Recovery and discharge of patients after long propofol infusion vs isoflurane anaesthesia for ambulatory surgery

Fifty unpremedicated patients scheduled for outpatient restorative dentistry and/or oral surgery lasting 2 to 4 h were anaesthetized with either propofol infusion or isoflurane inhalation. Before induction of anaesthesia with propofol (2.5 mg.kg-1), all patients were given 75 mg of diclofenac and 0.01 mg.kg-1 vecuronium intravenously. Intubation was facilitated with suxamethonium (1.5 mg.kg-1) and anaesthesia was maintained in random order either with propofol infusion (12 mg.kg-1.h-1 for the first 20 min, 9 mg.kg-1.h-1 for the next 20 min, and 6 mg.kg-1.h-1 for the rest of the anaesthesia) or with isoflurane (inspired concentration 1-2.5%), both with nitrous oxide and oxygen (30%). The patients breathed spontaneously using a non-rebreathing circuit. Patients given propofol infusion became re-orientated faster (11.0 +/- 5.5 min vs. 16.5 +/- 7.5 min; P less than 0.01) and at 30 min walked along a straight line better (P less than 0.01). At 60 min, none of the propofol patients displayed an unsteady gait, whereas 11 of the 25 isoflurane patients did (P less than 0.001). None of the patients receiving propofol had emesis at the clinic, compared with 10 of the 25 patients receiving isoflurane (P less than 0.001). The overall incidence of emesis was 2 of 25 and 14 of 25 in the propofol and isoflurane groups, respectively (P less than 0.01). Patients receiving propofol were discharged home earlier than patients receiving isoflurane (80 +/- 14 min and 102 +/- 32 min, respectively; P less than 0.01). It is concluded that propofol allows early discharge of patients, even after long anaesthesias.     

Anaesthesia for coronary artery bypass grafting: opioid-analgesia combined with either flunitrazepam,propofol or isoflurane

This is a prospective, open, randomized study comparing three different anaesthetic regimens with respect to haemodynamic stability (cardiac index and pressure measurements), ischaemia (ECG), and loss of awareness (midlatency auditory evoked potentials) in 58 patients undergoing coronary artery surgery. Anaesthesia was based on fentanyl 0.01 mg kg^-1 bw for induction and 0.8-2.0 mg h^-1 in combination with nitrous oxide for maintenance before cardiopulmonary bypass and 0.2-0.6 mg h^-1 without nitrous oxide during and after cardiopulmonary bypass. Eighteen patients were anaesthetised with flunitrazepam 0.01 mg kg^-1 bw for induction and received thereafter 1–2 mg h^-1 for maintenance (group F). In 40 patients anaesthesia was induced with etomidate and maintained with either isoflurane 0.4-1.2 vol% (group I) or propofol 4–10 mg kg^-1 bw h^-1 (group P). Vasodilators and inotropes were used for haemodynamic control when needed. Haemodynamic variables and ECG were studied at five timepoints (awake; after induction before surgery; after sternotomy; before cardiopulmonary bypass; and 20 min after separation from bypass). During surgical stimulation, vasodilators were needed significantly more frequently in group F, than in groups I and P. Surgery and sternotomy caused an increase in SVI and APs/SV in all groups. Differences between the groups were only found for systemic pressures, which after sternotomy were lowest in group I and before cardiopulmonary bypass were highest in group F. After termination of bypass all groups showed an increase in HR and a decrease in SVI, SVR, and LVSWI compared to the awake state, while CI remained unchanged. The only differences noted between the groups were a lower PCWP and a smaller reduction in SVR with propofol compared to the others and higher APs/SV with propofol compared to isoflurane. Concerning ST segment changes (> 0.1 mV, leads II and/or V5) at the five measurement times, significant differences were found comparing groups F and P after sternotomy (P < 0.10) and comparing groups F and I after separation from CPB (P <0.05), group F showing the highest incidences of ischaemic events. A blinded evaluation of auditory evoked potentials demonstrated more reduced midlatency auditory potentials after sternotomy during isoflurane and propofol anaesthesia than during flunitrazepam. The authors conclude that fentanyl supplemented with isoflurane or propofol was unequivocally superior to supplementation with flunitrazepam.     

Recovery times following induction of anaesthesia with propofol, methohexitone, enflurane or thiopentone in children

We have measured the times to early recovery in forty children aged 3-14 years in whom anaesthesia was induced by intravenous propofol, methohexitone, thiopentone or inhalation of enflurane. Maintenance anaesthesia consisted of inhalation of nitrous oxide, oxygen and enflurane via a face mask. Early recovery, assessed by the Steward recovery score, was significantly faster after propofol, methohexitone or inhalation of enflurane compared with thiopentone (P < 0.01). There were no significant differences in recovery times between propofol, methohexitone or enflurane. We conclude that the use of propofol to induce anaesthesia does not hasten recovery in children undergoing short day-case procedures compared with methohexitone or inhalation of enflurane.     

A review of recovery from sevoflurane anaesthesia: comparisons with isoflurane and propofol including meta-analysis

BACKGROUND: Sevoflurane has a lower blood:gas partition coefficient than isoflurane and thus should be associated with a more rapid recovery from anaesthesia. METHODS: A review and meta-analysis were employed to examine the recovery profiles of adult patients following anaesthesia, comparing sevoflurane to isoflurane and sevoflurane to propofol. RESULTS: There were significant differences in times to several recovery events that favoured sevoflurane to isoflurane anaesthesia, including time to emergence, response to commands, extubation, and orientation. Likewise, there were significant differences in times to the same recovery events following anaesthesia with sevoflurane versus propofol. There were no differences in time to recovery room discharge when comparing sevoflurane to isoflurane or propofol. CONCLUSION: The observed differences between sevoflurane and isoflurane or propofol anaesthesia support the postulate that the use of sevoflurane is associated with a more rapid recovery from anaesthesia than either isoflurane or propofol.     

Randomized comparison of recovery after propofol-nitrous oxide versus thiopentone-isoflurane-nitrous oxide anaesthesia in patients undergoing ambulatory surgery

A randomized, prospective study was performed to compare recovery characteristics in 41 ASA physical status I-II patients scheduled for ambulatory surgery with either propofol or thiopentone-isoflurane anaesthesia. Particular attention was focused on the recovery time needed to meet discharge criteria. The propofol group received propofol 2 mg.kg-1 for induction followed by propofol infusion (6-9 mg.kg-1.h-1) 1 min after intubation. The thiopentone-isoflurane group received thiopentone 4 mg.kg-1 for induction followed by isoflurane (0.5-2%) 1 min after endotracheal intubation. Other drugs administered during or after anaesthesia were similar between the groups. The propofol group had significantly (P less than 0.05) faster clinical recovery than the isoflurane group with respect to times to response to commands, eye opening, orientation, ability to stand and void, tolerance to oral fluids, "home-readiness", and recovery of perceptual speed. Patients in the propofol group had significantly less (P less than or equal to 0.05) emesis than the patients given isoflurane. We conclude that in patients undergoing ambulatory surgery propofol infusion is preferable to thiopentone-isoflurane anaesthesia, because it may allow faster discharge home.     

Tracheal intubation without neuromuscular blockade in children: a comparison of propofol combined either with alfentanil or remifentanil

Forty healthy children, aged between two and 12 years of age undergoing elective surgery where the anaesthetic technique involved tracheal intubation followed by spontaneous ventilation were studied. Induction of anaesthesia was with either alfentanil 15 μg·kg^?1 or remifentanil 1 μg·kg^?1 followed by propofol 4 mg·kg^?1 to which lignocaine 0.2 mg·kg^?1 had been added. Intubating conditions were graded on a four point scale for ease of laryngoscopy, vocal cord position, degree of coughing, jaw relaxation and limb movement. All children were successfully intubated at the first attempt. There were no significant differences in the assessments of intubating conditions between the two groups. Arterial blood pressure and heart changes were similar in the two groups with both alfentanil and remifentanil attenuating the haemodynamic response to tracheal intubation. The time taken to resumption of spontaneous ventilation was similar in both groups.     

A randomised controlled trial comparing the effects of propofol with isoflurane in patients with diastolic dysfunction undergoing coronary artery bypass graft surgery

There is a strong association between pre‐operative diastolic dysfunction and difficulty in weaning from cardiopulmonary bypass. We compared the effects of propofol and isoflurane on left ventricular diastolic function in patients with pre‐existing diastolic dysfunction undergoing coronary artery bypass grafting. We randomly allocated 60 patients to receive either propofol or isoflurane anaesthesia, and assessed left ventricular diastolic function using transoesophageal echocardiography. We measured early (E), late (A) diastolic velocities, E/A ratio, A‐wave duration and deceleration time using pulsed wave Doppler, and early (Em), late (Am) diastolic velocities of the mitral annulus, Em/Am ratio and isovolumetric relaxation time using tissue Doppler. We measured pulmonary venous flow velocity and recorded values for the peak systolic flow velocity (S), peak diastolic flow velocity (D), S/D ratio, peak reverse atrial flow velocity and duration of reverse atrial flow. All data were recorded immediately after tracheal intubation as a baseline, 5 min before sternotomy (T₁), 5 min before aortic cannulation (T₂) and 15 min after weaning from cardiopulmonary bypass (T₃). Both propofol and isoflurane improved left ventricular diastolic function as evidenced by significant increases in E/A ratios, and significant decreases in deceleration time and isovolumetric relaxation time; the improvement was greater in the isoflurane group (between groups, p = 0.001 for both E/A ratio and deceleration time at T₁ and T₂ and p = 0.006 for isovolumetric relaxation time at both T₁ and T₂). Furthermore, Em/Am ratio, S, D and S/D ratios were significantly better in the isoflurane group. The administration of isoflurane during cardiac surgery improves diastolic function comparatively more than propofol.     

Prospective,randomized cost analysis of anesthesia with remifentanil combined with propofol,desflurane or sevoflurane for otorhinolaryngeal surgery

BACKGROUND: In the era of cost containment, cost analysis should demonstrate the cost-effectiveness of new anesthetic drugs. METHODS: This single-blind, prospective, randomized study compared the costs of three remifentanil (REM)-based anesthetic techniques with a conventional one in 120 patients undergoing otorhinolaryngeal surgery. The patients were randomized (n=30 each group) to either receive a combination of REM with propofol, desflurane or sevoflurane, or a conventional anesthetic with thiopentone, alfentanil, isoflurane and N2O. RESULTS: The costs for anesthetic and nonanesthetic drugs and for disposables were twice as high in the three REM-based groups as in the conventional group (REM/PRO 0.51 Euro;/min, REM/DES 0.42 Euro;/min, and REM/SEVO 0.41 Euro;/min vs. 0.18 Euro;/min in the ALF/ISO/N2O group; P<0.05). Wastage of intravenous drugs accounted for up to 40% of total costs. In all REM groups, early recovery was predictably faster and more complete (P<0.05). Patient satisfaction was equally high (90-97%) in all groups, with less nausea in the REM/PRO group. CONCLUSION: This study demonstrates that REM-based anesthetic techniques are more expensive than a conventional technique using alfentanil, isoflurane and N2O. This is the result of higher costs of anesthetic and nonanesthetic drugs and of disposables. The wastage of intravenous drugs contributes considerably to these costs.     

Nausea: the most important factor determining length of stay after ambulatory anaesthesia. A comparative study of isoflurane and/or propofol techniques

Speed of recovery and length of stay in hospital were studied in 95 ambulatory patients undergoing laparoscopy or arthroscopy. The patients were divided into three groups regarding maintenance of anaesthesia. Group A (n = 32) received isoflurane 0.7% end-tidally, group B (n = 31) propofol infusion for 25 min and thereafter isoflurane, and group C (n = 32) received an infusion of propofol throughout the procedure. Recovery was assessed by a combination of the Maddox-Wing, the Choice Reaction Time test and p-deletion. The awakening period was somewhat shorter in group A, but psychomotor recovery was somewhat slower compared to groups B and C. The length of stay in hospital depended on whether the patient was nauseated or not. In group A, 44% suffered from nausea requiring medical intervention compared to 13% and 19% in groups B and C, respectively. The stay in hospital was 235 ± 90 min (mean ± standard deviation) in group A compared to 184 ± 56 min and 197 ± 55 min in groups B and C, respectively. The non-nauseated patients in group A had a stay in hospital of 188 ± 55 min compared to 184 ± 52 and 184 ± 37 in the non-nauseated patients in groups B and C, respectively. In total, the nauseated patients (n = 24) stayed 267 ± 95 min compared to 185 ± 47 min for the non-nauseated patients (n = 71), P < 0.001. We found nausea to be the most important factor determining length of stay after ambulatory anaesthesia. Propofol in a dose higher than a normal induction dose decreases the incidence of nausea and thus the length of stay in hospital.     

丙泊酚复合雷米芬太尼或氧化亚氮用于妇科腹腔镜诊疗手术麻醉苏醒的比较

目的对丙泊酚复合雷米芬太尼或氧化亚氮用于妇科腹腔镜诊疗术后麻醉苏醒、早期拔管进行比较。方法选择ASAⅠ级,临床诊断不孕,拟于气管内插管的全麻下择期行腹腔镜检查及治疗的患者45例,随机分为三组:丙泊酚3μg/ml组(A组),丙泊酚2μg/ml组(B组)和氧化亚氮组(C组),每组15例。三组患者均为丙泊酚靶控输注(TCI)给药诱导及术中维持麻醉,罗库溴铵维持肌松。A组:维持丙泊酚靶浓度3μg/ml不变,雷米芬太尼根据血液动力学变化按0~1μg.kg-1.min-1输注给药,维持血液动力学稳定。B组:维持丙泊酚靶浓度2μg/ml不变,同样通过调整雷米芬太尼的给药速度维持血液动力学稳定。C组:丙泊酚TCI诱导,气管内插管后伍用氧化亚氮吸入维持麻醉。呼气末氧化亚氮浓度保持(65±1)%,通过调整丙泊酚的靶浓度来维持血液动力学稳定。三组患者均在手术结束时同时停麻醉药。以停麻醉的时间为零点计时,记录呼患者睁眼时间、气管拔管时间及答问切题时间。结果在睁眼时间、拔管时间和答问切题时间三项观察指标中,各组之间差异均有极显著意义(P<0.01)。B组患者睁眼时间(4.5±2.1)min、拔管时间(5.4±2.3)min、答问切题时间(8.1±2.8)min最短,说明麻醉苏醒最快;C组分别为(11.6±3.4)、(12.7±3.6)、(20.2±4.5)min,患者苏醒最慢;A组分别为(8.7±2.9)、(10.0±3.2)、(14.5±3.8)min,处于中间。结论低浓度丙泊酚TCI(2μg/ml)复合雷米芬太尼用于妇科腹腔镜诊疗手术,可使患者术后清醒快,恢复迅速。     

Recovery characteristics using single-breath 8% sevoflurane or propofol for induction of anaesthesia in day-case arthroscopy patients

We studied the induction and recovery characteristics following inhalational induction with 8% sevoflurane in nitrous oxide and oxygen compared with intravenous propofol in 40 patients presenting for arthroscopy of the knee. Patients were randomly allocated to receive either induction agent, and anaesthesia was then maintained with sevoflurane in oxygen and nitrous oxide. A computerised test of hand--eye co-ordination and a p-deletion test were used to measure psychomotor recovery. The sevoflurane group had a faster onset of anaesthesia time. No significant differences between the groups were found in time to eye opening or psychomotor tests. Nausea and vomiting scores were significantly higher at 30 min in the sevoflurane group (p = 0.04); this difference was no longer significant by 90 min. We conclude that inhalational induction with sevoflurane in these patients has no important clinical advantages and causes more nausea and vomiting than propofol.     

Uptake and biotransformation of sevof lurane in humans: A comparative study of sevof lurane with halothane, enflurane, and isoflurane

Study Objective: To compare the volatile anesthetic sevoflurane with halothane, enfurane, and isof urane on the uptake and biotransformation in humans.

Design: Prospective pharmacokinetic study of sevofurane administration in human subjects.

Setting: Inpatient surgery clinic at a university medical center.

Patients: Thirty-two Japanese patients, free of systemic diseases, undergoing minor elective surgery with endotracheal general anesthesia.

Interventions: The patients were assigned randomly to one of four groups: halothane, enflurane, isofurane, or sevofurane. One of the four volatile anesthetics being investigated [equivalent to 1.1 minimum alveolar concentration (MAC): halothane, 0.85%; enfurane, 1.85%; isofurane, 1.27%; and sevofurane, 1.88%; in inspired concentrations throughout the first hour of anesthesia] was administered for 60 minutes.

Measurements and Main Results: In all patients, serum and urinary fluoride concentrations were measured. The concentrations of all gases were measured separately with a mass spectrometer. The cumulative uptake of each anesthetic agent during a certain period was calculated as an integration of the uptake rate per minute. The results for one-hour inhalation of sevofurane (1.1 MAC) showed an uptake (corrected for body surface area and MAC) of 490 ml/m²/MAC and estimated degradation rate of 3.3%. For purposes of comparison, similar studies of halothane (uptake, 653 ml/m²/MAC; degradation rate 15.7%), enfurane (1150 ml/m²/MAC; 1.3%), and isofurane (439 ml/m²/MAC; 0.6%) were also conducted. Sevofurane had a peak serum inorganic fluoride concentration of 19.3 μmol/L, and no abnormality in hepatic or renal functions was observed in any of the subjects during the two weeks postoperatively.

Conclusions: Accurate determinations of uptake and degradation rate for sevoflurane and three other volatile anesthetics in Japanese patients were obtained. These findings have established that, despite its relatively large MAC *1.71%), sevoflurane has a small uptake due to its low solubility. However, the degradation rade was shown to be as high as 3.3%, resulting in a higher serum fluoride concentration than seen after administration of isoflurane, halothane, and (possibly) enflurane.     

不同剂量右美托咪啶复合异丙酚和瑞芬太尼用于腹部手术病人麻醉的效果

目的 评价不同剂量右美托咪啶复合异丙酚和瑞芬太尼用于腹部手术病人麻醉的效果.方法 择期拟在全麻下行腹部手术病人90例,性别不限,年龄18-64岁,体重45～80 kg,ASA分级Ⅰ或Ⅱ级,采用随机数字表法,将其随机分为3组(n=30).对照组(C组)静脉输注生理盐水10ml/h;右美托咪啶0.25 μg·kg-1·h-1组(D1组)和右美托咪啶0.50μg·kg-1·h-1组(D2组)于15 min内静脉输注右美托咪啶负荷剂量0.5μg/kg,然后分别以0.25 μg·kg-1 ·h-1或的0.50 μg·kg -1·h-1速率静脉输注至拔除气管导管.麻醉诱导:TCI异丙酚,血浆靶浓度1.0μg/ml,静脉注射顺阿曲库铵0.2 mg/kg,TCI瑞芬太尼,血浆靶浓度3 ng/ml,气管插管后行机械通气.麻醉维持:TCI瑞芬太尼,血浆靶浓度5ng/ml,静脉输注顺阿曲库铵0.1 mg·kg-1·h-1,TCI异丙酚,调节其血浆靶浓度,维持Narcotrend指数37 ～ 46.记录术中瑞芬太尼、顺阿曲库铵和异丙酚的用量、气管导管拔除时间和苏醒时间、术中和麻醉恢复期不良反应的发生情况.结果 3间瑞芬太尼、顺阿曲库铵的用量和气管导管拔除时间差异无统计学意义(P＞0.05);与C组比较,D1组和D2组苏醒时间延长,术中高血压、心动过速和麻醉恢复期烦躁、呕吐、高血压、心动过速的发生率降低,D2组异丙酚用量减少(P＜0.05);与D1组比较,D2组苏醒时间延长,术中高血压和麻醉恢复期烦躁、心动过速和高血压的发生率降低(P＜0.05).结论 复合异丙酚和瑞芬太尼时,静脉输注右美托咪啶0.50 μg·kg-1·h-1用于腹部手术病人麻醉的效果较好.     

A comparison of the effect of total intravenous anaesthesia with propofol and remifentanil and inhalational anaesthesia with isoflurane on the release of pro- and anti-inflammatory cytokines in patients undergoing open cholecystectomy

The aim of the study was to investigate the effects of two anaesthetic techniques (total intravenous technique vs. inhalational technique) on changes in pro- and anti-inflammatory cytokine levels during open cholecystectomy. Forty ASA PS I-II patients undergoing open cholecystectomy were randomly assigned to two groups. Group R received total intravenous anaesthesia with propofol and remifentanil and group F received balanced inhalational anaesthesia with isoflurane. The plasma levels of tumour necrosis factor-alpha (TNF-alpha), interleukin IL-6 and interleukin IL-10 were measured during and after surgery. The pro-inflammatory cytokine levels (TNF-alpha and IL-6) and the anti-inflammatory cytokine (IL-10) showed a significant increase in their concentrations compared with pre-induction levels in both groups (P < 0.05). By the end of anaesthesia and surgery, TNF-alpha and IL-6 were significantly lower in group R than in group F (P < 0.05). At the end of anaesthesia and 12 hours postoperatively, IL-10 levels in group R were higher than in group F (P < 0.05). These findings suggest that total intravenous anaesthesia using propofol and remifentanil suppresses the inflammatory response caused by surgery to a greater extent than a balanced inhalation technique using isoflurane.     

复合丙泊酚时瑞芬太尼抑制妇科腹腔镜手术患者气腹反应的半数有效血浆靶浓度

目的确定复合丙泊酚时瑞芬太尼抑制妇科腹腔镜手术患者气腹反应的半数有效血浆靶浓度(median effective plasma concentration,Cp50)。方法择期拟行妇科腹腔镜手术患者22例,年龄20～60岁,BMI 18～30kg/m2,ASAⅠ或Ⅱ级。麻醉诱导采用靶控输注(TCI)瑞芬太尼和丙泊酚,对应血浆靶浓度(Cp)分别为5ng/ml和4μg/ml,静脉注射罗库溴铵0.6mg/kg。气管插管后稳定3min,调整瑞芬太尼Cp,第1例患者为6ng/ml,待效应室靶浓度与Cp平衡后建立气腹。发生气腹反应时,下一例采用高一级浓度,否则采用低一级浓度,浓度梯度的比值为1.2。发生气腹反应的标准:建立气腹后3min内HR增快和/或MAP升高幅度超过基础值的20%。计算复合丙泊酚时瑞芬太尼抑制妇科腹腔镜手术患者气腹反应的Cp50及其95%CI。结果复合丙泊酚时瑞芬太尼抑制妇科腹腔镜手术患者气腹反应的Cp50及其95%CI为4.58(4.14～5.08)ng/ml。结论复合丙泊酚时瑞芬太尼抑制妇科腹腔镜手术患者气腹反应的Cp50为4.58ng/ml。     

Extubation time, hemodynamic stability, and postoperative pain control in patients undergoing coronary artery bypass surgery: an evaluation of fentanyl, remifentanil, and nonsteroidal antiinflammatory drugs with propofol for perioperative and postoperative management

STUDY OBJECTIVE: To compare three anesthetic strategies with respect to the time of extubation after coronary artery bypass graft (CABG) surgery and to assess patient satisfaction with the procedure. DESIGN: Prospective, randomized, clinical study. SETTING: Tertiary-care referral center. PARTICIPANTS: 180 cardiac surgical patients undergoing primary CABG from January through June 2004. INTERVENTIONS: After induction of general anesthesia, patients were allocated to one of three groups. All three groups received a continuous infusion of intravenous (IV) propofol perioperatively and postoperatively. Group 1 (fentanyl infusion group, n = 60) received continuous IV fentanyl infusion perioperatively and postoperatively for analgesia. Group 2 (diclofenac group, n = 60) received fentanyl bolus doses intraoperatively and diclofenac suppository postoperatively. Group 3 (remifentanil group, n = 60) received continuous infusion of IV remifentanil perioperatively and IV fentanyl as an immediate postoperative bolus followed by continuous fentanyl infusion. Duration of postoperative ventilation up to the time of extubation, inotrope requirement, time at which analgesic infusion was discontinued, postextubation arterial blood gas analysis, pain evaluation via visual analog scale, need for rescue analgesia, awareness during surgery, and length of postcardiac surgical unit stay, were evaluated in each patient. MAIN RESULTS: The diclofenac group exhibited the shortest time to extubation, the least inotrope use, and the fewest rescue doses of analgesic than did patients of the other two groups. CONCLUSION: Intravenous propofol with bolus doses of IV fentanyl intraoperatively in combination with postoperative nonsteroidal antiinflammatory drugs had the best recovery profile in patients undergoing primary CABG than did the other two regimens studied.     

A comparison of the analgesic efficacy of 0.25% levobupivacaine combined with 0.005% morphine, 0.25% levobupivacaine alone, or 0.005% morphine alone for the management of postoperative pain in patients undergoing major abdominal surgery

We compared the relative efficacy of the combination of the single-isomer local anesthetic levobupivacaine and the opioid analgesic morphine versus both drugs alone for postoperative epidural analgesia after major abdominal surgical procedures. Thoracic epidural anesthesia was produced and maintained with levobupivacaine 0.75% in combination with general inhaled anesthesia without opioids. Patients were randomized to one of three postoperative treatment groups: 1) a combination of levobupivacaine 0.25% and morphine 0.005%; 2) levobupivacaine 0.25%; or 3) morphine 0.005%. Postoperatively, all epidural infusions were commenced at a rate of 4 mL/h. Patients could receive a 4 mL-bolus dose and an increase in the epidural infusion rate by 2 mL/h on request for supplemental analgesia. Patients were also allowed ketorolac as a supplemental analgesic at any time after the first analgesic request. Patients in the combination group had longer times to request for supplemental analgesia as compared with the levobupivacaine only group (P < 0.05) and a trend toward longer time to request as compared with the morphine only group (P = 0.066). Patients in the combination group had lower visual analog scale pain scores at rest and activity at 4 and 8 h and fewer requests for supplemental ketorolac (P < 0.05). In conclusion, this study demonstrates a significant improvement in postoperative analgesic efficacy with the combination of levobupivacaine and morphine for continuous epidural analgesia after major abdominal surgical procedures. IMPLICATIONS: A significant improvement in postoperative analgesic efficacy is demonstrated with the thoracic epidural administration of the combination of the single-isomer local anesthetic levobupivacaine 0.25% and morphine 0.005% in patients after major abdominal surgical procedures as compared with either drug used alone.