Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoracotomy

Background. The aim of this prospective, double-blind, randomizedcontrolled trial was to investigate the analgesic and adverseeffects of three commonly used concentrations of thoracic epiduralfentanyl with bupivacaine in patients undergoing thoracotomyfor lung resection. Methods. We studied 99 patients who were randomized to receivefentanyl 2 µg ml^–1 (group 2), fentanyl 5 µgml^–1 (group 5) and fentanyl 10 µg ml^–1 (group10) in bupivacaine 0.1% via a thoracic epidural. Postoperatively,pain on coughing was assessed using a visual analogue scale(VAS) and an observer verbal rating score (OVRS) at 2, 8, 16and 24 h. At the same times, sedation, pruritus and nausea wereassessed. Results. Of 29, 28 and 32 patients who completed the study ingroups 2, 5 and 10 respectively, there was no significant differencein baseline characteristics between the three groups. The numberof patients with episodes of unsatisfactory pain, i.e. VAS scores>30 mm and OVRS >1, at each of the four assessments postoperativelywas significantly (P<0.01) higher in group 2 than in groups5 and 10. In group 10, 16 patients had sedation scores >1compared with 10 each in groups 2 and 5. In addition, 19 patientsin group 10 experienced pruritus compared with 12 each, in groups2 and 5. These differences were not significant. Nausea wasnot significantly different between the three groups. Conclusion. We conclude that thoracic epidural fentanyl 5 µgml^–1 with bupivacaine 0.1% provides the optimum balancebetween pain relief and side effects following thoracotomy. Br J Anaesth 2004: 92: 670–4     

Intrathecal morphine reduces breakthrough pain during labour epidural analgesia

BACKGROUND: When using the combined spinal-epidural (CSE) technique forlabour analgesia, parturients often experience breakthroughpain after the spinal medication has receded. We tested thehypothesis that a small dose of intrathecal morphine would reducebreakthrough pain. METHODS: This was a randomized, double-blind, placebo-controlled trial.Subjects were randomized to receive either 100 µgof morphine (MS) or placebo (PLCB) with the spinal injectionof bupivacaine and fentanyl. Assessments included need for supplementationduring labour analgesia, use of pain medications for 24 hafter delivery, and side-effects. The primary end-point wasthe rate of breakthrough pain. RESULTS: Sixty subjects were enrolled, 55 subjects completed the trial.The MS group had a significantly lower rate of breakthroughpain than the PLCB group [0.6 (0.6) vs 1.1 (0.8) episodes perpatient; P < 0.01], and longer time to first episode of breakthroughpain (300 vs 180 min; P = 0.03). The MS group used 75%less opioid medications during the subsequent 24 h, buthad a 17% incidence of nausea. CONCLUSIONS: The addition of small dose of morphine to the spinal componentof the CSE technique improved the effectiveness of epidurallabour analgesia and reduced the need for pain medications over24 h, but resulted in a small increase in nausea.     

Effect of intrathecal diamorphine on block height during spinal anaesthesia for Caesarean section with bupivacaine

Background. Opioid analgesics are commonly added to intrathecalbupivacaine to improve patient comfort during Caesarean sectionunder spinal anaesthesia, and provide post-operative pain relief.We sought to discover if the addition of diamorphine influencedblock height when given with 0.5% w/v hyperbaric bupivacaine. Method. Eighty ASA I and II women of at least 37 weeks gestationand planned for elective Caesarean section under combined spinal–epiduralanaesthesia were recruited. They were randomized into two groupsto receive intrathecal hyperbaric bupivacaine 0.5% at an initialdose of 13 mg, with the next dose determined by the responseof the previous patient (dose interval 1 mg). One group alsoreceived diamorphine 400 µg intrathecally. If a blockheight of T5 to blunt light touch had been achieved after 20min, the block was deemed effective. A difference in the ED₅₀for hyperbaric bupivacaine between the groups would indicatethat diamorphine influenced block height. Intraoperative patientdiscomfort and need for analgesic supplementation was noted. Results. The median effective dose (ED₅₀) to achieve a T5 blockto light touch for Caesarean section using hyperbaric bupivacaine0.5% was 9.95 mg [95% confidence interval (CI) 9.0–10.90]and with the addition of diamorphine it was 9.3 mg (95% CI 8.15–10.40),while the ED₉₅ was 13.55 mg (95% CI 10.10–17.0) and 13.6mg (95% CI 9.15–18.05), respectively. Five women who hadreceived intrathecal diamorphine and 13 who had not receiveddiamorphine needed intraoperative supplementation (not significant). Conclusion. The addition of intrathecal diamorphine does notappear to influence block height.     

Comparison of intrathecal isobaric bupivacaine-morphine and ropivacaine-morphine for Caesarean delivery

Background. This study was designed to evaluate the effectsof intrathecal isobaric bupivacaine 0.5% plus morphine and isobaricropivacaine 0.5% plus morphine combinations in women undergoingCaesarean deliveries. Method. Twenty-five parturients received ropivacaine 15 mg andmorphine 150 µg (RM group) and twenty-five parturientsreceived bupivacaine 15 mg and morphine 150 µg (BM group)for spinal anaesthesia. Sensory and motor block, haemodynamics,postoperative analgesia, fetal outcomes, and side-effects wereevaluated. Results. Intrathecal bupivacaine–morphine and ropivacaine–morphineprovided effective sensory anaesthesia and motor block. Timeto reach complete motor block was shorter and time to completerecovery from motor block was longer in the BM group than theRM group (P<0.05). The time to regression of two dermatomesand time for the block to recede to the S2 dermatome were similarin both groups (P>0.05). Time to first complaint of painand the mean total consumption of tenoxicam were similar inboth groups (P>0.05). APGAR scores at 1 and 5 min were similarin the two groups, as were mean umbilical blood pH values (P>0.05).Hypotension and pruritus were the most common side-effects inboth groups during the operation. Conclusion. Intrathecal isobaric ropivacaine 0.5% 15 mg plusmorphine 150 µg provides sufficient anaesthesia for Caesareandelivery. The ropivacaine–morphine combination resultedin shorter motor block, similar sensory and postoperative analgesia. Br J Anaesth 2003; 90: 659–64     

Relation between fentanyl dose and predicted EC50 of propofol for laryngeal mask insertion

Background. This study sought to determine the effective concentrationfor 50% of the attempts to secure laryngeal mask insertion (predictedEC_50LMA) of propofol using a target-controlled infusion (Diprifusor^TM)and investigated whether fentanyl influenced these requiredconcentrations, respiratory rate (RR) and bispectral index (BIS). Methods. Sixty-four elective unpremedicated patients were randomlyassigned to four groups (n = 16 for each group) and given saline(control) or fentanyl 0.5, 1 or 2 µg kg^–1.Propofol target concentration was determined by a modificationof Dixon’s up-and-down method. Laryngeal mask airway insertionwas attempted without neuromuscular blocking drugs after equilibrationhad been established for >10 min. Movement was defined aspresence of bucking or gross purposeful muscular movement within1 min after insertion. EC_50LMA values were obtained by calculatingthe mean of 16 patients in each group. Results. Predicted EC_50LMA of the control, fentanyl 0.5, 1 and2 µg kg^–1 groups were 3.25 (0.20), 2.06 (0.55),1.69 (0.38) and 1.50 (0.54) µg ml^–1 respectively;those of all fentanyl groups were significantly lower than thatof control. RR was decreased in relation to the fentanyl doseup to 1 µg kg^–1. BIS values after fentanyl1 and 2 µg kg^–1 were significantly greaterthan in the control and 0.5 µg kg^–1 groups. Conclusions. A fentanyl dose of 0.5 µg kg^–1is sufficient to decrease predicted EC_50LMA with minimum respiratorydepression and without a high BIS value. Br J Anaesth 2004; 92: 238–41     

Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for caesarean section under spinal anaesthesia

Background. Co-administration of small doses of opioids andbupivacaine for spinal anaesthesia reduces intraoperative discomfortand may reduce postoperative analgesic requirements in patientsundergoing Caesarean section. Fentanyl and diamorphine are thetwo most frequently used agents in UK obstetric anaestheticpractice. Methods. Seventy-five healthy parturients scheduled for electiveCaesarean section under spinal anaesthesia using hyperbaric0.5% bupivacaine, were randomly allocated to additionally receiveintrathecal fentanyl 20 µg, diamorphine 300 µg or0.9% saline. Patients also received i.v. cyclizine and rectaldiclofenac. Results. Less supplementary intraoperative analgesia was requiredby patients in either opioid group (4%) compared with the control(32%) (P<0.05). Twenty four hours after spinal injection,total mean (SD) postoperative morphine requirement was significantlylower if diamorphine was administered (31 (21) mg), in comparisonwith the other two groups (control 68 (26) mg; fentanyl 62 (26)mg) (P<0.05). Reduced visual analogue pain scores were evident12 h following diamorphine, but observed only for 1 h afterfentanyl when compared with the control (P<0.05). Mild pruritiswas more common for 2 h after either spinal opioid (P<0.05),but no inter-group differences were observed for the remainderof the first 24 h. Patients displayed deeper levels of sedationboth acutely and 12 h after administration of intrathecal fentanyl(P<0.05). Conclusions. Both intrathecal opioids reduce intraoperativediscomfort, but only diamorphine reduced postoperative analgesicrequirement beyond the immediate postoperative period. Br J Anaesth 2002; 89: 452–8     

A prospective, double-blind, randomized trial of caudal block using ropivacaine 0.2% with or without fentanyl 1 microg kg-1 in children

Background. It has been reported that ropivacaine produces vasoconstrictionin contrast to vasodilation produced by bupivacaine. It is possiblethat additives to ropivacaine can provide further analgesicadvantages compared with bupivacaine. We thus evaluated whetherthe addition of fentanyl to ropivacaine prolonged the durationof analgesia after a single shot caudal block. Methods. A total of 36 children undergoing surgical proceduresbelow the umbilicus were randomly allocated to one of two groups:Group F received ropivacaine 0.2%, 1 ml kg^–1 with fentanyl1 µg kg^–1 and Group S received ropivacaine 0.2%,1 ml kg^–1 with saline. The analgesic effect of the caudalblock was evaluated using the Children's Hospital of EasternOntario Pain Scale (CHEOPS) and sedation was assessed usingthe Steward score at 30 min after extubation and at 1, 2, 4,6, 12 and 24 h. The first analgesic requirement time and side-effectsin a 24 h period were also recorded. Results. There were no differences in characteristics betweenthe groups. The end-tidal concentration of sevoflurane at extubationin Group F was significantly lower than in Group S. However,there was no significant difference in time from discontinuationof the volatile anaesthetics to tracheal extubation. No statisticaldifferences were found in the CHEOPS and Steward score, andthe time to first analgesia. The incidence of postoperativevomiting was not significantly different. Conclusion. We found that the addition of fentanyl 1 µgkg^–1 to ropivacaine 0.2% for caudal analgesia providesno further analgesic advantages over ropivacaine 0.2% alone.     

Influence of peroperative opioid on postoperative pain after major abdominal surgery: sufentanil TCI versus remifentanil TCI. A randomized, controlled study

Background. Sufentanil and remifentanil are characterized bytwo different pharmacokinetic profiles. The aim of this studywas to compare the effects of sufentanil and remifentanil administeredusing target-controlled infusion (TCI) on recovery and postoperativeanalgesia after major abdominal surgery. Methods. Thirty adult patients scheduled for open colorectalsurgery were included in a prospective, randomized study. SufentanilTCI (sufentanil group) or remifentanil TCI (remifentanil group)was administered during surgery. In the remifentanil group,30 min before the anticipated end of surgery, morphine 0.15mg kg^–1 was administered i.v. In the sufentanil group,an effect-site concentration of 0.25 ng ml^–1 wastargeted at extubation. In both groups, postoperative pain wascontrolled by titration of i.v. morphine and then patient-controlledanalgesia with morphine. Results. The extubation time was similar in the two groups (mean(SD) 13 (6) and 14 (6) min in the sufentanil and remifentanilgroups respectively). Visual analogue scale scores were significantlygreater during the first 2 h after tracheal extubation in theremifentanil group than in the sufentanil group. The time tofirst analgesic request in the postanaesthesia care unit wassignificantly longer in the sufentanil group than in the remifentanilgroup (55 (64) (range 2–240) vs 11 (7) (1–29) min;P<0.001). The cumulative morphine dose for titration wassignificantly greater in the remifentanil group (P<0.01).The cumulative morphine dose used during titration and patient-controlledanalgesia was significantly greater in the remifentanil group4, 12 and 24 h after extubation (P<0.05). Conclusion. TCI sufentanil (0.25 ng ml^–1 effect-siteconcentration at extubation) is more effective than the intraoperativecombination of remifentanil TCI infusion with morphine bolus(0.15 mg kg^–1) for postoperative pain relief aftermajor abdominal surgery and does not compromise extubation andrecovery. Br J Anaesth 2003; 91: 842–9     

Dolasetron prophylaxis reduces nausea and postanaesthesia recovery time after remifentanil infusion during monitored anaesthesia care for extracorporeal shock wave lithotripsy

Background. Remifentanil is used as an analgesic for differentprocedures performed during monitored anaesthesia care. Opioid-inducednausea and vomiting can be troublesome. Methods. This prospective, randomized, double-blind study wasperformed to evaluate the efficacy of prophylaxis with dolasetronin reducing the frequency of postoperative nausea and durationof discharge time. Forty urological patients, undergoing electiveambulatory extracorporeal shock wave lithotripsy (ESWL) receivedrandomly either dolasetron 12.5 mg i.v. (Group 1) or placebo(Group 2) 10 min before a patient-adapted continuous infusionof remifentanil 0.15–0.4 µg kg^–1 min^–1was administered. Frequency and intensity (VAS 0–100 mm)of nausea, retching, and vomiting were assessed by patientsand blinded investigators during and after the procedure. Results. Patient characteristics, baseline values, durationof ESWL, and total dose of remifentanil did not differ betweengroups. The frequency (Group 1/Group 2; 20/55%; P<0.05) andmean (SD) maximal intensity [15 (9)/45 (14) mm; P<0.05] ofnausea during 24 h was significantly reduced after dolasetronand discharge times in Group 1 were less than Group 2[22 (14)/45 (28) min; P<0.05]. Br J Anaesth 2003; 90: 194–8     

Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

Comparison of different quantitative sensory testing methods during remifentanil infusion in volunteers

Background. The aim of this study was to compare thermal andcurrent sensory testing stimuli with respect to opioid responsiveness. Methods. Eighteen healthy volunteers were randomized in a placebo-controlled,double-blind crossover study to receive an infusion of remifentanil0.08 µg kg^–1 min^–1 or saline for 40 min. Testprocedures included determination of pain perception thresholds(PPT) and pain tolerance thresholds (PTT) to heat, cold, andcurrent at 5, 250 and 2000 Hz, at baseline and at the end ofthe infusion. Results. Both current at 5 Hz (PPT 3.69 (SD 2.48) mA vs 2.01(1.52) mA; PTT 6.42 (2.79) mA vs 3.63 (2.31) mA; P<0.001)and 250 Hz (PPT 4.31 (2.42) mA vs 2.89 (1.57) mA; PTT 7.08 (2.68)mA vs 4.81 (2.42) mA; P<0.001) and heat (PPT 47.4 (2.7)°Cvs 45.2 (3)°C; PTT 51.1 (1.8)°C vs 49.7 (1.8)°C;P<0.05) detected a significant analgesic effect of remifentanilcompared with placebo. No analgesic effect was shown on coldor current at 2000 Hz. The magnitude of responsiveness of currentstimuli at 5 Hz and 250 Hz was superior to heat stimuli. Conclusion. Both current (5 and 250 Hz) and heat sensory testingdetected a significant analgesic effect of a remifentanil infusioncompared with saline. There was more response to current testing. Br J Anaesth 2003; 91: 203–8     

Electrophysiological effects of morphine in an in vitro model of the 'border zone' between normal and ischaemic-reperfused guinea-pig myocardium

Background. Morphine is commonly used in clinical practice inpain management. Although morphine has been shown to preconditionthe myocardium, its effects on action potential parameters andischaemia–reperfusion-induced arrhythmias and conductionblocks remain unknown. Methods. In a double-chamber bath, guinea-pig right ventricularmuscle strips were subjected partly to normal conditions andpartly to 30 min of simulated ischaemia (hypoxia, hyperkalaemia,acidosis, and lack of nutritional substrate) followed by 30 minof reperfusion. Action potential parameters were recorded continuouslyin the normal zone and in the ischaemic– reperfused zone.Spontaneous arrhythmias and conduction blocks were noted. Theelectro physiological effects of morphine were studied at 0.01and 0.1 µM. Results. In control conditions, morphine did not modify actionpotential parameters of resting membrane potential, maximalupstroke velocity (V_max), action potential amplitude (APA) andaction potential duration at 50 and 90% of repolarization. Morphinereduced ischaemia-induced depolarization and lessened the ischaemia-induceddecrease in APA and V_max. Morphine significantly decreased theoccurrence of conduction block during simulated ischaemia (20%at 0.01 and 0.1 µM vs 67% in the control group, P<0.05)and reperfusion-induced arrhythmias (40% at 0.01 µMand 30% at 0.1 µM vs 92% in the control group, P<0.05). Conclusions. In ischaemic–reperfused guinea-pig myocardium,morphine at clinically relevant concentrations decreased ischaemia-inducedconduction blocks and reperfusion-induced ventricular arrhythmias. Br J Anaesth 2002; 89: 888–95     

Efficacy of prophylactic ketamine in preventing postoperative shivering

Background. Treatment with ketamine and pethidine is effectivein postoperative shivering. The aim of this study was to comparethe efficacy of low-dose prophylactic ketamine with that ofpethidine or placebo in preventing postoperative shivering. Methods. A prospective randomized double-blind study involved90 ASA I and II patients undergoing general anaesthesia. Patientswere randomly allocated to receive normal saline (Group S, n=30),pethidine 20 mg (Group P, n=30) or ketamine 0.5 mg kg^–1(Group K, n=30) intravenously 20 min before completion of surgery.The anaesthesia was induced with propofol 2 mg kg^–1, fentanyl1 µg kg^–1 and vecuronium 0.1 mg kg^–1. It wasmaintained with sevoflurane 2–4% and nitrous oxide 60%in oxygen. Tympanic temperature was measured immediately afterinduction of anaesthesia, 30 min after induction and beforeadministration of the study drug. An investigator, blinded tothe treatment group, graded postoperative shivering using afour-point scale and postoperative pain using a visual analoguescale (VAS) ranging between 0 and 10. Results. The three groups did not differ significantly regardingpatient characteristics. The number of patients shivering onarrival in the recovery room, and at 10 and 20 min after operationwere significantly less in Groups P and K than in Group S. Thetime to first analgesic requirement in Group S was shorter thanin either Group K or Group P (P<0.005). There was no differencebetween the three groups regarding VAS pain scores. Conclusion. Prophylactic low-dose ketamine was found to be effectivein preventing postoperative shivering.     

Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain

Background. Despite extensive use, different aspects of thepharmacological action of epidural fentanyl have not been clarified.We applied a multi-modal sensory test procedure to investigatethe effect of epidural fentanyl on segmental spread, temporalsummation (as a measure for short-lasting central hyperexcitability)and muscle pain. Methods. Thirty patients received either placebo, 50 or 100µg single dose of fentanyl epidurally (L2–3), ina randomized, double-blind fashion. Heat pain tolerance thresholdsat eight dermatomes from S1 to fifth cranial nerve (assessmentof segmental spread), pain threshold to transcutaneous repeatedelectrical stimulation of the sural nerve (assessment of temporalsummation) and pain intensity after injection of hypertonicsaline into the tibialis anterior muscle (assessment of musclepain) were recorded. Results. Fentanyl 100 µg, but not 50 µg, producedanalgesia to heat stimulation only at L2. Surprisingly, no effectat S1 was detected. Both fentanyl doses significantly increasedtemporal summation threshold and decreased muscle pain intensity. Conclusions. The findings suggest that a single lumbar epiduraldose of fentanyl should be injected at the spinal interspacecorresponding to the dermatomal site of pain. Increased effecton L2 compared with S1 suggests that drug effect on spinal nerveroots and binding to opioid receptors on the dorsal root gangliamay be more important than traditionally believed for the segmentaleffect of epidurally injected fentanyl. Epidural fentanyl increasestemporal summation threshold and could therefore contributeto prevention and treatment of central hypersensitivity states.I.M. injection of hypertonic saline is a sensitive techniquefor detecting the analgesic action of epidural opioids. Br J Anaesth 2003; 90: 467–73     

Effect of continuous low-dose intravenous diltiazem on epidural fentanyl analgesia after lower abdominal surgery

Background. The postoperative opioid-sparing effects of systemicL-type calcium channel blockers are controversial. We investigatedwhether the postoperative analgesic effect of epidural fentanylwas enhanced by i.v. infusion of diltiazem at a rate that wouldminimize any cardiovascular depressant effect. Methods. After elective lower abdominal gynaecological surgery,30 patients were randomized to receive continuous i.v. diltiazem1 µg kg^–1 min^–1 (diltiazem group)or the same volume of saline (control group) for 24 h. Cumulativepostoperative epidural fentanyl consumption, visual analoguescale (VAS) scores and verbal rating scores (VRS) at rest andduring mobilization, sedation scores, incidence of side-effectsand overall patient satisfaction were assessed. Results. There was no significant difference in cumulative epiduralfentanyl consumption between the groups at any period. Althoughthere were no statistically significant differences in VAS scores,VRS, sedation scores, incidence of side-effects and overallpatient satisfaction, there was a trend to an increased incidenceof nausea in the diltiazem group. Conclusions. Continuous i.v. infusion of diltiazem did not reduceepidural fentanyl consumption when administered at dosages havingminimal haemodynamic depressant effects. Br J Anaesth 2003; 90: 507–9     

Comparison of remifentanil and alfentanil during anaesthesia for patients undergoing direct laryngoscopy without intubation

Background. Remifentanil and alfentanil are opioids often usedduring direct laryngoscopy (DL). This prospective, randomizedstudy compared these agents with respect to haemodynamic andBispectral Index (BIS) responses, glottic visualization, andrapidity of recovery (spontaneous ventilation, eye opening)in DL without intubation. Methods. A total of 60 patients undergoing DL were randomizedinto two groups: remifentanil (R) and alfentanil (A). Anaesthesiawas induced with propofol 2.5 mg kg^–1 and the opioid wasadministered 1 min later (R=2 µg kg^–1 or A=30 µgkg^–1 over 30 s). DL was commenced 1 min after (correspondingto 3 min after the beginning of induction). Glottic visualization,opioid and/or propofol re-injection, spontaneous ventilationrecovery, and eye opening were recorded. Results. During DL, mean arterial pressure (MAP) increased by6% in the R group vs 20% in the A group (P<0.05) when comparedwith post-induction values without affecting heart rate or BIS.No significant difference was observed between groups with respectto glottic exposure, opioid and/or propofol re-injection, andspontaneous ventilation recovery (mean (SEM) 3.8 (0.6) min,R group vs 3.2 (0.7) min, A group, NS) or eye opening (7.1 (1.1)min, R group vs 7.4 (0.9) min, A group, NS). Thirty minutesafter postanaesthesia care unit (PACU) admission, MAP returnedto its pre-induction value in the R group (104 (3) vs 109 (3)at baseline, NS), whereas in the A group MAP remained significantlylower at this time point (96 (4) vs 106 (3) at baseline, P<0.05). Conclusion. This study showed that only remifentanil preventedMAP increase without adverse effects such as bradycardia duringDL, and prevented MAP decrease 30 min after PACU admission. Br J Anaesth 2003; 91: 421–3     

Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia

Background. This multicentre, double-blind, placebo-controlledstudy compared the opioid-sparing effectiveness and clinicalsafety of parecoxib sodium over 48 h, in 195 postoperativepatients after routine total knee replacement surgery. Methods. Elective total primary knee arthroplasty was performedunder spinal anaesthesia, with a single dose of spinal bupivacaine10–20 mg, and intraoperative sedation with midazolam0.5–1.0 mg i.v., or propofol <6 mg kg^–1h^–1. Patients were randomized to receive either parecoxibsodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium40 mg bd i.v. (n=67), or placebo (n=63) at the completionof surgery, and after 12, 24, and 36 h. Morphine (1–2 mg)was taken by patient-controlled analgesia or by bolus dosesafter 30 min. Results. Patients receiving parecoxib sodium 20 mg bd and40 mg bd consumed 15.6% and 27.8% less morphine at 24 hthan patients taking placebo (both P<0.05). Both doses ofparecoxib sodium administered with morphine provided significantlygreater pain relief than morphine alone from 6 h (P<0.05).A global evaluation of study medication demonstrated a greaterlevel of satisfaction among patients taking parecoxib sodiumthan those taking placebo. Parecoxib sodium administered incombination with morphine was well tolerated. However, a reductionin opioid-type side-effects was not demonstrated in the parecoxibsodium groups. Conclusion. Parecoxib sodium provides opioid-sparing analgesiceffects in postoperative patients. Br J Anaesth 2003; 90: 166–72     

Intrathecal morphine and clonidine for coronary artery bypass grafting

Background. After cardiac surgery adequate postoperative analgesiais necessary. We assessed analgesia using intrathecal morphineand clonidine. Methods. In a double-blind randomized study, 45 patients havingcoronary artery bypass graft surgery were allocated randomlyto receive i.v. patient-controlled analgesia (PCA) morphine(bolus, 1 mg; lock-out interval, 7 min) (control group), eitheralone or combined with intrathecal morphine 4 µg kg^–1or with both intrathecal morphine 4 µg kg^–1and clonidine 1 µg kg^–1. Intrathecal injectionswere performed before the induction of general anaesthesia.Pain was measured after surgery using a visual analogue scale(VAS). We recorded i.v. PCA morphine consumption during the24 h after operation. Results. Morphine dosage [median (25th–75th percentiles)]was less in the first 24 h in the patients who were given intrathecalmorphine + clonidine [7 (0–37) mg] than in other patients[40.5 (15–61.5) mg in the intrathecal morphine group and37 (30.5–51) mg in the i.v. morphine group]. VAS scoreswere lower after intrathecal morphine + clonidine compared withthe control group. Time to extubation was less after intrathecalmorphine + clonidine compared with the i.v. morphine group [225(195–330) vs 330 (300–360) min, P<0.05]. Conclusion. Intrathecal morphine and clonidine provide effectiveanalgesia after coronary artery bypass graft surgery and allowearlier extubation. Br J Anaesth 2003; 90: 300–3     

Recovery from propofol anaesthesia supplemented with remifentanil

We have examined the effects on recovery end-points of supplementationof a propofol-based anaesthetic with remifentanil. After inductionof anaesthesia with propofol and remifentanil 1.0 µg kg^–1,15 patients each were randomly allocated to target plasma propofolconcentrations of 2, 3, 4 or 5 µg ml^–1for maintenance of anaesthesia. Remifentanil was administeredby infusion for supplementation in doses required for maintenanceof adequate anaesthesia. All patients received 50% nitrous oxidein oxygen and ventilation was controlled. The total amount ofdrugs used and times to different recovery end-points were recorded.Cognitive function was also assessed using a Mini-Mental Statequestionnaire. The median dose of remifentanil for maintenanceof adequate anaesthesia (excluding the initial bolus dose) inthe four groups was 0.21, 0.15, 0.11 and 0.13 µg kg^–1 min^–1respectively (P=0.0026). The median times to eye opening andorientation were shortest in the 2 µg ml^–1group [6.0 and 6.5 min, 8.5 and 10.8 min, 13.4 and15.8 min, and 14.2 and 19.5 min respectively in thepropofol 2, 3, 4, and 5 µg ml^–1 groups respectively(P<0.001)]. The times to discharge from the recovery wardand the Mini-Mental State scores were not significantly different. Br J Anaesth 2001; 86: 361–5     

Randomized, double-blind comparison of patient-controlled epidural infusion vs nurse-administered epidural infusion for postoperative analgesia in patients undergoing colonic resection

BACKGROUND: There is little published evidence of the analgesic efficacyof patient-controlled epidural analgesia (PCEA) for postoperativepain relief. The aim of this study was to compare the analgesicefficacy of epidural infusion of bupivacaine 0.125% and fentanyl4 µg ml^–1 administered by either PCEAwith a background infusion or nurse-administered continuousepidural infusion (CEI) after major intra-abdominal surgery. METHODS: In a double-blind, randomized clinical trial, 205 adult patientsundergoing colonic resection by laparotomy received either PCEAor CEI. Pain scores were recorded via a four-point verbal ratingscale at 1, 2, 3, 4, 8, 12, 24, 48, and 72 h after surgery.The administration of epidural top-ups and systemic analgesiaover the same period was also recorded, and patient satisfactionquestionnaires completed. RESULTS: The median area under the curve of pain against time was significantlylower in the PCEA group (2 vs 24, P<0.001) as were mediansummary pain scores on movement (0.67 vs 1.33, P<0.001).Significantly fewer patients in the PCEA group received oneor more epidural top-ups (13 vs 36%, P = 0.0002) or any systemicanalgesics (41 vs 63%, P = 0.0021). Patients in the PCEA groupwere significantly more likely to be very satisfied than inthe CEI group (76 vs 43%, P<0.0001). CONCLUSIONS: PCEA provides greater analgesic efficacy than CEI for postoperativeanalgesia after major intra-abdominal surgery, and a decreasedrequirement for physician or nurse intervention.