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.     

Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia: a randomized, double-blinded, placebo-controlled study.

Pain is the dominant complaint after laparoscopic cholecystectomy. No study has examined the combined effects of a somato-visceral blockade during laparoscopic cholecystectomy. Therefore, we investigated the effects of a somato-visceral local anesthetic blockade on pain and nausea in patients undergoing elective laparoscopic cholecystectomy. In addition, all patients received multi-modal prophylactic analgesic treatment. Fifty-eight patients were randomized to receive a total of 286 mg (66 mL) ropivacaine or 66 mL saline via periportal and intraperitoneal infiltration. During the first 3 postoperative h, the use of morphine and antiemetics was registered, and pain and nausea were rated hourly. Daily pain intensity, pain localization, and supplemental analgesic consumption were registered the first postoperative week. Ropivacaine reduced overall pain the first two hours and incisional pain for the first three postoperative hours (P < 0.01) but had no apparent effects on intraabdominal or shoulder pain. During the first 3 postoperative h, morphine requirements were lower (P < 0.05), and nausea was reduced in the ropivacaine group (P < 0.05). Throughout the first postoperative week, incisional pain dominated over other pain localizations in both groups (P < 0.01). We conclude that the somato-visceral local anesthetic blockade reduced overall pain during the first 2 postoperative h, and nausea, morphine requirements, and incisional pain were reduced during the first 3 postoperative h in patients receiving prophylactic multi-modal analgesic treatment. IMPLICATIONS: A combination of incisional and intraabdominal local anesthetic treatment reduced incisional pain but had no effect on deep intraabdominal pain or shoulder pain in patients receiving multimodal prophylactic analgesia after laparoscopic cholecystectomy. Incisional pain dominated during the first postoperative week. Incisional infiltration of local anesthetics is recommended in patients undergoing laparoscopic cholecystectomy.     

Femoral nerve block for total knee arthroplasty patients: a method to control postoperative pain

This study was designed to determine the effects of a single-injection femoral nerve block (FNB) using 30 mL of 0.5% bupivacaine with epinephrine 1:200,000, on pain control following total knee arthroplasty (TKA). Forty patients were randomly distributed into 2 groups: Group A received general anesthesia plus a FNB (n = 19), whereas Group B received general anesthesia plus a FNB with 30 mL of preservative-free saline (n = 21). The amount of morphine used, sedation, and average pain perception were measured for the first 24 hours and daily postoperatively. Group A used significantly less morphine (48.1 mg) compared with Group B, which used 76.2 mg during the first 24 hours after surgery (P = 0.003). Group A's sedation scale was significantly less than group B's (2.26 vs 2.67) (P = 0.045). The average pain perception was significantly different (P =.002). Postoperative management of pain following TKA can be improved through a preoperative single-injection FNB with 0.5% bupivacaine plus epinephrine 1:200,000. The cost is minimal, risks appear acceptable, and the procedure is efficacious.     

Intraperitoneal and intravenous routes for pain relief in laparoscopic cholecystectomy.

BACKGROUND: Postoperative abdominal and shoulder pain are the most common complaints after elective laparoscopic cholecystectomy. Postoperative pain is multifactorial in origin, and therefore multimodal therapy may be needed to optimize pain relief. METHODS: We conducted a double-blind study where patients were randomly allocated to 1 of 5 groups of 20 patients each. Statistical significance was considered P<0.05. Group 1 received 40 mL bupivacaine 0.25% intraperitoneal spray. Group 2 received 40 mL bupivacaine 0.25% intraperitoneal spray mixed with 200 mg ketoprofen. Group 3 received 40 mL bupivacaine 0.25% intraperitoneal spray and intravenous 200 mg ketoprofen. Group 4 received 200 mg ketoprofen intravenously. Group 5 was the control group. RESULTS: Demographic data were similar in the 5 groups. As compared with the control group, group 1 had significantly lower abdominal pain scores at 6 hours; group 2 at 0, 1, 2, and 6 hours; group 3 at 0, 1, 2, 6, 12, and 24 hours; and group 4 at 2 hours. Group 1 had significantly lower shoulder pain scores at 1 and 6 hours; group 2 at 0 and 6 hours; and groups 3 and 4 at 0, 1, and 6 hours. The number of patients requiring postoperative rescue analgesics and the incidence of postoperative vomiting were significantly lower in group 3 only. CONCLUSIONS: A multimodal approach to pain management following elective laparoscopic cholecystectomy is best achieved with a combination of 40 mL bupivacaine 0.25% intraperitoneal spray and 200 mg intravenous ketoprofen, achieving the least incidence of postoperative vomiting.     

Intraperitoneal application of bupivacaine plus morphine for pain relief after laparoscopic cholecystectomy

BACKGROUND AND OBJECTIVE: Intraperitoneal administration of a local anaesthetic in combination with an opioid, for the relief of postoperative pain, has already been reported except after laparoscopic cholecystectomy. This study was aimed at assessing the analgesic effect of the intraperitoneal administration of bupivacaine and morphine in patients undergoing laparoscopic cholecystectomy. METHODS: At the end of laparoscopic cholecystectomy, in a double-blind, randomized manner, one of the following injections was given intraperitoneally. There were 30 patients in each group: Group 1, physiological saline 30 mL; Group 2, bupivacaine 0.25% 30 mL; Group 3, bupivacaine 0.25% 30 mL plus morphine 2 mg. In addition, Group 2 received 2 mg intravenous (i.v.) morphine in 2 mL saline, and Groups 1 and 3, 2 mL saline intravenously. Patients' postoperative pain was evaluated using a visual analogue scale and a verbal rating score. The postoperative analgesic requirement was assessed by the total dose of metamizol administered by an i.v. patient-controlled analgesia (PCA) device. Pain, vital signs, supplemental analgesic consumption and side-effects were recorded for all patients for 24 h. RESULTS: There were no differences between the three groups regarding pain scores (at rest and coughing) during the study except in the first 2 h, when scores were lower for patients receiving intraperitoneal bupivacaine plus i.v. morphine (P < 0.05). Supplemental consumption of metamizol was significantly lower (P < 0.05) in Group 3 than in Group 1 during the first 6 h after surgery. However, the cumulative doses of metamizol were also lower in Group 2 than in Groups 1 and 3 over the entire study (2025 +/- 1044 mg vs. 4925 +/- 1238 and 4125 +/- 1276mg; P < 0.05). CONCLUSIONS: In patients undergoing laparoscopic cholecystectomy, the intraperitoneal administration of morphine plus bupivacaine 0.25% reduced the analgesic requirements during the first 6 postoperative hours compared with the control group. However, the combination of intraperitoneal bupivacaine 0.25% and i.v. morphine was more effective for treatment of pain after laparoscopic cholecystectomy.     

Local anesthesia and midazolam versus spinal anesthesia in ambulatory pilonidal surgery

STUDY OBJECTIVE: To evaluate two anesthetic techniques, namely, local anesthesia with sedation, and spinal anesthesia, with respect to recovery times, postoperative side effects, pain scores, patient satisfaction, and hospital costs for ambulatory pilonidal disease surgery. DESIGN: Prospective, randomized study. SETTING: University Hospital of Pamukkale. PATIENTS: 60 consenting patients scheduled for pilonidal disease operation with Limberg flap technique. INTERVENTION: Patients were randomly allocated into two groups: Group 1 (n = 30) received spinal anesthesia with hyperbaric bupivacaine 1.5 mL 0.5%, and Group 2 (n = 30) received local infiltration with a 50-mL mixture containing 10 mL bupivacaine 0.5%, 10 mL prilocaine HCl 2%, and 30 mL isotonic solution with 1:200,000 epinephrine in combination with intravenous (i.v.) midazolam sedation. MEASUREMENTS: Perioperative and postoperative side effects, patient satisfaction, preoperative visual analog scale (VAS) pain scores, and VAS scores from the fourth hour postoperatively until the seventh day were assessed. Anesthesia, operation, surgery, and total hospital time, and costs (drug, resources, and labor) were recorded. MAIN RESULTS: No difference was found between groups in the frequency of side effects. Urinary retention was diagnosed in two patients in the spinal anesthesia group. There was no statistical significant difference seen in satisfaction scores between groups. No statistical significance in VAS pain scores between groups was noted except for the fourth postoperative hour values. The average time spent in the operating room (OR) was greater in the spinal anesthesia group. All Group 2 patients achieved fast-tracking criteria in the OR and were able to bypass the postanesthesia care unit (PACU). Total hospital time and total cost were significantly higher in the spinal anesthesia group than local anesthesia-sedation group (p < 0.05). CONCLUSION: The use of local anesthesia-sedation for ambulatory anorectal surgery resulted in a shorter hospital time, lower hospital costs, and no side effects compared with spinal anesthesia.     

Comparison of postoperative analgesic effects of preemptively used epidural ketamine and neostigmine

STUDY OBJECTIVE: To compare the analgesic and side effects of preemptively used epidural ketamine +bupivacaine, neostigmine +bupivacaine, and bupivacaine alone on postoperative analgesia after major abdominal surgery. DESIGN: Randomized, controlled study. SETTING: Inpatient anesthesia at the department of surgery of a metropolitan hospital. PATIENTS: 30 ASA physical status I, II, and III patients scheduled for abdominal surgery. INTERVENTIONS: Group K received 1 mL (50 mg) ketamine and 5 mL (25 mg) bupivacaine epidurally, Group N received 1 mL (0.5 mg) neostigmine and 5 mL (25 mg) bupivacaine epidurally, and Group B received 1 mL saline and 5 mL (25 mg) bupivacaine epidurally 30 minutes before operation. All patients underwent anesthesia induction with thiopental and vecuronium; anesthesia was maintained with isoflorane and vecuronium. For postoperative analgesia, all patients received epidural morphine for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Standard monitoring included: 48 hours of analgesic requirement, visual analog scale (VAS), mean arterial pressure (MAP), and heart rate (HR) in the 1st, 2nd, 6th, 12th, 24th, and 48th hours. Data were analyzed using Kruskall-Wallis and Mann Whitney U tests, with a p < 0.05 considered statistically significant. No significant differences were observed regarding MAP and HR among the groups during the study period. In Group N, VAS was significantly lower than Group K and Group B. The total opioid consumption in Group N was significantly lower than in Groups K and B in the first 48 hours after the operation. CONCLUSIONS: Preemptive neostigmine can be a good choice for postoperative analgesia.     

The pre-emptive analgesic effect of intra-articular bupivacaine in arthroscopic knee surgery

BACKGROUND: The purpose of this study was to determine whether intra-articular injection of bupivacaine prior to surgery provided better pain control after arthroscopic meniscectomy as compared with post-operative administration of bupivacaine. METHODS: Forty patients of American Society of Anesthesiologists (ASA) class I or II undergoing arthroscopic meniscectomy were assigned in a randomized, double-blinded manner into two groups: Group I received 20 ml of 2.5 mg/ml bupivacaine without epinephrine 30 min before skin incision and 20 ml of saline immediately after skin closure. Group II received identical injections in reverse order. All patients received total intravenous anesthesia. Post-operative pain scores were evaluated at 1, 2, 4, 6, 8, 12 and 24 h at rest and movement of the knee, using a 10-cm visual analog scale (VAS). The time to first analgesic use and 24-h analgesic consumption were recorded. RESULTS: Pain scores were lower in Group I compared with Group II at 1, 2, 4 and 6 h at rest and on movement (P < 0.05). The time to first analgesic use was longer in Group I, but there was no statistically significant difference in 24-h analgesic consumption. CONCLUSION: Intra-articular bupivacaine administered before surgery provided a statistically significant reduction in post-operative pain scores compared with post-operative bupivacaine administration.     

Post-laparoscopic cholecystectomy pain: effects of intraperitoneal local anesthetics on pain control--a randomized prospective double-blinded placebo-controlled trial

Postoperative pain after laparoscopic cholecystectomy (LC) is generally less than open cholecystectomy; however, the postoperative shoulder and abdominal pain experienced by patients still causes preventable distress. Intraperitoneal irrigation of the diaphragmatic surface and gallbladder fossa using normal saline, bupivacaine, or lignocaine may effectively control visceral abdominal pain after an LC. Two hundred patients with similar demographics undergoing elective LC were randomized to one of four groups of 50 patients each, including Group A placebo control, Group B with isotonic saline irrigation, Group C with bupivacaine irrigation, and Group D with lignocaine irrigation. All patients received preperitoneal abdominal wall infiltration with 0.25 per cent bupivacaine to control parietal (somatic) abdominal pain. The visual analogue and verbal rating pain scores at 0, 4, 8, 12 and 24 hours for both shoulder and abdominal pain were recorded in a prospective double-blind fashion at four points during the first 24 postoperative hours. Analgesia requirements, vital signs, blood glucose, and incidence of nausea and vomiting were also recorded. Patients in each group demonstrated a significant difference in visual analogue and verbal rating pain scores and analgesic consumption when compared with controls. Lignocaine controlled pain significantly better than saline or bupivacaine. Bowel function recovery was similar in all patients, and there were no significant complications. We conclude that intraperitoneal irrigation with either saline, bupivacaine, or lignocaine can significantly reduce visceral abdominal pain after LC. Lignocaine was the most efficacious local anesthetic in this trial and has a high safety profile when used at recommended doses.     

Bilateral infraorbital block with 0.5% bupivacaine as post-operative analgesia following cheiloplasty in children.

Various studies have shown that bupivacaine nerve blocks provide prolonged post-operative analgesia. We studied the efficacy of a 0.5% bupivacaine infraorbital nerve block as post-operative analgesia in a random, prospective, double blind manner in children undergoing cleft lip repair. Following the induction of anesthesia with ketamine 2-4 mg/kg im, 60 patients, aged 2-13 years, ASA I and II were equally divided: Group A received 1-1.5 ml bupivacaine, 0.5% with 1:200,000 epinephrine; Group B received 1-1.5 ml saline injected into the vicinity of the infraorbital foramina. In every patient, the surgeon infiltrated the lip with 4-7 ml of 1% lidocaine with 1:100,000 epinephrine for both anesthesia and hemostasis. Post-operative evaluations were completed after 4, 8, and 12 to 24 hours and were based on a visual analogue scale for pain. Similarly, the nurses and the parents also evaluated post-operative discomfort using specific criteria. All the observers were kept unaware of the solutions used for the block. The results showed that Group A was pain free for a mean duration of 19.4 +/- 5.06 (SD) hours in contrast to 11.7 +/- 6.19 hours for Group B, (p less than 0.001). Group A required no other analgesic whereas a total of 17 patients in Group B required analgesic medication starting at four hours post-operatively, (p less than 0.001). Both the nurses and the parents confirmed that those who received infraorbital block were more comfortable than those who did not. One-way analysis of variance indicates that the mean scores for both groups differs significantly at all levels of comparison, (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of bupivacaine and fentanyl as an adjuvant of epidural morphine for postoperative analgesia

We conducted a retrospective study to determine whether bupivacaine or fentanyl is a better adjuvant to epidural morphine for postoperative analgesia using 108 patients. Following epidural lidocaine anesthesia with or without light general anesthesia for major gynecological surgeries, 59 patients received epidural morphine (EPM) 2 mg (group M), 21 patients received morphine 2 mg plus 0.25% plain bupivacaine 6–10 ml epidurally (group B), and 28 patients received morphine 2 mg plus fentanyl 100 μg epidurally (group F). The analgesic interval, defined as the duration from EPM injection to the first request of analgesics for incisional pain, was significantly longer in group F than in group M (29±11vs 19±17 h,P<0.05), but similar to group B (22±14 h). Group F patients required the least amount of analgesics for incisional pain of the three groups during the first 24 h postoperatively (P<0.01). The incidence of adverse effects was similar among all three groups. In conclusion, fentanyl appears to be a better adjuvant to epidural morphine than bupivacaine.     

Postoperative analgesia after peripheral nerve block for podiatric surgery: clinical efficacy and chemical stability of lidocaine alone versus lidocaine plus ketorolac

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine whether the addition of ketorolac tromethamine to local anesthesia for ankle block alters the quality or duration of analgesia after podiatric surgery. The second aim was to determine the chemical stability of ketorolac tromethamine when added to local anesthetic solutions. METHODS: The study design was double-blinded, placebo-controlled, and randomized. Seventy-nine American Society of Anesthesiologists (ASA) class I or II patients scheduled for bunionectomy or hammer toe repair, or both were randomized to 1 of 4 groups. Group L received plain 1.73% lidocaine for their ankle block. Group K received 1.73% lidocaine with ketorolac (4 mg/mL) added to the local solution. Group Kiv received 1.73% plain lidocaine for ankle block and 20 mg of ketorolac intravenously. Group E received 1.73% lidocaine with .67% ethanol added. The final concentration of lidocaine for all groups was 1.73%. The block performed in each patient was a 5-point ankle block. Beginning at 1 hour after the completion of the block and every 30 minutes thereafter, visual analogue scale (VAS) and verbal pain scores were recorded. The time from performance of the block to the initial pain and time to the first oral pain medication intake were also recorded. The time and amount of postoperative oral analgesics in the first 9 hours after the block were recorded. Adverse events were also recorded for each group. RESULTS: There were significantly lower overall VAS and verbal pain scores for group K compared with groups E and L and group Kiv compared with group E. Group K also had a significantly longer time to the first reported pain and first oral pain medications than groups E and L, but not with Group Kiv. The same group had significantly fewer average doses of pain medications postoperatively than Groups E and L. Group E had significantly shorter times to first report of pain and first pain medications and higher mean dose of postoperative oral analgesics than group K and Group Kiv. There were no untoward side effects reported from any group. Chemical analysis by gas chromatography (GC) and capillary electrophoresis (CE) showed no significant change in composition of the solutions when ketorolac was mixed with lidocaine and/or bupivacaine and stored at 37 degrees C for 1 week. CONCLUSIONS: The addition of ketorolac to lidocaine for ankle block contributed to longer duration and better quality analgesia after foot surgery compared with plain 1.73% lidocaine or 1.73% lidocaine plus intravenous ketorolac. The ethanol vehicle is unlikely responsible for the analgesic effects of ketorolac. Ketorolac retains its chemical stability when placed in local solutions of lidocaine or bupivacaine.     

Prior ibuprofen exposure does not augment opioid drug potency or modify opioid requirements for pain inhibition in total hip surgery

PURPOSE: In previous animal studies, a prior exposure to non-steroidal anti-inflammatory drugs (NSAID) augmented opioid drug potency. This study was designed to answer the question whether a similar effect can be attained in man. The objective was to use NSAID for preoperative pain reduction and at the same time use the NSAID exposure to reduce opioid requirements for pain inhibition in major orthopedic surgery. METHODS: In this double-blind, randomized study, 50 patients scheduled for total hip surgery were included. Patients of Group I received a placebo drug three times a day two weeks before surgery, and those allocated to Group II received ibuprofen (600 mg) three times a day. For surgical anesthesia, all patients received intrathecal bupivacaine 20 mg plus 0.1 mg morphine in a total volume of 4 mL. RESULTS: The preoperative or postoperative visual analogue scale pain scores or the amount of iv morphine showed no differences between the two groups in the first 24 hr after surgery. The median total blood loss in the ibuprofen group was 1161 mL vs 796 mL in the placebo group (P < 0.01). CONCLUSION: Pretreatment with ibuprofen before major hip surgery does not improve the pain scores or reduce morphine requirement but significantly increases blood loss. Considering the presence of relevant adverse effects, pretreatment with a non-selective NSAID is not recommended.     

Evaluation of postoperative pain relief by infiltration of bupivacaine or epidural block after laparoscopic cholecystectomy]

We compared the analgesic effect of bupivacaine infiltration into surgical wounds with that of epidural block after laparoscopic cholecystectomy (LC). Forty-five patients (ASA physical status I-II) for LC were randomized into three groups (n = 15 in each group). Patients received only general anesthesia (Group C), received infiltration of 0.5% bupivacaine into the surgical wound before surgery combined with general anesthesia (Group L), or received epidural anesthesia combined with general anesthesia (Group E). Postoperative pain was assessed using visual analogue scale (scale: 0-10) at 1, 2, 6 and 12 hours after the operation, the need for additional supplemental analgesics, and the cost of anesthesia. Visual analogue scale in Group C at 1, 2, or 6 hours was significantly greater than that of Group L and E. The number of patients who needed supplemental analgesics was 9 in Group C, 5 in Group L, and 2 in Group E. The cost of pharmaceutical and anesthetic practice of Group E was more expensive than Group L and C. In conclusion, infiltration of bupivacaine combined with general anesthesia is an effective and economical method of postoperative pain relief.     

Brachial plexus block with midazolam and bupivacaine improves analgesia

PURPOSE: Adjuncts to local anesthetics for brachial plexus block may enhance the quality and duration of analgesia. Midazolam, a water-soluble benzodiazepine, is known to produce antinociception and enhance the effect of local anesthetics when given epidurally or intrathecally. The purpose of this study was to assess the effect of midazolam added to brachial plexus anesthesia. METHODS: A prospective, randomized, double blind study was conducted on 40 ASA I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly divided into two groups. Patients in Group B (n = 20) were administered 30 mL of 0.5% bupivacaine and Group BM (n = 20) were given 30 mL of 0.5% bupivacaine with midazolam 50 microg x kg(-1). Hemodynamic variables (i.e., heart rate, noninvasive blood pressure), pain scores and rescue analgesic requirements were recorded for 24 hr postoperatively. RESULTS: The onset of sensory and motor block was significantly faster in Group BM compared to Group B (P < 0.05). Pain scores were significantly higher in Group B compared to Group BM from two hours to 24 hr postoperatively (P < 0.05). Rescue analgesic requirements were significantly less in Group BM compared to Group B (P < 0.05). Hemodynamics and sedation scores did not differ between groups in the post-operative period. CONCLUSION: Midazolam (50 microg x kg(-1)) in combination with 30 mL of bupivacaine (0.5%) hastened onset of sensory and motor block, and improved postoperative analgesia when used in brachial plexus block, without producing any adverse events.     

Comparative evaluation of intraperitoneal bupivacaine and bupivacaine ketamine combined with lung recruitment for reducing postoperative shoulder pain in laparoscopic cholecystectomy

Background

Shoulder pain (SP) was first reported after laparoscopic gynecological procedures. It is assumed to be multifactorial in nature. Several methods to reduce SP after laparoscopic cholecystectomy (LC) have been postulated. In this study, we have worked to decrease it using 2 approaches; lung recruitment maneuver and intraperitoneal local analgesic instillation.

Patient analgesia after axillary lymph node dissection (ALND): outcomes in pain management using long-term continuous local anesthesia delivery

Background: Although considered a safe surgical procedure, ALND is associated with post-operative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique, and absent evidence of long thoracic or thoracodorsal nerve injury, the risk of these complications have been reported as 35-50%, with a subset of patients developing chronic pain. Methods: Female patients (n = 25) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group #1 received no pump or infusion. Patients assigned to group #2-#3 (double-blinded) received 120 hours continuous bupivacaine (BPV) or saline infusion using an On-Q pump (I-Flow Corporation) via an axillary catheter. Patients were discharged with oral opioid analgesics and performed twice-daily assessment of pain, sedation, and nausea using validated visual-analog scale measures. Daily opioid analgesic requirements were recorded. Results: Patients treated with bupivacaine experienced statistically-significant lower pain scores (p < 0.002) during the first five post-operative days. Post-operative sedation and nausea scores and opioid analgesic requirements were significantly decreased in the bupivacaine group, and these effects persisted until post-operative day 14 (p < 0.001, p < 0.04, and p < 0.00001 respectively). Data are summarized in Table I. There were no complications. Conclusions: Use of continuous administration of axillary local anesthesia significantly decreases pain, sedation, and opioid analgesic requirements following ALND. This pilot study is encouraging, warranting further evaluation of this treatment modality to determine its potential impact upon long-term complications following ALND.     

Pediatric caudal block with mepivacaine, bupivacaine or a mixture of both drugs: requirement for postoperative analgesia and plasma concentration of local anesthetics

STUDY OBJECTIVES: To assess the effects of pediatric caudal block using mepivacaine, bupivacaine, or a mixture of both drugs on postoperative analgesia, and to examine plasma concentrations of the local anesthetics after caudal injection. DESIGN: Prospective, randomized, double-blind study. SETTING: Operating room and pediatric surgical ward. PATIENTS: 60 ASA physical status I children weighing 10 to 20 kg (26 females, 34 males), and scheduled for inguinal herniorrhaphy. INTERVENTIONS: Patients randomly received caudal block with 1 mL/kg of mepivacaine 1% (Group M, n = 20), 1 mL/kg of bupivacaine 0.25% (Group B, n = 20), or a mixture of 0.5 mL/kg of mepivacaine 1% and 0.5 mL/kg of bupivacaine 0.25% (Group MB, n = 20) after induction of anesthesia with sevoflurane in 50% oxygen (O2). Anesthesia was maintained with 66% nitrous oxide in O2 supplemented with sevoflurane at an end-tidal concentration of less than 1%. MEASUREMENTS AND MAIN RESULTS: Postoperative pain scores using a pediatric pain scale and plasma concentration of each local anesthetic were measured. In Group M, four patients required postoperative analgesics within the first 24 hours. However, no patients required postoperative analgesics in Groups B and MB. In Group M, the plasma concentration of mepivacaine of two patients exceeded 5 microg/kg of the level of toxicity. However, these patients did not show any toxic symptoms. Because a mixture of two local anesthetics halves the concentration of each local anesthetic, the plasma concentrations of mepivacaine and bupivacaine in Group MB were significantly lower than those of Groups M and B. CONCLUSIONS: Pediatric caudal block with a mixture of mepivacaine and bupivacaine is effective for intraoperative and postoperative analgesia.     

Evaluation of a local anaesthesia regimen using a subphrenic catheter after gynaecological laparoscopy

BACKGROUND AND OBJECTIVE: The purpose of intraperitoneal local anaesthetic administration is to block visceral nociceptive conduction and to provide an additional route of analgesia. The present study evaluates the effects of sequential injections of bupivacaine on postoperative pain through a subphrenic catheter. METHODS: In this double-blinded controlled study, patients scheduled for gynaecological laparoscopy were randomly divided into two groups. One group received 20 mL of saline with 1:200000 epinephrine through a subphrenic catheter before the incision closure and at 4-hourly intervals for the first postoperative 20 h. The second group received 20 mL of bupivacaine 0.125% with 1:200000 epinephrine at the same injection times. Postoperative pain scores and consumption of analgesics were compared. RESULTS: There were no statistical differences in pain scores at rest or incidence of shoulder pain between the two groups, but the patients of the bupivacaine group reported lower pain scores on coughing only in the first hour postoperatively (P = 0.007). Although the patients consumed comparable amounts of metamizole and ondansetron, the number of patients requiring supplemental meperidine and flurbiprofen in the bupivacaine group were significantly lower than in the saline group (P < 0.05). CONCLUSIONS: This study demonstrates that intraperitoneal bupivacaine may reduce pain on coughing in the early postoperative period and the consumption of analgesics postoperatively. The subphrenic catheter technique had no impact upon pain at rest and shoulder-tip pain after gynaecological laparoscopy.     

The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy

The objective of our study was to see if incisional and intraperitoneal bupivacaine with epinephrine produces analgesia after total abdominal hysterectomy. Forty-six ASA physical status I and II patients received a standardized anesthetic, patient-controlled analgesia (PCA) morphine, and rectal paracetamol 1 g every 6 h. Patients were randomized to receive 50 mL of bupivacaine 0.25% with epinephrine 5 microg/mL or 50 mL of normal saline. Thirty milliliters and 20 mL of treatment solution were administered into the peritoneum and incision, respectively, before wound closure. Seventeen and 16 patients in the Placebo and Bupivacaine groups, respectively, completed the study. The reasons for withdrawal were PCA malfunction, PCA discontinued too early, nausea, chest infection, intraabdominal drain insertion, and protocol violation. There were no significant differences between the Bupivacaine and Placebo groups in age, height, weight, or duration of surgery. Pain on movement was significantly more intense in the Placebo group than in the Bupivacaine group on awakening. Morphine consumption (interquartile range) over 24 h was 62 mg (53-85 mg) in the Placebo group compared with 44 mg (33-56 mg) in the Bupivacaine group (P < 0.01). This significant difference was attributable to the larger morphine consumption in the Placebo group in the first 4 postoperative h. We conclude that a combination of intraperitoneal and incisional bupivacaine with epinephrine provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy. IMPLICATIONS: A combination of intraperitoneal and incisional bupivacaine with epinephrine may be recommended because it provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.