Patient-controlled femoral nerve analgesia versus patient-controlled intravenous analgesia for postoperative analgesia after trochanteric fracture repair

We assessed the efficacy of intravenous patient-controlled analgesia (PCA) and femoral nerve PCA after trochanteric fracture repair. A total of 40 patients were randomised to receive either femoral nerve PCA (Group I) or intravenous (IV) PCA (Group II) in the postoperative period. Group I received a continuous infusion of 0.125 bupivacaine at rate of 4 ml h⁻¹ plus PCA boluses of 3 ml with lockout time of 20 min. Morphine by IV PCA was applied as 1 mg bolus dose and 7 min lockout time in Group II. Pain scores (active–passive movement and during the resting), side effects, and patient satisfaction were recorded. Pain scores at rest were similar in both groups. Significantly better pain control at movement was observed in the Group I. Side effects were observed significantly more frequently in the Group II. Patient satisfaction was greater in Group I. Of the two PCA techniques tested, femoral nerve PCA with continuous infusion provides greater patient comfort both at rest and with ambulation than does IV PCA.     

Continuous epidural infusion of ropivacaine for the prevention of postoperative pain after major orthopaedic surgery: A dose-finding study

The present study investigated the dose relationship of ropivacaine with regard to analgesia and motor block when administered as a continuous 21 hour epidural infusion following major orthopaedic surgery.Forty six patients scheduled for elective total knee or hip arthroplasty were compared in this double-blind study. Patients were randomly assigned to one of four treatment groups: saline (n=12); ropivacaine 0.1% (n=11); ropivacaine 0.2% (n=12); ropivacaine 0.3% (n=11). Initial epidural analgesia was established with 0.5% ropivacaine and general anaesthesia was then induced for surgery. Within 30 minutes of the end of surgery, epidural infusions were commenced at a rate of 10 ml/hour for 21 hours. All patients had access to PCA morphine. Morphine consumption, VAS pain scores at rest, sensory and motor block and overall quality of treatment were assessed at regular intervals.The morphine consumption and VAS scores were lower overall in the ropivacaine groups than in the group receiving only PCA morphine. The difference was more evident during the first 8 hours of postoperative infusion, when significant differences between the ropivacaine 0.2% and 0.3% groups and the saline group were found. The incidence and degree of motor block were dose dependent. There was significantly higher patient satisfaction in all ropivacaine groups compared to the saline control group.In conclusion, 21 hour epidural infusion of ropivacaine, combined with PCA morphine, provides effective pain relief following major joint surgery and without significant adverse events. Morphine consumption and pain scores were lowest in the 0.3% ropivacaine group but this group had a higher degree of motor block. Pain relief with the combination of ropivacaine and PCA morphine is superior to that of PCA morphine alone.     

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.     

罗比卡因与布比卡因用于连续臂丛阻滞术后镇痛的比较

目的:比较0.125%罗比卡因与0.125%布比卡因应用于上肢连续臂丛阻滞病人术后自控镇痛的效果。方法:45例拟行上肢择期手术病人随机分为R组、B组和N组,每组15例。术前均予肌间沟径路或腋路臂丛阻滞以及臂丛神经鞘内置管。术后R组与B组使用便携式病人自控镇痛泵,泵内液体分别为0.125%的罗比卡因和0.125%的布比卡因,N组为对照组,观察24h。记录3组患者的疼痛视觉模拟评分和镇痛药使用情况,记录R组与B组患者的运动阻滞、麻木感、局麻药用量、满意度、镇痛技术问题和并发症。结果:R组与B组在术后各个时间点的疼痛评分均较低,组间无明显差异(P>0.05)。N组疼痛评分在术后0h、3h时与R组和B组比较无明显差异(P>0.05);在术后6、12、18、24h均较高,与R组和B间差异均有显著性(P<0.05)。R组与B组镇痛满意度较高,组间无明显差异(P>0.05),运动阻滞、麻木感、补充用药、局麻药用量无统计学差异(P>0.05);技术问题与并发症两组发生率均低。结论:0.125%罗比卡因与0.125%布比卡因均可有效地用于上肢术后的连续臂丛阻滞病人自控镇痛,并且效果相似。     

The addition of clonidine to bupivacaine in combined femoral-sciatic nerve block for anterior cruciate ligament reconstruction

Clonidine has been shown to prolong sensory analgesia when given as an adjunct to peripheral nerve blocks but has not been evaluated when given in conjunction with a femoral-sciatic nerve block. The purpose of this investigation was to determine whether the addition of clonidine to a femoral-sciatic nerve block would prolong the duration of sensory analgesia in groups of patients undergoing anterior cruciate ligament (ACL) reconstruction. This prospective, randomized, double-blind investigation was performed on 64 subjects undergoing ACL reconstruction. Patients were assigned randomly to receive a femoral-sciatic nerve block using 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine (control group) or 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 1 microg/kg of clonidine (experimental group). Variables measured included demographics, timed pain intensity measurements, postoperative analgesic consumption, duration of analgesia, and patient satisfaction. No significant differences were noted between groups for pain intensity scores, duration of sensory analgesia, postoperative analgesic requirements, or overall patient satisfaction. Both groups reported minimal amounts of postoperative pain and high analgesic satisfaction scores. Based on our results, we do not recommend the addition of clonidine to a femoral-sciatic nerve block when given to facilitate postoperative analgesia in patients undergoing ACL reconstruction.     

Anesthesia (9)

Lumbar plexus clock reduces pain and blood loss associated with total hip arthroplasty. (Hôpitaux Universitaires de Genéve, Geneva, Switzerland) Anesthesiology 2000;93:115–121. In this study, 60 patients undergoing total hip arthroplasty were randomized to receive general anesthesia with (plexus group, n = 30) or without (control group, n = 30) a posterior lumbar plexus block. The block was performed after induction using a nerve stimulator, and 0.4 mL/kg bupivacaine, 0.5%, with epinephrine was injected. General anesthesia was standardized, and supplemental fentanyl was administered per hemodynamic guidelines. Postoperative pain and patient‐controlled intravenous morphine use were serially assessed for 48 h. The proportion of patients receiving supplemental fentanyl intraoperatively was more than 3 times greater in the control group (20 of 30 vs. 6 of 29, P = 0.001). In the postanesthesia care unit, a greater than fourfold reduction in pain scores was observed in the plexus group and “rescue” morphine boluses were administered 10 times less frequently. Pain scores and morphine consumption remained significantly lower in the plexus group until 6 h after randomization. Operative and postoperative (48 h) blood loss was decreased modestly in the treated group. Epidural‐like distribution of anesthesia occurred in 3 of 28 plexus group patients, but no other side effects were noted. Conclude that posterior lumbar plexus block provides effective analgesia for total hip arthroplasty, reducing intraoperative and postoperative opioid requirements. Blood loss during and after the procedure is diminished. Epidural anesthetic distribution should be anticipated in a minority of cases. Comment by Alan David Kaye, MD, PhD. The benefits of regional anesthetic techniques are well established for patients undergoing total hip arthroplasty. For example, it is common knowledge to the clinical anesthesiologist that regional anesthesia results in reduced blood loss as well as a reduction in thromboembolic events postoperatively. This interesting study considered a posterior lumbar plexus block since a significant portion of the hip is innervated via branches of the lumbar plexus. A randomized, double‐blinded trial of 60 consecutive patients undergoing total hip arthroplasty under general anesthesia was performed. Thirty patients had general anesthesia alone and 30 patients had general anesthesia with the lumbar plexus block. Pain scores and morphine consumption postoperatively were evaluated over a 48‐h period. Patients in the control group required supplemental narcotic (20/30) versus those in the lumbar plexus block group (6/30). No BIS monitor was employed simply with the end point of additional analgesic being an increase in blood pressure or heart rate greater than 130% of the baseline. Epidural‐like distribution of anesthesia occurred in 3 of 28 patients receiving the block. Incidence of nausea and vomiting was similar in both groups and pain scores were significantly lower until the 6‐h period postoperatively. There was a block‐associated reduction in hemorrhage. These results are not surprising; however, it would be unlikely that this block would be done in a repeated series and the authors describe a continuous catheter‐based technique, which they have presented in abstract form for longer‐term postoperative pain relief. The associated complications with this block must be weighed with these positive and predictable findings. The complexity of proper placement of this block compared with other regional techniques and its potential side effects would make this block difficult to implement in the operating room. The authors should be complemented for this study and great consideration for its potential benefits in clinical practice should be considered.     

A comparison of motor block between ropivacaine and bupivacaine for continuous labor epidural analgesia.

The aim of the present study was to compare the amount of motor block produced by different loading doses of ropivacaine and bupivacaine when delivered in a dilute solution with added opioid. Sixty-eight healthy term primigravid parturients were randomized to receive an initial bolus dose of 10 mL of 1 of the following: 0.25% bupivacaine (high bupivacaine), 0.25% ropivacaine (high ropivacaine), 0.125% bupivacaine (low bupivacaine), or 0.125% ropivacaine (low ropivacaine). Each loading dose had 10 micrograms of sufentanil added to it. All groups received a continuous infusion of a 0.1% study drug infusion with 0.6 microgram/mL of sufentanil at a rate of 8 to 14 mL/h to maintain analgesia. Supplemental doses of 10 mL of a 0.125% study solution with 10 micrograms of sufentanil were given as needed. Pain scores and a modified Bromage scale were used to assess analgesia and motor block. A statistically significant greater percentage of parturients receiving bupivacaine had motor block than those who received ropivacaine, with a marked decrease in the occurrence of motor block in the low ropivacaine group. The pain relief seemed to be less satisfactory in the ropivacaine groups, but the difference was not statistically significant. Ropivacaine produced significantly less motor block than bupivacaine in the 0.25% and the 0.125% loading doses, with the greatest difference seen in the lower concentration loading dose of ropivacaine.     

超声引导下连续股神经阻滞联合喉罩下全麻与硬膜外阻滞复合喉罩下全麻用于全膝关节置换术的效果比较

目的 比较超声引导下连续股神经阻滞联合喉罩全麻与连续硬膜外阻滞复合喉罩全麻用于全膝关节置换术的效果.方法 择期行全膝关节置换术的类风湿性关节炎和骨关节炎造成的膝关节破坏患者60例,采用随机数字表法分为2组.Ⅰ组超声引导行连续股神经阻滞联合喉罩下全麻,Ⅱ组在连续硬膜外阻滞复合喉罩下全麻.记录术中和PACU停留期间的生命体征用药情况.记录术后48 h内PAC药物用量和恶心呕吐、低血压的发生情况,术后VAS评分和患者总体满意度评价.结果 2组一般资料比较无显著差异（P＞0.05）,2组患者术后6h、12 h、24 h、48 hVAS评分比较无显著差异（P＞0.05）.Ⅰ组术中截骨后即刻平均动脉压、心率与Ⅱ组比较有显著差异（P＜0.05）,其他效果基本一致,Ⅱ组术后恶心呕吐,低血压发生率比Ⅰ组高（P＜0.05）.结论 两种方式均能满足术后镇痛需要,但Ⅰ组并发症少、风险低,操作简单直观,患者舒适度高.     

Opioid‐Free Perioperative Analgesia for Hemicolectomy in a Patient With Opioid‐Induced Delirium: A Case Report and Review of the Analgesic Efficacy of the Alpha‐2 Agonist Agents

Abstract: Surgical pain in patients with documented opioid‐induced delirium can be difficult to treat. We present a case of a patient undergoing laparoscopic hemicolectomy effectively treated with an opioid‐free, alpha‐2 adrenoreceptor agonist analgesic regimen. Case report: A 21‐year‐old woman with persistent abdominal pain presented to the operating room for laparoscopic hemicolectomy for redundant right colon. Her medical history included a recently diagnosed postoperative opioid‐induced delirium. Epidural infusion with local anesthetic offered partial pain relief with sensory levels of T9‐L2. With the addition of dexmedetomidine infusion in the immediate postoperative period, the patient was comfortable with pain scores of 1 to 2/10 on Numerical Rating Scale (NRS). On postoperative day 1, the infusion was discontinued and the clonidine, 12 μg/hours was added to the epidural bupivacaine. With increased sedation 48 hours later, neuraxial clonidine was discontinued in favor to transdermal clonidine 0.1 mg/week, which was maintained until hospital discharge. Pain scores were maintained at 2 to 3/10 on NRS for the next 3 days when increased abdominal distention because of abscess formation rendered a new surgical intervention. The analgesia for the exploratory laparoscopy was maintained using epidural clonidine and bupivacaine infusion as well as intravenous dexmedetomidine, which were maintained another 2 days. Pain scores remained minimal until discharged home 3 day later. Discussion: Nonopioid analgesic regimens are beneficial in patients at risk of postoperative cognitive dysfunction attributable to opioids. Successful postoperative analgesia was achieved in our patient by alternating various routes of administration of alpha‐2 adrenoreceptor agonists.     

Effects of intrathecal fentanyl on duration of bupivacaine spinal blockade for outpatient knee arthroscopy.

The purpose of this study was to determine if intrathecal fentanyl speeds the onset and prolongs the duration of sensory and motor block, prolongs the duration of postoperative analgesia, or increases the incidence of adverse effects in patients undergoing spinal anesthesia for outpatient knee arthroscopy. Fifty patients were randomized to receive 12 mg of hyperbaric bupivacaine 0.75% with 25 micrograms (0.5 mL) of fentanyl (group 1) or 12 mg of hyperbaric bupivacaine 0.75% with 0.5 mL of preservative-free normal saline (group 2). One-tailed t tests were used to determine differences in onset and duration of sensorimotor block and postoperative analgesia. No differences were found in onset and duration of sensory or motor block. Group 1 experienced significantly better postoperative analgesia lasting more than 3 hours longer than analgesia for group 2. Group 1 demonstrated significantly more pruritus, but there were otherwise no differences. We conclude that fentanyl does not enhance the onset and duration of sensory or motor block produced by 12 mg of intrathecal bupivacaine. Fentanyl, however, prolongs postoperative analgesia and increases the risk of pruritus.     

'Balanced analgesia' in the perioperative period: is there a place for ketamine?

We investigated whether intraoperative 'subanesthetic doses' of ketamine have a postoperative anti-hyperalgesic and an analgesic effect and which is the preferential route of administration, either systemic (intravenous, i.v.) or epidural. One hundred patients scheduled for rectal adenocarcinoma surgery under combined epidural/general anesthesia were included. Before skin incision all the patients received an epidural bolus followed by an infusion of continuous bupivacaine/sufentanil/clonidine mixture. They were randomly assigned to receive no ketamine (group 1), i.v. ketamine at the bolus dose of 0.25 mg/kg followed by an infusion of 0.125 mg/kg per h (group 2), 0.5 mg/kg and 0.25 mg/kg per h (group 3), epidural ketamine 0.25 mg/kg and 0.125 mg/kg per h (group 4), or 0.5 mg/kg and 0.25 mg/kg per h (group 5). All i.v. and epidural analgesics were stopped at the end of surgery and patients were connected to an i.v. morphine patient-controlled analgesia (PCA) device. Short-term postoperative analgesia (72 h) was assessed by pain visual analog scale scores at rest, cough, and movements as well as by PCA requirements. Wound mechanical hyperalgesia was evaluated and residual pain was assessed by asking the patients at 2 weeks, and 1, 6, and 12 months. The area of hyperalgesia and morphine PCA requirements were significantly reduced in group 3. These patients reported significantly less residual pain until the sixth postoperative month. These observations support the theory that subanesthetic doses of i.v. ketamine (0.5 mg/kg bolus followed by 0.25 mg/kg per h) given during anesthesia reduce wound hyperalgesia and are a useful adjuvant in perioperative balanced analgesia. Moreover, they show that the systemic route clearly is the preferential route.     

Intrathecal morphine compared with diamorphine for postoperative analgesia following unilateral knee arthroplasty

Objectives: To compare the efficacy and side effects of low dose intrathecal morphine and diamorphine for postoperative analgesia after total knee arthroplasty.Methods: Sixty-four patients were included in a prospective, randomised, double-blind study. Following a standardised general anaesthetic technique, patients received either 0.3 mg of intrathecal morphine or diamorphine with 2–2.5 ml of 0.5% heavy spinal bupivacaine. Supplementary analgesia was provided postoperatively by regular eight hourly diclofenac and patient controlled IV morphine (bolus 1 mg, lockout 5 min, no background infusion).Results: Patients in the morphine group had significantly lower median numerical rating score (NRS) for pain on movement at 4 h [0 versus 3.5] (P=0.0008) and 8 h [0 versus 4] (P=0.0083). In addition, median PCA morphine consumption was significantly reduced at 4 h [0 versus 1] (P=0.0005), 8 h [0.5 versus 6] (P=0.0063) and 12 h [3 versus 8.5] (P=0.0426) in the morphine group. There was no significant difference in the total morphine consumption or NRS for pain at 24 h between the two groups. There was no significant difference in the incidence of side effects between the two groups.Conclusion: In the doses used in this study, morphine produced more effective analgesia than diamorphine in the early postoperative period with comparable side effects [Acute Pain 4 (1) (2001) 7].     

Schmerztherapie mit Stimulationskathetern bei Kniegelenkersatz

Background

Epidural analgesia and continuous femoral nerve blocks are often used for pain therapy after total knee arthroplasty. The additional use of a continuous sciatic nerve block is controversially discussed. To avoid the problem of inaccurate placement a stimulating catheter may be useful. The aim of this study was to compare the effectiveness of a continuous femoral nerve block with an additional continuous sciatic nerve block for improved functional recovery and pain relief.

Material and methods

An open randomized prospective controlled study was carried out with 54 patients to receive either a stimulating catheter placed in the femoral nerve sheath or two stimulating catheters placed in the femoral and in the sciatic nerve sheath or an epidural analgesia. Pain was recorded with the visual analogue scale at rest and with passive motion of the knee during the first 3 postoperative days. The angle of nearly pain-free bending of the knee, side effects and opioid consumption were recorded.

Results

The reported pain scores and opioid consumption did not differ significantly between the groups. However, functional recovery up to the third postoperative day was significantly worse in the femoral catheter group.

Conclusion

Using stimulating catheters for pain therapy the three methods are largely comparable and other parameters should be used for individual selection.     

加巴喷丁和可乐定对子宫全切术患者术后焦虑、疼痛的影响

【目的】探讨加巴喷丁和可乐定对子宫全切术患者术后焦虑和疼痛的影响。【方法】60例ASAⅠ～Ⅱ级的择期妇科手术病人,随机分为3组,每组20例。G组：手术前夜和术前2h和术后24h口服加巴喷丁1200mg;C组：手术前夜和术前2h以及术后24h口服可乐定100μg;P组：口服安慰剂。手术前夜以及术后2,6,12,24,48h进行疼痛评分（VAS）,此外,采用状态－特质焦虑量表（State-Trait Anxiety Inventory,STAI）对患者手术前夜以及术后6h,24h,48h的焦虑水平进行评估。术后镇痛应用持续泵入镇痛给药模式,总量100mL,芬太尼1．0mg,负荷量2mL,持续输注2mL／h。【结果】3组患者术后48h内血压、心率、呼吸、脉搏氧饱和度稳定,各组间副反应差异无统计学意义。与安慰剂组相比较,术后48h内G组和c组的疼痛和焦虑评分明显降低。【结论】加巴喷丁和可乐定能够明显减轻子宫全切术患者术后疼痛和焦虑并不增加不良反应的发生率。     

Clonidin bei Remifentanil-induzierter Hyperalgesie

Background

In the postoperative period, ??2-adrenergic agonists have an opioid sparing effect. In a previous, experimental study, it was also shown that clonidine attenuates remifentanil-induced hyperalgesia. In this study, we examined under clinical conditions whether early administration of a single dose of clonidine can inhibit remifentanil-induced hyperalgesia in patients undergoing elective surgery of the shoulder and with continuous intraoperative use of remifentanil.

Patients and methods

In this study 40?patients received double-blind and randomized either 150???g clonidine or placebo intravenously before skin incision. Anaesthesia was maintained with propofol and remifentanil (0.23±0.09???g/kg body weight/min) and morphine (0.1?mg/kg body weight) was administered 20?min before incision closure. Postoperatively, the patients were given a patient-controlled analgesia pump (PCA) with morphine.

Results

Overall morphine consumption as well as overall assessment of pain with the visual analogue scale in the first 24?h postoperatively did not differ significantly between the groups. Isolated pain scores at 12?h and 24?h were significantly enhanced in the clonidine group (p<0.05).

Conclusion

An early single dose of 150???g of clonidine did not reduce the postoperative morphine consumption and pain scores in patients undergoing elective surgery of the shoulder with remifentanil/propofol-based anaesthesia. After the effect of clonidine has presumably subsided the pain can even increase, therefore further studies with repetitive doses of clonidine should be carried out.     

Efficacy of various epidural analgesia regimens after lung surgery

A prospective study included 90 adult patients undergoing thoracic surgery. After placing an epidural catheter at the Th4-Th5 level, all the patients were randomized in 3 groups. Twenty-nine patients received controlled epidural analgesia (PCEA) with fentanyl, 2 microg/ml, in 0.2% bupivacaine solution (Group 1). In other groups, these analgesics were given either as bolus infections (Group 2; n = 30) or as a continuous epidural infusion of fentanyl, 2 microg/ml, in 0.2% bupivacane solution (Group 3; n = 27). Pain scores and the incidence of adverse effects were assessed within the first 24 hours after surgery. The data were compared using the Student's t-test and x2 test with Bonferroni correction; p < 0.017 was regarded as statistically significant. The VAS scores in coating were significantly lower in Group 1 than in Groups 2 and 3. The need for epidural opioids for adequate analgesia within the first 24 hours after surgery was significantly less in Group 1 than in Groups 2 and 3. There were no excessive sedation episodes in all the groups. In Group 2, the incidence of nausea was 20%. These adverse reactions were not found during PCEA and continuous infusion (p < 0.017). Opioid-induced pruritis was mostly (23%) observed in Group 2. Thoracic PCEA with fentanyl-bupivacaine solution provided adequate postoperative analgesia after thoracotomy and reduced the need for opioids. In addition, PCEA reduced the incidence of adverse reactions of opioids.     

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.     

The efficacy of intrathecal morphine in post-thoracotomy pain management

This study compared the analgesic efficacy of intrathecal (IT) morphine plus IV patient-controlled analgesia (PCA) morphine with IV PCA morphine alone in 33 patients undergoing thoracotomy randomized to two groups: the IT morphine group (n=17) received 10 microg/kg morphine 1 h before the end of surgery, while the control group (n=16) did not. All patients had access to an IV PCA pump post-operatively that delivered 2 mg morphine boluses. Post-operative pain and sedation scores, respiratory and haemodynamic parameters, and morphine demand and delivery were assessed up to 48 h. Post-operative pain scores and morphine consumption were significantly reduced, while peak expiratory flow rates were significantly increased in the IT morphine group compared with controls. We concluded that IT morphine in addition to IV PCA established superior analgesia and maintained better respiratory function compared with IV PCA alone in post-thoracotomy patients.     

Nerve guidance with versus without prepuncture ultrasound visualization for psoas compartment block and perineural catheter insertion: A randomized, prospective, blinded study

Lumbar plexus block may offer significant advantages in terms of postoperative analgesia, patient satisfaction, surgical outcome and patient rehabilitation. Ultrasound guidance has been used to describe psoas compartment block-related anatomy and to estimate transverse process depth before needle insertion and prediction of actual needle-to plexus intercept depth. The aim of this prospective randomized blinded study is to compare the Nerve-Stimulation Guidance with versus without the Pre-puncture Ultrasound Visualization in terms of onset time of the lumbar plexus sensory and motor block in patients undergoing total hip replacement.46 patients undergoing total hip replacement were randomly allocated to receive posterior lumbar plexus block (LPB) using nerve stimulation guidance with (group US, n = 23) or without pre-puncture ultrasound imaging (group NS, n = 23).Onset time of sensory and motor blocks was recorded every 5 min for the first 30 min starting from the injection of the local anesthetic injection. Readiness for surgery was defined as complete numbness to pinprick test in the region supplied by the lumbar plexus and Bromage’s score = 3.Need for additional local anesthetic boluses or general anesthesia, intraoperative opioid consumption and first postoperative 24 h local anesthetic and rescue Analgesics consumption were also recorded.The time required for the execution of the block was 3 (2–15) min in Group US and 5 (2–20) min in Group NS (p = 0.06). The mean time to readiness for surgery was 12 ± 5 in Group US and 19 ± 6 min in Group NS (p = 0.04) . 3 Patients in Group US (13%) and 4 patients in Group NS (17%) (p = 0.73) required general anesthesia due to failed block. Intraoperative opioid consumption was similar in the two groups. There were no differences in complications, postoperative local anesthetic and rescue analgesics consumption and pain scores.Nerve-Stimulation technique combined with Pre-puncture Ultrasound Visualization for continuous lumbar plexus blocks is comparable to Nerve-Stimulation technique in terms of percentage of block success, intraoperative opioid consumption and postoperative pain relief. Pre-puncture Ultrasound Visualization may reduce the time required for readiness to surgery.     

全膝关节置换后的多模式镇痛

背景：围全膝关节置换期疼痛处理一直是临床所关注的重点问题,寻找安全有效的镇痛方式,成为关节外科医生的重要任务之一。目的：比较硬膜外镇痛和股神经阻滞镇痛在患者全膝关节置换后镇痛、康复的效果,探索相关的多模式联合镇痛方案。方法：随机选取行单侧膝关节置换的患者40例,按照镇痛方案的不同分为硬膜外镇痛组和股神经阻滞镇痛组,每组20例。患者在连续硬膜外麻醉下进行单侧膝关节置换并进行术前宣教和塞来昔布给药。置换后硬膜外镇痛组通过留置导管连接0．2％罗哌卡因、2mg／L芬太尼止痛泵镇痛;股神经阻滞镇痛组通过股神经阻滞导管间断注射0．2％罗哌卡因镇痛。观察全膝关节置换后患者6,12,24h和2—7d每天的疼痛程度,以及2-7d每天的膝关节活动度。结果与结论：全膝关节置换后2-7d,2组患者每天的静息痛和活动痛的目测类比评分均呈下降的趋势,股神经阻滞镇痛组患者的疼痛程度小于硬膜外镇痛组患者。置换后2-7d,股神经阻滞镇痛组和硬膜外镇痛组患者膝关节活动度都逐渐升高,股神经阻滞镇痛组患者膝关节活动度大于硬膜外镇痛组。结果说明虽然硬膜外镇痛和股神经阻滞镇痛都能缓解全膝关节置换术后疼痛,但股神经阻滞镇痛在全膝关节置换后近期的运动镇痛效果优于硬膜外镇痛,能加快患者关节功能的康复,且多模式联合镇痛方案能有效控制疼痛。