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

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

Anesthesia for pediatric renal transplantation with and without epidural analgesia--a review of 7 years experience

BACKGROUND: Few objective data exist describing current anesthesia practice for pediatric renal transplantation. We describe here, the experience from an Australian tertiary pediatric center that has continued an active pediatric renal transplantation program after relocation in 1995. Areas of interest include preoperative status, fluid management, hemodynamic stability, perioperative complications, and the use of epidural analgesia. In particular, the influence of perioperative epidural analgesia on hemodynamic stability is addressed. METHODS: A retrospective review of anesthesia records of all patients undergoing pediatric renal transplantation performed at the Children's Hospital at Westmead (CHW), from November 1995 to October 2002 was carried out. RESULTS: Fifty-three pediatric renal transplants were performed in 50 patients. Average age and weight were 10.2 years (range: 1-18 years) and 31.4 kg (range: 9-66 kg), respectively. A total of 14 recipients were less than or equal to 6 years of age. Twenty-four children were recipients of cadaveric transplants, 29 children received kidneys from living related donors. Few children presented with severe anemia (two patients) gross electrolyte abnormalities (three patients) or uncontrolled hypertension. Intraoperatively, all children had central venous pressure monitoring and only four had invasive arterial blood pressure monitoring. Average intraoperative fluid administration was 88 ml x kg(-1) (range: 30-190). Twenty-three children received blood transfusions intraoperatively. Postoperative analgesia was provided using an epidural infusion in 39 patients and an opioid infusion/patient controlled analgesia in the remainder. There was a tendency to greater hemodynamic stability in the group, which received intra-operative epidural analgesia. Half the patients who had epidural analgesia required parenteral opioid supplementation. Five patients had postoperative pulmonary edema. Minor postoperative adverse events included epidural associated motor block (three cases) and opioid related oversedation (one patient). No perioperative mortality or major morbidity was recorded. CONCLUSIONS: Anesthesia for renal transplantation in pediatric patients at CHW is safe and effective using a selected range of drugs and techniques. Pretransplant medical optimization, careful preoperative assessment, adequate monitoring and precise fluid management together with appropriate postoperative analgesia typify the perioperative care of CHW renal transplant recipients.     

Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery

Combined spinal-epidural anesthesia balancing low-dose intrathecal bupivacaine/fentanyl and low-dose epidural bupivacaine may be more useful than single-shot spinal anesthesia for cesarean delivery in reducing incidences of adverse effects such as hypotension and nausea and in shortening motor recovery. Combined spinal-epidural anesthesia (n=50) or spinal anesthesia (n=50) was randomly performed in 100 parturients. Intrathecal bupivacaine 6 mg added by fentanyl 20 mug followed after 5 min by 10 mL of 0.25% epidural bupivacaine were used for combined spinal-epidural and intrathecal bupivacaine 9 mg with fentanyl 20 mug for spinal anesthesia. The initial sensory block level was higher in the spinal group (P<0.001), although the maximum levels were the same (T3). Complete surgical anesthesia was achieved and no patient complained of intraoperative pain in either group. Patients in the spinal group had denser motor block in the extremities and a higher incidence of hypotension (P<0.05) and nausea and vomiting (P<0.05). Motor recovery was faster in the combined spinal-epidural group (P<0.001). We concluded that combined spinal-epidural anesthesia using low-dose local anesthetic-opioid spinal anesthesia and routine epidural supplementation before surgery had some potential advantages over single-shot spinal anesthesia in the lower incidences of adverse effects and quicker recovery.     

Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.

BACKGROUND: Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta. METHODS: One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones. RESULTS: Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups. CONCLUSIONS: In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.     

0.2% ropivacaine with or without sufentanil for patient-controlled epidural analgesia after anterior cruciate ligament repair

AIM: The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia (PCEA) on the quality of postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: Twenty ASA physical status I-II patients, scheduled to have elective ACL repair were studied. Combined spinal-epidural anesthesia was performed at the L3-L4 or L4-L5 interspace using a needle-through-needle technique. Spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine. Postoperative epidural analgesia was started at the end of surgery using a continuous epidural infusion of 0.2% ropivacaine alone (n=10) or 0.2% ropivacaine/0.5 mg mL(-1) sufentanil (n=10). The degree of pain was evaluated at 1, 8, 16, 24 and 48 hours after surgery; at the same observation times the degree of motor block, sedation, oxygen saturation, total consumption of PCEA solution and incremental doses given to the patient were also recorded. RESULTS: No differences in the quality of intraoperative anesthesia was observed, and in no case general anesthesia was required to complete surgery. Patients receiving the combination of ropivacaine and sufentanil showed lower levels of VAS from 16 hours after surgery as compared with ropivacaine group (P=0.02). However, no differences in the degree of pain were observed between the 2 groups during continuous passive mobilization. CONCLUSION: Adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia improved pain control at rest but did not result in significant improvement of postoperative analgesia during continuous passive mobilization.     

Combined general and epidural anesthesia with ropivacaine for renal transplantation

AIM: To evaluate the effectiveness and safety of epidural ropivacaine anesthesia in association with light general anesthesia during renal transplantation and compare epidural and endovenous analgesia techniques for postoperative pain control. METHODS: Experimental design: prospective randomized study. SETTING: Organ Transplantation Center, Department of Surgery, "Tor Vergata" University of Rome, St. Eugenio Hospital, Rome. PATIENTS: 25 patients affected by chronic renal failure were enrolled in this study. Thirteen constituted the combined epidural-general anesthesia group (EPI-GEN), mean age 40.15+/-9.81 years; while the others constituted the general anesthesia group (GEN), mean age 46.75+/-7.45 years. Operation: cadaveric renal transplantation. Group EPI-GEN: epidural anesthesia performed with 12-15 ml of a ropivacaine 0.75% and fentanyl 5 microg/ml solution followed by light intravenous or inhalatory general anesthesia and postoperative epidural analgesia with ropivacaine 0.2% and fentanyl 2 mg/ml. Group GEN: inhalatory or intravenous general anesthesia and intravenous tramadol postoperative analgesia. Measurements: hemo-dynamics, renal function, arterial blood gases analysis, acid-base balance and postoperative pain data was collected and examined. RESULTS: Postoperative epidural analgesia resulted significantly more effective than intravenous tramadol. PaO(2)/FiO(2) ratio was significantly higher in group EPI-GEN patients both on awakening and throughout postoperative observation. Hemodynamics and renal function did not appear to differ significantly. CONCLUSION: Combined epidural-general anesthesia is as valid a technique as any for renal transplantation; however postoperative epidural ropivacaine analgesia resulted more effective than intravenous tramadol. Respiratory function appeared less affected, facilitating a fast and uncomplicated postoperative recovery.     

Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Anesthesia and Postoperative Analgesia in Abdominal Aortic Surgery

Background : Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta.

Methods : One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones.

Results : Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups.     

The use of central regional anesthesia techniques in Sweden: results of a nation-wide survey

Background: Epidural and subarachnoid anesthesia are well established central regional techniques for surgical anesthesia. TWO additional techniques, combined spinal epidural (CSE) block and continuous spinal anesthesia (CSA), have recently become popular. However, data on nation-wide use of central regional blocks are not available.
Method: With the aims to survey the use of central regional techniques, to evaluate the risk of complications to central regional blocks and to document the use of continuous epidural techniques for postoperative pain management in Sweden during 1993, a questionnaire was mailed to all 105 Swedish anesthesiology departments.
Results: Questionnaires were returned by 62 departments, representing all categories of Swedish hospitals. Central regional blocks were used for surgical anesthesia in 2040% of reported surgical procedures. Subarachnoid anesthesia was the main technique for orthopedic surgery on the lower limb, elective cesarean section and transurethral resection of the prostate. Epidural block was used for orthopedic and vascular surgery. CSE block was used by 42 departments and CSA by 21 departments. Postoperative epidural analgesia was used by 59 departments, most commonly with continuous infusion of local anesthestics and/or epidural bolusdoses of morphine. Nineteen neurological sequelae were reported after epidural (n=7) and subarachnoid (n=12) blocks. Routines for registration of complications varied greatly.
Conclusions: Subarachnoid block was preferred for shorter surgical procedures (<60 min), whereas epidural and CSE blocks were chosen when severe postoperative pain could be anticipated, as continuous epidural analgesia was well established for postoperative pain management. Improved routines for registration of complications to central regional blocks are needed.     

Combined subarachnoid-epidural technique for obstetric analgesia

Combined spinal-epidural blockade for labor pain has enjoyed increasing popularity in obstetric anesthesia. The usual procedure is to use a single space and a single needle for dural puncture, inserting a spinal needle through an epidural needle followed by insertion of a catheter. A small dose of one or several substances (usually a lipophilic opioid and a local anesthetic) is first injected in the intrathecal space to provide rapid, effective analgesia with minimal muscle blockade. The epidural catheter is used if labor lasts longer than the spinal block, if the spinal block is insufficient, or in case of cesarean section. Combined spinal-epidural blockade is a safe, valid alternative to conventional epidural analgesia and has become the main technique for providing obstetric analgesia in many hospitals. The most widely-recognized advantage of the technique is high maternal satisfaction with rapid and effective analgesia. Mobility of the lower extremities is preserved and the mother is often able to walk. Because opioids are injected into the intrathecal space and because the technique is more invasive than standard epidural analgesia, the potential risk to mother and fetus increases.     

Combined spinal-epidural anesthesia for Cesarean section in a patient with peripartum dilated cardiomyopathy

PURPOSE: To report a case of peripartum dilated cardiomyopathy associated with morbid obesity and possible difficult airway presenting for elective Cesarean section, which was successfully managed with combined spinal-epidural anesthesia. CLINICAL FEATURES: A morbidly obese parturient with a potentially difficult airway, suffering from idiopathic peripartum cardiomyopathy (ejection fraction 20%), was scheduled for an elective Cesarean section. A combined spinal epidural anesthesia was performed and 6 mg of bupivacaine were injected into the subarachnoid space. This was supplemented after 60 min with 25 mg of bupivacaine injected epidurally. The patient's hemodynamic status was monitored with direct intra-arterial blood pressure and central venous pressure measurements. The patient's perioperative course was uneventful. CONCLUSION: In patients suffering from peripartum cardiomyopathy, undergoing Cesarean section, combined spinal-epidural anesthesia may be an acceptable anesthetic alternative.     

Spinal versus epidural anesthesia for vesicovaginal fistula repair surgery in a rural sub-Saharan African setting

STUDY OBJECTIVE: To compare spinal anesthesia with epidural anesthesia in patients undergoing surgery for vesicovaginal fistula (VVF) repair. DESIGN: Nonrandomized, prospective, clinical, pilot study. SETTING: Rural African hospital with 165 beds. PATIENTS: 60 ASA physical status I and II patients undergoing VVF repair surgery. INTERVENTIONS: 30 patients were included in each study group. Spinal (1.5-2 mL hyperbaric bupivacaine 0.75%) or lumbar epidural (20-24 mL bupivacaine 0.5%) anesthesia was administered to the patients. MEASUREMENTS: Demographics, quality of anesthesia, duration of postoperative analgesia, as well as preoperative, intraoperative, and postoperative data, were all recorded. Data were compared between study groups using unpaired Student's t test for continuous variables and chi(2) and Fisher's exact tests for categorical data. MAIN RESULTS: Quality of anesthesia was different between groups (P = 0.009). Good anesthesia quality was significantly more frequent in the spinal (86.7%) than the epidural group (50%, P = 0.005). Postoperative analgesia quality was comparable (P = 0.347). There were no differences between groups in hemodynamic parameters before, during, or after surgery. CONCLUSION: Spinal anesthesia proved to be the better anesthetic technique for VVF repair surgery when compared with epidural anesthesia in a rural, sub-Saharan African setting.     

Critical incidents during regional anesthesia in Japanese Society of Anesthesiologists-Certified Training Hospitals: an analysis of responses to the annual survey conducted between 1999 and 2002 by the Japanese Society of Anesthesiologists

BACKGROUND: Recently, a national survey in France including 35,439 patients who had received spinal anesthesia showed that the incidences of cardiac arrest and mortality associated with spinal anesthesia were 2.5 and 0.8 per 10,000 anesthetics, respectively. In this study, we investigated these values using data obtained from annual surveys conducted by the Japanese Society of Anesthesiologist (JSA). METHODS: Since 1994, JSA has conducted annual surveys concerning critical incidents in the operating theater by sending confidential questionnaires to JSA-certified training hospitals, then collecting and analyzing the responses. We investigated critical incidents associated with regional anesthesia using data from annual surveys between 1999 and 2002. The questionnaire was identical in each survey conducted during these years. The total number of anesthetics available for this analysis was 3,855,384, of which spinal anesthesia, combined spinal-epidural anesthesia and epidural anesthesia were performed in 409,338, 146,282, and 69,001 patients, respectively. In patients receiving regional anesthesia, 628 critical incidents including 108 cardiac arrests, and 45 subsequent deaths were reported. The causes of critical incidents were classified as follows: totally attributable to anesthetic management, due mainly to intraoperative pathological events, preoperative complications, and surgical management. IP consists of coronary ischemia including coronary vasospasm not suspected preoperatively, arrhythmias including severe bradycardia, pulmonary thromboembolism, and other conditions. Mortality was determined by postoperative day 7. Statistical analysis was performed by chi-square test and Mann-Whitney test. A p value less than 0.05 was considered significant. RESULTS: The incidences of cardiac arrest and mortality due to all etiologies were 1.69 and 0.76 with spinal anesthesia, 1.78 and 0.68 with combined spinal-epidural anesthesia, and 1.88 and 0.58/10,000 anesthetics with epidural anesthesia, respectively. The incidences of cardiac arrest and mortality due to anesthetic management were 0.54 and 0.02 with spinal anesthesia, 0.55 and 0.00 with combined spinal-epidural anesthesia, and 0.72 and 0.14/10,000 anesthetics with epidural anesthesia, respectively. These values did not significantly differ among regional anesthesia. Death attributable to anesthetic management was reported in 2 patients: both patients were classified as ASA-PS 3 E, and developed cardiac arrest; one due to inadvertent high spinal anesthesia with spinal anesthesia, and the other due to local anesthetic intoxication with epidural anesthesia. Anesthetic management and intraoperative pathological events comprised 33 and 43% of cardiac arrests, respectively. The distribution of causes of death was as follows: anesthetic management, 5%; intraoperative pathological events, 34%; preoperative complications, 35%; surgical management, 26%. Among the causes of anesthetic management-induced critical incidents, inadvertent high spinal anesthesia was the leading cause of cardiac arrest in spinal and combined spinalepidural anesthesia: 90% of arrests occurred in patients with ASA-PS 1+2; 88% in patients below 65 years of age; 45 and 25% in patients undergoing hip or lower extremities surgery, and cesarean section, respectively. Among the causes of intraoperative pathological event-induced critical incidents, pulmonary thromboembolism was the leading cause of cardiac arrest in spinal and combined spinal-epidural anesthesia: 59% of arrests occurred in patients with ASA-PS 1+2; 81% in patients above 66 years of age; 91% in patients undergoing hip or lower extremity surgery. CONCLUSIONS: The incidence of cardiac arrest and mortality associated with spinal anesthesia in Japan was shown to be in the same order as in France by analyzing a larger population. In patients with good ASA-PS, critical incidents occurred more often under regional anesthesia than under general anesthesia. Inadvertent high spinal anesthesia should be carefully avoided. We should also pay much attention to subclinical deep vein thrombosis in patients who were scheduled for hip or lower extremity surgery, and tourniquet- or bone cement-associated pulmonary embolism in these patients.     

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.     

Combined spinal-epidural technique for vaginal hysterectomy in a patient with Machado-Joseph disease

OBJECTIVE: Machado-Joseph disease is a form of progressive spino-cerebellar ataxia with both bulbar and peripheral neurological manifestations. To date, anesthesia for patients affected by this disease has not been described. General anesthesia may be problematic because of the risk of pulmonary aspiration and hypoxia. We describe our experience with the successful use of combined spinal-epidural in a patient with Machado-Joseph Disease (MJD).CASE REPORT: A 38-year-old woman with MJD complicated by significant bulbar and peripheral neuropathy presented for an elective vaginal hysterectomy. She had no other medical history of note. After informed consent, subarachnoid block was performed by combined spinal-epidural anesthesia at the L2-3 lumbar intervertebral space with hyperbaric bupivacaine 12 mg, morphine 100 microg, and fentanyl 10 microg. Surgery proceeded uneventfully, with excellent postoperative analgesia. There was full recovery of preinduction neurologic function by the sixth postoperative hour. CONCLUSIONS: Central neuraxial anesthesia is an option for patients with MJD presenting for lower abdominal and lower extremity operations. Combined spinal-epidural anesthesia confers hemodynamic stability yet allows for augmentation of intraoperative anesthesia and postoperative analgesia.     

A randomized study comparing combined spinal epidural or general anesthesia for renal transplant surgery

INTRODUCTION: The appropriate anesthesia for renal transplantation requires minimal toxicity for patients and for the transplanted organ, as well as sufficient pain relief and maintenance of vital functions. The aim of this study was to determine how the anesthetic technique influences the outcome in patients after renal transplantation in terms of preoperative and intraoperative hemodynamic changes and blood gas changes. METHODS: Fifty adult patients undergoing renal transplantation were randomly divided into two groups receiving standardized general anesthesia or combined spinal and epidural anesthesia. RESULTS: Demographically both groups were similar. Total anesthesia time (202 +/- 53 vs 186 +/- 37 minutes) and surgical time (191 +/- 52 vs 162 +/- 31 minutes) did not differ between the groups. The heart rate and systolic blood pressure values of the groups as measured before induction and 5, 15, 20, 30, as well as 60 minutes thereafter did not differ between the groups. Neither the frequency of bradycardia (four vs two) nor of hypotension (six vs four) during anesthesia differed between regional versus general anesthesia groups. CONCLUSION: Regional is an important alternative to general anesthesia during renal transplantation surgery in adult patients.     

七氟醚复合全麻对上腹部手术应激反应的影响

目的 探讨吸入七氟醚全麻基础上复合硬膜外阻滞或瑞芬太尼靶控输注对上腹部手术患者应激反应的影响。方法选择60例ASAⅠ～Ⅱ级拟行上腹部手术患者随机分为3组（n=20）：对照组（七氟醚维持）、瑞芬太尼组（七氟醚＋瑞芬太尼靶控输注）、硬外组（七氟醚＋硬膜外阻滞）。所有患者入室后常规监护ECG、血压、血氧饱和度,行中心静脉穿刺及桡动脉穿刺测压后,快速诱导插管。记录三组麻醉前（T1）、插管后即刻（T2）、手术开始即刻（T3）、手术开始后30min（T4）及术毕（T5）的平均动脉压（MAP）、心率（HR）、脑电双频谱指数（BIS）及测量末梢血糖（Glu）、乳酸（Lac）、血浆皮质醇（Cor）浓度。记录拔管时间及术后恶心呕吐。结果硬膜外组及瑞芬组术中皮质醇浓度均较对照组低,术后皮质醇浓度瑞芬组低于对照组及硬膜外组。结论七氟醚复合瑞芬太尼靶控输注或硬膜外阻滞的全麻比单用七氟醚更有效减轻术中应激反应。     

Onset of spinal block is more rapid with isobaric than hyperbaric bupivacaine

PURPOSE: To compare isobaric with hyperbaric 9.75 mg bupivacaine injected intrathecally, and to evaluate the effects of subsequent injection of lidocaine 2% into the epidural space. METHODS: Patients in group 1 (n = 30) received isobaric 9.75 mg bupivacaine and in group 2 (n = 30) hyperbaric 9.75 mg bupivacaine injected into the subarachnoid space in a combined spinal-epidural technique. They were undergoing urological, gynecological, orthopedic, gastro-intestinal or vascular surgery. Using a double blind technique, the followings parameters were measured: cutaneous analgesia to pinprick, motor blockade, time for two segment regression, time for complete regression of the motor block, quality of anesthesia. In 12 patients the effect of epidural injections of 3 ml lidocaine 2% was observed. RESULTS: Motor and sensory block developed more rapidly (five minutes) in the isobaric group (P<0.05). Maximum upper level (T7+/-2), two-segment regression (52 min in both groups), motor recovery (160 vs. 157 min), and quality of anesthesia did not differ between the two groups. Thirty nine epidural injections of 3 ml lidocaine 2% were given in 12 patients 10 min after spinal injection, 28 were in the hyperbaric group (P<0.05). Twenty six of the epidural injections produced an increase in sensory block of 0 or 1 dermatome, and 13, of 2 or more. CONCLUSION: The block developed more rapidly in the isobaric group, but both isobaric and hyperbaric 9.75 mg bupivacaine produced adequate upper levels of analgesia for surgery. The effect of epidural injections of 3 ml lidocaine 2% was usually minimal.     

Laparoscopic ovarian cystectomy with abdominal wall lift during pregnancy under combined spinal-epidural anesthesia

Abdominal wall lift laparoscopic surgery is often used for patients during pregnancy because it is physiologically superior to CO2 pneumoperitoneum laparoscopic surgery. Operation for adnexal cysts is performed in the 1st trimester. We report seven cases of ovarian cysts during pregnancy, resected using gassless laparoscopic method with a whole abdominal wall lift under combined spinal-epidural anesthesia (CSEA). Combined spinal-epidural anesthesia had several advantages in these cases; 1. In the 1 st trimester, general anesthesia should be avoided. We could manage these cases without general anesthesia nor sedative medications. 2. During pregnancy, it is difficult to estimate the level of sensory blockade by spinal anesthesia. Epidural top-up helped us to easily control the level of sensory blockade. 3. Differential diagnosis of pain related to uterine contraction and postoperative pain is difficult. Post-operative analgesia was established by epidural PCA, thus anti uterine contraction medicines were prophylactically administered in only one of seven cases. There was no particular trouble during the anesthesia and all the operative procedures were performed uneventfully. Based on our limited experiences, CSEA may be a safe and appropriate anesthetic technique for laparoscopic ovarian cystectomy with abdominal wall lift during pregnancy.     

Postoperative analgesia using continuous lumbar epidural infusion of ropivacaine in comparison with bupivacaine

BACKGROUND: Epidural bupivacaine infusion is a commonly used technique for postoperative analgesia because of its motor-sparing properties. Recently a new long acting local anesthetic, ropivacaine, has become available. The aim of this study was to investigate the efficacy of ropivacaine and bupivacaine with regard to postoperative analgesia when administered continuously into the lumbar epidural space. METHODS: All patients were ASA I II and undergoing ipsi-lateral leg orthopedic surgery with epidural or combined spinal-epidural anesthesia. Patients were randomly assigned to following three groups: 0.1% ropivacaine (0.1 R); 0.2% ropivacaine (0.2 R); 0.125% bupivacaine (0.125 B). At the end of surgery, continuous infusion was begun at a rate of 6 ml.hr 1 after a bolus epidural administration of 5 ml of 0.2% ropivacaine in R groups and 0.25% bupivacaine in B group. Sensory and motor block, blood pressure, pulse rate, verbal pain score (VPS), analgesic consumption were assessed at 20 min, 1, 3, 10-20 hrs following the beginning of continuous infusion. RESULTS: Vital signs were stable at every measuring point in all groups. In 0.1 R group (n = 20), the spread of sensory block at 3 hrs after infusion was lower than 0.2 R group (n = 19), and VPS during the study was higher than 0.125 B group (n = 17). Bromage scale after 3 hrs was higher in 0.2 R group compared with 0.125 B group. The degree of sensory and motor block gradually decreased, resulting in little difference between the groups. When epidural anesthesia was spread over the surgical area throughout the study, 0.2 R or 0.125 B was sufficiently relieved from postoperative pain. CONCLUSIONS: After leg orthopedic surgery, 6 ml.hr-1 of 0.2 R or 0.125 B provided enough postoperative analgesia when the spread of anesthesia covered the operated area. 0.2 R would be better compared to 0.125 B in continuous epidural infusion for postoperative analgesia due to less systemic toxicity, even though it accompanies a little more intense motor block.     

High thoracic epidural anesthesia for off-pump coronary artery bypass surgery

OBJECTIVE: To assess the feasibility of high thoracic epidural anesthesia combined with sevoflurane for off-pump coronary artery bypass surgery and to evaluate the postoperative pain control, side effects, and perioperative hemodynamics. DESIGN: Retrospective review of prospectively collected data. SETTING: A university teaching hospital. PARTICIPANTS: One hundred six consecutive patients receiving thoracic epidural combined with sevoflurane. INTERVENTION: From November 1999, the patients undergoing off-pump coronary artery bypass grafting were offered the epidural-inhalation anesthetic approach. MEASUREMENTS AND MAIN RESULTS: Insertion of the epidural catheter was successful in all but 2 patients; 1 bloody tap occurred and the dura was never punctured, although 1 patient presented with postoperative paraplegia. An emergency spinal cord nuclear magnetic resonance excluded signs of medullary compression caused by epidural or spinal hematoma. Visual analog scale scores for pain during the first 24-hour period were < 2 in all patients. Mean time to extubation was 4.6 +/- 2.9 hours. The average intensive care unit stay was 1.5 +/- 0.8 days. Incidences of perioperative myocardial infarction, myocardial ischemia, and atrial fibrillation were 2.8%, 7.5%, and 10.6%, respectively. Two patients died: 1 from multiorgan failure and the other from myocardial infarction. Heart rate, mean arterial pressure, cardiac index, and systemic vascular resistance were not affected by thoracic epidural alone. Mean arterial pressure and cardiac index decreased (p < 0.05) when general anesthesia was induced and remained stable thereafter. Neither heart rate nor systemic vascular resistance changed from baseline during operation. CONCLUSIONS: Thoracic epidural as an adjunct to general anesthesia is a feasible technique in off-pump coronary artery bypass surgery. It induces intense postoperative analgesia and does not compromise central hemodynamics.