Patient-controlled lumbar epidural fentanyl compared with patient-controlled intravenous fentanyl for post-thoracotomy pain

Thirty-four patients undergoing thoracotomy were entered into a randomized, double-blind, placebo-controlled study to compare the effects of patient-controlled, lumbar epidural (PCA-E) fentanyl with patient-controlled intravenous (PCA-i.v.) fentanyl with respect to drug requirements, analgesic efficacy and respiratory function. Prior to chest closure patients received fentanyl 2 micrograms.kg-1 by the epidural or i.v. route. In the recovery room further doses of epidural or i.v. fentanyl, 50 micrograms, were administered by the patients who controlled two PCA pumps. Background fentanyl infusion rates were increased by 10 micrograms.hr-1 each time the patient administered a drug bolus and were decreased by 10 micrograms.hr-1 whenever visual analogue scale (VAS) pain scores were less than 2 on a maximum 10 scale. Twenty-nine patients completed the study. Patients in the PCA-E group (n = 14) required less total fentanyl than those in the PCA-i.v. (n = 15) group (1857 +/- 693 micrograms vs 2573 +/- 890 micrograms respectively, P less than 0.05). Fentanyl infusion rates were lower in the PCA-E group at most measurement times. There were no differences between groups in respiratory rates, PaCO2, VAS pain scores or changes in pulmonary function as measured by FVC and FEV1. It is concluded that satisfactory patient-controlled analgesia can be achieved with both epidural and i.v. fentanyl after thoracotomy but that fentanyl requirements are less when given via the epidural route. This supports a direct spinal cord site of action for lumbar epidural fentanyl.     

A randomized double-blind comparison of epidural versus intravenous fentanyl infusion for analgesia after thoracotomy

This study compared epidural and intravenous fentanyl infusions for pain relief for the first 20 h after thoracotomy, in order to examine whether an thoracic epidural fentanyl infusion offers clinical advantage over an intravenous infusion. Forty patients were assigned randomly to receive either fentanyl epidurally and saline intravenously or fentanyl intravenously and saline epidurally in a double-blind fashion. For each patient the fentanyl infusion was titrated to a rate required for pain relief (pain score less than 3, maximum 10). Patients reported similar median pain scores, but in the epidural group the required mean fentanyl infusion rate was less (0.95 +/- 0.23 vs. 1.67 +/- 0.46 micrograms.kg-1.h-1, P = 0.0001) and plasma fentanyl concentrations were less at 4 and 18 h (4 h: 0.81 +/- 0.27 vs. 1.38 +/- 0.36 ng.ml-1, P = 0.0001; 18 h: 0.94 +/- 0.32 vs. 1.54 +/- 0.65 ng.ml-1, P = 0.0007) than those in the intravenous group. Respiratory function was better preserved and the incidence of nausea and sedation was less in the epidural group than in the intravenous group. In conclusion there appears to be a clinical advantage to the epidural infusion over the intravenous infusion of fentanyl for analgesia after thoracotomy.     

Thoracic epidural infusions for post-thoracotomy pain: a comparison of fentanyl–bupivacaine mixtures vs. fentanyl alone

A randomised double-blind clinical trial was conducted on 106 patients scheduled for pulmonary resection. Patients received an epidural infusion containing 0.1%, 0.2% bupivacaine or saline in combination with fentanyl 10 microgram.ml -1. Adequacy of analgesia was assessed at rest and during movement over 24 h. Analgesic efficacy was assessed using visual analogue scores and an observer/verbal ranking scale. Pain scores were higher in the fentanyl-only group at the 2 h assessment (p < 0.05). Otherwise, there were no between-group differences in pain scores or in the total amounts of epidural solution used. All patients received continuous haemodynamic monitoring. There were no between-group differences in the number of episodes of hypotension or in the number of interventions for hypotension. However, the use of intra-operative vasopressor and the incidence of temporary neurological complications was higher in the 0.2% bupivacaine group (p < 0.05). We conclude that, in the early postoperative period, the addition of bupivacaine 0.1% improves fentanyl epidural analgesia in patients undergoing lung resection and is not associated with the disadvantages seen with the addition of bupivacaine 0.2%.     

A randomized double-blind comparison of epidural versus intravenous fentanyl infusion for analgesia after cesarean section

The authors conducted a randomized double-blind controlled study comparing groups of patients receiving iv or epidural fentanyl infusions to determine whether, at comparable levels of analgesia, 1) the severity of side effects was different; and 2) plasma fentanyl concentrations differed between the two groups. Twenty-eight ASA physical status 2 women scheduled to undergo elective cesarean section were randomized into two groups to either receive fentanyl intravenously and saline epidurally or fentanyl epidurally and saline intravenously. After delivery of the infants under epidural anesthesia, each patient received a bolus of fentanyl 1.5 microgram/kg either intravenously or epidurally, and a fentanyl infusion was begun via the same route. Concurrently, a saline bolus and infusion were given via the alternate route. The rates of the fentanyl and saline infusions were adjusted until each patient was comfortable. Patients rated their pain, nausea, and pruritus on visual analogue scales. Sedation was evaluated by an observer. Respiratory depression was evaluated by end-tidal PCO2. Data were analyzed by unpaired two-tail t tests. Plasma fentanyl concentrations were measured at 12 and 24 h. Three patients in the iv group were dropped from the study because of inadequate pain relief. For the remaining 25 patients, similar infusion rates of fentanyl were required to produce similar levels of analgesia at 12 and 24 h. The severity of nausea, pruritus and sedation, and end-tidal PCO2 were similar for both groups. The plasma concentrations of fentanyl were significantly greater in those who received iv fentanyl at 12 h but not at 24 h.(ABSTRACT TRUNCATED AT 250 WORDS)     

The control of post-thoracotomy pain. A comparative evaluation of thoracic epidural fentanyl infusions and cryo-analgesia

This is a comparative study of two methods to relieve postoperative thoracotomy pain. Continuous thoracic epidural infusion of fentanyl produced superior analgesia when compared with cryo-analgesia of the relevant thoracic nerves. Linear analogue pain scores were consistently lower in the epidural group reaching significance (p less than 0.05) at 32 and 40 hours after operation. All 36 patients in the cryo-analgesia group required additional analgesia, while 12 out of the 32 patients in the epidural group did not. This difference was significant at p less than 0.001. Respiratory and cardiovascular measurements were similar in both groups and the only side effect attributable to the epidural fentanyl was itching but this was not a problem.     

Continuous epidural perfusion of morphine and bupivacaine for post-thoracotomy analgesia. Comparison between thoracic and lumbar epidural analgesia]

Relief of postoperative pain and the incidence of side effects occurring after continuous epidural infusion of morphine and bupivacaine were evaluated in patients undergoing a thoracotomy. We also studied the relevance of a close proximity of the epidural catheter to the metameric segment were the pain originated. The study involves 17 patients divided into two groups. In one series (lumbar group) (LG) the catheter was located at the lumbar region and in the other series (thoracic group) (TG) the catheter was localized at the thoracic area. The study was carried out during the first 48 hours following surgery. Bupivacaine 2% and 0.2 mg/ml of morphine hydrochloride were administered at an initial rate of 1.5 ml/h. The total dose required for pain relief was greater in LG than in TG (p less than 0.05). There were no significant group differences in the hemodynamic and respiratory parameters measured in this study. Only respiratory rate was occasionally lower in LG. Three patients presented postoperative atelectasis (2 in TG and 1 in LG) and required bronchoscopy. One patient of LG complained pruritus and another one of the same group presented nausea and vomiting. The epidural perfusion was interrupted in only one patient of TG due to the presence of arterial hypotension. The association of narcotics and local anesthetics in continuous epidural perfusion was an excellent method for achieving pain relief with minimum side effects. We conclude that both thoracic and lumbar epidural routes are advisable for post-thoracotomy pain relief.     

A dose-response study of nalbuphine for post-thoracotomy epidural analgesia

The analgesic efficacy and side-effects of epidural nalbuphine (0.075-0.3 mg.kg-1) were compared with epidural morphine 0.1 mg.kg-1 in a randomised double-blind study in post-thoracotomy patients. The drugs were administered via a lumbar epidural catheter one hour before the end of surgery. Efficacy was assessed using visual analogue pain scores and supplementary iv fentanyl requirements; respiratory function was studied with an inductive plethysmograph and arterial blood gas analysis; and plasma nalbuphine levels were measured. Pain scores and fentanyl supplementation were lowest in the morphine group (P less than 0.01). No dose-response effect was apparent in the nalbuphine dose-range studied. Respiratory depression was more common in patients receiving morphine (higher mean PaCO2P less than 0.01, more frequent apnoeas greater than 15 sec P less than 0.05, and incidence of PaCO2 greater than 50 mmHg requiring naloxone P less than 0.01). There were no differences in haemodynamic variables, sedation, or other side-effects among the groups. The pharmacokinetic profile of epidural nalbuphine was similar to that seen with rapid iv injection. The results indicate that, relative to morphine, lumbar epidural nalbuphine is an ineffective analgesic after thoracotomy. Despite the lower incidence of respiratory depression its administration by this route cannot be recommended.     

A randomized, double-blind comparison of lumbar epidural and intravenous fentanyl infusions for postthoracotomy pain relief. Analgesic, pharmacokinetic, and respiratory effects.

Although epidural opioids frequently are used to provide postoperative analgesia, several articles have suggested that the analgesia after epidural fentanyl is similar to that after an equal dose of fentanyl given intravenously. To address this issue further, 29 postthoracotomy patients were studied in a randomized, double-blinded trial comparing a lumbar epidural fentanyl infusion with an intravenous fentanyl infusion for analgesia, plasma fentanyl pharmacokinetics, and respiratory effects for 20 h postoperatively. In all patients in both groups, good analgesia was achieved (pain score less than 3, maximum 10) over a similar time course, although the patients receiving epidural infusion required a significantly larger fentanyl infusion dose than did the patients receiving intravenous infusion (group receiving epidural fentanyl infusion: 1.95 +/- 0.45 micrograms.kg-1.h-1; group receiving intravenous fentanyl infusion: 1.56 +/- 0.36 micrograms.kg-1.h-1; P = 0.0002). The time course for the plasma fentanyl concentrations was similar in the two groups, and plasma fentanyl concentrations were not significantly different at any sampling period (T7-T20; group receiving epidural fentanyl infusion: 1.8 +/- 0.5 ng/ml; group receiving intravenous fentanyl infusion: 1.6 +/- 0.6 ng/ml; P = 0.06). Similarly, calculated clearance values for the two groups were not significantly different (group receiving epidural fentanyl infusion: 0.95 +/- 0.26 l.kg-1.h-1; group receiving intravenous fentanyl infusion: 0.87 +/- 0.25 l.kg-1.h-1; P = 0.3). Both groups demonstrated a similar degree of mild to moderate respiratory depression postoperatively, which was assessed with continuous respiratory inductance plethysmography and sequential arterial blood gas analysis. Side effects (nausea, vomiting, pruritus) were mild and did not differ between groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison of ropivacaine with fentanyl to bupivacaine with fentanyl for postoperative patient-controlled epidural analgesia

Ropivacaine for patient-controlled epidural analgesia (PCEA) may facilitate postoperative patient mobilization because it causes less motor block than bupivacaine. Forty patients undergoing abdominal surgery were randomized in a double-blinded manner to the following: 0.05% bupivacaine/4 microg fentanyl, 0.1% bupivacaine/fentanyl, 0.05% ropivacaine/fentanyl, or 0.1% ropivacaine/fentanyl for standardized PCEA. We measured pain scores, side effects, and PCEA consumption for 42 h. Lower-extremity motor function was assessed with electromyography and isometric force dynamometry. Analgesia was equivalent among groups. Local anesthetic use was more in the 0.1% Ropivacaine and 0.1% Bupivacaine groups (77% increase, P = 0.001). Motor function decreased during PCEA (10%-35% decrease from preoperative, P < 0.001) and was equivalent among groups. Eight patients were transiently unable to ambulate. These patients used more local anesthetic (45 vs 33 mg mean, P < 0.05) with additional decrease in motor function (32%, P < 0.004) compared with ambulating patients. Other side effects were mild and equivalent among solutions. PCEA with bupivacaine/fentanyl and ropivacaine/fentanyl as 0.05% or 0.1% solutions appears clinically equipotent. Lower-extremity motor function decreases, but is unlikely to result in prolonged inability to ambulate. Use of a 0.05% solution may be advantageous to decrease local anesthetic use and prevent transient motor block. IMPLICATIONS: Patient-controlled epidural analgesia with bupivacaine/fentanyl and ropivacaine/fentanyl as either 0.05% or 0.1% solutions are clinically similar. Lower-extremity motor function will decrease with the use of any of these combinations, but is unlikely to result in the inability to walk.     

A comparison of epidural infusions in the combined spinal/epidural technique for labor analgesia

We compared the clinical effects of three epidural infusions initiated after subarachnoid medication was administered as part of the combined spinal/epidural technique for labor analgesia. Fifteen minutes after administering subarachnoid fentanyl 25 microg and 1 mL of bupivacaine 0.25%, and 5 min after an epidural test dose of 3 mL of bupivacaine 0.25%, women were randomized to receive an epidural infusion of saline, bupivacaine 0.125%, bupivacaine 0.0625%, or bupivacaine 0.04% with epinephrine 1:600,000. All epidural infusions were started at 10 mL/h, and all except the Saline Group also received fentanyl 2 microg/mL. The end point of the study was delivery or request for additional medication for analgesia. We found that time until request for additional analgesia was longest in women who received bupivacaine 0.125% (median duration, 300 min) versus saline (median duration, 118 min) (P = 0.0001) and was intermediate for bupivacaine 0.0625% and bupivacaine 0.04% (median duration, 162 and 180 min, respectively) (P = 0.0001 versus saline). Women who received bupivacaine 0.125% had the most motor block. We conclude that all the bupivacaine-based infusions we tested maintained the analgesia from subarachnoid medication longer than saline, with the longest duration, but the most motor block, from bupivacaine 0.125%. IMPLICATIONS: In this prospective, randomized, and double-blinded study we found that initiating an epidural infusion of bupivacaine 0.125% with fentanyl 2 microg/mL at 10 mL/h 15 min after subarachnoid fentanyl 25 microg with 1 mL of bupivacaine 0.25%, followed by an epidural test dose of 3 mL of bupivacaine 0.25%, maintained the analgesia for longer but with more motor block than with either bupivacaine 0.04% or bupivacaine 0.0625%.     

A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia

Purpose  

To compare thoracic epidural analgesia (TEA) using a bupivacaine/fentanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy.     

Addition of epinephrine to epidural bupivacaine infusions following initiation of labor analgesia with epidural fentanyl

Study Objective

To evaluate the analgesic effects of the addition of epinephrine to a bupivacaine epidural infusion in early labor after a fentanyl bolus, following a lidocaine-epinephrine test dose.

Design

Randomized, double-blinded study.

Setting

Labor suite of a tertiary care hospital.

Patients

60 ASA physical status 1 and 2, laboring, nulliparous women.

Interventions

All laboring women received a 3 mL epidural test dose of 1.5% lidocaine with 1:200,000 epinephrine, followed by a fentanyl 100 μg bolus in 10 mL of diluent volume. Patients were randomized to receive one of two continuous epidural infusions: bupivacaine 0.625 mg/mL at 10 mL/hr (control group) or bupivacaine 0.625 mg/mL with epinephrine 5 μg/mL at 10 mL/hr (epinephrine group).

Measurements

Time to re-dose, pain scores, and side effects were recorded.

Main Results

The mean duration of satisfactory analgesia prior to re-dose was 159 ± 62 min for the control group and 221 ± 111 min for the epinephrine group (P < 0.02). Pain scores were significantly higher in the control group than the epinephrine group at two time periods: 2.5 hours and 4.5 hours (P < 0.04).

Conclusions

The administration of 0.625 mg/mL bupivacaine with epinephrine 5 μg/mL at 10 mL/hr, compared with plain 0.625 mg/mL bupivacaine at 10 mL/hr, provided a longer time to re-dose, decreased pain scores at two time intervals, and had no significant difference in duration of labor or side effects.     

A comparison of general anesthesia and lumbar epidural analgesia for elective cesarean section

Controversy exists concerning the choice of anesthetic technic for elective cesarean section. Several maternal and newborn parameters were compared during general anesthesia (GA) and lumbar epidural analgesia (LEA). High inspired maternal O2 levels were achieved with both technics. Vigorous, well-oxygenated infants with good umbilical-cord acid-base values were delivered during both GA and LEA. Umbilical artery and vein pH were better with GA, but 1-minute Apgar-minus-color scores were higher and time to sustained respiration was shorter with LEA. On the basis of this study, neither technic can be vigorously recommended over the other from the standpoint of the newborn's condition.     

Effects of preemptive epidural analgesia on post-thoracotomy pain

OBJECTIVE: The purpose of this study was to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain and the incidence of chronic post-thoracotomy pain. METHOD: Meta-analysis of randomized controlled trials (RCTs). SEARCH STRATEGY: MEDLINE, the Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE were searched from 1966 to December 2004 for prospective RCTs published in all languages using the following MeSH terms: post-thoracotomy pain, epidural analgesia, chronic pain, and preemptive analgesia. SELECTION CRITERIA: All RCTs that compared thoracic epidural analgesia initiated before surgical incision (preemptive group) versus thoracic epidural analgesia initiated after completion of surgery (control group) in adult patients undergoing unilateral thoracotomy. MEASUREMENTS AND MAIN RESULTS: Three authors reviewed all citations and simultaneously extracted data on sample size, patient characteristics, surgical and analgesic interventions, methods of pain assessment, and pain scores at 24 hours, 48 hours, and 6 months postoperatively. Six studies were included with a total of 458 patients. Pooled analyses indicated that preemptive TEA was associated with a statistically significant reduction in the severity of acute pain on coughing at 24 and 48 hours (weighted mean difference -1.17 [95% confidence interval (CI) -1.50 to -0.83] and -1.08 [95% CI -1.17 to -0.99]), respectively. Acute pain was a good predictor of chronic pain. However, there was no statistically significant difference in the overall incidence of chronic pain at 6 months between the preemptive TEA group (39.6%) and the control group (48.6%). CONCLUSION: Preemptive TEA appeared to reduce the severity of acute pain but had no effect on the incidence of chronic pain.     

A comparison of 0.0625% bupivacaine with fentanyl and 0.1% ropivacaine with fentanyl for continuous epidural labor analgesia

We compared the analgesic efficacy and the degree of motor block achieved with epidural infusion of 0.0625% bupivacaine (Group B) versus 0.1% ropivacaine (Group R), both with 0.0002% fentanyl (2 microg/mL) in laboring patients. A prospective, double-blinded study was performed in 98 ASA physical status I-II parturients who were divided randomly into two groups to receive either bupivacaine or ropivacaine after catheter location had been tested with an initial bolus of lidocaine and fentanyl. The infusion rate was 15 mL/h in every case. When pain was perceived, 5-mL boluses of the assigned epidural analgesic were administered every 10 min until analgesia was achieved. We recorded pain intensity, level of sensory block, degree of motor block, hemodynamic variables, secondary effects, mode of delivery, neonatal outcome, and patient satisfaction. There were no statistically significant differences in any of the factors analyzed. Highly effective analgesia was achieved in both groups with a small incidence of motor block. These findings suggest that bupivacaine may be more potent than ropivacaine. IMPLICATIONS: We compared different concentrations of epidural bupivacaine and ropivacaine thought to be equipotent. Both solutions were equally efficient in providing highly effective epidural analgesia for labor with minimal motor block. These findings suggest that bupivacaine may be more potent than ropivacaine.     

A randomized double-blind comparison of epidural versus intravenous tramadol infusion for postoperative analgesia

BACKGROUND: This study compared epidural and intravenous tramadol infusions for postoperative analgesia after gastrectomy. METHODS: Twenty patients were assigned randomly to receive either tramadol epidurally and saline intravenously (group-E) or tramadol intravenously and saline, epidurally (group-I) in a double-blind fashion. At the end of the operation, each patient received a bolus of tramadol 2 mg x kg(-1) either epidurally or intravenously and 7 mg x kg(-1) x day(-1) tramadol infusion was begun via the same route. Concurrently, a saline bolus and its infusion were given via the alternate route. RESULTS: Both groups obtained adequate pain relief and there was no difference between the groups in pain score. But one patient in E-group was excluded from the study for respiratory depression 8 hours after the operation. No other side effects were detected in either group except mild nausea. CONCLUSIONS: We conclude that intravenous tramadol infusion provides effective and safe postoperative analgesia. A futher examination is required for the suitable dose of tramadol in epidural infusion.     

A comparison of patient-controlled analgesia fentanyl and alfentanil for labour analgesia

PURPOSE: To determine the analgesic efficacy of equipotent doses of PCA (patient-controlled analgesia) fentanyl and PCA alfentanil for labour pain. METHODS: Twenty three, ASA I - II parturients between 32-42 wk gestational age in whom epidural analgesia was contraindicated were randomized to receive PCA fentanyl (Group F)or alfentanil (Group A). Plain numbered vials contained 21 ml fentanyl 50 microg x ml(-1) or alfentanil 500 microg x ml(-1). A one millilitre loading dose was administered. The PCA solution was prepared by diluting 10 ml study drug with 40 ml saline and the PCA pump was programmed to deliver a dose of 2 ml, delay of five minutes and a basal rate of 2 ml x hr(-1). Maternal measurements obtained were hourly drug dose, total dose, Visual Analog Pain Score (VAPS) q 30 min, sedation score q 1 hr and side effects. Neonates were assessed by 1,5, and 10-min Apgar scores, umbilical venous and arterial blood gases and neurobehavioural scores at four and 24 hr. RESULTS: Mean VAPS from 7 - 10 cm cervical dilatation were higher in Group A than in Group F (85.7+/-13.9 vs. 64.6+/-12.1; P<0.01) There were no inter-group differences in VAPS from 1-3 cm, or from 4-6 cm dilatation, in maternal sedation scores or side effects, or in neonatal outcomes. CONCLUSION: In the doses prescribed in this study, PCA fentanyl was found to provide more effective analgesia in late first stage labour than PCA alfentanil.     

A comparison of intrathecal, epidural, and intravenous sufentanil for labor analgesia.

A number of recent studies have suggested that the analgesic effects of highly lipid-soluble opioids are similar when these agents are administered either epidurally or intravenously. We sought to test whether the lipid-soluble opioid sufentanil was more effective when administered intrathecally than when administered epidurally or intravenously. Twenty-four women during active labor received sufentanil 10 micrograms either intrathecally (n = 9), epidurally (n = 8), or intravenously (n = 7), using a combined spinal-epidural technique. The sufentanil was administered alone, without concomitant local anesthetics. Analgesia was assessed using the visual analogue score as well as the time elapsed from the administration of study drug to the patient's request for additional analgesia via the epidural catheter (bupivacaine 0.25%). The median duration of analgesia (median, interquartile range) was 84 (70-92) min in the intrathecal group, 30 (23-32) min in the epidural group, and 34 (17-30) min in the intravenous group (P < 0.001). The intrathecal group showed rapid and significant decrease in visual analogue scale scores, whereas visual analogue scale scores in the other two groups did not decrease and remained significantly elevated compared to those of the intrathecal group at all observation points. Side effects were limited to pruritus in 3 patients (2 moderate and 1 severe) in the intrathecal group. No patient developed post-dural puncture headache. We conclude that sufentanil 10 micrograms intrathecally provides rapid and effective analgesia of 1-2-h duration during labor. Epidural and intravenous use of this dose of sufentanil did not provide evidence of satisfactory analgesia.(ABSTRACT TRUNCATED AT 250 WORDS)