-severe pain after surgery. Triple preincisional therapy that included rofecoxib, 50 mg PO, ketamine, 0.2 mg/kg IV, and local anesthetic field block reduced pain scores and analgesic use in the first 24 h after discharge.     

Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axillary brachial plexus block

BACKGROUND AND OBJECTIVES: To evaluate the analgesic and anesthetic effects of 40 mL bupivacaine 0.25%, 40 mL bupivacaine 0.25% plus fentanyl 2.5 microg/mL, and 40 mL bupivacaine 0.125% plus fentanyl 2.5 microg/mL for axillary brachial plexus block. METHODS: Sixty patients were randomly allocated to 3 groups and received axillary brachial plexus block with 40 mL bupivacaine 0.25% (group B), 40 mL bupivacaine 0.25% with fentanyl 2.5 microg/mL (group BF), or 40 mL bupivacaine 0.125% with fentanyl 2.5 microg/mL (group DBF). The onset times and the duration of sensory and motor blocks, duration of analgesia, hemodynamic parameters, and adverse events were noted. RESULTS: The mean duration of sensory block and analgesia were longer in group BF (10.1 hours and 20.9 hours) than group B (6.9 hours and 11.6 hours) and DBF (5.9 hours and 12.0 hours) (P < .01, P < .001, respectively). The mean duration of motor block was also longer in group BF (10.7 hours) than group B (4.9 hours) (P < .01). Only 2 patients experienced motor block in group DBF. The frequency of successful block was 35% in group DBF (P < .01). Hemodynamic parameters were similar in all groups. In group B, only 1 patient experienced dizziness. Nausea was observed in 1 patient in each fentanyl group. CONCLUSION: The addition of 100 microg/mL fentanyl to 0.25% bupivacaine almost doubles the duration of analgesia following axillary brachial plexus block when compared with 0.25% bupivacaine alone.     

Levobupivacaine versus racemic bupivacaine for thoracic and upper lumbar epidural anesthesia-analgesia in children

OBJECTIVES: We compared levobupivacaine to bupivacaine for epidural analgesia for thoracic or upper abdominal surgery in children. Our working hypothesis was that at equivalent doses levobupivacaine and bupivacaine behave in the same way. MATERIAL AND METHODS: ASA 1-4 patients between the ages of 5 and 16 years were randomized to a levobupivacaine or a bupivacaine group. After general anesthesia was induced, we inserted a thoracic or upper lumbar epidural catheter and administered a dose of 0.25% bupivacaine or levobupivacaine (1 mgxkg(-1)) while maintaining general anesthesia. Analgesia was provided with an epidural infusion of 0.125% bupivacaine or levobupivacaine with fentanyl. Fentanyl was used as a perioperative rescue analgesic and metamizole magnesium as a postoperative rescue analgesic. The epidural infusion was reduced by 25% each day beginning on the second day. We analyzed hemodynamic and respiratory variables, rescue analgesia, time until extubation and discharge from the recovery unit, complications associated with the technique, adverse effects, and degree of comfort achieved. RESULTS: We studied 64 patients; 33 received levobupivacaine and 31 bupivacaine. Mean (SD) duration of recovery unit stay was significantly longer in the bupivacaine group (4.2 [0.99] days) than in the levobupivacaine group (35 [0.6] days; P<.05). Significantly more patients needed perioperative rescue analgesia in the levobupivacaine group (n=6 [18.18%]) than in the bupivacaine group (n=3 [9.67%]; P<.01). After 48 hours, the need for postoperative rescue analgesia was significantly lower with levobupivacaine (P<.01). Motor block was significantly greater with bupivacaine (P<05). Adverse effects and complications included 2 cases of persistent bradycardia and 1 case of dural puncture with no subsequent clinical manifestations. CONCLUSIONS: This experience with epidural anesthesia for thoracic and upper abdominal surgery showed levobupivacaine and racemic bupivacaine to have similar profiles. Levobupivacaine, which is less toxic, could be used to replace bupivacaine in children.     

Comparison of intraarticular bupivacaine with the addition of morphine or fentanyl for analgesia after arthroscopic surgery

A randomized study on 30 patients undergoing knee arthroscopy was performed. Group I (n = 15) received 50 mg of 0.25% bupivacaine and 1 mg of morphine, and group II (n = 15) received 50 mg of 0.25% bupivacaine and 100 μg of fentanyl. The visual analogue scale was recorded at intervals of 1, 2, 3, 4, 6, 12, 24, and 48 hours after the operation. Supplementary analgesia requirements were also recorded. In group I, pain scores were lower than group II (P < .05) during the 1st, 2nd, 3rd, 12th, 24th, and 48th hours. The duration of analgesia on group I was significantly longer than group II. The combination of intraarticular morphine and bupivacaine has a longer analgesic duration and effect than a combination of fentanyl and bupivacaine.     

Analgesic effects of interpleural bupivacaine with fentanyl for post-thoracotomy pain

OBJECTIVE: The analgesic effect of bupivacaine/fentanyl with epinephrine given interpleurally after thoracotomy was investigated in a randomized placebo and intravenous controlled study. DESIGN: Prospective clinical study. SETTING: University teaching hospital. PARTICIPANTS: Sixty American Society of Anesthesiologists physical status II and III patients scheduled for posterolateral thoracotomy with general anesthesia. INTERVENTIONS: Patients were randomly divided into 4 groups to receive either 0.5% bupivacaine/1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine (n = 15, group IPBF), 0.5 % bupivacaine with 5 microg/mL of epinephrine (n = 15, group IPB), or saline (n = 15, group IPS) in a total volume of 15 to 20 mL in 60 seconds by an interpleural catheter placed at the end of surgery by direct vision. The same volume of bupivacaine 0.25% and 1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine to group IPBF, bupivacaine 0.25% with 5 microg/mL of epinephrine to group IPB or saline to group IPS was injected through the interpleural catheter every 6 hours for 48 hours postoperatively. Intravenous fentanyl (n = 15, group IVF) and interpleural saline groups received 1.5 microg/kg of fentanyl intravenously at the first complaint of pain. All patients also received patient-controlled analgesia (PCA) with fentanyl for 48 hours postoperatively. Metamizol sodium was used as a rescue analgesic. MEASUREMENTS and MAIN RESULTS: Adequacy of pain relief was evaluated with the "Prince Henry Pain Scale" and visual analog pain scale. Fentanyl consumption via PCA and complications were evaluated for 48 hours. Visual analog scale scores were significantly higher in the interpleural saline group at 4 and 12 hours (6.6 +/- 1.2 and 5.0 +/- 2.1, respectively) postoperatively. Significantly more patients in the IPBF group had lower pain scores during coughing and deep breathing. Fentanyl consumption via PCA device was significantly higher in the intravenous fentanyl group (1,069 +/- 96.9 microg) than the interpleural groups (577.3 +/- 72.2 microg, 651.1 +/- 61.9 microg, and 601.0 +/- 22.6 microg in IPBF, IPB, and IPS groups, respectively). CONCLUSION: It is concluded that total fentanyl consumption via PCA decreased in all interpleural groups, but pain during coughing and deep breathing was significantly reduced in only the interpleural bupivacaine/fentanyl with epinephrine group.     

Postcesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac

STUDY OBJECTIVE: To assess the analgesic efficacy of diclofenac when administered as an adjuvant to bupivacaine wound instillation. DESIGN: Prospective, randomized, double blind, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: 90 women recovering from cesarean delivery performed via a Pfannenstiel incision. INTERVENTIONS: A standard intrathecal anesthetic was administered. On completion of surgery, a multiorifice 20-gauge epidural catheter was placed within the surgical wound. Postoperatively, the catheter was attached to a patient-controlled analgesia (PCA) device programmed to deliver 9 mL with a 60-minute lockout time and no basal infusion. In group bupivacaine-diclofenac, the PCA device delivered 0.25% bupivacaine, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline). Thereafter, oral diclofenac (50 mg) was administered every 8 hours. In group bupivacaine-placebo, 0.25% bupivacaine and an equal volume of intravenous saline or oral placebo were administered 20 minutes before the end of surgery and every 8 hours thereafter. In group placebo-diclofenac, wound instillation was with sterile water, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline) and thereafter oral diclofenac (50 mg) at 8-hour intervals. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, intravenously). Thereafter, subcutaneous morphine (0.05 mg/kg) was administered on patient request for additional analgesia. MEASUREMENTS AND MAIN RESULTS: The number of attempts to activate the PCA device was significantly higher in group bupivacaine-placebo (39 +/- 32) when compared with group bupivacaine-diclofenac (24 +/- 28). During the first 6 postoperative hours, the number of patients requiring rescue morphine and the total rescue morphine administered were significantly different between the groups. During the subsequent 18 hours, subcutaneous morphine administration was significantly higher in group bupivacaine-placebo. Postoperative pain scores were significantly higher in group bupivacaine-placebo when compared with those recorded in groups placebo-diclofenac and bupivacaine-diclofenac. Finally, patient satisfaction was significantly lower in group bupivacaine-placebo. CONCLUSION: In the context of this study, the bupivacaine wound instillation with adjuvant diclofenac administration is associated with similar postoperative analgesia to that induced by diclofenac alone.     

Does tramadol wound infiltration offer an advantage over bupivacaine for postoperative analgesia in children following herniotomy?

BACKGROUND: It has been demonstrated that tramadol is an effective analgesic. We aimed to compare postoperative analgesic effects of wound infiltration with tramadol (T) or bupivacaine (B) and intramuscular tramadol (I) after herniotomy in children. METHODS: In this study, 75 children were randomly assigned to group T, group B and group I. Wound infiltration was performed to the patients in group T (2 mg.kg-1 tramadol in 0.2 ml.kg-1 saline) and group B (0.2 ml.kg-1 0.25% bupivacaine) into the surgical incision. Twenty minutes before the end of the surgery 2 mg.kg-1 tramadol was injected i.m. in group I. Faces pain scale was used for assessing pain severity. Patients with pain score>2 were treated with paracetamol. The frequency of side effects and analgesic use were recorded. Patients were discharged on the next day. RESULTS: No side effects were recorded in any group. The pain scores of the patients at the first, fourth and eighth hours were significantly higher in group B and group I than group T (P<0.05). The pain scores of the patients at the first hour were significantly higher in group I compared with group B (P<0.05). Average time to first analgesic requirement was significantly longer in group T (6.72+/-4.09 h after herniotomy than both group I (4.49+/-3.9 h) and group B (6.04+/-3.7 h) (P<0.05). CONCLUSIONS: Wound infiltration with tramadol may be a good choice for postoperative analgesia in children having inguinal herniotomy.     

Ropivacaine 0.25% is as effective as bupivacaine 0.25% in providing surgical anaesthesia for lumbar plexus and sciatic nerve block in high-risk patients: preliminary report

Ropivacaine is potentially less cardiotoxic and neurotoxic than bupivacaine. The aim of this study was to compare the effectiveness of ropivacaine 0.25% and bupivacaine 0.25% for surgical anaesthesia and postoperative analgesia during lumbar plexus and sciatic nerve block in high-risk patients. We performed combined lumbar plexus and sciatic nerve blockade on 62 consecutive ASA III or IV patients undergoing unilateral hip or femur surgery. The first 30 patients received bupivacaine (Group 1) and the remaining 32 patients received ropivacaine (Group 2). Perioperative management was otherwise similar The groups were compared for the time of onset of the block, additional analgesics and sedatives required, time from end of surgery to the first analgesic requirement and the need for rescue analgesia. Ninety percent (29/32) of the patients in the ropivacaine group and 86% (26/30) of the patients in the bupivacaine group reached surgical anaesthesia. The time from the end of the surgery to the first analgesic requirement was similar between the two groups (10.3 +/- 5.2 hours for ropivacaine, 11.2 +/- 4.6 hours for bupivacaine). There was no statistically significant difference between the two groups in any of the measured variables (P > 0.05). The results of this preliminary study suggest that ropivacaine 0.25% is as effective as bupivacaine 0.25% when used for blocking lumbar plexus and sciatic nerve in high-risk patients undergoing hip or femur surgery.     

The efficacy and safety of continuous epidural analgesia versus intradural-epidural analgesia during labor]

OBJECTIVE: To determine the efficacy and safety of intradural-epidural analgesia in comparison with continuous epidural analgesia during labor and childbirth. PATIENTS AND METHOD: Forty-two women whose labor began spontaneously were enrolled and distributed randomly in two groups. The intradural-epidural analgesia group (IEA, n = 21) received 25 microgram of intradural fentanyl with 2.5 mg of isobaric bupivacaine with adrenalin, after which analgesia was maintained with epidural administration of one 8 mL bolus of 0.125% bupivacaine, followed by perfusion of a balanced concentration at a rate of 8 ml/h. Patients in the continuous epidural analgesia group (CEA, n = 21) were given 8 ml of 0.25% bupivacaine with adrenalin; the epidural perfusion of 0.125% bupivacaine and 1 microgram/ml of fentanyl was started at the same rate as in the IEA group. We recorded pain as assessed on a visual analog scale, extension of sensory and motor block, maternal hemodynamic constants, number of boluses of bupivacaine used, total doses of bupivacaine and oxytocin, instruments needed for childbirth, and side effects (pruritus, nausea and vomiting). RESULTS: Analgesic efficacy during the first 30 minutes was greater in the IEA group. The total dose of bupivacaine, required top-up boluses, and the extension of sensory block at 30 minutes, one hour and two hours were also significantly less in the IEA group. The incidence of pruritus was higher in the IEA group. No significant differences were observed for other variables. CONCLUSIONS: Intradural-epidural analgesia provides effective analgesia for labor, with rapid onset, reduced extension of sensory block, lower total doses of local anesthetics and few side effects.     

Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief

BACKGROUND: The present study was designed to evaluate the effectiveness of intrapleural 0.25% bupivacaine delivered by intermittent infusions for post-thoracotomy pain relief. METHODS: Forty patients undergoing elective lobectomy were randomly, but equally, placed into two groups. An intrapleural catheter was inserted under direct vision during surgery. Group I received intrapleural 40 mL of 0.25% bupivacaine, group II was administered 40 mL of saline solution as a control group. Diclofenac sodium was administered as an additional analgesic, if required. Postoperative pain was evaluated using a visual analog scale (VAS), and Prince Henry pain scale. Arterial oxygen saturation, heart rate, and systemic arterial pressures were monitored. All observations were recorded 5, 10, 15, 20, 25, and 30 minutes after the injection, and thereafter at hourly intervals through the postoperative 24 hours. RESULTS: The mean analgesia times were 5 hours and 2 hours in group I and group II, respectively. Therefore, bupivacaine administrations were repeated every 6 hours in group I, and saline with additional analgesic were administered every 4 hours in group II. The heart rate and arterial pressures did not show a significant difference. While the additional analgesic requirement was 180 +/- 10 mg/d in group II, there was no need for additional analgesic administration in the group I patients. Arterial oxygen was significantly higher in group I than in group II. Arterial carbon dioxide tension of group II was significantly higher than that of group I. While the postoperative atelectasis and pneumonia developed in four patients and one, respectively, in group II, no such complication was observed in group I. CONCLUSIONS: The easy placement of an intrapleural catheter and better pain relief observed in the present study suggest that intermittent pleural infusion of 0.25% bupivacaine has proven to be a safe and effective method for relief of post-thoracotomy pain.     

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.     

Postoperative analgesia and intraoperative inhalational anesthetic requirements during umbilical herniorrhaphy in children: Postincisional local infiltration versus preincisional caudal epidural block

Study Objective: To determine the postoperative analgesic efficacy of, and the effects on, intraoperative inhalational anesthetic requirements of preincisional caudal epidural block versus postincisional infiltration of local anesthetic following umbilical herniorrhaphy in children.Design: Randomized, double-blind, prospective study.Setting: University medical center.Patients: 16 ASA status I and II patients (11 males, 5 females), ages 11 to 20 months, weighing up to 17 kg.Interventions: During standard anesthetic care, 16 children were randomized to receive either caudal block with 1.5 ml/kg of 0.2% bupivacaine (group 1) or local infiltration of the surgical site with up to 1.2 ml/kg of 0.25% bupivacaine (Group 2).Measurements and Main Results: Patients in Group 1 had significantly decreased pain scores and requirements for supplemental postoperative intravenous (IV) fentanyl. Five of eight patients in Group 1 did not require supplemental IV fentanyl during their in-hospital postoperative course, while all eight patients in Group 2 required supplemental IV fentanyl. The patients who received caudal epidural block also had decreased intraoperative requirements for isoflurane, shorter time to extubation (4.1 ± 0.8 min vs. 8.4 ± 1.5 min), and quicker discharge home (129 ± 13 min vs. 163 ± 22 min). Five of eight patients in Group 1 were ready for discharge at our usual time of 120 minutes, as opposed to one of eight patients in Group 2.Conclusion: Preincisional caudal epidural block is more effective in controlling pain following umbilical herniorrhaphy than is postincisional local infiltration.     

布比卡因阻滞对腹腔镜胆囊切除术后超前镇痛的比较研究

目的探讨躯体-内脏神经阻滞对腹腔镜胆囊切除术后超前镇痛效果. 方法病人随机分为4组,每组25例,A组(躯体阻滞组)在切皮前以0.25%布比卡因25 ml(含1∶200 000肾上腺素)进行切口周围浸润;B组(内脏阻滞组)在气腹后立即以0.25%布比卡因35 ml腹腔内喷洒;C组(躯体-内脏联合阻滞组)进行A组和B组综合处理;D组(对照组)不予处理.在术后1、2、3、6、12、24、48 h分别评估疼痛强度、部位和恶心情况. 结果术后12 h内,D组切口痛明显强于其它部位疼痛(P<0.05).A、C组在术后6 h内疼痛强度和镇痛药物需求量比B、D组明显减少(P<0.05). 结论腹腔镜胆囊切除术后疼痛以切口痛为主,术前躯体-内脏神经阻滞处理能明显减轻术后早期切口痛,但对腹内痛、肩部痛的镇痛效果并不比单用躯体阻滞更好.术前布比卡因切口躯体神经阻滞值得推荐.     

Post-herniorrhaphy pain in outpatients after preincision ilioinguinal-hypogastric nerve block during monitored anaesthesia care

The objective of this study was to evaluate the effect of an ilioinguinal-hypogastric nerve block (IHNB) with bupivacaine 0.25% on the postoperative analgesic requirement and recovery profile in outpatients undergoing inguinal herniorrhaphy with local anaesthetic infiltration. Thirty consenting healthy men undergoing elective unilateral inguinal herniorrhaphy procedures were randomly assigned to receive an IHNB with either saline or bupivacaine according to a double-blind, IRB-approved protocol. All patients received midazolam, 2 mg iv, and fentanyl 25 μg iv, prior to injection of 30 ml of either bupivacaine 0.25% or saline through the oblique muscle approximately 1.5 cm medial to the anterior superior iliac spine. Subsequently, the surgeon infiltrated the incision site with a lidocaine 1% solution. Sedation was maintained during the operation with a variable-rate propofol infusion, 25–140 μg · kg^?1 · min^?1. No significant differences were noted in the intraoperative doses of lidocaine, propofol and fentanyl in the two treatment groups. However, the pain visual analogue score at 30 min after entering the PACU was lower in the bupivacaine (versus saline) group (P < 0.05). Although the times to ambulation (86 ± 18 vs 99 ± 27 min) and being judged “fit for discharge” (112 ± 49 vs 126 ± 30 min) were similar in the two groups, the bupivacaine-treated (vs saline) patients required less oral analgesic medication after discharge (46% vs 85%). We concluded that the use of an ilioinguinal-hypogastric nerve block with bupivacaine 0.25% as an adjuvant during inguinal herniorrhaphy under monitored anaesthesia care decreased pain in the PACU and oral analgesic requirements after discharge from the day-surgery unit.     

Postoperative pain relief after laparoscopic cholecystectomy: A placebo-controlled double-blind randomized trial of preincisional infiltration and intraperitoneal instillation of levobupivacaine 0.25%

Background The aim of this study was to test the use of preincisional and intraperitoneal levobupivacaine (L-B) 0.25% in laparoscopic cholecystectomies for postoperative analgesia. Methods A total of 108 patients under general anesthesia were randomly assigned to receive preincisional local infiltration of 20 ml solution and intraperitoneal instillation of another 20 ml solution. Group A received for local infiltration and intraperitoneal instillation normal saline (NS). Group B received for local infiltration L-B 0.25% and for intraperitoneal instillation NS. Group C received for local infiltration NS and for intraperitoneal instillation L-B 0.25%. Group D received both for local infiltration and intraperitoneal instillation L-B 0.25%. Abdominal and right shoulder pain were recorded for 24 h postoperatively. Results The pain scores were lower in group D than in the other groups during rest, cough, and movement (p < 0.05). Rescue analgesic treatment was significantly lower in patients of group D (35%) as compared with that of group A (84%) (p < 0.05). The incidence of right shoulder pain was significantly lower in groups C (22%) and D (18%) than in any of the other groups (p < 0.05). Conclusions The combination of preincisional local infiltration and intraperitoneal instillation of L-B 0.25% shows an advantage for postoperative analgesia after laparoscopic cholecystectomy.     

Effect of scalp block on postoperative pain relief in craniotomy patients

The efficacy of scalp nerve block using 0.5% bupivacaine with adrenaline for postoperative pain relief in craniotomy patients was evaluated in 40 ASA I or II adult patients undergoing supratentorial craniotomy. A standard general anaesthesia technique was followed. Patients were randomly divided into two groups. Group B received 0.5% bupivacaine with 1:400,000 adrenaline and group S received normal saline with 1:400,000 adrenaline, both after skin closure. Postoperative pain was assessed at 30 seconds and 1, 2, 4, 6, 8 and 12 hours using a numerical rating scale. Diclofenac IM was administered as rescue analgesia if patients reported a numerical rating scale of 40 or more. Tramadol IV was administered as second rescue analgesia. Sixty per cent of patients in group S experienced moderate to severe pain (numerical rating scale of 40 or more) at some time during the first 12 postoperative hours in comparison to 25% patients in group B. Median pain scores were significantly lower in group B for up to 6 hours. Significantly more patients were pain free up to four hours in group B. Median duration for the requirement of first dose of diclofenac was longer in group B compared to group S (360 min vs 30 min, P < 0.01). The number of doses of diclofenac (5 vs 19) was significantly lower in group B compared to group S (P < 0.01). Tramadol was required by six patients in group S only. Scalp nerve block using 0.5% bupivacaine with 1:400,000 adrenaline decreases the incidence and severity of postoperative pain in patients undergoing supratentorial craniotomy.