Epidural buprenorphine in management of pain in multiple rib fractures

BACKGROUND: Pain from multiple rib fractures may affect pulmonary function, morbidity, and length of stay in the intensive care units. This study describes some clinical characteristics of epidural buprenorphine, a lipophilic and partial opiate agonist with a higher micro receptor affinity than morphine, in combating the pain in multiple rib fractures. METHODS: The study was conducted prospectively over a 15-month period. A total of 27 patients admitted to the hospital with multiple rib fractures were studied. Buprenorphine at a concentration of 0.3 mg in 5-10 ml normal saline was administered epidurally, twice daily the first 24 h, thereafter once daily. Ventilatory function tests (including vital capacity, tidal volume, respiratory rate, and minute volume) and assessment of pain intensity using a simple, categorical, verbal rating scale were obtained before and after institution of analgesia. Any nausea, vomiting, hypotension, urinary retention, respiratory depression or pruritis were recorded. RESULTS: We found a significant improvement in ventilatory function tests during the 1st, 2nd, and 3rd day after epidural analgesia when compared with the preanalgesia levels (P < 0.001). Changes in the verbal rating scale demonstrated that epidural buprenorphine was associated with marked improvement in pain at rest and pain during coughing and deep breathing. None of our patients developed hypotension (<10% of the baseline), urinary retention or respiratory depression. Nausea, vomiting, and mild pruritis were the only reported complications. CONCLUSIONS: Epidurally introduced narcotic, like buprenorphine in saline, has been found to be effective in our study to achieve adequate analgesia in treatment of patients with multiple rib fractures. In addition, this methodology of pain relief eliminates the costly delivery system and early discharge, and allows walking epidurals and follow-up on outpatient basis.     

Intrapleural catheter analgesia in patients with multiple rib fractures

Patients with multiple rib fractures often suffer from severe pain that impairs their respiratory performance. The effect of interpleural administration of bupivacaine (20 ml 0.25% every 4 h) for pain management was evaluated in ten patients. The initial interpleural injection resulted in significant pain relief and improvement of arterial oxygen tension. Two patients needed additional i.v. injections of opioids (piritramide 15-22.5 mg/24 h). In one patient a small asymptomatic pneumothorax was observed following placement of the catheter, which resolved spontaneously. No other complications were reported. In an intraindividual comparison, bupivacaine alone and bupivacaine plus epinephrine 1:200,000 were compared with regard to pharmacokinetics of bupivacaine, analgesic effect, side effects, and respiratory performance. The addition of epinephrine yielded only minor advantages from a pharmacokinetic point of view (median peak concentration of bupivacaine 1.8 micrograms/ml vs 2.0 micrograms/ml for bupivacaine alone). The quality and duration of analgesia and the effects on respiration were not influenced by epinephrine. The heart rate was significantly higher and the blood pressure significantly lower when epinephrine was added to the solution. Nevertheless, these differences were too small to be of clinical importance. Even though maximum total plasma concentrations of bupivacaine above 2 micrograms/ml were found in some patients, there were no signs of CNS toxicity, most probably because of the increased protein binding of bupivacaine following trauma. Accordingly, the maximum free plasma concentrations in all patients were below the threshold level of 0.24 micron/ml. We therefore conclude tht interpleural administration of bupivacaine could be a valuable means of pain relief in patients with multiple rib fractures, providing no severe pulmonary contusions or concomitant injuries are present.     

Epidural analgesia improves early rehabilitation after total knee replacement

STUDY OBJECTIVE: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement. DESIGN: Randomized prospective study. SETTING: Tertiary care, academic medical center. PATIENTS: Thirty-eight patients scheduled for total knee replacement. INTERVENTIONS: Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200,000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis. MEASUREMENTS: Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05. MAIN RESULTS: All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention. CONCLUSION: By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.     

Catheter epidural analgesia in serial rib fractures

According to our results, permanent epidural anaesthesia was significantly superior to systemic opioid treatment in patients with serial rib fractures. The main advantages were not only continuous pain relief despite the fact that the nonepidural control group required more than twice the dosage of morphine derivatives; also, the respiratory and pain-related recovery time was reduced. Another advantage was the selective effect (due to the local application) on respiratory pain and therefore on respiration as a whole. Deep breathing and expectoration were easier, so that the use of respirators and other artificial breathing aids could be avoided or at least reduced in duration in some cases. This makes the method particularly suitable for use in the management of polytraumatized patients. The standard dose was a mixture of 3.3 mg morphine and 37.5 mg bupivacaine (= 1/3 ampoule morphine + 15 ml Carbostesin 0.25%) every 12 h. When morphine was temporary contraindicated (frequently the final diagnosis in the case of an "acute abdomen" delayed the administration of morphine) the use of bupivacaine alone provided a satisfactory result for a certain time (we never observed tachyphylaxis). Additional systemic pain relievers were only necessary when the patient was suffering from pain caused by other injuries beyond the area of effectiveness of the epidural catheter (the only obvious disadvantage of the local application technique). On the other hand, epidural anaesthesia enabled us to treat a patient's lower-leg fracture by interlocking nailing, while adding only 0.01 mg fentanyl (= 2 ml Fentanyl Janssen) and 1.2 mg flunitrazepam (Rohypnol).     

Balanced analgesia improves recovery and outcome after outpatient tubal ligation

Outpatient surgery benefits patients only if postoperative sequelae are effectively treated. After laparoscopic tubal ligation (TL) intense pain and consequent postoperative nausea and vomiting (PONV) has been a problem delaying recovery and resulting in hospital admission.
Ninety patients were randomised to this double-blind study, the aim being to evaluate the effect of balanced analgesia on postoperative pain and recovery after sterilization. The balanced analgesia group received 5 ml of 2% lidocaine gel on the sterilization clips and perioperatively 200 mg of ketoprofen i.v. The lidocaine group received 5 ml of 2% lidocaine gel on the clips and placebo i.v. perioperatively. The placebo group received 5 ml of placebo gel on the clips and placebo i.v. perioperatively. Infusion of propofol and 67% nitrous oxide in oxygen were used for maintenance of anesthesia. Succinylcholine and vecuronium were used for muscle relaxation and 0.1 mg of fentanyl i.v. was given to dl patients at induction of anesthesia.
Postoperative pain and analgesic requirements, incidence of POW and need for antiemetic medication were all significantly lower in the balanced analgesia group. Home readiness was consistently achieved 70–90 min sooner in the balanced analgesia group compared to the other groups ( P < 0.01 between the balanced analgesia and the placebo group), and the patients were able to return to normal activity sooner (cumulatively 93% of the patients in the balanced analgesia group vs. 60% in the other two groups ( P < 0.01 between the balanced analgesia and the other groups) had returned to normal activity on the 2nd postoperative day).
It is concluded that in patients undergoing laparoscopic TL the combination of analgesic regimens with different mechanisms of action offer a simple and efficient way of postoperative pain relief, as well as an improvement of quality (i.e. less PONV) and speed of recovery.     

Impact of rib fixation on quality of life after major trauma with multiple rib fractures

Introduction

Multiple rib fractures have been shown to reduce quality of life both in the short and long term. Treatment of rib fractures with operative fixation reduces ventilator requirements, intensive care unit stay, and pulmonary complications in flail chest patients but has not been shown to improve quality of life in comparative studies to date. We therefore wanted to analyse a large cohort of multiple fractured rib trauma patients to see if rib fixation improved their quality of life.

Epidural meperidine analgesia after cardiac surgery

Epidural meperidine (1 mg X kg-1) was administered for relief of sternal pain to ten patients, at a mean of 24.8 hours after infusion of high dose fentanyl for cardiac surgery. Lung function, cough, pain score, somnolence, respiratory rate, PaCO2, pulse and blood pressure were studied before and for six hours after analgesic administration. Following epidural meperidine, four of ten patients were pain-free, and three had only minimal pain. Duration of analgesia was 8.8 +/- 4.9 hours. Cough score was significantly improved for five hours. Postoperatively vital capacity was approximately 40 per cent, and FEV1 was approximately 55 per cent of the preoperative value. There was no significant change in FEV1 or vital capacity, following analgesia with epidural meperidine. The somnolence score increased in seven patients. In the first two hours after epidural meperidine, three patients exhibited a fall in their respiratory rate, one had a PaCO2 greater than 45, and two of these patients had marked hypotension. These side effects are easily treated without mechanical or pharmacological support, and do not preclude the use of epidural meperidine after a high dose fentanyl anaesthetic.     

Epidural clonidine analgesia after cesarean section

Epidurally administered clonidine has been reported to produce postoperative analgesia. To assess the efficacy, safety, and appropriate dose of epidural clonidine for post-cesarean section analgesia, we designed a double-blind, placebo-controlled study. Sixty women were randomly assigned to receive epidural administration of saline bolus followed by 24-h saline infusion, 400-micrograms clonidine bolus followed by 10 micrograms/h clonidine infusion, or 800-micrograms clonidine bolus followed by 20 micrograms/h clonidine infusion. Supplemental analgesia was provided with patient-controlled iv morphine. Compared to saline, both clonidine regimens produced analgesia, as measured by verbal pain scores and supplemental iv morphine use during the first 6 h after bolus injection. Time to first morphine use was similar for both clonidine groups and significantly greater than saline. However, compared to saline, only the 20 micrograms/h clonidine infusion resulted in decreased morphine usage over the entire 24-h period. Compared to saline, both clonidine doses decreased blood pressure. This decrease was greater in the 400-micrograms than in the 800-micrograms clonidine group, but no patient required treatment for hypotension. Clonidine decreased heart rate (one patient required atropine for asymptomatic bradycardia) and produced transient sedation. The 800-micrograms clonidine dose prolonged resolution of local anesthetic-induced motor blockade compared to saline. The results suggest that epidurally administered clonidine provides analgesia, as measured by decreased need for supplemental morphine, after cesarean section, but continuous infusion is required for analgesia of more than 6 h duration.     

Epidural versus intravenous pain control in elderly patients with rib fractures

BACKGROUND: Epidural catheters are used in older patients with rib fractures to improve outcome. We reviewed the efficacy of epidural analgesia (EA) compared with intravenous narcotics (IVN) in this population. METHODS: Rib fracture patients >55 years old admitted to our level I trauma center from 1999 through 2002 were reviewed for demographics, Injury Severity Score (ISS), Abbreviated Injury Score for chest, length of stay, cardiopulmonary comorbidities, complications, and type of analgesia. RESULTS: There were 187 patients: 72 men and 115 women. The mean age was 77 years. For ISS <9, length of stay for EA patients was 12 +/- 5 days versus 5 +/- 4 days for IVN patients (P < 0.001). Complications occurred in 9 of 10 EA patients versus 21 of 52 IVN patients (P < 0.001). No difference was noted in length of stay for patients with ISS > or =9. Complications in the high ISS group occurred in 29 of 43 EA patients versus 37 of 82 IVN patients (P <0.05). Stratification of patients based on low versus high Abbreviated Injury Score for chest yielded similar results. CONCLUSIONS: EA is associated with prolonged length of stay and increased complications in elderly patients, particularly those with less significant injuries, regardless of cardiopulmonary comorbidities. EA for elderly patients with rib fractures should be prospectively re-evaluated.     

Multiple rib fractures: transcutaneous nerve stimulation versus conventional analgesia

We have used transcutaneous electrical nerve stimulation (TENS) to treat the acute pain of rib fractures. The study shows that it is an effective technique, achieving higher subjective pain relief scores by patients when compared with analgesic combinations, and achieving greater increases objectively in arterial oxygen concentrations and peak expiratory flow rates. TENS approaches the ideal analgesic in that it is continuous in effect and the dose is patient regulated. It is recommended as an important adjunct to conventional therapy.     

Sciatic nerve blockade improves early postoperative analgesia after open repair of calcaneus fractures

OBJECTIVE: To determine the effectiveness of analgesia, with or without sciatic nerve blockade, after open repair of calcaneus fracture. DESIGN: Randomized, prospective trial involving 30 patients divided into 3 groups of 10, all having open repair of calcaneus fractures. Group 1 used morphine patient-controlled analgesia alone. Groups 2 and 3 had morphine patient-controlled analgesia and a "one-shot" bupivacaine sciatic nerve blockade, either presurgically (group 2) or postsurgically (group 3). SETTING: Harborview Medical Center operating rooms and orthopedic floors. OUTCOME MEASURES: Morphine use over 24 hours, visual analogue scale pain scores, and sciatic nerve blockade duration. RESULTS: In the absence of sciatic nerve blockade, initial postoperative pain was marked, even with a mean recovery room dose of intravenous morphine more than 30 mg. Sciatic nerve blockade with bupivacaine had a mean duration of 14 hours and substantially reduced pain for the first 24 postoperative hours. Presurgical blockade confers no advantage over postsurgical blockade. CONCLUSION: Sciatic nerve blockade confers significant benefit over morphine alone for analgesia after open repair of calcaneus fractures. Postsurgical sciatic nerve blockade provides the longest possible postoperative block duration.