Analgesic effect of epidural neostigmine after abdominal hysterectomy

STUDY OBJECTIVE: To evaluate the effects of epidurally administered neostigmine on pain after abdominal hysterectomy. DESIGN: Prospective, randomized, double-blind study. SETTING: Teaching hospital. PATIENTS: 45 ASA physical status I adult patients scheduled for abdominal hysterectomy. INTERVENTIONS: All patients received identical general and epidural anesthesia. At the end of the surgery, they received epidural bupivacaine (10 mg) with either saline (control group, n = 15), 5 micro g/kg (5-micro g group, n = 15), or 10 micro g/kg neostigmine (10-micro g group, n = 15). Postoperatively, 50 mg diclofenac suppository was given for pain relief on patient demand. MEASUREMENTS AND MAIN RESULTS: The time to first diclofenac administration and the number of times diclofenac was required during the first 24 postoperative hours were recorded. Pain was assessed using a 10-cm visual analog pain scale (VAS) at rest at the first diclofenac request, and at 15 and 24 hours after surgery. The time to first diclofenac administration was significantly longer (p < 0.05) in the 10-micro g group (223 +/- 15 min) than in the control (78 +/- 17 min) or 5-micro g groups (88 +/- 18 min). However, epidural neostigmine at both doses did not reduce the number of postoperative diclofenac administrations. There were no differences in VAS among the three groups. CONCLUSIONS: Epidural neostigmine of 10 micro g/kg in bupivacaine provides a longer duration of analgesia than does bupivacaine alone or with 5 micro g/kg of neostigmine after abdominal hysterectomy.     

Postoperative analgesia by intraarticular and epidural neostigmine following knee surgery

STUDY OBJECTIVES: To define the analgesic efficacy, and to identify a possible site of action, of epidural and intraarticular neostigmine. DESIGN: Randomized, double-blind study. SETTING: Postoperative analgesia, teaching hospital. PATIENTS: 58 ASA physical status I and II patients undergoing knee surgery. INTERVENTIONS: All patients were premedicated with 0.05 to 0.1 mg/kg intravenous midazolam and received combined epidural/intrathecal technique. Intrathecal anesthesia consisted of 20 mg bupivacaine. A 10 mL epidural and intraarticular injection was administered to all patients; this consisted of either the study drug or normal saline. Postoperatively, pain was assessed using the 10 cm Visual Analog Scale (VAS), and intramuscular (IM) 75 mg diclofenac was available at patient request. The control group (CG) received both epidural and intraarticular saline. The 1 microg/kg epidural group (1 microg/kg EG) received epidural neostigmine and intraarticular saline. The 1 microg/kg intraarticular group (1 microg/kg AG) received epidural saline and intraarticular neostigmine. Finally, the 500 microg intraarticular group (500 microg AG) received epidural saline and intraarticular neostigmine. MEASUREMENTS AND MAIN RESULTS: 56 patients were evaluated. Groups were demographically the same and did not differ in intraoperative characteristics. The VAS score at first rescue analgesic and the incidence of adverse effects were similar among groups (p< 0.05). The time (min) to first rescue analgesic was shorter for both the CG (228+/-54) and 1 microg/kg AG (251+/-87) groups compared to the 1 microg/kg EG (333+/-78) and 500 microg AG (335+/- 111) groups (p<0.05). The analgesic consumption (number of IM diclofenac injections (mean [25(th)-75(th) percentile]) in 24 hours was higher in the CG group than both the 1 microg/kg EG and 500 microg AG groups (p<0.05). The overall 24-hour pain VAS score (cm) was higher in the CG group than in the 1 microg/kg EG (p<0.05) group. CONCLUSION: Although peripheral neostigmine 1 microg/kg did not result in postoperative analgesia, the same dose applied epidurally resulted in over 5 hours of analgesia, similar to a fivefold dose applied peripherally. The results suggest that epidural neostigmine has a greater analgesic efficacy than peripherally applied neostigmine.     

Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia

N-methyl-D-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.     

The efficacy of thoracic epidural neostigmine infusion after thoracotomy

Few anesthesia studies have explored perioperative continuous epidural infusion of neostigmine. We examined such a regimen in thoracotomy patients. Ninety patients were randomized to one of three groups in this double-blind trial. Before anesthesia induction, an epidural catheter was inserted in all patients at T5-8 levels under local anesthesia. Pre-neo patients received bolus 500-microg epidural neostigmine before anesthesia induction followed by infusion of 125 microg/h until the end of surgery. Post-neo patients received epidural saline during the same time periods plus bolus 500-microg epidural neostigmine at end of surgery. Patients in the control group received saline placebo during all three periods. Patients in the neostigmine groups postoperatively received patient-controlled epidural analgesia with morphine 0.02 mg/mL, bupivacaine 0.08 mg/mL, and neostigmine 7 microg/mL. Control patient-controlled epidural analgesia excluded neostigmine. Data were recorded for 6 postoperative days. Daily patient-controlled epidural analgesia consumption (mL) for Pre-neo patients was significantly less than that of post-neo and control group patients for postoperative days 1-6 (at least 10% and 16% less, respectively; P < 0.05). There was a modest decrease in pain intensity on postoperative days 3-6 for pre-neo patients versus other groups (P < 0.05). These results suggest that continuous thoracic epidural neostigmine started before anesthesia provided preemptive, preventive analgesia and an analgesic-sparing effect that improved postoperative analgesia for these patients without increasing the incidence of adverse effects.     

Epidural dexamethasone reduces postoperative pain and analgesic requirements

PURPOSE: Epidural steroids may have potential advantages for providing postoperative analgesia. We therefore undertook a study to evaluate the efficacy of epidurally administered dexamethasone in reducing postoperative morphine requirements, as a measure of analgesia following laparoscopic cholecystectomy. METHODS: In a randomized, double-blind study, 94 patients undergoing laparoscopic cholecystectomy were randomly assigned to one of three groups. Group 1 (Control) patients received dexamethasone 5 mg iv with epidural injection of 0.25% bupivacaine 8 mL and normal saline 2 mL, Group 2 (D1) patients received normal saline 2 mL iv with epidural injection of 0.25% bupivacaine 8 mL and dexamethasone 5 mg in normal saline 2 mL, and Group 3 (D2) patients received normal saline 2 mL iv with epidural injection of dexamethasone 5 mg in normal saline 10 mL. After surgery, morphine 2-4 mg iv was administered as needed for analgesia. Postoperative morphine requirements, visual analogue scale (VAS) pain scores at rest and with effort, and time to first analgesic administration were recorded by a blinded observer. RESULTS: Total morphine consumption for the first 24 hr following surgery was lower in both epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reduction in morphine consumption in Group D1 was 53.9% and in Group D2 was 52.9% in the first 24 hr. Postoperatively at 12 hr, 18 hr and 24 hr, the VAS scores at rest and during effort were also lower in the epidural dexamethasone groups (D1, D2) compared to the control group (P < 0.05). The percentage reductions in VAS scores with effort at 12 hr, 18 hr and 24 hr in Group D1 were 50%, 52.9% and 50% respectively, and in Group D2 percentage reductions in pain scores with effort were 54.8%, 58.8% and 55.5% at corresponding sampling intervals. CONCLUSION: Preoperative epidural administration of dexamethasone 5 mg, with or without bupivacaine, reduces postoperative pain and morphine consumption following laparoscopic cholecystectomy.     

Efficacy of three doses of ketamine with bupivacaine for caudal analgesia in pediatric inguinal herniotomy

BACKGROUND AND OBJECTIVES: Ketamine administered systemically is a potent analgesic at subanesthetic plasma concentrations. Addition of ketamine to bupivacaine for caudal epidural block significantly prolongs the duration of postoperative analgesia. The purpose of this prospective, randomized double-blind study is to identify the optimal dose of ketamine that produces the maximum duration of caudal analgesia with minimal adverse effects as an adjuvant to bupivacaine for caudal epidural block. METHODS: Sixty children, aged 6 months to 10 years, undergoing inguinal herniotomy were allocated randomly to receive 1 of 3 solutions for caudal epidural block. Group 1 received 0.75 mL/kg of bupivacaine 0.25% with preservative-free ketamine 0.25 mg/kg, group 2 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 0.5 mg/kg, and group 3 received 0.75 mL/kg of bupivacaine 0.25% with ketamine 1 mg/kg. Postoperative pain was assessed using the All India Institute of Medical Sciences pain discomfort scale. Rescue analgesia in the form of pethidine 1 mg/kg intramuscularly was administered when this score exceeded 4. RESULTS: The mean duration of caudal analgesia was 8.8 hours in group 1 compared with 22.1 hours in group 2 (P <.001) and 25.2 hours in group 3 (P <.001). Supplemental analgesia requirements with pethidine were significantly less in group 2 (4 subjects) and group 3 (no subject) when compared with group 1 (18 subjects). There were no differences between the groups in the incidence of motor blockade, urinary retention, emesis, or sedation. Group 3 had a significantly higher incidence of behavioral side effects such as odd behavior, agitation, or restlessness than groups 1 and 2. CONCLUSIONS: The optimal dose of ketamine in our study was 0.5 mg/kg added to 0.75 mL/kg bupivacaine 0.25% for caudal epidural block without an increase in side effects.     

Epidural administration of low-dose morphine combined with clonidine for postoperative analgesia after lumbar disc surgery.

This study evaluates the efficacy and side effects of a low dose of epidural morphine combined with clonidine for postoperative pain relief after lumbar disc surgery. In 36 of 51 patients who accepted the procedure, an epidural catheter was inserted (L1-L2 level). General anesthesia was induced with propofol and sufentanil, and maintained with sevoflurane in O2/N2O. After emergence from anesthesia, epidural analgesia was initiated according to two randomly assigned protocols: 1 mg of morphine with 75 microg of clonidine (Group M) or 12.5 mg of bupivacaine with 75 microg of clonidine (Group B), in 10 mL saline. Piritramide was administered during the first postoperative 24 hours using a patient-controlled analgesia device (PCA). The following parameters were recorded: piritramide consumption during the first 24 hours; pain at rest during the first postoperative hours (D0), during the first night (D1), and during the first mobilization; [visual analogue scale (VAS)]; and the occurrence of drowsiness, motor blockade, respiratory depression, nausea, vomiting, itching, micturition problems, and bladder catheterization during D0 and D1. Epidural administration of morphine-clonidine significantly improved postoperative pain relief and reduced piritramide consumption as compared to epidural bupivacaine-clonidine. Side effects did not differ between groups except for a higher incidence of micturition problems in Group M during D1. The occurrence of bladder catheterization was not significantly higher in that group. We conclude that a low dose of epidural morphine combined with clonidine offers a better postoperative analgesia than does bupivacaine-clonidine. The excellent analgesic conditions were obtained at the expense of a higher incidence of difficulties in initiating micturition.     

Evaluation of the safety and efficacy of epidural ketamine combined with morphine for postoperative analgesia after major upper abdominal surgery

STUDY OBJECTIVE: To evaluate the efficacy of the combination of epidural ketamine and morphine compared with epidural morphine alone for postoperative pain relief following major upper abdominal surgery. STUDY DESIGN: Prospective, randomized, double-blinded study. SETTING: Tertiary care referral and teaching hospital. PATIENTS: 46 ASA physical status I and II patients who underwent major upper abdominal procedures. INTERVENTIONS: Patients were randomly allocated to one of the two treatment groups: patients in Group 1 received epidural morphine 50 microg/kg whereas patients in Group 2 received epidural ketamine 1 mg/kg combined with 50 microg/kg of morphine postoperatively. MEASUREMENTS: A blinded observer using a visual analog scale (VAS) for pain assessment followed up patients for 48 hours postoperatively. Top-up dose of epidural morphine was provided when VAS was higher than 4. Analgesic requirements and side effects were compared between the two groups. RESULTS: Only 40 patients completed the study. There were no differences between the two groups with respect to age, gender, weight, duration, or type of surgical procedure or intraoperative opioid requirements. Onset of analgesia was faster (p < 0.001) in Group 2 (11 min) than in Group 1 patients (25 min). The time for first requirement of analgesia was significantly (p < 0.01) longer (19.8 +/- 9.8 hours) in Group 2 patients than Group 1 (12.8 +/- 6.2 hours). Total number of supplemental doses of epidural morphine required in the first 48 hours postoperatively was also significantly less (p < 0.005) in Group 2 compared to Group 1. Patients in Group 2 had higher sedation scores than Group I patients for the first 2 hours postoperatively. None of the patients in either group developed hallucinations or respiratory depression. Other side effects such as pruritus, nausea, and vomiting were also similar in both groups. CONCLUSIONS: The addition of epidural ketamine 1 mg/kg to morphine 50 microg/kg improved analgesia after major upper abdominal surgery without increasing side effects.     

硬膜外泵入布托啡诺复合小剂量氯胺酮用于妇科患者术后镇痛

目的 观察术后硬膜外持续泵人布托啡诺复合小剂量氯胺酮用于妇科患者术后的镇痛效果.方法 60例ASA Ⅰ或Ⅱ级在腰-硬联合麻醉下行腹式子宫切除的妇科患者术后随机均分为两组,A组为观察组,用布托啡诺0.1 mg/kg 氯胺酮1 mg/kg 生理盐水至100 ml持续泵人;B组为对照组,用布托啡诺0.1 mg/kg 生理盐水至100 ml持续泵入.观察患者术后各时间段的视觉模拟镇痛评分(VAS)、Ramsay镇静评分及对术后镇痛的满意度进行评估,并观察不良反应情况.结果 A组在给药后4 h的VAS低于B组(P<0.05);B组在给药后4、8和12 h的Ramsay镇静评分高于A组(P<0.05),但是两组的评分均在镇静满意的范围.结论 硬膜外持续泵入布托啡诺0.1mg/kg对于妇科术后患者能提供安全有效的镇痛,同时复合小剂量的氯胺酮能增强其镇痛效果,不增加其不良反应的发生.     

Efficacy of the fascia iliaca compartment block vs continuous epidural infusion for analgesia following total knee replacement surgery

Background and objective: Total knee replacement causes moderate to severe postoperative pain. The aim of this trial was to compare postoperative analgesia from a fascia iliaca compartment block to continuous epidural analgesia following knee arthroplasty. Patients and Methods: Clinical trial enrolling patients in American Society of Anesthesiologists (ASA) classes 1 to 3 randomized to 2 groups. One group received spinal anesthesia plus a fascia iliaca compartment block with 0.1% bupivacaine at a rate of 10 mL/h. The second group received combined spinal-epidural anesthesia plus epidural analgesia with 0.1% bupivacaine in continuous infusion at a rate of 8 mL/h. Postoperative pain on a visual analog scale (VAS) at rest and on movement was recorded every 3 hours for the first 24 hours. Use of intravenous morphine and the adverse events were also recorded. Results: Forty patients (20 for each group) were enrolled. The distribution of age, weight, body mass index, sex, ASA class, duration of surgery, use of morphine, and the incidence of adverse effects were similar in the 2 groups. Postoperative VAS scores at rest and on movement were also similar. The incidence of arterial hypotension was higher in the epidural analgesia group. Conclusions: The fascia iliaca compartment block and continuous epidural infusion are similarly efficient in providing postoperative analgesia for patients after total knee replacement. The fascia iliaca compartment block is associated with a lower incidence of postoperative hemodynamic complications. Early, safe rehabilitation is facilitated by both analgesic techniques.     

Addition of 0.1% bupivacaine to buprenorphine and droperidol in patient-controlled epidural analgesia improved postoperative pain scores on coughing after gynecological surgery

STUDY OBJECTIVE: To compare the analgesic efficacy of additional 0.1% bupivacaine to patient-controlled epidural analgesia (PCEA) using buprenorphine and droperidol after gynecological surgery. DESIGN: Randomized, double-blinded study. SETTING: Operating theater and general ward at Jichi Medical School Hospital. PATIENTS: Thirty patients with American Society of Anesthesiologists physical status I and II scheduled for gynecological surgery. INTERVENTIONS: Patients received combined general and epidural anesthesia for surgery and epidural analgesia for postoperative analgesia. Patients were assigned to receive PCEA with or without 0.1% bupivacaine. Group 1 (n = 15) received buprenorphine 20 microg and droperidol 0.1 mg diluted with saline, and group 2 (n = 15) received bupivacaine 2 mg, buprenorphine 20 microg, and droperidol 0.1 mg diluted with saline (0.1% bupivacaine solution) in a bolus dose of the PCEA, respectively. No background epidural infusion was used. MEASUREMENTS: Visual analog pain scale (VAPS) scores at rest and on coughing, and cumulative frequency of self-administrated analgesic solution in PCEA were recorded at 24 and 48 hours postoperatively. MAIN RESULTS: There were no significant differences noted between the groups in VAPS scores at rest or in cumulative volumes of PCEA solution in 24 or 48 hours postoperatively. Median VAPS scores on coughing in group 2 were significantly lower than those values in group 1 at 24 hours (36 vs 65 mm, P < .001) and 48 hours (32 vs 54 mm, P = .036) postoperatively. CONCLUSIONS: Addition of 0.1% bupivacaine to PCEA using buprenorphine and droperidol provides better analgesia on coughing after gynecological surgery.     

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

PurposeThe purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery.Type of studyProspective, randomized, double-blind, clinical study.MethodsIn this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient.ResultsVAS values were lower for the 3 medication groups compared with the placebo at rest and 90° knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P < .05). The total amount of pethidine and analgesia time were longer for the 3 medication groups.ConclusionsOur basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects.Level of evidenceLevel I.     

No anesthetic or analgesic benefit of neostigmine 1 mg added to intravenous regional anesthesia with lidocaine 0.5% for hand surgery

BACKGROUND AND OBJECTIVES: Neostigmine has shown analgesic benefit when used as an adjunct to epidural or intrathecal anesthesia and analgesia, but evidence of benefit in the peripheral nervous system is controversial. This study aimed to determine if neostigmine 1 mg added to intravenous regional anesthesia (IVRA) provided any advantage in terms of intraoperative anesthesia or postoperative analgesia. METHODS: We recruited 54 patients booked for hand surgery into this randomized, double-blind study. For the IVRA technique, patients were administered 3 mg/kg of 0.5% lidocaine (maximum 45 mL). The treatment group (group N) had 1 mg neostigmine added to lidocaine before dilution. The control group (group C) had no additives to the IVRA solution. At the completion of surgery and after transfer to the recovery room, patients had verbal response pain scores measured at 30 minutes, 1 hour, and 2 hours after cuff deflation. Time to first request for analgesic, side effects, and analgesic consumption at 24 hours were also recorded. RESULTS: Significantly more patients in group N had motor block at 5 and 10 minutes after injection of study solution. There were no other significant differences in sensory block onset, intraoperative anesthesia, postoperative analgesia, or adverse effects between groups. CONCLUSIONS: Neostigmine 1 mg provides no anesthetic or analgesic advantage when added to IVRA for upper limb surgery.     

Postoperative analgesic effect of epidural neostigmine and plasma cortisol and IL-6 responses

STUDY OBJECTIVES: To examine whether epidural administration of neostigmine reduces the stress and inflammatory responses thereby improving postoperative pain status. DESIGN: Randomized, double-blinded clinical study. SETTING: Operating rooms and wards of a university hospital. PATIENTS: 40 ASA physical status I patients undergoing lower open abdominal surgery for benign gynecological disease. INTERVENTIONS: Patients were randomly divided into four groups to receive different doses of epidural neostigmine (0, 0.05, 0.1, or 0.15 mg) with mepivacaine (100 mg) before general anesthesia induction. MEASUREMENTS: The plasma levels of cortisol and interleukin-6 (IL-6) were determined perioperatively. The patients' pain rating was assessed by visual analog scale (VAS) in the postoperative period. MAIN RESULTS: Epidural neostigmine at all doses significantly reduced the plasma levels of cortisol in the early surgical period; however, IL-6 levels were not affected by the neostigmine. The VAS scores were significantly decreased at 2 hours after the end of surgery by all doses of epidural neostigmine used in this study. CONCLUSIONS: The preincisional epidural neostigmine transiently suppresses the stress responses during surgery and improves postoperative analgesia in patients undergoing lower open abdominal surgery.     

Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary resection

Supraventricular tachyarrhythmias after pulmonary surgery are well described. Some investigators suggest that tachyarrhythmias after thoracic operations may result from the relative sympathotonic status produced by injury to the cardiac parasympathetic nerves. We examined whether postoperative thoracic sympathetic blockade by thoracic epidural bupivacaine might reduce the tachyarrhythmias after pulmonary resection. Fifty patients with lung cancer were randomized to receive epidural bupivacaine (Group B) or epidural morphine (Group M). Patients in Group B were given 6 to 10 mL of 0.25% bupivacaine epidurally, followed by epidural infusion at 3 to 5 mL/h for 3 days, and patients in Group M were given 2 to 3 mg morphine epidurally, followed by morphine infusion at a rate of 0.2 mg/h. Tachyarrhythmias were diagnosed by using the continuous heart rate trend and arrhythmia trend with a central monitoring system. Postoperative analgesia was not statistically different between groups. However, the incidence of postoperative tachyarrhythmias in Group B was significantly less than in Group M (1 of 23 vs 7 of 25, P = 0.0497, Fisher's exact test). The continuous infusion of thoracic epidural bupivacaine can reduce supraventricular tachyarrhythmias compared with epidural morphine infusion, presumably because of attenuation of the sympathotonic status after pulmonary resection. IMPLICATIONS: We examined whether postoperative thoracic sympathetic blockade by thoracic epidural bupivacaine after pulmonary resection might reduce the tachyarrhythmias that may result from the relative sympathotonic status produced by injury to the cardiac parasympathetic nerves. The continuous infusion of thoracic epidural bupivacaine was shown to reduce supraventricular tachyarrhythmias.     

Anesthetic quality during cesarean section following subarachnoid or epidural administration of bupivacaine with or without fentanyl

Background: It is often assumed that subarachnoid administration of local anesthetics produces a more profound blockade than epidural anesthesia. Furthermore, the addition of fentanyl has been reported to increase preferentially intraoperative analgesia. In the present study we set out to study these two issues in a randomized and controlled study with respect to perceived pain and discomfort during surgery and postoperative pain. Methods: In the present study, 100 parturients subjected to elective cesarean section, 34 nullipara and 66 multipara, received one out of four combinations of the local anesthetic bupivacaine and the opioid fentanyl; group A - bupivacaine 12.5 mg+10 μg fentanyl subarachnoidally, group B - bupivacaine 12.5 mg+saline subarachnoidally, group C - bupivacaine 100 mg+100 μg fentanyl epidurally, group D - bupivacaine 100 mg+saline epidurally; N=25 in each group. Pain intensity and discomfort during surgery was assessed with a visual analogue scale (VAS). Postoperative pain intensity and need for analgesics postoperatively, ketobemidone, was registered for 24 h following surgery. Results: Intraoperative pain intensity and discomfort did not differ significantly between parturients in any of the four groups. Postoperative pain was significantly more intense in parturients receiving local anesthetics subarachnoidally as compared to the epidural groups during the first 6-h period. This difference was also reflected in a significantly increased consumption of analgesics during this period. No significant differences between the groups were observed with regard to hemo-dynamics (blood pressure), respiration (oxygen saturation) or other effects such as nausea or itching. All neonates had normal Apgar and neonatal adaptive capacity scores (NACS). Conclusion: We conclude that subarachnoidal (12.5 mg) and epidural (100 mg) injections with bupivacaine both produced adequate anesthetic quality in women undergoing elective cesarean section. The addition of fentanyl (10 μg subarachnoidally or 100 μg epidurally) did not significantly improve the quality of these already profound blockades.     

Epidural ketamine for postoperative analgesia

Thirty-four patients of ASA physical status I or II scheduled for gall bladder surgery were studied in a comparative prospective trial to evaluate the efficacy of epidural and intramuscular ketamine for postoperative pain relief. They were divided randomly into three groups. Group I (11 patients) received 30 mg intramuscular ketamine. Group II (10 patients) and Group III (13 patients) received 10 and 30 mg ketamine in 10 ml saline respectively, through epidural catheters. Pain was evaluated every two hours for the first 24 hours post-operatively by using a linear analogue pain scale from 0-10. Ketamine was given on the patient's request and whenever the pain score exceeded three. Ketamine produced analgesia in all patients studied. The reduction of pain score after two and four hours in Group I and III was significant when compared to Group II. Seven patients (54 per cent) in Group III did not require further analgesia after the initial injection. However, following 10 mg epidural ketamine or 30 mg IM ketamine, post-operative pain was more frequent. Four patients who received epidural ketamine complained of transient burning pain in the back during injection. No patient developed respiratory depression, psychic disturbance, cardiovascular instability, bladder dysfunction or neurologic deficit. It is concluded that 30 mg epidural ketamine is a safe and effective method for postoperative analgesia.     

Bupivacaine/ketamine is superior to intra-articu-lar ketamine analgesia following arthroscopic knee surgery

PURPOSE: Centroneuraxial and parenteral administration of ketamine has been shown to produce analgesia. However, this analgesia is limited by adverse effects. The purpose of this study was to determine whether ketamine alone or in combination with bupivacaine provides superior pain relief after surgery in patients undergoing knee arthroscopy. METHODS: Sixty patients (classified as ASA status I or II) under-going arthroscopic meniscus repair during general anesthesia were randomized to receive 1.0 mg x kg(-1) ketamine (Group K), 0.25% bupivacaine (Group B) or a combination of 1.0 mg x kg(-1) ketamine and 0.25% bupivacaine (Group BK) to a total volume of 20 mL by intra-articular route following surgery. Visual analogue score in the postanesthesia care unit at 0.5, 1, 2, 4, 6, 8, 12 and 24 hr after surgery, duration of analgesia and subsequent 24 hr consumption of rescue analgesic (dextroproxyphene/acetaminophen) were evaluated. RESULTS: The results showed significantly higher pain scores in Group K as compared to Group B and Group BK. The duration of analgesia was significantly shorter in Group K as compared to the other two groups (Group B = 5.7 +/- 0.8; Group BK = 5.1 +/- 1.1 vs Group K = 1.7 +/- 0.9 hr; P < 0.05). However, 24 hr consumption of analgesic was similar in the three groups. CONCLUSION: We conclude that intra-articular bupivacaine-ketamine combination provides better pain relief than intra-articular ketamine after day care arthroscopic knee surgery.     

Epidural anesthesia during hysterectomy diminishes postoperative pain and urinary cortisol release

Purpose To examine the hypothesis that epidural anesthesia throughout lower abdominal surgery would depress both postoperative pain and cortisol release. Methods Forty adult patients undergoing abdominal total hysterectomy were studied. The patients were randomly assigned to two groups. Group G received general anesthesia alone (sevoflurane 1.5%–2.5%); group E received a combination of epidural anesthesia (1.5% mepivacaine) with a light plane of general anesthesia (sevoflurane<0.5%). Postoperative analgesia was obtained epidurally by patient-controlled analgesia. Postoperative pain at rest and during movement was assessed by a visual analogue scale (VAS) at 2, 24, and 48 h following surgery. The plasma concentration and urinary excretion of cortisol were measured during the perioperative period. Results VAS values were lower in group E than in group G during movement at 24h (4.6±0.5vs 6.1±0.4 cm). Urinary cortisol excretion on the first postoperative day was less in group E than in group G (192±34vs 480±120μg). Conclusions Epidural blockade prior to surgical stimuli and throughout lower abdominal surgery reduces the postoperative dynamic pain and stress response.