Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]

In 1987, Yeager et al. reported that intraoperative epidural anesthesia with local anesthetics and postoperative epidural analgesia with opiates diminished postoperative morbidity. In our first clinical trial on this topic, the better postoperative analgesia with epidural bupivacaine-fentanyl failed to improve the outcome after major abdominal operations over that obtained with parenteral piritramide. This randomized controlled investigation was designed to assess whether intraoperative epidural anesthesia with bupivacaine plus light general anesthesia and postoperative epidural analgesia with morphine would diminish the overall rate of postoperative complications after major abdominal operations compared with general anesthesia (without epidural) followed by patient controlled analgesia with morphine, and with intraoperative epidural anesthesia with bupivacaine and light general anesthesia followed by postoperative bupivacaine-morphine analgesia. METHODS. A total of 292 patients undergoing infrarenal aortic bypass operation, gastric resection, gastrectomy, duodenum-preserving pancreatic resection, Whipple's operation or cystectomy and neobladder formation were randomly divided into three groups: 1. PCA group (patient controlled analgesia, n = 107): patients were operated on under general anesthesia (midazolam, fentanyl, N2O/O2, if necessary with addition of halothane, enflurane or isoflurane; muscle relaxation with pancuronium bromide). Postoperative management consisted in patient-controlled analgesia with morphine (Prominject), bolus 2 mg, lock-out 5 min (recovery room, intensive care unit) or 15 min (surgical ward). 2. EBM group (epidural bupivacaine+morphine, n = 95): operation under light general anesthesia (midazolam, low-dose fentanyl, N2O/O2, pancuronium bromide). In addition, a mixture of bupivacaine (0.25%) and morphine (60 micrograms/ml) was infused (approximately 0.1 ml/kg.h) via an epidural catheter during and after the operation (approximately 72 h). 3. EM group (epidural morphine, n = 90): operation under the same kind of general-epidural anesthesia as in the EBM group. Postoperatively, epidural injection of morphine (0.05 mg/kg in 10 ml of saline) on request up to the 3rd postoperative day. Quality of analgesia (at rest and when patients coughed vigorously), strength of cough, and rate-pressure product were recorded at 8:00 h, 12:00 noon, 16:00 h and 20:00 h on the 1st, 2nd and 3rd postoperative days. Incidence and intensity of all postoperative complications (cardiovascular, pulmonary, renal and other organ failure, reoperations, major infection, sepsis, thromboembolism, metabolic and mental disturbances) were assessed from the day of operation until discharge or death (n = 10), respectively. RESULTS AND DISCUSSION. In the PCA and EM groups analgesia was equal but of slightly inferior quality compared with the EBM group. The ability to cough was best in the EBM group and significantly worse in the PCA and EM groups, with no difference between the last two. (ABSTRACT TRUNCATED AT 400 WORDS)     

Failure of Epidural Analgesia to Modify Postoperative Depression of Delayed Hypersensitivity

Delayed hypersensitivity to four common antigens was assessed in 32 patients undergoing major abdominal surgery randomly allocated to either general anesthesia (fentanyl + O2/N2O + postoperative pain relief with systemic opiates) or general anaesthesia + epidural analgesia (local anaesthetics + morphine) continued for 72 h. Skin-test responses were performed 2 days before surgery and 1 day after surgery and compared to a similar retesting schedule in 16 comparable non-operative control patients. Cumulated mean skin-test responses increased from 1290 to 2330 mm2 (P less than 0.0001) during retesting in the non-operative control group. In contrast, mean skin-test responses in patients operated during general anaesthesia + systemic opiates for postoperative pain relief fell from 1422 to 1227 mm2 (P = 0.3) and in patients receiving epidural analgesia from 1228 to 890 mm2 (P = 0.06), without statistically significant differences between these two groups (P greater than 0.5). Thus, surgery leads to depression of delayed hypersensitivity and this impairment in immunofunction is not modified by an epidural analgesic regimen providing adequate pain relief.     

Anesthesia for inguinal hernioplasty: a comparison of techniques

New surgical and modern anaesthesia techniques for inguinal hernioplasty have significantly reduced the duration of the procedure and the postoperative length of hospital stay. From 1994 to 1998, 405 patients with a mean age of 54.7 years (range: from 18 to 90) undergoing inguinal hernioplasty were studied. Four different anaesthetic techniques were used: (i) surgical field infiltration (SFI) with 0.5% carbonated lidocaine + 0.125% bupivacaine (193 pts.) in which monitored anaesthesia care was administered with propofol (3 to 4 mg/kg/h) when necessary; (ii) epidural anaesthesia with 2% lidocaine + fentanyl 100 mg (137 pts.); (iii) general anesthesia with isoflurane and fentanyl in N2O:O2 (48 pts.); and (iv) intrathecal anaesthesia with 1% hyperbaric bupivacaine 1-2 ml (25 pts.). Intra- and postoperative complications, intraoperative sedation, postoperative supplemental drugs for analgesia and postoperative length of hospital stay were recorded. The data obtained were analyzed statistically using Student's t-test Anova, Bonferroni post hoc analysis, chi square, and P values less than 0.05 were considered significant. Intraoperative hypotension/brachycardia were observed in 4 patients (2%) in the SFI group and in 6 patients (4%) in the epidural group. Sedation was required in 29.5% of patients in the SFI group and in 15.3% in the epidural group (P < 0.05). Postoperative supplemental analgesic drugs administered and length of hospital stay were similar in the 4 groups. No difference in intra- and postoperative complications was observed among the 4 groups. Patients who required sedation in the SFI group were significantly more numerous than those with epidural anaesthesia. In conclusion, both SFI and epidural anaesthesia are safe and suitable for the inguinal hernioplasty procedure, without intra- or postoperative complications.     

Does epidural fentanyl decrease the efficacy of epidural morphine after cesarean delivery?

Earlier studies have suggested that epidural fentanyl improves intraoperative analgesia during cesarean section, but others have suggested that it worsens postoperative analgesia from epidural morphine. The purpose of this study was to determine whether epidural fentanyl given before epidural morphine improves the quality of intraoperative epidural anesthesia without worsening postoperative analgesia provided by epidural morphine. Sixty patients having epidural anesthesia for cesarean delivery were studied. Epidural anesthesia was established using 2% lidocaine with epinephrine 5 micrograms/mL. After delivery, either fentanyl 100 micrograms/10 mL or normal saline-control 10 mL was injected through the epidural catheter in a randomized, double-blind manner. All patients received 3.5 mg of morphine epidurally after uterine repair. After administration of the epidural study drug, there were no significant differences in the pain responses during surgery between the two groups. Patients in the fentanyl group experienced significantly less nausea and vomiting between delivery and the end of surgery than did patients in the normal saline-control group (P = 0.013). Postoperatively, visual analogue scale scores for pain, pruritus, nausea, and sedation were similar at 1, 2, 4, and 8 h in the two groups. We conclude that fentanyl 100 micrograms administered epidurally during cesarean delivery did not improve intraoperative analgesia, but significantly reduced intraoperative nausea and vomiting without diminishing the efficacy of postoperative analgesia provided by epidural morphine.     

Dextromethorphan-associated epidural patient-controlled analgesia provides better pain- and analgesics-sparing effects than dextromethorphan-associated intravenous patient-controlled analgesia after bone-malignancy resection: a randomized, placebo-controlled, double-blinded study

Pain after bone malignancy surgery is intense and requires large amounts of analgesics. The augmented antinociceptive effects of dextromethorphan (DM), a N-methyl-D-aspartate receptor antagonist, were demonstrated previously. We assessed the use of postoperative patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia with or without DM. Patients (n = 120) were randomly allocated to receive PCEA (ropivacaine 3.2 mg plus fentanyl 8 microg/dose) or IV-PCA (morphine 2 mg/dose) postoperatively, starting at subjective visual analog scale pain intensity >or=4 of 10 for up to 96 h. Placebo or DM 90 mg orally (30 patients/group/set) was given in a double-blinded manner before surgery and for 2 days afterwards. Diclofenac 75 mg IM was available as a rescue drug. DM patients used PCA and rated their pain >50% less than their placebo counterparts in each set, especially during the first 2 postoperative days (P < 0.01). Hourly and overall maximal pain intensity among PCEA patients was approximately 50% less than in the IV-PCA set (P < 0.01). Diclofenac was used 42% less (P < 0.01) by the PCA-DM patients compared with their placebo counterparts. Seven PCEA-DM and 11 IV-PCA-DM individuals reported having side effects compared with 44 in the PCEA-placebo and the IV-PCA-placebo groups (P < 0.01). Time to first ambulation was similar with both analgesia techniques but shorter among the DM-treated patients compared with the placebo recipients (1.5 +/- 0.8 versus 2.1 +/- 1.1 days, P = 0.02). Thus, DM afforded better pain control and reduced the demand for analgesics, augmented the PCEA effect versus IV-PCA, and was associated with minimal untoward effects in each analgesia set. DM patients ambulated earlier than placebo recipients. IMPLICATIONS: Patients undergoing bone-malignancy surgery under combined general and epidural anesthesia received randomly patient-controlled epidural analgesia (PCEA) or IV patient-controlled analgesia (PCA) postoperatively and dextromethorphan (DM) 90 mg or placebo double-blindly for 3 days (n = 30/group/set). The DM effect was recorded with minimal untoward effects: it afforded better pain control and reduced the demand for analgesics compared with the placebo, especially when associated with PCEA. DM patients ambulated earlier than placebo recipients.     

Combined general and epidural anesthesia with ropivacaine for renal transplantation

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

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)     

The efficacy of thoracic epidural neostigmine infusion after thoracotomy

Few anesthesia studies have explored perioperative continuous epidural infusion of neostigmine. We examined such a regimen in thoracotomy patients. Ninety patients were randomized to one of three groups in this double-blind trial. Before anesthesia induction, an epidural catheter was inserted in all patients at T5-8 levels under local anesthesia. Pre-neo patients received bolus 500-microg epidural neostigmine before anesthesia induction followed by infusion of 125 microg/h until the end of surgery. Post-neo patients received epidural saline during the same time periods plus bolus 500-microg epidural neostigmine at end of surgery. Patients in the control group received saline placebo during all three periods. Patients in the neostigmine groups postoperatively received patient-controlled epidural analgesia with morphine 0.02 mg/mL, bupivacaine 0.08 mg/mL, and neostigmine 7 microg/mL. Control patient-controlled epidural analgesia excluded neostigmine. Data were recorded for 6 postoperative days. Daily patient-controlled epidural analgesia consumption (mL) for Pre-neo patients was significantly less than that of post-neo and control group patients for postoperative days 1-6 (at least 10% and 16% less, respectively; P < 0.05). There was a modest decrease in pain intensity on postoperative days 3-6 for pre-neo patients versus other groups (P < 0.05). These results suggest that continuous thoracic epidural neostigmine started before anesthesia provided preemptive, preventive analgesia and an analgesic-sparing effect that improved postoperative analgesia for these patients without increasing the incidence of adverse effects.     

Antipruritic and antiemetic effect of epidural droperidol: comparative study between single and continuous epidural injection

BACKGROUND AND OBJECTIVES: This study was designed to investigate whether single epidural droperidol or continuous epidural droperidol inhibit pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl administration, and to identify the optimal method of administering epidural droperidol. METHODS: 120 ASA I-II patients undergoing subtotal gastrectomy with general anaesthesia combined with epidural anaesthesia were randomly allocated into three groups: control (no droperidol), single injection (droperidol 2.5 mg) and continuous group (droperidol 2.5 mg 2 day(-1)). Postoperatively the frequency and severity of pruritus and postoperative nausea and vomiting in all groups were compared during 48 h. RESULTS: The frequency and severity of pruritus was significantly lower in both single injection and continuous groups than control group after epidural fentanyl administration (P < 0.05). The frequency and severity of postoperative nausea and vomiting was significantly lower in single injection group than control group after epidural fentanyl administration (P < 0.05). CONCLUSION: Epidural continuous droperidol is effective for reducing pruritus, and single epidural droperidol injection is effective for reducing pruritus and postoperative nausea and vomiting induced by postoperative continuous epidural fentanyl analgesia.     

布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛安全性探讨

目的探讨布比卡因、罗哌卡因与芬太尼不同配伍用于连续术后硬膜外镇痛的效果、并发症及安全陛。方法1600例行连续术后硬膜外镇痛的患者,按所用镇痛药物配伍不同分为：0．1％布比卡因＋5μg／ml芬太尼组（B组,n=920）和0．2％罗哌卡因＋2μg／ml芬太尼组（R组,n=680）。对两组镇痛效果（视觉模拟评分及患者对镇痛效果的满意度）、并发症和处理措施进行总结分析。结果视觉模拟评分两组无差异（P〉0．05）。患者对镇痛的满意度R组明显高于B组（P〉0．05）。并发症的发生率B组高于R组（P〉0．05）。两组内年龄≥60岁的患者低血压的发生率高于年龄〈60岁者（P〈0．05）;女性患者恶心呕吐的发生率高于男性（P〈0．05）;腰段硬膜外镇痛患者下肢乏力或麻木的发生率明显高于胸段硬膜外镇痛患者（P〈0．05）。结论布比卡因、罗哌卡因与芬太尼不同配伍均可安全有效地用于连续术后硬膜外镇痛,罗哌卡因组并发症较少,并发症的发生与镇痛药物、年龄、性别及硬膜外置管部位有关。     

Superiority of postoperative epidural over intravenous patient-controlled analgesia in orthopedic oncologic patients

BACKGROUND: Surgery for bone malignancy is associated with intense postoperative pain. Patient-controlled epidural analgesia (PCEA) and intravenous patient-controlled analgesia (IV-PCA) are used currently for postoperative pain control. METHODS: The degree of pain control after resection of bone malignancy under combined general and epidural anesthesia followed postoperatively by prospectively randomized PCEA (ropivacaine 3.2 mg + fentanyl 8 microg/dose) or IV-PCA (morphine 2 mg/dose) (n = 35/group) was assessed. Postoperative analgesia delivery continued for up to 96 h; intramuscular rescue with diclofenac 75 mg was also available. RESULTS: The mean hourly pain score among the PCEA patients was 3.0 +/- 0.9, compared with 4. 7 +/- 0.6 (P < .01) among the IV-PCA patients. All mean hourly pain scores in the PCEA patients, except for the first 2 hours of treatment, were less than 4/10, but they were higher in the IV-PCA patients. The demand for diclofenac was 2 times (n = 10) lower for the PCEA patients, compared with their IV counterparts (n = 20, P < .01); the same difference applied to the overall side effects (n = 15 vs n = 30, P < .01). Self-rated wakefulness and feelings of well-being were better in the PCEA patients. CONCLUSIONS: Postoperative ropivacaine + fentanyl via PCEA reduces pain better and affords better subjective feelings than IV morphine via PCA after resection of bone malignancy carried out under combined general and epidural anesthesia.     

Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group.

The aim of our study was to compare epidural anesthesia and analgesia (EDA) with ropivacaine versus general anesthesia followed by IV patient-controlled analgesia with morphine (GA/PCA) after hip replacement regarding pain, side effects, and discharge from the postanesthesia care unit. After ethics committee approval, randomization, and informed consent, 90 patients were enrolled. In Group EDA, epidural anesthesia (ropivacaine 10 mg/mL, 15-25 mL) was followed by an epidural infusion (2 mg/mL, 4-6 mL/h for 24 h, plus top-up doses of 6-10 mL for 48 h). GA/PCA patients received general anesthesia (isoflurane/N2O/fentanyl) followed by IV patient-controlled analgesia with morphine postoperatively. Pain was assessed by using visual analog scales (0-100 mm) at rest and during physiotherapy. Pain at rest was less in the EDA (n = 43) group than in the GA/PCA (n = 45) group (at 10 h: 11.8+/-12.9 vs. 28.4+/-17.1 [P< 0.001]; at 24 h: 14.3+/-11.7 vs. 24.0+/-17 [P<0.01]; in 48 h: 14.3+/-9.3 vs. 21.1+/-17.4 [P = 0.1]). Whereas EDA patients were deemed ready for discharge from the postanesthesia care unit earlier than GA/PCA patients (5.6+/-8.9 vs. 39.7+/-41.5 min), the actual discharge time was comparable. The median time for first passage of flatus was shorter in the EDA group than in the GA/PCA group (26 vs. 47 h). Nausea and vomiting were more common in the GA/PCA group than in the EDA group (16% vs. 28% and 11% vs. 22%, respectively), whereas hypotension (11% vs. 4%) and bradycardia (14% vs. 2%) were less frequent. Under the conditions of the present study, EDA with ropivacaine provided pain control after hip replacement superior to that provided by IV patient-controlled analgesia with morphine, particularly during the first 24 h. Both approaches to pain management were equally safe. IMPLICATIONS: Compared with general anesthesia and postoperative IV patient-controlled analgesia with morphine, epidural anesthesia and analgesia with the new local anesthetic ropivacaine enables patients to be discharged sooner from a postanesthesia care unit and provides superior pain relief during the first 24 h after hip replacement.     

Postoperative wound oxygen tension with epidural or intravenous analgesia: a prospective,randomized, single-blind clinical trial

BACKGROUND: Adequate tissue oxygen tension is an essential requirement for surgical-wound healing. The authors tested the hypothesis that epidural anesthesia and analgesia increases wound tissue oxygen tension compared with intravenous morphine analgesia. METHODS: In a prospective, randomized, blind clinical study, the authors allocated patients having major abdominal surgery (n = 32) to receive combined general and epidural anesthesia with postoperative patient-controlled epidural analgesia (epidural group, n = 16), or general anesthesia alone with postoperative patient-controlled intravenous analgesia (intravenous group, n = 16). An oxygen sensor and a temperature sensor were placed subcutaneously in the wound before closure. Wound oxygen tension (P(w)O(2)) and temperature were measured continuously for 24 h. Other variables affecting wound tissue oxygenation and visual analogue scale (VAS) pain scores were also documented. RESULTS: Despite epidural patients having lower body temperatures at the end of surgery (35.7 +/- 0.3) versus 36.3 +/- 0.5 degrees C, = 0.004), they had significantly higher mean P(w)O(2) over the 24 h period, compared with the intravenous group (64.4 +/- 14 vs. 50.7 +/- 15) mmHg, mean (SD), 95% CI difference, -22 to -5, = 0.002). Area under the P(w)O(2) -24 h time curve was also significantly higher in the epidural group (930 +/- 278 vs. 749 +/- 257) mmHg x h, 95% CI difference -344 to -18, = 0.03). VAS pain scores at rest and moving were significantly lower in the epidural group at all times. CONCLUSION: Epidural anesthesia and postoperative analgesia for major abdominal surgery increases wound tissue oxygen tension compared with general anesthesia and intravenous morphine analgesia.     

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

OBJECTIVE: To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures. SUMMARY BACKGROUND DATA: Even though many beneficial aspects of epidural anesthesia have been reported, clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results. METHODS: The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic, gastric, biliary, or colon operations. They were assigned randomly to receive either general anesthesia and postoperative analgesia with parenteral opioids (group 1) or epidural plus light general anesthesia and postoperative epidural morphine (group 2). The patients were monitored for death and major complications during and for 30 days after surgery, as well as for postoperative pain, time of ambulation, and length of hospital stay. RESULTS: Overall, there was no significant difference in the incidence of death and major complications between the two groups. For abdominal aortic surgical patients, unlike the other three types of surgical patients, the overall incidence of death and major complications was significantly lower in group 2 patients (22%) than in group 1 patients (37%), stemming from differences in the incidence of new myocardial infarction, stroke, and respiratory failure between the two groups. Overall, group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients. In group 2 aortic patients, endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter. CONCLUSIONS: The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief. Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations.     

A randomized,double-blinded comparison of thoracic epidural ropivacaine,ropivacaine/fentanyl,or bupivacaine/fentanyl for postthoracotomy analgesia

Epidural ropivacaine has not been compared with bupivacaine for postthoracotomy analgesia. Eighty patients undergoing elective lung surgery were randomized in a double-blinded manner to receive one of three solutions for high thoracic epidural analgesia. A continuous epidural infusion of 0.1 mL. kg(-1). h(-1) of either 0.2% ropivacaine, 0.15% ropivacaine/fentanyl 5 micro g/mL, or 0.1% bupivacaine/fentanyl 5 micro g/mL was started at admission to the intensive care unit. We assessed pain scores (rest and spirometry), IV morphine consumption, spirometry, hand grip strength, PaCO(2), heart rate, blood pressure, respiratory rate, and side effects (sedation, nausea, vomiting, and pruritus) for 48 h. Thoracic epidural ropivacaine/fentanyl provided adequate pain relief similar to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. The use of plain 0.2% ropivacaine was associated with worse pain control during spirometry, larger consumption of IV morphine, and increased incidence of postoperative nausea and vomiting. Morphine requirements were larger in the ropivacaine group, with no differences between bupivacaine/fentanyl and ropivacaine/fentanyl groups. Patients in the ropivacaine group experienced more pain and performed worse in spirometry than patients who received epidural fentanyl. There was no significant difference in motor block. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia. IMPLICATIONS: Thoracic epidural ropivacaine/fentanyl provided adequate pain relief and similar analgesia to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. Plain 0.2% ropivacaine was associated with worse pain control and an increased incidence of postoperative nausea and vomiting. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia.     

Postoperative morphine use and hyperalgesia are reduced by preoperative but not intraoperative epidural analgesia: implications for preemptive analgesia and the prevention of central sensitization

BACKGROUND: The aim of this study was to evaluate the postoperative morphine-sparing effects and reduction in pain and secondary mechanical hyperalgesia after preincisional or postincisional epidural administration of a local anesthetic and an opioid compared with a sham epidural control. METHODS: Patients undergoing major gynecologic surgery by laparotomy were randomly assigned to three groups and studied in a double-blinded manner. Group 1 received epidural lidocaine and fentanyl before incision and epidural saline 40 min after incision. Group 2 received epidural saline before incision and epidural lidocaine and fentanyl 40 min after incision. Group 3 received a sham epidural control (with saline injected into a catheter taped to the back) before and 40 min after incision. All patients underwent surgery with general anesthesia. RESULTS: One hundred forty-one patients completed the study (group 1, n = 45; group 2, n = 49; group 3, n = 47). Cumulative patient-controlled analgesia morphine consumption at 48 h was significantly lower (P = 0.04) in group 1 (89.8 +/- 43.3 mg) than group 3 (112.5 +/- 71.5 mg) but not group 2 (95.4 +/- 60.2 mg), although the hourly rate of morphine consumption between 24 and 48 h after surgery was significantly lower (P < 0.0009) in group 1 (1.25 +/- 0.02 mg/h) than group 2 (1.41 +/- 0.02 mg/h). Twenty-four hours after surgery, the visual analog scale pain score on movement was significantly less intense (P = 0.005) in group 1 (4.9 +/- 2.2 cm) than group 3 (6.0 +/- 2.6 cm) but not group 2 (5.3 +/- 2.5 cm), and the von Frey pain threshold near the wound was significantly higher (P = 0.03) in group 1 (6.4 +/- 0.6 log mg) than in group 3 (6.1 +/- 0.8 log mg) but not group 2 (6.2 +/- 0.7 log mg). CONCLUSIONS: Preincisional administration of epidural lidocaine and fentanyl was associated with a significantly lower rate of morphine use, lower cumulative morphine consumption, and reduced hyperalgesia compared with a sham epidural condition. These results highlight the importance of including a standard treatment control group to avoid the problems of interpretation that arise when two-group studies of preemptive analgesia (preincisional vs. postsurgery) fail to find the anticipated effects.     

Comparison of continuous epidural bupivacaine infusion plus either continuous epidural infusion or patient-controlled epidural injection of fentanyl for postoperative analgesia.

We compared the postoperative epidural analgesia provided by the continuous epidural infusion of bupivacaine supplemented with patient-controlled injection (PCA) of epidural fentanyl with that provided by a continuous infusion of bupivacaine supplemented with a continuous epidural infusion of fentanyl. Our patient population comprised 16 ASA physical status I or II patients undergoing laparotomy with a midline incision under general anesthesia combined with bupivacaine epidural analgesia. Post-operatively, a continuous epidural infusion of bupivacaine (0.1 mg.kg-1.h-1) was combined with epidural fentanyl given by either (a) PCA (15-micrograms bolus with a lockout interval of 12 min, n = 8) or (b) continuous infusion (1 microgram.kg-1.h-1, n = 8). In the case of inadequate pain relief in the latter group, the fentanyl infusion rate was increased by 10 micrograms/h. Analgesia evaluated by a visual analogue pain score and by a verbal pain score was similarly effective in both groups. The sedation score was also similar in both groups. The total dose of epidural fentanyl administered during the first 24 h was significantly lower in the PCA group than in the continuous infusion group (405 +/- 110 micrograms vs 1600 +/- 245 micrograms, P less than 0.001). The dose of fentanyl given during each 4-h interval ranged between 40 and 160 micrograms in the PCA group and 251 and 292 micrograms in the continuous infusion group. Clinically detectable respiratory depression was not observed in either group. In conclusion, epidural administration of 0.1 mg.kg-1.h-1 bupivacaine combined with fentanyl provides effective postoperative analgesia with a total dose of fentanyl required that is lower when fentanyl is administered by epidural PCA rather than by continuous epidural infusion.     

Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy

A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on bowel function after abdominal hysterectomy. The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces. Twenty-two patients were randomly allocated to two equal groups. An "epidural morphine" group received general anesthesia and epidural morphine for postoperative pain relief, and an "epidural bupivacaine" group was given combined general anesthesia and epidural anesthesia with 0.5% bupivacaine intraoperatively and epidural analgesia with 0.25% bupivacaine postoperatively. Epidural morphine or bupivacaine was given for 42 h postoperatively. Pain intensity (visual analog scale) was low in both groups, but lower (P less than 0.05) in the epidural bupivacaine group. The time to first passage of flatus was 22 +/- 16 h in the epidural bupivacaine group and 56 +/- 22 h in the epidural morphine group (P less than 0.001). The time to first postoperative passage of feces was shorter (P less than 0.05) in the former than in the latter 57 +/- 44 h vs 92 +/- 22 h). The patients of the epidural bupivacaine group started intake of oral fluids earlier (P less than 0.01) and to a greater extent (P less than 0.05) than those in the epidural morphine group. It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine.     

Postoperative analgesia after radical retropubic prostatectomy: a double-blind comparison between low thoracic epidural and patient-controlled intravenous analgesia

BACKGROUND: Postoperative pain after radical retropubic prostatectomy can be severe unless adequately treated. Low thoracic epidural analgesia and patient-controlled intravenous analgesia were compared in this double-blind, randomized study. METHODS: Sixty patients were randomly assigned to receive either low thoracic epidural analgesia (group E) or patient-controlled intravenous analgesia (group P) for postoperative pain relief. All patients had general anesthesia combined with thoracic epidural analgesia during the operation. Postoperatively, patients in group E received an infusion of 1 mg/ml ropivacaine, 2 microg/ml fentanyl, and 2 microg/ml adrenaline, 10 ml/h during 48 h epidurally, and a placebo patient-controlled intravenous analgesia pump intravenously. Patients in group P received a patient-controlled intravenous analgesia pump with morphine intravenously and 10 ml/h placebo epidurally. Pain, the primary outcome variable, was measured using the numeric rating scale at rest (incision pain and "deep" visceral pain) and on coughing. Secondary outcome variables included gastrointestinal function, respiratory function, mobilization, and full recovery. Health-related quality of life was measured using the Short Form-36 questionnaire, and plasma concentration of fentanyl was measured in five patients to exclude a systemic effect of fentanyl. RESULTS: Incisional pain and pain on coughing were lower in group E compared with group P at 2-24 h, as was deep pain between 3 and 24 h postoperatively (P < 0.05). Maximum expiratory pressure was greater in group E at 4 and 24 h (P < 0.05) compared with group P. No difference in time to home discharge was found between the groups. The mean plasma fentanyl concentration varied from 0.2 to 0.3 ng/ml during 0-48 h postoperatively. At 1 month, the scores on emotional role, physical functioning, and general health of the Short Form-36 were higher in group E compared with group P. However, no group x time interaction was found in the Short Form-36. CONCLUSIONS: The authors found evidence for better pain relief and improved expiratory muscle function in patients receiving low thoracic epidural analgesia compared with patient-controlled analgesia for radical retropubic prostatectomy. Low thoracic epidural analgesia can be recommended as a good method for postoperative analgesia after abdominal surgery.     

Postoperative Morphine Use and Hyperalgesia Are Reduced by Preoperative but Not Intraoperative Epidural Analgesia: Implications for Preemptive Analgesia and the Prevention of Central Sensitization

Background: The aim of this study was to evaluate the postoperative morphine-sparing effects and reduction in pain and secondary mechanical hyperalgesia after preincisional or postincisional epidural administration of a local anesthetic and an opioid compared with a sham epidural control.

Methods: Patients undergoing major gynecologic surgery by laparotomy were randomly assigned to three groups and studied in a double-blinded manner. Group 1 received epidural lidocaine and fentanyl before incision and epidural saline 40 min after incision. Group 2 received epidural saline before incision and epidural lidocaine and fentanyl 40 min after incision. Group 3 received a sham epidural control (with saline injected into a catheter taped to the back) before and 40 min after incision. All patients underwent surgery with general anesthesia.

Results: One hundred forty-one patients completed the study (group 1, n = 45; group 2, n = 49; group 3, n = 47). Cumulative patient-controlled analgesia morphine consumption at 48 h was significantly lower (P = 0.04) in group 1 (89.8 +/- 43.3 mg) than group 3 (112.5 +/- 71.5 mg) but not group 2 (95.4 +/- 60.2 mg), although the hourly rate of morphine consumption between 24 and 48 h after surgery was significantly lower (P < 0.0009) in group 1 (1.25 +/- 0.02 mg/h) than group 2 (1.41 +/- 0.02 mg/h). Twenty-four hours after surgery, the visual analog scale pain score on movement was significantly less intense (P = 0.005) in group 1 (4.9 +/- 2.2 cm) than group 3 (6.0 +/- 2.6 cm) but not group 2 (5.3 +/- 2.5 cm), and the von Frey pain threshold near the wound was significantly higher (P = 0.03) in group 1 (6.4 +/- 0.6 log mg) than in group 3 (6.1 +/- 0.8 log mg) but not group 2 (6.2 +/- 0.7 log mg).