A randomized, double-blind comparison of the effects of interpleural bupivacaine and saline on morphine requirements and pulmonary function after cholecystectomy

The effect of interpleural bupivacaine and saline placebo on morphine requirements and pulmonary function after cholecystectomy was investigated. Twenty-six patients were randomly assigned on postoperative day 1 to receive either 20 ml preservative-free saline (group 1) or 20 ml 0.5% bupivacaine with epinephrine, 5 micrograms/ml (group 2) through an interpleural catheter. Adequacy of pain relief was determined by the amount of morphine used by the patient following interpleural injection. Morphine use via a patient-controlled analgesia (PCA) system was recorded for several hours before and after interpleural injection. All patients had a forced vital capacity (FVC) and FEV1 measurement immediately before and 1 h after interpleural injection. Mean hourly PCA morphine use ranged from 1.6 to 2.8 mg for the 6 h prior to interpleural treatment for groups 1 and 2. There was no difference in PCA use between the groups during this time. Group 1 patients did not reduce PCA morphine use after interpleural saline. Patients in group 2, however, significantly reduced PCA morphine use after interpleural bupivacaine. Mean PCA morphine use for group 2 was 0.38 +/- 0.15 mg/h (mean +/- SE) (81% reduction vs. control) for the first 2 h after bupivacaine (P less than 0.05). Mean PCA use in group 2 was 0.52 +/- 0.2 mg/h (73% reduction vs. control) for the third hour after bupivacaine (P less than 0.05). At the fourth and fifth hours after bupivacaine injection, mean PCA morphine use was not significantly different from that in group 1. FVC and FEV1 did not improve after interpleural saline.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of interpleurally administered bupivacaine 0.5% on opioid analgesic requirements and endocrine response during and after cholecystectomy: a randomized double-blind controlled study

In 30 patients undergoing cholecystectomy, a randomized double-blind saline-controlled study was performed using interpleural 0.5% bupivacaine with or without epinephrine (5 micrograms.ml-1) in combination with 0.8% halothane inspired concentration in oxygen. The aim of the study was to investigate whether interpleural 0.5% bupivacaine could decrease the intraoperative opioid requirements and attenuate the metabolic endocrine response to surgical stress. Patients were randomly allocated to one of three groups: Group 1: 0.5% bupivacaine; Group 2: 0.5% bupivacaine with epinephrine (5 micrograms.ml-1); and Group 3: saline. The interpleural catheter was inserted after induction of anesthesia in the spontaneously breathing patient. The study drug was injected 30 min prior to surgery. Peak plasma bupivacaine concentrations in the respective groups were 1.30 +/- 0.78 and 1.16 +/- 0.48 micrograms.ml-1. In all patients concentrations were below suggested convulsive level. Two patients in Group 1 and two in Group 2 required intraoperative fentanyl (0.1 mg each). In contrast, eight patients in the saline group received an average of 0.21 mg (range 0.1 +/- 0.4 mg) fentanyl (P less than 0.05). Postoperatively, a second dose of the study drug was given. Subsequently, pain was assessed using a visual analog score and a verbal rating scale. Pain scores decreased significantly 30 min after the interpleural injection in both bupivacaine groups and remained unchanged in the saline group (P less than 0.05). Pain management by means of interpleural bupivacaine was successful in 17 of the 20 patients. In the saline group seven out of ten patients needed additional analgesics (P less than 0.05). Cortisol levels increased in response to surgery in all groups: maximum levels in Groups 1, 2 and 3 were: 1.09 +/- 0.29, 1.11 +/- 0.20 and 1.19 +/- 0.16 mumol.l-1, respectively. Plasma glucose concentrations increased significantly in all groups: maximum levels in Groups 1, 2 and 3 were: 7.6 +/- 1.3, 7.3 +/- 1.7 and 8.3 +/- 1.7 mmol.l-1, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

The influence of a bupivacaine and fentanyl epidural infusion after epidural fentanyl in patients allowed to ambulate in early labor

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. This study was designed to determine the influence of an epidural infusion of bupivacaine plus fentanyl administered after initiation of epidural labor analgesia with fentanyl. Specifically, we evaluated whether there is an increase in motor block or an increased time to request for further analgesic medication. Fifty-one laboring primigravid women at <5 cm cervical dilation who requested epidural analgesia were enrolled. After a 3-mL epidural test dose of 1.5% lidocaine with epinephrine (5 microg/mL), patients received fentanyl 100 microg via the epidural catheter. They then randomly received either an infusion (10 mL/h) of 0.0625% bupivacaine with fentanyl (3 microg/mL) or an infusion of preservative-free saline. After the administration of the initial analgesic, pain scores and side effects were recorded for each patient at 10, 20, and 30 min, every 30 min thereafter, and at the time of request for additional analgesic medication, by an observer blinded to the technique used. There were no demographic differences between the two groups. The mean duration of analgesia (time from initial dose to request for additional analgesia) was increased in the group that received a continuous infusion of bupivacaine and fentanyl compared with the Saline group (198 +/- 86 vs 145 +/- 50 min; P < 0.009). Side effects were similar between the two groups. No patient in either group experienced any detectable motor block. Fourteen patients chose to ambulate in the Saline group, and 12 patients chose to ambulate in the Infusion group. In early laboring patients, a continuous infusion of 0.0625% bupivacaine infusion with fentanyl (3 microg/mL) prolonged the duration until top-up was required, after epidural fentanyl 100 microg after a lidocaine and epinephrine test dose, and did not cause any clinically detectable motor block. IMPLICATIONS: A 0.0625% bupivacaine and fentanyl (3 microg/mL) infusion, when added to epidural fentanyl (100 microg), prolongs the analgesic duration without increasing motor block in women in early labor.     

Epinephrine is not a useful addition to intrathecal fentanyl or fentanyl-bupivacaine for labor analgesia

BACKGROUND AND OBJECTIVES: Intrathecal fentanyl provides effective labor analgesia for a limited time with frequent side effects. We evaluated the effects of adding epinephrine to intrathecal fentanyl with and without bupivacaine. METHODS: Eighty healthy, term, nulliparous parturients with cervical dilation of 5 cm or less received combined spinal-epidural (CSE) analgesia. Subjects were randomized in a double-blind fashion to 1 of 4 intrathecal solutions containing fentanyl 35 microg with either saline (F); bupivacaine 2.5 mg + saline (FB); bupivacaine 2.5 mg + epinephrine 100 microg (FBE); or epinephrine 100 microg + saline (FE). Patients were evaluated for visual analog pain score, duration of spinal analgesia (time until patient request for additional analgesia), nausea/vomiting, pruritus, sensory and motor block, maternal blood pressure, and fetal heart rate (FHR). RESULTS: Intrathecal bupivacaine significantly prolonged fentanyl analgesia with or without epinephrine (P =.018), but epinephrine did not significantly prolong the duration of fentanyl alone or with bupivacaine (F, 92 +/- 39 minutes; FB, 125 +/- 31 minutes; FBE, 134 +/- 42 minutes; and FE, 117 +/- 48 minutes). Intrathecal epinephrine was associated with a higher incidence of severe nausea (P =.001), and the FBE group had more lower extremity weakness (P =.047). There was no difference in the incidence of severe pruritus, FHR deceleration, or delivery outcome between the groups. CONCLUSIONS: These results suggest that intrathecal epinephrine does not prolong the duration of fentanyl or fentanyl with bupivacaine for labor analgesia in nulliparous parturients. Additionally, intrathecal epinephrine did not decrease the incidence of side effects and therefore cannot be recommended.     

Intraarticular morphine and bupivacaine reduces postoperative pain after rotator cuff repair

BACKGROUND AND OBJECTIVES: To determine whether intraarticular injection of morphine, fentanyl, or sufentanil added to bupivacaine provided pain control after open rotator cuff repair. METHODS: These data were collected as a prospective, randomized, blinded observer study. All patients received a standard interscalene anesthetic with 1.4% mepivacaine with 1:200,000 epinephrine. At the conclusion of surgery, they received an intraarticular injection after the shoulder capsule was closed. Patients were randomized into 4 groups. All received 20 mL of 0.25% bupivacaine: group 1, plain; group 2, with 1 mg of morphine added; group 3, with 50 microg of fentanyl added; and group 4, with 10 microg of sufentanil added. Pain scores in the postanesthesia care unit were evaluated at 0, 30, 60, 90, 120, and 240 minutes and at 4-hour intervals postoperatively using a visual analogue scale. Breakthrough pain was managed with morphine, via patient controlled analgesia pump. RESULTS: Thirty-nine patients were entered into the study. Pain scores at 2 hours and beyond were lowest in group 2. Total morphine utilization was significantly lower for the first 24 hours in group 2. CONCLUSIONS: Intraarticular injection of the shoulder with 0.25% bupivacaine and 1 mg morphine at the conclusion of surgery provided pain control and diminished morphine used in the first 24 hours after open rotator cuff repair. Fentanyl and sufentanil did not improve the analgesia over that achieved with bupivacaine alone.     

The primary action of epidural fentanyl after cesarean delivery is via a spinal mechanism

We tested the hypotheses that the primary mechanism of action of epidural fentanyl after cesarean delivery is spinal and that very small dose epidural bupivacaine with epinephrine enhances this effect. After elective cesarean delivery, 100 parturients were randomized in a double-blinded design to four groups. Group I and II patients received a continuous 12 mL/h epidural infusion of bupivacaine 0.015% with epinephrine 1 microg/mL for 48 h and Groups III and IV received a 12 mL/h saline epidural infusion instead. Fentanyl 20 microg/mL was administered via a patient-controlled analgesia device either into the epidural infusion (Groups I and IV) or IV (Groups II and III). When compared to patients receiving epidural fentanyl, those receiving IV fentanyl required larger mean infused and total dose of fentanyl (P < 0.0001), reported more pain (P < 0.001), and had a more frequent incidence of excessive sedation (P < 0.01), nausea (P < 0.01), and vomiting (P < 0.01). Plasma concentrations of fentanyl were larger for Group II and III than for Groups I and IV (P < 0.001) at 24 and 48 h. Our results support the hypothesis that the primary mechanism of analgesia of epidural fentanyl after cesarean delivery is spinal. Our data also show that the total required dose of epidural, but not IV, fentanyl is reduced by very small dose epidural bupivacaine and epinephrine (Group I versus Group IV, P < 0.02 and Group II vs Group III, not significant). IMPLICATIONS: Fentanyl administered epidurally to parturients after cesarean delivery has a primarily spinal mechanism of action and this effect is enhanced by very small dose epidural bupivacaine and epinephrine.     

Continuous infusion of interpleural bupivacaine maintains effective analgesia after cholecystectomy

Twenty-five patients who had undergone elective cholecystectomy were prospectively randomized to receive via an interpleural catheter either a continuous infusion of 0.25% bupivacaine at 0.125 mL.kg-1.h-1 (n = 13) or repeated bolus injections (n = 12) of 0.5% bupivacaine with epinephrine 1:200,000 at 0.4 mL/kg every sixth hour. Adequacy of pain relief was measured by the amount of patient-controlled analgesia morphine required postoperatively and by patient scores on a visual analog scale obtained every sixth hour. Two venous blood samples for measurements of serum bupivacaine levels were obtained from patients in the continuous group at hours 6 and 24; four blood samples were obtained from patients in the bolus group, both immediately before and 30 min after injections at hours 6 and 24. Among the patients receiving the bolus injections, morphine was required 62 +/- 15 (SEM) times over the 24-h study period with total morphine dosage averaging 30 +/- 15 mg. Corresponding values for patients in the continuous groups were 35 +/- 10 times and 23 +/- 5 mg of morphine. The difference was not, however, statistically significant, but when activity during the 2-h time periods immediately before reinjection were examined, patients in the bolus group required and received significantly more morphine than did those in the continuous group (P less than 0.05). Patients in the continuous group had visual analog scale scores that averaged 2.9 +/- 0.6 over the 24-h study period. Patients within the bolus group had visual analog scale scores before and again 30 min after injection that averaged 5.8 +/- 0.8 and 1.8 +/- 0.5, respectively (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Clonidine combined with a long acting local anesthetic does not prolong postoperative analgesia after brachial plexus block but does induce hemodynamic changes

Clonidine in brachial plexus block prolongs analgesia of local anesthetics of short and intermediate duration. We performed a prospective randomized double-blinded study to determine the efficacy and adverse effects of clonidine mixed with a long-acting local anesthetic on postoperative analgesia. Sixty adult patients underwent elective rotator cuff repair using interscalene brachial plexus block combined with general anesthesia and were randomly divided into one of the following three groups. Placebo (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine (1/200000) and 1 mL of 0.9% saline, completed by 1 mL of 0.9% saline IM in the controlateral shoulder; Control (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 1 mL of 0. 9% saline, completed by 150 microg (=1 mL) of clonidine IM; Clonidine (n = 20): interscalene block with 40 mL of 0.5% bupivacaine with epinephrine and 150 microg (=1 mL) of clonidine, completed by 1 mL of 0.9% saline IM. During anesthesia hemodynamic variables and fractional expired isoflurane concentration (FeISO) were recorded. The following postoperative variables were assessed: duration of interscalene block, quality of pain relief on a visual analog scale, side effects, and consumption of morphine with a patient-controlled analgesia device over 48 h. Patient characteristics were comparable. During anesthesia mean arterial pressure, heart rate, and FeISO were significantly decreased in Clonidine and Control groups compared with Placebo group. Duration of analgesia, defined as the time elapsed from interscalene injection to the first morphine request, was 983 +/- 489 min in the Placebo, 909 +/- 160 min in the Control, and 829 +/- 159 min in the Clonidine groups. Pain scores and consumption of morphine at 24 h and 48 h showed no differences among the three groups. We conclude that adding 150 microg of clonidine in interscalene block does not prolong analgesia induced by 40 mL of bupivacaine 0.5% with epinephrine, but decreases mean arterial blood pressure and heart rate. Implications: Clonidine in brachial plexus block does not improve postoperative analgesia when mixed with a long-lasting anesthetic. Nevertheless, with or without clonidine, bupivacaine in interscalene block provides a long-lasting analgesia of approximately 15 h.     

Anaesthesia for caesarean delivery: low-dose epidural bupivacaine plus fentanyl

To determine the acceptability of epidural bupivacaine-induced sixth thoracic (T6) sensory blockade and the analgesic efficacy of epidural fentanyl 50 microg, 24 parturients undergoing elective caesarean section were given a test dose of lidocaine 60 mg plus epinephrine followed by 10 ml of either 0.5 % bupivacaine (control group) or 0.5 % bupivacaine plus 50 microg fentanyl (fentanyl group) in a randomized double-blind manner. Fifteen minutes later loss of pinprick sensation was determined. Additional local anaesthetic was titrated to achieve T6 sensory blockade. Intraoperative pain intensity was assessed using a 10 cm visual analogue scale (VAS); total dose of bupivacaine and need for i.v. rescue fentanyl were recorded. The incidence of intraoperative respiratory depression, nausea, vomiting and pruritus were documented. Mean (+/- SD) volume of bupivacaine was 14.1 +/- 3.05 ml versus 13 +/- 1.48 ml for the control and fentanyl groups respectively. The most severe intraoperative VAS for pain was significantly (P=0.023) lower in the fentanyl group (0.4 +/- 0.08 cm) than in the control group (3.1 +/- 0.3 cm). Rescue fentanyl was administered in 40% and 0% of patients in the control and fentanyl groups respectively. The incidence of side-effects was unaffected by treatment group. Apgar scores were similar in the two groups. We conclude that following administration of 10-15 ml 0.5% bupivacaine plus fentanyl 50 microg, T6 sensory blockade is associated with good intraoperative analgesia without obvious maternal or neonatal respiratory depression.     

Effects of hyperbaric spinal ropivacaine for caesarean section: with or without fentanyl

BACKGROUND AND OBJECTIVE: Adding various opioids to the local anaesthetic solution administrated intrathecally improves the analgesic potency of spinal analgesia. The purpose of this study was to evaluate the efficacy and safety of intrathecal fentanyl 10 microg added to 15 mg hyperbaric ropivacaine in patients undergoing caesarean section under spinal anaesthesia. METHODS: Thirty-seven healthy, full-term parturients were randomly assigned into two groups: Group S (saline group, n=17) received 15 mg hyperbaric ropivacaine in 2.5 mL + 0.5 mL saline; Group F (fentanyl group, n=20) received 15 mg hyperbaric ropivacaine in 2.5 mL + 10 microg fentanyl in 0.5 mL, intrathecally. Characteristics of spinal block, intraoperative quality of spinal anaesthesia, time to first feeling of pain (complete analgesia), time to first request of analgesics postoperatively (effective analgesia), side-effects and fetal outcomes were evaluated. RESULTS: Regression of sensory block to L5 was significantly prolonged in the fentanyl group compared with the saline group (P = 0.001). Time to the first feeling of pain (130.6 +/- 15.8 min vs. 154.3 +/- 31.1 min; P = 0.008) and the first analgesic requirement (161.2 +/- 32.6 min vs. 213.0 +/- 29.3 min; P < 0.001) were significantly shorter in the saline group compared with the fentanyl group. Side-effects, umbilical arterial and venous blood gases did not differ between the groups. Apgar scores were similar in both groups and no infants had an Apgar score < or =7 at 5 min. CONCLUSIONS: The addition of fentanyl 10 microg, to hyperbaric ropivacaine 15 mg, for spinal anaesthesia increased the duration of analgesia in the early postoperative period in patients undergoing caesarean delivery.     

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.     

Continuous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery

BACKGROUND: Both epidural analgesia and intravenous patient-controlled analgesia (PCA) have been found efficacious after various types of surgery. We compared the efficacy, safety, side effects and patient satisfaction of these methods in a randomized double-blind fashion after elective anterior cruciate ligament reconstruction of the knee. METHODS: Fifty-six patients had an epidural catheter placed at the L2-L3 interspace. Spinal anaesthesia with 15 mg of plain bupivacaine 5 mg/ml was performed at the L3-L4 interspace. After surgery the patients were randomly divided into three groups: 19 received a continuous epidural infusion with bupivacaine 1 mg/ml and fentanyl 10 mg/ml (F10), 19 patients received bupivacaine 1 mg/ml and fentanyl 5 microg/ml (F5) and 18 patients received saline (S). The rate of the epidural infusions was 0.1 ml kg(-1) h(-1). Each patient could also use an intravenous (i.v.) PCA device with 40 microg/kg bolus doses of morphine with a lockout period of 10 min and a maximum dose 240 microg kg(-1) h(-1). At the end of surgery ketoprofen 100 mg i.v. was given and continued orally three times a day. Patients were assessed for pain with a visual analogue scale (VAS) at rest and during activity, side effects and satisfaction at 3, 9 and 20 h. RESULTS: Both epidural infusions (F10, F5) provided better analgesia than epidural saline plus i.v. PCA (S) (P<0.05). There was slightly less nausea in the S group (NS). In spite of the difference in the quality of pain relief, there was no difference between the groups in patient satisfaction regarding analgesic therapy. CONCLUSION: Epidural infusion of fentanyl (1 microg kg(-1) h(-1) or 0.5 microg kg(-1) h(-1)) and bupivacaine (0.1 mg kg(-1) h(-1)) provided better pain relief but more side effects than intravenous morphine patient-controlled analgesia after knee ligament surgery. Almost all patients in all groups were satisfied with their pain relief.     

Intrathecal labor analgesia with bupivacaine and sufentanil: the effect of adding 2.25 microg epinephrine

BACKGROUND AND OBJECTIVES: Epinephrine, 25 microg and 200 microg, has been found to prolong the duration of intrathecal labor analgesia when added to an opioid. In our hospital we use the standard epidural mixture, prepared by the pharmacist, containing epinephrine 1:800,000; i.e., 1.25 microg/mL for both spinal and epidural labor analgesia. We wanted to evaluate whether such a low dose, depending on its effect on duration or quality of analgesia, should be maintained or deleted in future mixtures. METHODS: Forty-five term parturients were randomly assigned to receive 1.8 mL intrathecally of a mixture containing bupivacaine 0.125% and sufentanil 0.75 microg/mL with or without epinephrine 1.25 microg/mL. The quality and duration of analgesia, side effects, and obstetric/neonatal outcome were compared. RESULTS: For both combinations, the onset until the first painless contraction was between 5 and 6 minutes. Most patients were pain free during the second uterine contraction. The duration of complete analgesia was 93.2 +/- 24.2 minutes in the epinephrine group and 79.3 +/- 18.1 minutes for patients not receiving epinephrine (P = .014). The quality of the block, bupivacaine consumption, side effects, and obstetric/neonatal outcome were not different between groups. CONCLUSIONS: It was concluded that epinephrine in a dose as low as 2.25 microg significantly prolonged the duration of intrathecal analgesia of bupivacaine-sufentanil by 15 minutes. No other differences were noticed. Diluting the commercially available bupivacaine 0.5% with epinephrine 1:200,000 may avoid the need of freshly prepared epinephrine solutions.     

Intrathecal versus intravenous fentanyl for supplementation of subarachnoid block during cesarean delivery

Forty-eight healthy parturients scheduled for elective cesarean delivery were randomly allocated to receive intrathecally either 12 mg of hyperbaric bupivacaine plus 12.5 microg of fentanyl (n = 23) or bupivacaine alone (n = 25). In the latter group, IV 12.5 microg of fentanyl was administered immediately after spinal anesthesia. We compared the amount of IV fentanyl required for supplementation of the spinal anesthesia during surgery, the intraoperative visual analog scale, the time to the first request for postoperative analgesia, and the incidence of adverse effects. Additional IV fentanyl supplementation amounting to a mean of 32 +/- 35 microg was required in the IV Fentanyl group, whereas no supple- mentation was required in the Intrathecal Fentanyl group (P = 0.009). The time to the first request for postoperative analgesia was significantly longer in the Intrathecal Fentanyl group than in the IV Fentanyl group (159 +/- 39 min versus 119 +/- 44 min; P = 0.003). The incidence of systolic blood pressure <90 mm Hg and the ephedrine requirements were significantly higher in the IV Fentanyl group as compared with the Intrathecal Fentanyl group (P = 0.01). Also, intraoperative nausea and vomiting occurred less frequently in the Intrathecal Fentanyl group compared with the IV Fentanyl group (8 of 23 vs 17 of 25; P = 0.02). IMPLICATIONS: Supplementation of spinal bupivacaine anesthesia for cesarean delivery with intrathecal fentanyl provides a better quality of anesthesia and is associated with a decreased incidence of side effects as compared with supplementation with the same dose of IV fentanyl.     

A comparison of epidural infusions in the combined spinal/epidural technique for labor analgesia

We compared the clinical effects of three epidural infusions initiated after subarachnoid medication was administered as part of the combined spinal/epidural technique for labor analgesia. Fifteen minutes after administering subarachnoid fentanyl 25 microg and 1 mL of bupivacaine 0.25%, and 5 min after an epidural test dose of 3 mL of bupivacaine 0.25%, women were randomized to receive an epidural infusion of saline, bupivacaine 0.125%, bupivacaine 0.0625%, or bupivacaine 0.04% with epinephrine 1:600,000. All epidural infusions were started at 10 mL/h, and all except the Saline Group also received fentanyl 2 microg/mL. The end point of the study was delivery or request for additional medication for analgesia. We found that time until request for additional analgesia was longest in women who received bupivacaine 0.125% (median duration, 300 min) versus saline (median duration, 118 min) (P = 0.0001) and was intermediate for bupivacaine 0.0625% and bupivacaine 0.04% (median duration, 162 and 180 min, respectively) (P = 0.0001 versus saline). Women who received bupivacaine 0.125% had the most motor block. We conclude that all the bupivacaine-based infusions we tested maintained the analgesia from subarachnoid medication longer than saline, with the longest duration, but the most motor block, from bupivacaine 0.125%. IMPLICATIONS: In this prospective, randomized, and double-blinded study we found that initiating an epidural infusion of bupivacaine 0.125% with fentanyl 2 microg/mL at 10 mL/h 15 min after subarachnoid fentanyl 25 microg with 1 mL of bupivacaine 0.25%, followed by an epidural test dose of 3 mL of bupivacaine 0.25%, maintained the analgesia for longer but with more motor block than with either bupivacaine 0.04% or bupivacaine 0.0625%.     

General anaesthesia combined with bilateral paravertebral blockade (T5-6) vs. general anaesthesia for laparoscopic cholecystectomy: a prospective, randomized clinical trial

BACKGROUND AND OBJECTIVE: The efficiency of bilateral paravertebral blockade combined with general anaesthesia (active) vs. general anaesthesia alone (control) in reducing postoperative pain following laparoscopic cholecystectomy was evaluated using a prospective randomized study design. METHODS: Patients were randomly assigned to either group. Nerve-stimulator guided paravertebral blockade at the T5-6 level was performed with a local anaesthetic mixture (0.30 mL kg(-1)). Twenty millilitres of the mixture contained lidocaine 2% 6 mL; lidocaine 2% 6 mL with epinephrine 1/200 000; bupivacaine 0.5% 5 mL; fentanyl 1 mL (50 microg mL(-1)) and clonidine 2 mL (150 microg mL(-1)). Postoperative pain and consumption of opioids were assessed during the first 72 h. RESULTS: Two-times 30 patients were analysed. Patient characteristics data, and pre- and peroperative variables were similar in both groups. Mean pain scores visual analogue scale were significantly less with active compared with control (P < 0.05) at 6h (1.56 +/- 1.58 vs. 4.78 +/- 1.67), at 12 h (1.52 +/- 1.58 vs. 3.81 +/- 1.63), at 24 h (1.16 +/- 1.34 vs. 2.71 +/- 1.50), at 36h (0.68 +/- 1.02 vs. 2.29 +/- 1.41), at 48h (0.60 +/- 1.04 vs. 1.61 +/- 1.33) and at 72 h (0.40 +/- 0.86 vs. 1.19 +/- 1.16). The number of patients consuming supplemental analgesics was significantly less (P < 0.05) with active compared with control, at 6 h (6 vs. 29), at 12 h (2 vs. 26), at 24 h (1 vs. 23) and at 36 h (2 vs. 15). More patients were free from nausea (P < 0.05) with active compared with control at 6 h (23 vs. 9) and at 12 h (29 vs. 19). CONCLUSION: When used as a complement to general anaesthesia, bilateral nerve-stimulator guided paravertebral blockade with lidocaine, bupivacaine, fentanyl and clonidine may improve postoperative pain relief.     

The safety and efficacy of intrabursal oxycodone and bupivacaine in analgesia after shoulder surgery

Background and Objectives. Peripherally administered opioids, e.g., intra-articular morphine, exert their analgesic action on local opioid receptors. The present study investigated the safety and efficacy of intrabursal oxycodone and bupivacaine in comparison with bupivacaine infiltration and interscalene brachial plexus block in conjunction with shoulder surgery. Methods. A prospective, randomized study was conducted in 45 patients (15 per group) undergoing elective shoulder surgery during general anesthesia. At the end of the surgery, patients received either 10 mL 0.5% bupivacaine (group B) or 5 mg oxycodone and 10 mL 0.5% bupivacaine (group OB) in the subacromial bursa; interscalene plexus blocks were performed preoperative (group IPB). Postoperative analgesia was provided by patient-controlled analgesia, and the amount of intravenous fentanyl used during the total perioperative period was recorded. Postoperative pain was assessed by a visual analog scale. Results. The total fentanyl consumption was lower in groups OB and IPB than in group B, and the difference reached statistical significance for both groups (P = .045 and P = .006, respectively). However, the groups OB and IPB did not differ in respect to their fentanyl requirements (P = 1.000). Visual analog scores for pain were lowest in group IBP during the first 6 postoperative hours. The incidence of adverse effects was similar in all groups; serious adverse effects did not occur. Conclusions. According to the present study, intrabursal oxycodone and bupivacaine offer an acceptable and efficient method for postoperative analgesia after shoulder surgery.     

Preincision 0.25% bupivacaine scalp infiltration and postcraniotomy pain: a randomized double-blind,placebo-controlled study

This prospective, double-blind, randomized, and placebo-controlled trial was performed to evaluate the effect of preincisional scalp infiltration with 0.25% bupivacaine on the postoperative pain perception and analgesic requirement of patients undergoing elective supratentorial craniotomy. Twenty patients (bupivacaine group) received scalp infiltration with 25 mL of 0.25% bupivacaine followed by intravenous 5 mL of saline as placebo 5 minutes before incision, and another 21 patients (fentanyl group) received scalp infiltration with a similar volume of 0.9% saline solution followed by 2 microg/kg of intravenous fentanyl 5 minutes before incision. Following standard anesthesia technique, basal, preincisional, and postincisional hemodynamic data were recorded. Postoperative pain was assessed at 1, 6, 12, 24, and 48 hours by using a 10-cm visual analog scale. Diclofenac sodium was used as rescue analgesic in the postoperative period. Results showed rescue analgesic was required only during the first 12 hours. In each group the same number of patients needed rescue analgesia, but bupivacaine delayed this requirement 105 (30-720; median [range]) minutes compared with 60 (15-720; median [range]) minutes for the fentanyl group (P = 0.13). But there was no difference in the amount of analgesic consumed at different time intervals. Six of 20 patients in the bupivacaine group required rescue analgesic at the end of 1 hour compared with 9 of 21 fentanyl patients (P = 0.61). At 6 hours, the fraction of patients who required rescue analgesia were 7 of 20 and 11 of 21, respectively (P = 0.44). In conclusion, bupivacaine preincision scalp infiltration did not have any significant effect on postcraniotomy pain and analgesic requirement. However, bupivacaine may delay the requirement of the first analgesic dose.     

Interpleural analgesia does not influence postthoracotomy pain

The management of postthoracotomy pain is a problem and may contribute to atelectasis, leading to hypoxemia, pulmonary infection, and permanent alveolar damage. We sought to determine the efficacy of interpleural analgesia for pain control and to evaluate independent predictors for postoperative pain intensity. Eighty-three patients undergoing elective anterolateral (n = 37) and posterolateral (n = 46) thoracotomy were included in a prospective, randomized, double-blinded trial. Patients were assigned to receive either 0.5% bupivacaine or saline solution interpleurally every 4 h for 10 doses postoperatively. All patients also received patient-controlled analgesics (PCA) with piritramide as the opioid for additional pain control. Pain was assessed on the basis of PCA requirements and by using a visual analog scale. Visual analog scale scores and PCA requirements were not different between groups. Both interpleural bupivacaine and saline significantly reduced pain scores 30 min after the administration. We concluded that pain reduction by interpleural instillation of bupivacaine reflects a placebo-like effect; however, interpleural analgesia is not effective in patients undergoing lateral thoracotomy. Sex and surgical approach were shown to influence postoperative pain intensity at rest, but not during coughing. The female patients, and those undergoing posterolateral thoracotomy, exhibited higher pain scores. This observation appears to be of only marginal clinical significance. The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study we demonstrated a lack of efficacy of interpleural analgesia. IMPLICATIONS: The efficacy of interpleural analgesia to reduce postoperative pain intensity in patients after lateral thoracotomy is controversial. In this study, we demonstrated a lack of efficacy of interpleural analgesia.     

An analysis of the need for anesthetic interventions with differing concentrations of labor epidural bupivacaine: an observational study

BACKGROUND: Labor epidural analgesia techniques using lower concentrations of bupivacaine are designed to maintain pain control with fewer side effects such as hypotension and motor block. However, the increase in sensation may allow breakthrough pain resulting in the need for additional interventions. We examined the number of interventions, both for analgesia and for treatment of side effects, required when using three concentrations of bupivacaine. METHODS: Retrospective observational investigation examining 4493 women who received epidural analgesia during two periods. In the first period, higher concentrations of bupivacaine were used (0.125% and 0.0625%, both with fentanyl 2 microg/mL). In the second period, a very low concentration was used (0.04% plus fentanyl 1.7 microg/mL and epinephrine 1.7 microg/mL). Outcomes were compared using univariate tests, and multivariate Poisson regression was used to identify independent factors influencing interventions. RESULTS: The frequencies of interventions were similar for women receiving bupivacaine concentrations of 0.04% (1.4+/-2.0) and 0.125% (1.5+/-2.0), while women receiving the 0.0625% solution required more interventions (1.8+/-2.3; P<0.001). Women who received 0.04% or 0.0625% bupivacaine required more treatment of breakthrough pain (P<0.002), while those receiving 0.125% bupivacaine required more treatment for hypotension and motor block (P<0.05). Multivariate Poisson regression showed that duration of treatment, maternal age and body mass index were independent factors for the number of interventions. CONCLUSIONS: Neither the total interventions nor intervention rate per hour varied significantly with the concentrations of bupivacaine used in this study. Lower concentrations produced fewer side effects including hypotension, while the higher concentration resulted in less breakthrough pain.