Analgesic effects of interpleural bupivacaine with fentanyl for post-thoracotomy pain

OBJECTIVE: The analgesic effect of bupivacaine/fentanyl with epinephrine given interpleurally after thoracotomy was investigated in a randomized placebo and intravenous controlled study. DESIGN: Prospective clinical study. SETTING: University teaching hospital. PARTICIPANTS: Sixty American Society of Anesthesiologists physical status II and III patients scheduled for posterolateral thoracotomy with general anesthesia. INTERVENTIONS: Patients were randomly divided into 4 groups to receive either 0.5% bupivacaine/1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine (n = 15, group IPBF), 0.5 % bupivacaine with 5 microg/mL of epinephrine (n = 15, group IPB), or saline (n = 15, group IPS) in a total volume of 15 to 20 mL in 60 seconds by an interpleural catheter placed at the end of surgery by direct vision. The same volume of bupivacaine 0.25% and 1.5 microg/kg of fentanyl with 5 microg/mL of epinephrine to group IPBF, bupivacaine 0.25% with 5 microg/mL of epinephrine to group IPB or saline to group IPS was injected through the interpleural catheter every 6 hours for 48 hours postoperatively. Intravenous fentanyl (n = 15, group IVF) and interpleural saline groups received 1.5 microg/kg of fentanyl intravenously at the first complaint of pain. All patients also received patient-controlled analgesia (PCA) with fentanyl for 48 hours postoperatively. Metamizol sodium was used as a rescue analgesic. MEASUREMENTS and MAIN RESULTS: Adequacy of pain relief was evaluated with the "Prince Henry Pain Scale" and visual analog pain scale. Fentanyl consumption via PCA and complications were evaluated for 48 hours. Visual analog scale scores were significantly higher in the interpleural saline group at 4 and 12 hours (6.6 +/- 1.2 and 5.0 +/- 2.1, respectively) postoperatively. Significantly more patients in the IPBF group had lower pain scores during coughing and deep breathing. Fentanyl consumption via PCA device was significantly higher in the intravenous fentanyl group (1,069 +/- 96.9 microg) than the interpleural groups (577.3 +/- 72.2 microg, 651.1 +/- 61.9 microg, and 601.0 +/- 22.6 microg in IPBF, IPB, and IPS groups, respectively). CONCLUSION: It is concluded that total fentanyl consumption via PCA decreased in all interpleural groups, but pain during coughing and deep breathing was significantly reduced in only the interpleural bupivacaine/fentanyl with epinephrine group.     

Evaluation of buprenorphine hydrochloride suppositories for postoperative pain relief]

An analgesic is often administered upon the occurrence of pain following surgery. Buprenorphine hydrochloride suppository (0.2 mg) was given immediately postoperatively to patients who had undergone surgery under general anesthesia. Post-operative pain has been observed after 782 +/- 41 minutes (n = 148, mean +/- SE) in the patients with suppository and 127 +/- 18 minutes (n = 57) in the control group (P less than 0.01). Analgesics were given to 68% of the control group within 2 hours, while it was given to 14% of the study group. Further 57% of the latter did not complain of any pain after 20 hours. The pharmacokinetics of buprenorphine was studied in 7 patients. Intrarectal administration of 0.2 mg buprenorphine suppository just after surgery had a sufficient analgesic action and did not induce any adverse reactions of any clinical importance.     

The site of action of epidurally administered opioids and its relevance to postoperative pain management

The use of epidurally administered opioids to control postoperative pain is a well established and widely accepted technique. However, despite this longstanding use, there is still an ongoing debate concerning the site of action of the opioids used. Some argue that analgesia is mediated by a spinal mechanism and others that a supraspinal mechanism is responsible. On close inspection of the evidence it becomes apparent that epidural opioids act predominantly spinally when administered as a bolus, and predominantly supraspinally when administered as a continuous infusion. A concentration of 10 microg x ml(-1) appears to be the threshold at which epidurally administered fentanyl can elicit segmental analgesia, a value which may have significant clinical applications. The evidence supporting a synergistic relationship between epidural opioids and local anaesthetics is weak and unsupported by a plausible physiological mechanism. Thus the 'threshold concentration' of approximately 10 microg x ml(-1) is unlikely to be lowered by co-administering opioids with local anaesthetics.     

Analgesic effects of sublingual buprenorphine

The analgesic effects of sublingually administered buprenorphine 0.4 mg have been compared with morphine 10 mg given intramuscularly in patients following operation. The results indicate a slower onset of action for buprenorphine but of much longer duration than morphine. There were no serious side effects or difference in their incidence between the two drugs.     

Continuous epidural infusion of bupivacaine and buprenorphine for postoperative pain relief]

The efficacy for postoperative analgesia and side-effect of combined epidural infusion of bupivacaine and buprenorphine in comparison with each of these drugs alone were evaluated in 150 patients. All patients received initially bupivacaine 8 ml and buprenorphine 0.1 mg. In a random order, epidural infusion of 5 micrograms.ml-1 buprenorphine 1 ml.h-1 (group A; n = 50), 0.25% bupivacaine 1 ml.h-1 (group B; n = 50), or a combination of the two drugs 1 ml.h-1 (group C; n = 50) was continued for 48 h by a portable disposable device. The analgesic efficacy in group C was superior to that in group A or group B. No significant difference in the incidence of side-effect was found among the three groups. We conclude that epidural analgesia with the combination of buprenorphine and bupivacaine is safe, and easy to manage, giving pain relief superior to that provided by each of these drugs alone.     

Caudal analgesia with buprenorphine for postoperative pain relief in children

Caudal buprenorphine was investigated as a postoperative analgesic in a randomized double blind study in thirty children aged 5–12 years undergoing lower abdominal and lower limb surgery. Comparison was made between two groups of patients, one group receiving plain bupivacaine and the other a combination of plain bupivacaine with buprenorphine. Postoperative analgesia was assessed using a linear analogue scale, and by the response to direct questioning of children using an illustration of sequence of faces. Any untoward side effects and the need for additional analgesics were recorded. The degree and duration of analgesia was far superior in the buprenorphine group and there was a highly significant difference in the requirement of postoperative analgesia between the two groups. There were no major adverse side effects and no motor weakness in either groups, however the incidence of nausea and vomiting was higher in the buprenorphine group. It is concluded that a combination of bupivacaine with buprenorphine administered through the caudal epidural space is a safe and reliable means of providing postoperative pain relief in children for up to 24 h.     

A combination of sufentanil and 0.25% bupivacaine administered epidurally for obstetrical analgesia. Comparison with fentanyl and placebo

The study reported was designed to determine whether 15 micrograms sufentanil would provide analgesia comparable in duration and quality with that given by 75 micrograms fentanyl, when associated with plain 0.25% bupivacaine for extradural analgesia for labour. Patients (n = 124) in labour and at full term were randomly divided into 3 groups. Group 1 (n = 41) were given 12 ml of 0.25% plain bupivacaine with saline, group 2 (n = 41) 12 ml of 0.25% plain bupivacaine with 75 micrograms fentanyl and group 3 (n = 42) 12 ml of 0.25% plain bupivacaine with 15 micrograms sufentanil. 11 cases were excluded from the study (8 Caesarean sections, 3 technical failures). The duration of analgesia obtained with the two opioids was similar (group 2: 126.7 +/- 6.5 min, p less than 0.01; group 3: 114.9 +/- 5.8 min, p less than 0.01; group 1: 93.6 +/- 5.4 min) as well as the quality of pain relief. There were no differences between the three groups with regard to Apgar scores. The only side-effect seen with sufentanil and fentanyl was pruritus (group 2: 21.9%, p less than 0.05; group 3: 21.4%, p less than 0.05; group 1: 2.4%). These results showed that 15 micrograms sufentanil could replace 75 micrograms fentanyl for extradural pain relief of labour with plain 0.25% bupivacaine. However, the use of opioids with local anaesthetics would seem to be of interest only if labour is likely to be prolonged.     

Transdermal fentanyl against postoperative pain

60 patients (ASA class I-II) undergoing knee arthrotomy received in a double blind fashion, a transdermal drug delivery system, containing either fentanyl (delivery rate of 75 micrograms/hour)--Fentanyl TTS--or placebo. The system remained in place for 24 hours. Even when piritramid was added as escape analgesia, all respiratory and hemodynamic parameters, as well as blood gas analysis showed no statistical significant difference between both groups (fentanyl or placebo). One patient had evidence of a beginning respiratory depression, but no specific therapy was needed. No significant side effects were seen. Concerning escape medication, a highly statistically significant difference in favour of Fentanyl TTS was found (p less than 0.001).     

Comparison of epidurally administered sufentanil, morphine, and sufentanil-morphine combination for postoperative analgesia

Postoperative analgesia provided by epidurally administered sufentanil and/or morphine was evaluated in 45 patients recovering from major gynecologic surgery. At the first complaint of pain in the Postanesthesia Care Unit, patients received a single epidural bolus of 30 micrograms sufentanil (group A), 5 mg morphine (group B), or 30 micrograms sufentanil plus 3 mg morphine (group C) in a randomized blinded fashion. Analgesic efficacy was assessed throughout the 24-h study period with 10-cm visual analog scales. The need for additional postoperative analgesia (patient-controlled analgesia, 1 mg of morphine every 6 min as necessary) and the incidence of adverse effects were also assessed. Patients receiving sufentanil (groups A and C) had significantly faster onset of analgesia than did patients given morphine alone (group B, P less than 0.05). Group B subjects experienced the longest duration of analgesia (B vs A and C, P less than 0.05) and required significantly less patient-controlled analgesia (morphine) than patients in group A (P less than 0.05). No patient developed clinically significant respiratory depression or excessive sedation, and there were no intergroup differences in incidence of pruritus or nausea (P value not significant). The data indicate that a mixture of sufentanil and morphine provides either a more rapid onset of epidural analgesia or reduced patient-controlled analgesia narcotic requirement than respective doses of each agent administered alone.     

Comparison of intravenous buprenorphine or fentanyl and epidural buprenorphine for pain relief after upper abdominal surgery

In three groups [(1) intravenous buprenorphine (0.1mg) or (2) fentanyl (100 micrograms.hr-1) and (3) epidural injection of buprenorphine (0.1mg diluted with 10ml normal saline)], we determined the effects of postoperative pain relief in patients after upper abdominal surgery. There are no differences in postoperative analgesia in the three groups, but respiratory depression was seen in some patients who had intravenous buprenorphine or fentanyl. We conclude that epidural injection of buprenorphine is a useful method for postoperative analgesia because of little adverse effect. As respiratory depression caused by buprenorphine was reversed with naloxone, it is not necessary to employ fentanyl instead of buprenorphine.     

The effects of secondhand smoke on postoperative pain and fentanyl consumption

Background

Although the need for increased postoperative analgesia in smokers has been described, the effect of secondhand smoke on postoperative analgesia requirements has not been studied. We examined the effects of secondhand smoke on fentanyl consumption and postoperative pain.

Methods

In this study, 101 patients (American Society of Anesthesiology physical status I and II) who underwent abdominal hysterectomy were divided into 3 groups according to history of exposure to cigarette smoke as per medical records which was retrospectively confirmed by measurement of serum cotinine: smokers (n = 28), nonsmokers (n = 31), and secondhand smokers (n = 32). All patients received propofol–remifentanil total intravenous anesthesia and used fentanyl patient controlled analgesia for postoperative pain. The fentanyl consumption visual analogue scale-pain intensity (VAS-PI) score and side effects were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 h after surgery.

Results

Fentanyl consumption at all the evaluation time points was significantly higher in secondhand smokers than in nonsmokers (P < 0.05). However, fentanyl consumption in secondhand smokers was lower than that in smokers in the PACU and at 24 h (P < 0.05). VAS-PI scores during movement and at rest in the PACU and at 4, 6, and 24 h after surgery were higher in secondhand smokers than in nonsmokers (P < 0.05). There were no statistically significant differences between the groups with regard to side effects such as nausea, vomiting, and dizziness (P > 0.05).

Conclusion

Secondhand smoking was associated with increased postoperative fentanyl consumption, and increased VAS-PI scores. These findings may be beneficial for managing postoperative pain in secondhand smokers.