酒石酸布托啡诺在硬膜外术后镇痛中的应用

目的通过与吗啡作对比研究酒石酸布托啡诺在术后硬膜外镇痛中的效能和副作用。方法56例择期行在腰硬联合麻醉下行下腹部手术患者,男36例,女20例,年龄21岁～63岁,ASAⅠ～Ⅱ,随机分成二组：M组（吗啡组n=28）：0．004％吗啡＋0．12％布比卡因,B组（酒石酸布托啡诺n=28）：0．004％酒石酸布托啡诺＋0．12％布比卡因,进行硬膜外术后镇痛。手术缝皮时分别向两组病人硬膜外腔注射吗啡或酒石酸布托啡诺1mg做为负荷剂量,然后接硬膜外PCA泵,参数设定如下背景输入速度2ml／h,自控镇痛剂量0．5ml／次,锁定时间15min。用VAS评分评价镇痛效果,同时观察硬膜外术后镇痛的并发症。结果两组镇痛效果都较为满意;酒石酸布托啡诺组的VAS评分低于吗啡组,但无统计学意义。酒石酸布托啡诺组瘙痒、恶心、呕吐的发生率低于吗啡组。结论酒石酸布托啡诺硬膜外术后镇痛效果可靠,副作用少,值得在临床中推广使用。     

Continuous postoperative epidural analgesia in management of postoperative surgical pain

In the last fifteen months we have used continuous postoperative epidural analgesia after open urologic surgery and herein report our experience with the first 64 patients. Incisional pain was completely eliminated in 96 percent of patients. Epidural analgesia diminished pain-related pulmonary complications without sedation. Complications were tolerable and manageable. Hypotension due to sympathetic blockade responds to intravenous fluid administration. Urinary retention is avoidable if the epidural infusion is discontinued prior to removing the urethral catheter. Itching is an undesirable consequence observed by 20 percent of patients when morphine is used.     

The use of intrathecal morphine for postoperative pain relief after liver resection: a comparison with epidural analgesia

An epidural catheter is used in some institutions for postoperative analgesia after liver surgery. However, anesthesiologists may not feel comfortable leaving a catheter in the epidural space because of concern about coagulation disturbances and possible bleeding complications caused by impaired liver function. In this study, we tested a single-shot intrathecal morphine technique and compared it to a continuous epidural naropine infusion for postoperative analgesia in liver surgery. Fifty patients were randomly assigned to an epidural analgesia group (EP group; n = 25) and an intrathecal analgesia group (IN group; n = 25). The quality of analgesia assessed by a visual analog scale (VAS), the side effects, and the additional IV analgesic requirements were recorded. We did not observe any signs of cord compression. Time to first pain drug requirement was longer in the EP group compared to the IN group (25 +/- 18.5 h versus 12 +/- 10.3 h; P < 0.05). In both groups, the VAS remained less than 30 mm throughout the 48-h follow-up period. Consumption of IV morphine with a patient-controlled analgesia device in the IN group was larger (mostly from 24 to 48 h after surgery) than the EP group (12.0 +/- 5.54 mg versus 3.1 +/- 2.6 mg, respectively; P < 0.01). The incidence of vomiting was 4% in both groups, whereas the incidence of pruritus (16% versus 0%) and nausea (16% versus 4%) was more frequent in the IN group. No postdural puncture headache and no spinal hematoma occurred. After liver resection, a single dose of intrathecal morphine followed by patient-controlled morphine analgesia can provide satisfactory postoperative pain relief. The quality of this treatment, according to the VAS, is not inferior to continuous epidural analgesia up to 48 h after surgery.     

Preoperative adjuvant epidural tramadol: the effect of different doses on postoperative analgesia and pain processing

Background: Tramadol is an analgesic with combined opioid agonist and monoamine reuptake blocker properties, which may be useful as a perioperative analgesic and antinociceptive adjuvant.
Methods: The dose-dependent effects of adjuvant preoperative epidural tramadol on postoperative analgesia (pain scores and patient-controlled analgesia (PCA) use) and pain processing (heat pain thresholds) were prospectively studied in a double-blind, randomised, placebo-controlled 5-day trial. Forty patients undergoing knee or hip surgery received anaesthesia with epidural lidocaine and epidural tramadol 20, 50 or 100 mg or placebo as a preoperative adjuvant. Postoperative analgesia was by intravenous PCA tramadol in all patients.
Results: Postoperative pain scores were similar in all groups. The time to first PCA use was shorter, the total dose and duration of PCA use greater, and side-effects more common with 20 mg tramadol than with 100 mg or placebo ( P <0.05). There were no differences in PCA doses required or side-effects between the tramadol 100 mg and placebo treatment groups. Heat pain tolerance thresholds were increased with 100 mg tramadol at 48 h postoperatively compared to baseline and placebo ( P = 0.01).
Conclusions: Preoperative adjuvant epidural tramadol does not improve postoperative analgesia after lidocaine epidural anaesthesia compared to placebo. Tramadol 20 mg results in anti-analgesia and increased side-effects. While tramadol 100 mg depresses postoperative pain-processing, as measured by heat pain tolerance thresholds, this is not reflected in improved clinical pain measures.     

Comparison of pain management after laparoscopic distal gastrectomy with and without epidural analgesia

Purpose

The optimal analgesia following laparoscopic distal gastrectomy (LDG) has not been determined; moreover, it has been unclear whether epidural anesthesia has benefits for laparoscopic surgery. In this study, we evaluated the effectiveness of epidural analgesia after LDG.

Methods

This retrospective study included 84 patients who underwent LDG for gastric cancer. Patients received either combined thoracic epidural and general anesthesia (Epidural group, n = 34) or general anesthesia alone (No epidural group, n = 50). We recorded data on the patients, surgery, postoperative outcomes and anesthesia-related complications.

Results

In the Epidural group, the first day of flatus was significantly earlier (2.21 vs. 2.44 days, p = 0.045) and the number of additional doses of analgesics was significantly lower (2.85 vs. 4.86 doses, p = 0.007) than in the No epidural group. Postoperative urinary retention occurred at a significantly higher rate in the Epidural group (n = 7; 20.6 %) than in the No epidural group (p < 0.001).

Conclusion

Epidural anesthesia may reduce the need for additional analgesics after LDG, but increases the risk of urinary retention.

     

An analysis of postoperative epidural analgesia failure by computed tomography epidurography

In this prospective study involving 125 patients, we analyzed epidural analgesia failure after major abdominal surgery using computed tomography (CT) epidurographies to compare the incidence of dislodgement of epidural catheters and leakage of solution from the epidural space between two groups of patients: patients with successful or failed epidural analgesia. Our hypothesis was that the incidence of dislodgement and leakage should be low when epidural analgesia is successful. A thoracic epidural catheter was inserted before general anesthesia and secured by subcutaneous tunneling. Bupivacaine (0.25%) was administered during surgery followed by continuous epidural analgesia with 0.125% bupivacaine (10 mL/h) and morphine (0.25 mg/h) for 48 h. Failure was defined as a visual analog scale pain score at rest more than 30 mm and/or interruption of epidural analgesia before 48 h for any reason. When failure was not due to unintentionally withdrawn, kinked catheters or adverse events (n = 11), a CT scan with contrast injection was performed. Control CT scans were also performed in patients with adequate analgesia (i.e., the success group). The incidence of failure was 24.8% (n = 31). CT scans in the failure group (n = 20) showed seven patients with catheters outside the epidural space, nine with normal distribution, one with unilateral spread, and three with leakage of solution outside the epidural space. In the success group, CT scans (n = 19) showed 11 patients with normal distribution, five with unilateral spread, and three with leakage. We conclude that the major cause of epidural analgesia failure was dislodgment of the catheter. CT scans were mostly useful for detecting leakage of injectate, which may be the early phase of dislodgment.     

The use of intraoperative epidural or spinal analgesia modulates postoperative hyperalgesia and reduces residual pain after major abdominal surgery

INTRODUCTION: The use of intraoperative multimodal analgesia has clearly improved postoperative pain control, mortality and morbidity after major surgical procedures. However, very few clinical trials have studied the longterm impact of intraoperative epidural or spinal analgesia on chronic postsurgical pain (CPSP) development. Even less studies have evaluated the modulatory effect of intraoperative neuraxial analgesia on objective changes (i.e. mechanical hyperalgesia) reflecting central sensitization. METHODS: The present work compares general anesthesia alone (GA group) versus general anesthesia combined to either intraoperative epidural analgesia (EPID group: combination of bupicavaine, sufentanil and clonidine 1 microg/kg) or spinal analgesia (IT group: either bupivacaine or clonidine 300 microg) on the development of secondary mechanical hyperalgesia and the incidence of CPSP after major abdominal surgery. Data analyzed in the present work involve adult patients undergoing surgical resection of rectal adenocarcinoma who participated in three previously published randomized trials. RESULTS: Intraoperative epidural and particularly spinal analgesia reduced both incidence (p < 0.05 between GA alone and spinal analgesia) and extent (area) of secondary mechanical hyperalgesia surrounding the wound at 48h and 72 h after surgery. The use of intraoperative epidural and spinal analgesia also reduced CPSP incidence. Postoperative area of mechanical hyperalgesia seems positively correlated with the incidence CPSP. CONCLUSION: An effective intraoperative neuraxial block of nociceptive inputs from the wound using multimodal analgesia--specifically when involving spinal analgesics and antihyperalgesic drugs--contributes to prevent central sensitization and hence reduces CPSP after major abdominal procedures.     

The dose of caudal epidural analgesia and duration of postoperative analgesia

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

Imaging human cerebral pain modulation by dose-dependent opioid analgesia: a positron emission tomography activation study using remifentanil

BACKGROUND: Previous imaging studies have demonstrated a number of cortical and subcortical brain structures to be activated during noxious stimulation and infusion of narcotic analgesics. This study used O-water and positron emission tomography to investigate dose-dependent effects of the short-acting mu-selective opioid agonist remifentanil on regional cerebral blood flow during experimentally induced painful heat stimulation in healthy male volunteers. METHODS: Positron emission tomography measurements were performed with injection of 7 mCi O-water during nonpainful heat and painful heat stimulation of the volar forearm. Three experimental conditions were used during both sensory stimuli: saline, 0.05 microg x kg x min remifentanil, and 0.15 microg x kg x min remifentanil. Cardiovascular and respiratory parameters were monitored noninvasively. Across the three conditions, dose-dependent effects of remifentanil on regional cerebral blood flow were analyzed on a pixel-wise basis using a statistical parametric mapping approach. RESULTS: During saline infusion, regional cerebral blood flow increased in response to noxious thermal stimulation in a number of brain regions as previously reported. There was a reduction in pain-related activations with increasing doses of remifentanil in the thalamus, insula, and anterior and posterior cingulate cortex. Increasing activation occurred in the cingulofrontal cortex (including the perigenual anterior cingulate cortex) and the periaqueductal gray. CONCLUSIONS: Remifentanil induced regional cerebral blood flow increases in the cingulofrontal cortex and periaqueductal gray during pain stimulation, indicating that mu-opioidergic activation modulates activity in pain inhibitory circuitries. This provides direct evidence that opioidergic analgesia is mediated by activation of established descending antinociceptive pathways.     

The use of positron emission tomography in detecting hepatoblastoma recurrence--a cautionary tale

Purpose

The use of positron emission tomography (PET) with [18F] fluorodeoxyglucose (FDG) in the detection of recurrences has been well established in many tumor types. Here the authors present their experience using this modality in the evaluation of posttreatment hepatoblastoma patients.

Methods

The authors conducted a retrospective review on patients with hepatoblastoma diagnosed from 1996 to 2003. FDG-PET imaging was performed together with measurement of alpha-fetal protein (AFP) during posttreatment follow-up.

Results

Sixteen patients (8 boys and 8 girls) were identified in this series. The mean age was 23.5 months (range, 5 months to 4 years). Three posttreatment patients had PET results suggestive of tumor recurrence. One of these patients had normal AFP level and suspected recurrence in the caudate lobe. Radiologic-guided biopsy was performed 3 times, and there was no evidence of tumor. The other 2 patients underwent further liver resections because of mildly raised AFP levels. The histology of these showed regenerative liver tissue only with no hepatoblastoma recurrence.

Conclusions

Although PET has been gaining popularity as a tool in the detection of tumor recurrences worldwide, it has been shown in this series that PET may not be useful in hepatoblastoma patients, and caution must be taken in the interpretation of positive results.     

The risks of overly effective postoperative epidural analgesia

Continuous epidural analgesia is frequently used to provide supplemental postoperative pain control. Epidural analgesia has the potential to mask the early symptoms that signal impending complications after even routine surgical procedures. We report a case of sciatic nerve palsy following epidural anesthesia after an uncomplicated leg length correction. Good epidural anesthesia may remove a patient's normal protective sensation, allowing pain and other signs of nerve compression from prolonged unchanged postoperative positioning to go unnoticed. This case highlights the need for heightened awareness of potential neurologic compromise in the setting of epidural analgesia. We recommend closely monitoring the patient's neurologic condition and frequently evaluating the patient's position in bed.     

Safety and efficacy of postoperative epidural analgesia

Br J Anaesth 2001; 87: 47–61