High thoracic epidural analgesia in the postoperative period after correction of congenital heart defects in children

The effects and side effects of thoracic epidural analgesia on the respiratory response, awakening time, and cooperation with nurses were studied. Forty children received epidural analgesia after open-heart surgery. Lidocaine was injected in a dose of 1.5-2 mg/kg every 1.5-2 h. Controls (16 pts) received intravenous fentanyl + diazepam analgesia. Respiratory response and awakening were significantly earlier (p < 0.001) in the epidural group. Cooperation with nurses was much better in this group, too. No side effects were observed in the epidural group. Therefore, thoracic epidural analgesia is a safe and effective method of postoperative analgesia for children subjected to open-heart surgery.     

Acute pain services in the United Kingdom

This survey addresses the structure and function of the acute pain services (APS) in the UK 10 years after its initial commencement. APS is now available in many hospitals (89.4%). The APS team consists mainly of anaesthetists, occasionally includes nurses and pharmacists, and rarely physiotherapists and psychologists. Anaesthetists, mainly, cover the out-of-hours service and nurses only occasionally. Dedicated medical staff sessions did not exist in 37%, and were limited to 1–2 sessions per week in 49% of the hospitals that responded to the questionnaire. Regular training commitment by medical staff did not exist in 25% of hospitals. Frequency of nursing training sessions varied from nil in 12% to almost monthly in 40% of hospitals.

Patient controlled analgesia (PCA) and epidurals were available for post-operative analgesia in almost every single hospital responding to this questionnaire.

Protocols for epidurals were available in 92% of hospitals, without clear relationship to the actual presence of APS. Anaesthetists designed these protocols in 27%, nurses in 1%, both anaesthetists and nurses in 43% and the whole team in 20% of hospitals. Written consent for epidurals was rarely obtained. The place of care for patients with post-operative epidural analgesia was surgical wards in 73%, HDU in 51% and ITU in 48% of respondent hospitals. The most single common factor in the decision on place of care was the availability of trained nursing staff. Monitoring usually comprised respiratory rate, sedation and pulse oximetry.

Bupivacaine 0.1% was the most commonly used local anaesthetic for post-operative epidural analgesia, while diamorphine followed by fentanyl were the most commonly used epidural opioids. Other adjuvants to epidurals were rarely ever used; only clonidine was used in 7% of hospitals. Continuous epidural infusions were used in 84% of hospitals while patient controlled epidural analgesia PCEA was used only in 19% of hospitals.     

Epidural fentanyl by continuous infusion for relief of postoperative pain

Data from the charts of 40 patients in whom a continuous epidural infusion of fentanyl had been used to effect postoperative pain relief were retrospectively reviewed. Of these patients, 39 out of 40 (97.5%) reported adequate analgesia at an average fentanyl infusion rate of 1.3 micrograms/kg/h. After discharge from the postanesthesia recovery room, each patient was sent to a general medical-surgical nursing floor with standard orders for medications to be administered as required. The overall incidence of side effects was low, and, in particular, respiratory depression was not noted. In our experience, this analgesia technique is safe, effective, and could be readily introduced into most community hospital settings.     

Sufentanil: clinical use as postoperative analgesic--epidural/intrathecal route.

Although morphine and fentanyl remain the predominant epidural opioids, sufentanil offers some unique advantages. Because of its greater lipophilicity and mu-receptor binding capacity, sufentanil has a faster onset of action and longer duration than epidural fentanyl. Compared with morphine, sufentanil has been associated with a lower incidence of side effects, particularly delayed respiratory depression. The effective doses and adverse effects profile of epidural sufentanil are relatively well understood. Ventilatory depression is minimal with both bolus and continuous administration. Rapid vascular uptake after large epidural bolus, however, has been associated with acute-onset respiratory depression and even respiratory arrest. Sufentanil is more ideally suited than morphine to continuous epidural administration. The faster onset in comparison with fentanyl may make sufentanil the ideal agent for patient-controlled epidural analgesia. The synergistic effect of combined sufentanil and low-concentration bupivacaine offers advantages over sufentanil alone. High doses of epidural sufentanil have been uniquely associated with cessation of shivering and hypothermia. As with fentanyl, the intrathecal administration of sufentanil for postoperative analgesia is limited by its short duration of action.     

Fentanyl: clinical use as postoperative analgesic--epidural/intrathecal route.

The administration of epidural and intrathecal opioids for the management of postoperative pain is well established. Fentanyl, because of its greater lipophilicity, offers a number of advantages over morphine for epidural analgesia, including a lower incidence of side effects and reduced risk of delayed-onset respiratory depression. The relatively short duration of action of epidural fentanyl makes this agent more ideally suited for continuous infusion or patient-controlled epidural analgesia (PCEA). The effective doses and adverse effects profile of epidural fentanyl are reasonably well understood. Because of the lack of spread through the cerebrospinal fluid (CSF) and hence the segmental nature of the analgesia achieved, location of epidural catheter placement is of paramount importance when this agent is used. Prolonged epidural infusion of fentanyl may result in high systemic concentrations not dissimilar to IV infusion, and, therefore, the greatest efficacy of epidural fentanyl administration may be in combination with low concentrations of bupivacaine, an approach that achieves a synergistic effect. 2-Chloroprocaine has been shown to antagonize epidural fentanyl analgesia. Intrathecal fentanyl for postoperative analgesia is limited by its short duration of action with single-bolus administration. The widespread international increase in the use of epidural fentanyl for postoperative analgesia promises further improvements and refinement in techniques.     

Approaches to anesthesia management of a patient during oncological pulmonary surgery

The results of lungs' excision in 82 patients made under a combined anesthesia of 2 types are comparatively analyzed. A surface low-level endobronchial narcosis by isoflurane was administered in 42 patients concurrently with a "high" epidural anesthesia by bupivakain and fentanyl. The other 40 patients received isoflurane and intravenous bolus injections of fentanyl concurrently with epidural anesthesia by morphine administered at the lumbar level. The epidural analgesia by bupivakain and fentanyl made at the thoracal level or by morphine made at the lumbar level was carried on in the early postoperative period. The results show both variations to ensure a reliable intraoperative anesthesia, a smooth recovery and a good postoperative analgesia. Better results were on the whole obtained by the variant of high epidural anesthesia/analgesia; however, the method of lumbar morphine administration has a number of advantages primarily related with its simplicity.     

Nurse Practitioner-Administered Chloroprocaine in Children with Postoperative Pain

Background: Pain is a complex physical and emotional experience. Therefore, assessment of acute pain requires self-report when possible, observations of emotional and behavioral responses and changes in vital signs. Peripheral nerve and epidural catheters often provide postoperative analgesia in children. Administration of chloroprocaine (a short acting local anesthetic) via a peripheral nerve or epidural catheter allows for a comparison of pain scores, observations of emotional and behavioral responses and changes in vital signs to determine catheter function. Aims: The aims of this study are to describe the use chloroprocaine injections for testing catheters; patient response; and how changes to pain management are guided by the patient response. Methods: This study describes the use of chloroprocaine injections to manage pain and assess the function of peripheral nerve or epidural catheters in a pediatric population. We examined 128 surgical patients, (0-25 years old), who received chloroprocaine injections for testing peripheral nerve or epidural catheters. Patient outcomes included: blood pressure, respiratory rate, heart rate and pain intensity scores. Results: There were no significant adverse events. The injection guided intervention by determining the function of regional analgesia in the majority (98.5%) of patients. Discussion: Chloroprocaine injections appear to be useful to evaluate functionality of peripheral nerve and epidural catheters after surgery in a pediatric population.     

The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries

Fentanyl has been shown to be effective for the management of intense pain of short duration. We have recently used intravenous fentanyl for burn wound procedures because of its rapid onset, high potency, and short duration. In this report, we reviewed our experience with fentanyl in a variety of procedural burn pain settings to develop specific recommendations about its effectiveness and safety for the treatment of pain in patients with burn injuries. The medical records of patients with burn injuries who received fentanyl for wound procedures over a 2-year period were retrospectively reviewed. Patient demographics, the amount of fentanyl administered, the level of analgesia achieved, and the incidence of adverse effects were analyzed. Fifty-five patients who were 9 months to 75 years old with burn wounds (range, 1%-90% of total body surface area) received 148 doses of fentanyl for the treatment of procedural pain. An average of 8.0 +/- 7.0 microg/kg of fentanyl (range, 0.7 to 38.0 microg/kg) was required for the first wound procedure with fentanyl. No correlation between dosage of fentanyl given and either age or percentage of total body surface area burned was observed. Transient respiratory depression was observed in 17 patients (31%). No patient required intubation or additional supplemental oxygen after the conclusion of the procedure. High doses of fentanyl are required to achieve adequate analgesia during some burn wound procedures. Respiratory depression associated with fentanyl use is transient but requires adequate preparation and trained personnel. Fentanyl may be effectively integrated into the pain control strategy for patients with burn injuries.     

术后芬太尼皮下镇痛及对胃肠功能影响的研究

目的 比较术后芬太尼皮下镇痛(PCSA)与硬膜外镇痛(PCEA)的临床效果,以及对胃肠功能的影响.方法 2009年1-6月间观察择期硬膜外麻醉下经腹子宫切除术患者120例,术后分别实施PCSA与PCEA,观察术后第4、8、12、24、48 h的镇痛、镇静情况,呼吸循环、恶心呕吐及其他不良事件,记录术后首次肛门排气时间,...     

Epidural Labor Analgesia: Continuous Infusion Versus Patient-Controlled Epidural Analgesia With Background Infusion Versus Without a Background Infusion

The purpose of this study was to compare the total epidural dose of 3 commonly used labor epidural modalities. After local institutional review board approval, 195 laboring parturients received an epidural catheter for labor analgesia. All patients received an initial bolus of 0.1% ropivacaine (10 mL) and fentanyl (100 microg). Maintenance of labor analgesia consisted of ropivacaine 0.1% with fentanyl 2 microg/mL. Patients were then randomly assigned into 3 groups: Group 1 (continuous epidural infusion [CEI]), continuous infusion at 10 mL/h; group 2 (CEI + patient-controlled epidural analgesia [PCEA]), CEI at 5 mL/h with a demand dose of 5 mL allowed every 20 minutes with a 20 mL/h maximum dose; group 3 (PCEA), demand doses only of 5 mL every 15 minutes with a 20 mL/h maximum dose. Measured variables included total epidural dose, total bolus requests and boluses delivered, number of staff interventions, pain Visual Analog Scale (VAS; 0-100), modified Bromage scores, stage I and II labor duration, delivery outcome, and maternal satisfaction after delivery. No differences were noted with respect to pain VAS, modified Bromage scores, stage I and II labor duration, number of staff interventions, delivery outcome, and maternal satisfaction score. Total infusion dose was lower in demand dose only PCEA compared with CEI and CEI + PCEA groups (P = < .01). Demand dose-only PCEA results in less total epidural dose compared with CEI and CEI + PCEA without affecting labor duration, motor block, pain VAS, maternal and neonatal outcomes, and maternal satisfaction. PERSPECTIVE: This article compares 3 commonly used labor epidural delivery modalities (traditional continuous epidural infusion, patient-controlled epidural analgesia with a background infusion, and demand dose-only patient-controlled epidural analgesia). Benefits in epidural dose reduction with demand dose only PCEA does not translate into improved maternal and neonatal outcome.     

Efficacy of thoracic epidural analgesia for laparoscopic cholecystectomy

Introduction Postoperative pain is a commonly observed phenomenon after laparoscopic procedures. The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with them is not sufficiently known. Optimally, analgesic therapy should be started in sufficient time as to be effective at the point of emergence from anaesthesia. We compared the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period. Methods Thirty adult patients with American Society of Anesthesiologists (ASA) physical status I–II, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the intravenous group (n=15) received general anaesthesia with sevoflurane and intravenous infusion of 1.5 μg/ml/kg/h fentanyl analgesia followed by postoperative intravenous infusion of 1.0 μg/ml/kg/h fentanyl, supplied by a programmed continuous analgesia pump. The patients in the epidural group (n=15) had combined epidural analgesia with 0.125% bupivacaine plus 50 μg fentanyl and general anaesthesia with sevoflurane, followed by continuous epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. Visual analogue scores and the patients’ needs for analgesics and were recorded.     

舒芬太尼复合罗哌卡因用于开胸术后硬膜外镇痛的疗效

【目的】观察舒芬太尼或芬太尼复合罗哌卡因用于开胸手术后硬膜外自控镇痛（PCEA）的临床镇痛效果和安全性。【方法】ASAⅠ～Ⅱ级,全麻复合连续硬膜外阻滞麻醉行开胸手术病人70例,随机分为两组（n=35）,使用0．75μg／ml舒芬太尼（S组）或3μg／ml芬太尼（F组）复合0．125％罗哌卡因,术后行PCEA。镇痛泵设定持续背景剂量2mL／h、PCA每次0．5mL,锁定时间15min。观察病人术后镇痛效果,记录术后4h、8h、12h、24h、48h各时间点的疼痛评分（VAS）、镇静评分、PCA使用次数、不良反应和病人满意度。【结果】S组术后8h、24h和48hVAS评分明显低于F组（P〈0．05）;S组各时间点镇静评分均明显大于F组（P〈0．05）;S组PCA按压次数显著低于F组（P〈0．05）;S组病人对PCA的满意度明显高于F组（P〈0．05）。两组恶心、呕吐发生率低,呼吸抑制相比无明显差异。【结论】舒芬太尼复合罗哌卡因用于开胸手术后PCEA,镇痛安全有效,镇痛镇静效果优于芬太尼,不良反应程度较轻。     

Role of paracetamol in a balanced postoperative analgesia scheme after thoracotomy

The efficiency of paracetamol used in the balanced multimodal analgesia after thoracotomy still remains unclear. The prospective study covered 75 adult patients operated on the chest. The patients were randomized to 3 groups. They all received epidural autoanalgesia with a mixture of fentanyl (2 microg/ml) in 0.2% ropivacaine solution and intramuscular injections of ketorolac, 30 mg, every 8 hours. In Group 1 (n = 25), paracetamol was intravenously injected in a dose of 4 g daily. In Group 2 (n = 23), rectal paracetamol was used in an equipotential dose. In Group 3 (n = 24), paracetamol was not given. Within the first 24 postoperative hours, the severity of the pain syndrome and the incidence of adverse reactions of analgesia were estimated in all the patients. The obtained data were compared using Student's t-test and x2 test, by taking into account Bonferroni's correction. The p values of < 0.0017 were determined as statistically significant. The resting VAS did not differ between the groups. In cough, the severity of the pain syndrome was significantly less in Group 1 than in Groups 2 and 3. The use of the epidural mixture of ropivacaine and fentanyl required for adequate analgesia within the first 24 hours after surgery was much less in Groups 1 and 2 than that in Group 3. The high incidence of skin itch (20%) and urinary retention (8%) was observed in Group 3 (p < 0.017). No difference was found between the groups in the development of dyspepsia. The use of paracetamol in the postoperative multimodal analgesic therapy program after thoracotomy reduces the daily dose of epidurally administered ropivacaine and fentanyl with evident upgrade of analgesia quality, and the incidence of opioid-induced adverse reactions.     

A prospective randomized pilot comparison of intranasal fentanyl and intramuscular morphine for analgesia in children presenting to the emergency department with clinical fractures

Abstract Objective: To evaluate the tolerability and efficacy of intranasal fentanyl analgesia for children. Methods: A prospective, open-label, two-arm pilot study was conducted. Children, aged 3 to 10 years, with clinical limb fractures were randomized to receive 1 μg/kg intranasal fentanyl via nasal spray or 0.2 mg/kg intramuscular morphine. Tolerance to administration, pain scores, rescue analgesia, adverse events and physiological data were recorded at intervals over 30 min. Results: Forty-seven children were recruited to the study. Tolerance to administration was better for intranasal fentanyl compared with intramuscular morphine (median scores 1 vs 2; P < 0.001). Pain scores over the trial period were similar in both groups. One child receiving intranasal fentanyl required rescue analgesia. No significant adverse effects were noted. Conclusions: Intranasal fentanyl provides effective paediatric analgesia comparable to intramuscular morphine and is better tolerated. A larger study is needed to determine dose range and confirm safety.     

Postoperative epidural analgesia with Bupivacaine-HCl 0.06%/Fentanyl 0.0002%. Experiences and physicochemical stability in infusion bags

Continuous epidural infusion of bupivacaine with the opioid fentanyl represents an effective analgesic method in the therapy of strong postoperative pain after major surgery. Preparation of the required infusion solution in syringes with a volume of 50 ml immediately prior to administration is routinely performed by nursing staff in Germany. The effort required for the preparation is associated with logistical and pharmaceutical difficulties. The preparation of a mixture of bupivacaine hydrochloride 0.06% and fentanyl 0.0002% in 250 ml infusion bags at the pharmacy of the University Hospital Mainz is described. To determine the physicochemical stability, the concentration of bupivacaine-HCl and fentanyl was assessed using HPLC over a period of 32 days; in addition the pH values were determined. After 32 days 95% of the bupivacaine hydrochloride and fentanyl baseline values were recorded. The pH baseline value had decreased from 5.48-5.52 to 0.5-0.7 units. The measured values confirm the physicochemical stability of the mixture of bupivacaine hydrochloride 0.06% and fentanyl 0.0002% over a period of 32 days. The infusion bag can be stored for 4 weeks at room temperature.     

Combined spinal-epidural analgesia vs. intermittent bolus epidural analgesia for pain relief after major abdominal surgery. A prospective, randomised, double-blind clinical trial

BACKGROUND: The primary aim of this study was to compare the efficacy of combined spinal-epidural (CSE) analgesia vs. intermittent bolus epidural analgesia (EA) for pain relief after major abdominal surgery. The secondary aim was to assess the effects of fentanyl addition to subarachnoid morphine and bupivacaine. METHODS: This was a prospective, randomised, double-blind trial; 160 patients scheduled for major abdominal surgery enrolled. All patients had a thoracic epidural catheter for administration of intra-operative and postoperative analgesia. Patients were assigned to one of four groups: (i) subarachnoid morphine, bupivacaine and fentanyl (MBF group); (ii) morphine and bupivacaine (MB group); (iii) morphine (M group) and (iv) normal saline (EA group). Use of additional intravenous (i.v.) fentanyl and epidural bupivacaine was recorded to measure the need for supplemental intra-operative analgesia. Pain at rest, with movement, and with cough (measured with a visual analogue scale), additional analgesia requests, and side effects were recorded over 72 h postoperatively. RESULTS: Compared with the EA group, the MBF group had significantly reduced pain with cough and lower analgesia requirements during the first 24 h (p<0.001) and after EA discontinuation (p=0.041). The MBF group required less intra-operative epidural bupivacaine compared with all other groups (p<0.001), and less intra-operative i.v. fentanyl compared with group M (p<0.001). CONCLUSIONS: Combined spinal-epidural improved intra-operative analgesia and reduced pain with cough in the immediate postoperative period. The addition of fentanyl to subarachnoid morphine and bupivacaine decreased the need for additional i.v. fentanyl and epidural bupivacaine analgesia.     

Intranasal fentanyl in 1–3‐year‐olds: A prospective study of the effectiveness of intranasal fentanyl as acute analgesia

The primary objective of the present study was to determine the effectiveness of intranasal fentanyl analgesia in children aged 1–3 years with acute moderate to severe pain presenting to the ED. We also aimed to gather information on the safety and acceptability of intranasal fentanyl in this age group. Two paediatric ED enrolled children aged 1–3 years, with acute moderate or severe pain. Intranasal fentanyl was administered (1.5 µg/kg) via a mucosal atomiser device using a 50 µg/mL solution of fentanyl. Physiological parameters (heart rate, respiratory rate, oxygen saturations and level of consciousness) were measured at regular intervals. Objective pain assessment was completed using the Faces, Legs, Arms, Cry, Consolability (FLACC) score. Forty‐six children presenting with acute moderate to severe pain were included. The median FLACC score before intranasal fentanyl administration was 8 (interquartile range [IQR] 5–10), decreasing to 2 (IQR 0–4) 10 min post fentanyl (P < 0.0001) and 0 (IQR 0–2) 30 min post fentanyl (P < 0.0001). A clinically significant decrease in FLACC scores was seen in 93% of children 10 min post fentanyl administration and 98% of children 30 min post fentanyl. Intranasal fentanyl delivery using a mucosal atomiser was well tolerated by all children. There were no adverse drug reactions or adverse events detected. Intranasal fentanyl is an effective, safe and well‐tolerated mode of analgesia for children aged 1–3 years with moderate to severe pain.     

Epidural analgesia—experience of 5628 patients in a large teaching hospital derived through audit

A prospective audit of 5628 surgical patients was conducted to determine the success, failure and complication rates associated with postoperative epidural analgesia. The majority of patients received infusions of bupivacaine 0.1% with hydromorphone 20 μg/cm³. However, elderly and frail patients received plain bupivacaine 0.1% or bupivacaine 0.1% with fentanyl 2 μg/cm³. Postoperatively, epidural infusions were selected, adjusted or terminated as indicated. Termination of epidural analgesia was defined as either success, if the infusion was continued until there was no further need for epidural analgesia, or failure, if the infusion was discontinued prematurely due to problems with the catheter or treatment that could not be controlled through intervention. Twenty-two percent of patients had their epidural catheter removed prematurely due to either technical (catheter) or treatment (medication) problems that could not be resolved. Technical problems with the catheter caused 807 failures (14% of all patients). Almost 70% of the technical failures (N=554) were due to catheter dislodgement. Treatment problems resulted in 451 failures (8% of all patients). The majority of treatment failures were due to inadequate analgesia despite functioning catheters. This audit has proved useful in maintaining standards of care and in identifying problems with postoperative epidural therapy that still need improvement. It allows a balanced assessment of the value of this treatment in the setting of a large teaching hospital and is the largest reported series of postoperative epidural hydromorphone analgesia.     

舒芬太尼用于髋关节置换术后患者自控硬膜外镇痛的观察

目的比较舒芬太尼与等效剂量芬太尼在髋关节置换术后患者硬膜外镇痛的临床效果。方法 2006年11月-2008年9月收治的50例硬膜外麻醉下髋关节置换术患者,随机分为两组（n=25）。芬太尼组（A组）：芬太尼0.75mg加0.894%甲磺酸哌卡因20mL加生理盐水至100mL;舒芬太尼组（B组）,舒芬太尼75μg加0.894%甲磺酸哌卡因20mL加生理盐水至100mL硬膜外镇痛。其中,A组患者于手术结束时,静脉滴注格拉司琼3mg。持续剂量2mL/h,单次给药量（PCA）0.5mL/次,锁定时间15min。观察两组的镇痛效果,恶心、呕吐次数,记录脉搏血氧饱和度、心率、呼吸的变化。结果镇痛泵开机后,B组各时段镇静评分,2分以上者明显多于A组,镇痛评分明显低于A组,有统计学意义（P〈0.05）,两组术后恶心、呕吐发生率都较低,组间差异无统计学意义（P〉0.05）。两组4、12、24h的呼吸频率和脉搏血氧饱和度差异有统计学意义（P〈0.05）,但48h的呼吸频率和脉搏血氧饱和度无统计学意义（P〉0.05）。结论在等效剂量下,髋关节置换术后患者硬膜外镇痛,舒芬太尼明显优于芬太尼。