Cranial nerve block with bupivacaine for postoperative analgesia following supratentorial craniotomy

OBJECTIVE: To assess the effectiveness of analgesia by cranial nerve block with bupivacaine in the first 24 hours following elective supratentorial craniotomy. PATIENTS AND METHODS: A prospective, randomized, double-blind study was performed in 30 patients who underwent craniotomy for excision of a tumor. The cranial nerve block was performed using saline (control group, n=15) or 0.25% bupivacaine with epinephrine at 1:200 000 (bupivacaine group, n=15). Morphine (2 mg, intravenous bolus) was used for rescue analgesia. Pain was assessed on a visual analog scale (VAS) at 2, 4, 8, 12, 16, and 24 hours following the cranial nerve block. The following data were recorded: time elapsed until appearance of pain, use of rescue analgesia, and incidence of adverse effects. RESULTS: The use of morphine was significantly lower in the group of patients who received a cranial nerve block with bupivacaine than in the control group (mean [SD], 3.7 [1.6] mg vs 172 [2.5] mg). The mean time to the first requirement for rescue analgesia was longer in the bupivacaine group than in the control group (731 [247] minutes vs 80 [71] minutes). The VAS score during the first 16 hours was significantly lower in the bupivacaine group than in the control group. The incidence of nausea and vomiting was significantly higher in the control group (67% vs 13%). CONCLUSIONS: Cranial nerve block with 0.25% bupivacaine following supratentorial craniotomy improves postoperative analgesia, reduces the requirement for morphine, and contributes to reducing nausea and vomiting.     

Preincision 0.25% bupivacaine scalp infiltration and postcraniotomy pain: a randomized double-blind,placebo-controlled study

This prospective, double-blind, randomized, and placebo-controlled trial was performed to evaluate the effect of preincisional scalp infiltration with 0.25% bupivacaine on the postoperative pain perception and analgesic requirement of patients undergoing elective supratentorial craniotomy. Twenty patients (bupivacaine group) received scalp infiltration with 25 mL of 0.25% bupivacaine followed by intravenous 5 mL of saline as placebo 5 minutes before incision, and another 21 patients (fentanyl group) received scalp infiltration with a similar volume of 0.9% saline solution followed by 2 microg/kg of intravenous fentanyl 5 minutes before incision. Following standard anesthesia technique, basal, preincisional, and postincisional hemodynamic data were recorded. Postoperative pain was assessed at 1, 6, 12, 24, and 48 hours by using a 10-cm visual analog scale. Diclofenac sodium was used as rescue analgesic in the postoperative period. Results showed rescue analgesic was required only during the first 12 hours. In each group the same number of patients needed rescue analgesia, but bupivacaine delayed this requirement 105 (30-720; median [range]) minutes compared with 60 (15-720; median [range]) minutes for the fentanyl group (P = 0.13). But there was no difference in the amount of analgesic consumed at different time intervals. Six of 20 patients in the bupivacaine group required rescue analgesic at the end of 1 hour compared with 9 of 21 fentanyl patients (P = 0.61). At 6 hours, the fraction of patients who required rescue analgesia were 7 of 20 and 11 of 21, respectively (P = 0.44). In conclusion, bupivacaine preincision scalp infiltration did not have any significant effect on postcraniotomy pain and analgesic requirement. However, bupivacaine may delay the requirement of the first analgesic dose.     

Postoperative pain relief in children

Two hundred and fifty children undergoing herniotomy or orchidopexy under general anaesthesia were randomly allocated to receive pre-operatively either diclofenac sodium 1 mg.kg^-1 given intramuscularly or a caudal injection of bupivacaine 0.25% 1 ml.kg^-1 with or without adrenaline or no analgesia. Plasma diclofenac and beta-endorphin concentrations were determined in eight and 21 patients respectively. Postoperative pain was assessed by ward nurses who were blinded to the group allocation. Comparison with the control group showed diclofenac to be an effective analgesic. Caudal bupivacaine provided more pain-free children during the early postoperative hours, but later the need for pethidine as rescue analgesic was lower among the children who had received intramuscular diclofenac. Caudal analgesia abolished the stress-induced increase in plasma beta-endorphin level which was found in the children given diclofenac and in those who served as controls. Total plasma clearance of intramuscular diclofenac sodium appears to be higher in children than in adults. A single intramuscular dose of diclofenac significantly reduces the need for an opioid analgesic in children after inguinal herniotomy or orchidopexy, and owing to its long duration of action, it offers an alternative or complementary method of pain relief to caudal analgesia.     

Scalp infiltration with bupivacaine plus epinephrine or plain ropivacaine reduces postoperative pain after supratentorial craniotomy

Local anesthetic infiltration has been proposed to decrease postoperative pain. The aim of this study was to determine whether scalp infiltration with bupivacaine or ropivacaine would improve analgesia after supratentorial craniotomy for tumor resection. Eighty patients were recruited into a randomized double-blind study. Infiltration was performed after skin closure with 20 mL of saline 0.9% (placebo group, n = 40), of 0.375% bupivacaine with epinephrine 1:200,000 (bupivacaine group, n = 20), or of 0.75% ropivacaine (ropivacaine group, n = 20). Postoperative analgesia was provided with patient-controlled morphine IV analgesia (PCA). The study was continued until PACU discharge, which occurred early in the morning following surgery. Results are reported on 37 patients in the placebo group, 20 in the bupivacaine group, and 19 in the ropivacaine group because 4 patients experienced postoperative complications and were excluded from the study. Morphine titration at arrival in the postanesthesia care unit was necessary more often in the placebo group (62% of the patients) than in the 2 treated groups (19% in each, P = 0.02). The median quantity of morphine administered during the first 2 postoperative hours, including initial titration administered by a nurse and PCA-administered morphine, was lower in each treated group than in the placebo group (P < 0.01). The median morphine consumption up to the 16th postoperative hour was not significantly different among the 3 groups. There was no difference in the visual analogue scale scores among the 3 groups at any time. Scalp infiltration with either bupivacaine or ropivacaine had a statistically significant effect on morphine consumption during the first 2 postoperative hours.     

Postcesarean analgesia: the efficacy of bupivacaine wound instillation with and without supplemental diclofenac

STUDY OBJECTIVE: To assess the analgesic efficacy of diclofenac when administered as an adjuvant to bupivacaine wound instillation. DESIGN: Prospective, randomized, double blind, placebo-controlled study. SETTING: Large referral hospital. PATIENTS: 90 women recovering from cesarean delivery performed via a Pfannenstiel incision. INTERVENTIONS: A standard intrathecal anesthetic was administered. On completion of surgery, a multiorifice 20-gauge epidural catheter was placed within the surgical wound. Postoperatively, the catheter was attached to a patient-controlled analgesia (PCA) device programmed to deliver 9 mL with a 60-minute lockout time and no basal infusion. In group bupivacaine-diclofenac, the PCA device delivered 0.25% bupivacaine, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline). Thereafter, oral diclofenac (50 mg) was administered every 8 hours. In group bupivacaine-placebo, 0.25% bupivacaine and an equal volume of intravenous saline or oral placebo were administered 20 minutes before the end of surgery and every 8 hours thereafter. In group placebo-diclofenac, wound instillation was with sterile water, and 20 minutes before the end of surgery, patients received intravenous diclofenac (75 mg/100 mL saline) and thereafter oral diclofenac (50 mg) at 8-hour intervals. During the first 6 postoperative hours, a coinvestigator administered "rescue" morphine (2 mg, intravenously). Thereafter, subcutaneous morphine (0.05 mg/kg) was administered on patient request for additional analgesia. MEASUREMENTS AND MAIN RESULTS: The number of attempts to activate the PCA device was significantly higher in group bupivacaine-placebo (39 +/- 32) when compared with group bupivacaine-diclofenac (24 +/- 28). During the first 6 postoperative hours, the number of patients requiring rescue morphine and the total rescue morphine administered were significantly different between the groups. During the subsequent 18 hours, subcutaneous morphine administration was significantly higher in group bupivacaine-placebo. Postoperative pain scores were significantly higher in group bupivacaine-placebo when compared with those recorded in groups placebo-diclofenac and bupivacaine-diclofenac. Finally, patient satisfaction was significantly lower in group bupivacaine-placebo. CONCLUSION: In the context of this study, the bupivacaine wound instillation with adjuvant diclofenac administration is associated with similar postoperative analgesia to that induced by diclofenac alone.     

Comparison of haemodynamic responses following different concentrations of adrenaline with and without lignocaine for surgical field infiltration during cleft lip and cleft palate surgery in children

Surgical field infiltration with adrenaline is common practice for quality surgical field during cleft lip and palate repair in children. Intravascular absorption of adrenaline infiltration often leads to adverse haemodynamic responses. In this prospective, double-blinded, randomised study the haemodynamic effects, quality of surgical field and postoperative analgesia following surgical field infiltration with different concentrations of adrenaline with and without lignocaine were compared in 100 American Society of Anesthesiologists physical status I children aged six months to seven years undergoing cleft lip/palate surgery. A standard anaesthesia protocol was used and they were randomised into four groups based on solution for infiltration: adrenaline 1:400,000 (group A), adrenaline 1:200,000 (group B), lignocaine + adrenaline 1:400,000 (group C) and lignocaine + adrenaline 1:200,000 (group D). Statistically significant tachycardia and hypertension occurred only in group B as compared to other groups (P <0.001). The peak changes in heart rate and mean arterial pressure following infiltration occurred at 4.3 ± 2.4, 3.8 ± 1.5, 5.7 ± 3.2 and 5.9 ± 4.9 minutes in groups A, B, C and D respectively. Surgical field was comparable among all groups. Postoperative pain scores and rescue analgesic requirements were lesser in the groups where lignocaine was added to the infiltrating solution (P <0.05). We found that 1:400000 or 1:200000 adrenaline with lignocaine 0.5 to 0.7% is most suitable for infiltration in terms of stable haemodynamics, quality of surgical field and good postoperative analgesia in children.     

A placebo-controlled,double-blind,randomized study of single-dose intravenous diclofenac for pain relief after a cesarean section

BackgroundThis study was conducted to avoid the pain of an intramuscular injection of diclofenac after a cesarean section, by modifying it to an intravenous infusion by diluting it with 5% dextrose in 100 mL of water.ObjectiveThe aim of this study was to determine the efficacy of a single-dose modified diclofenac being given intravenously, instead of intramuscularly, for pain relief after a cesarean section.Study designA double-blind, randomized controlled trial was conducted.ParticipantsWe enrolled 30 patients who underwent cesarean sections with Pfannenstiel skin incision.MethodsAll patients received 2.2–2.5 mL of 0.5% bupivacaine with 0.2 mg morphine for spinal anesthesia. The participants were equally and randomly allocated to two groups to receive intravenous diclofenac or placebo at 12 hours postoperatively. Both groups received the same regimen for postoperative pain control.Main outcome measurementsThe severity of postoperative pain was measured directly using a verbal numerical rating scale (0–10) and a pain-relief scale (1–4), and indirectly from the amount of tramadol used.ResultsThe characteristics of the two groups of patients were similar. The mean postoperative pain relief at 24 hours in the study group was better than that in the control group (3.14 ± 0.66 vs. 2.13 ± 0.99; p < 0.05). The severity of postoperative pain at 24 hours and the amount of tramadol used were not different between groups.ConclusionIntramuscular diclofenac (75 mg), modified by diluting it with 5% dextrose in 100 mL of water, for intravenous administration in combination with spinal morphine (0.2 mg) provided good analgesia after a cesarean section within 24 hours when assessed by the pain-relief scale; however, the mean pain intensity was not different.     

A double-blind, randomized, active-controlled study for post-hemorrhoidectomy pain management with liposome bupivacaine, a novel local analgesic formulation

This randomized, active-controlled study evaluated the extent and duration of analgesia after administration of liposome bupivacaine (LB), a novel formulation of bupivacaine, compared with bupivacaine HCl given via local infiltration in excisional hemorrhoidectomy. One hundred patients were randomly assigned to receive a single dose of bupivacaine HCl 75 mg (0.25% with 1:200,000 epinephrine) or LB 66, 199, or 266 mg upon completion of hemorrhoidectomy. Postoperative pain intensity was assessed using a numeric rating scale at rest to calculate a cumulative pain score (area under the curve). Cumulative pain scores were significantly lower with LB at each study dose (P < 0.05) compared with bupivacaine HCl 72 hours after surgery. Post hoc analysis showed that mean total postoperative opioid consumption was statistically significantly lower for the LB 266-mg group compared with the bupivacaine HCl group during the 12- to 72-hour postoperative period (P = 0.019). Median time to first opioid use was 19 hours for LB 266 mg versus 8 hours for bupivacaine HCl (P = 0.005). Incidence of opioid-related adverse events was 4 per cent for LB 266 mg compared with 35 per cent for bupivacaine HCl (P = 0.007). Local infiltration with LB resulted in significantly reduced postsurgical pain compared with bupivacaine HCl in patients after hemorrhoidectomy surgery.     

Evaluation of obstetrical pain by a questionnaire of adjectives. Comparison of 2 epidural analgesia protocols

A French version of the McGill pain questionnaire, the "Questionnaire Douleur Saint Antoine" (QDSA), was assessed prospectively by comparing two epidural analgesia protocols using bupivacaine. One hundred women in labour who asked for epidural analgesia were randomly allocated to two groups and received either 0.25% or 0.5% bupivacaine (mean initial doses 32.5 and 50 mg respectively) with adrenaline 1 in 200,000. All the patients were then instructed to trigger a patient controlled analgesia (PCA) device for top-up doses of 0.25% bupivacaine with adrenaline 1 in 400,000 once they became aware of pain returning. This PCA device was preset to give on-demand injections of 12.5 mg with a lockout interval of 20 min, together with a continuous infusion rate of 10 mg.h-1. Pain was evaluated using four rating scales: QDSA, visual analogue scale (VAS), verbal rating scale (VRS) and behavioural scale (BS). Pain was measured at least four times: before analgesia (T0), 20 min after the initial injection (T20), before starting PCA (TRe), and immediately after delivery of the newborn (TEx). In addition, the level of anxiety was ranked at the beginning of labour with the Spielberger state trait anxiety inventory (STAI). In the 396 questionnaires completed by the patients, there was a significant correlation between the QDSA and the other scales (p less than or equal to 0.05), but at T0, BS was mostly correlated with the affective index of QDSA (p = 0.01), as well as with the STAI (p = 0.0001). At T20, in the group of women who had been given 0.5% bupivacaine initially, the decrease in QDSA score was significantly greater for the sensory index (p = 0.04); the first re-injection interval was longer than in the other group of women (p = 0.05). At TRe, the total QDSA score of all the patients was half that at T0, indicating the good sensitivity of this score. These results are in agreement with those reported by Melzack with the McGill pain questionnaire. The QDSA varies in the same direction as the other scales. On the other hand, the affective part of the score was only correlated with the level of anxiety and behaviour. The sensory part of this score was the only one to show a difference between the different initial doses given to the patients. The results obtained with this series of patients underline the value of a multidimensional assessment of labour pain.     

The minimally effective concentration of adrenaline in a low-concentration thoracic epidural analgesic infusion of bupivacaine,fentanyl and adrenaline after major surgery. A randomized,double-blind,dose-finding study

BACKGROUND: We have documented that adrenaline 2.0 micro g.ml- 1 markedly improves relief of dynamic pain when added to a thoracic epidural analgesic infusion of bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1. Concern about possible adverse effects on spinal cord blood flow, expressed by others, prompted us to find the lowest concentration of adrenaline needed to produce effective and reliable pain relief after major surgery. METHODS: A prospective, randomized, double-blind, parallel group study was carried out in 36 patients after major thoracic or upper abdominal surgery. Patients with only mild pain when coughing during titrated thoracic epidural infusion of approximately 9 ml per hour of bupivacaine 1 mg.ml- 1, fentanyl 2 micro g.ml- 1, and adrenaline 2.0 micro g.ml- 1 were included. The study was conducted as a dose-finding study comparing three different adrenaline concentrations in the epidural mixture (0.5, 1.0, and 1.5 micro g.ml- 1) with each other and with adrenaline 2.0 micro g.ml- 1 in our standard epidural mixture. On the 1st postoperative day, the patients were randomly allocated into three equal groups of 12 patients each, and given a double-blind epidural infusion at the same rate, but with different adrenaline concentrations (0.5, 1.0, or 1.5 micro g.ml- 1). The effects were observed for 4 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections per hour (4 ml) and subsequent i.v. morphine, if necessary. All patients received rectal paracetamol 1 g, every 6th hour. Main outcome measures were pain intensity at rest and when coughing, evaluated by a visual analogue scale and an overall quality of pain relief score. The extent of sensory blockade was evaluated by determining dermatomal hypaesthesia to cold. RESULTS: Pain intensity when coughing increased (P < 0.001) and the number of hypaesthetic dermatomal segments decreased (P < 0.002) when the concentration of adrenaline was reduced below 1.5 micro g.ml- 1 in the triple epidural mixture. This change started within two hours after reducing the concentration of adrenaline below 1.5 micro g.ml- 1. The differences in pain intensities at rest were less pronounced. After 4 h with adrenaline 0.5 or 1.0 micro g.ml- 1 pain intensity when coughing was unacceptable in spite of rescue analgesia. After restarting the standard epidural mixture with adrenaline 2.0 micro g.ml- 1, pain intensity was again reduced to mild pain when coughing and the sensory blockade was restored. Occurrence of pruritus increased with a decreasing adrenaline concentration. CONCLUSIONS: Adrenaline in a dose-related manner improves the pain-relieving effect and sensory blockade and decreases the occurrence of pruritus of a low-concentration thoracic epidural analgesic infusion of bupivacaine 1 mg. ml- 1 and fentanyl 2 micro g.ml- 1 after major thoracic or upper abdominal surgery. The minimally effective concentration of adrenaline, when added to bupivacaine 1 mg.ml- 1 and fentanyl 2 micro g.ml- 1, to maintain relief of dynamic pain is approximately 1.5 micro g.ml- 1. The data clearly document that dynamic, cough-provoked pain is a more sensitive outcome measure for postoperative pain relief than pain at rest.     

Analgesic efficacy of two doses of intrathecal midazolam with bupivacaine in patients undergoing cesarean delivery

OBJECTIVES: In this prospective, randomized, double-blind, placebo-controlled study, we investigated the postoperative analgesic efficacy of 2 doses of intrathecal midazolam as an adjunct to bupivacaine for spinal anesthesia. METHODS: Sixty patients undergoing elective cesarean delivery under spinal anesthesia were allocated randomly to 3 groups: group B, 2 mL hyperbaric bupivicaine 0.5%; group BM1, 2 mL bupivacaine plus midazolam 1 mg (preservative free); and group BM2, 2 mL bupivicaine plus midazolam 2 mg. RESULTS: The mean duration of postoperative analgesia (determined by request for rescue medication) was 3.8 +/- 0.5 hours in group B compared with 4.3 +/- 0.7 hours in group BM1 (P = .18), and 6.1 +/- 1.0 hours in group BM2 (P = .001). Supplemental analgesic requirements with diclofenac were significantly less in group BM2 (93 +/- 29 mg) compared with group B (145 +/- 12 mg) and group BM1 (148 +/- 16 mg, P < .001). Time to block regression was longer in group B (182 +/- 30 minutes) compared with group BM1 (152 +/- 32 minutes) and group B (126 +/- 20 minutes) (both P < .001). Arterial pressure, heart rate, oxygen saturation, sedation score, and time to first void were comparable between groups. Group B had a significantly higher incidence of nausea and vomiting than groups BM1 and BM2 (P = .02). No neurologic deficits were observed. CONCLUSIONS: Intrathecal midazolam 2 mg provided a moderate prolongation of postoperative analgesia when used as an adjunct to bupivacaine in patients undergoing cesarean delivery. Intrathecal midazolam, 1 mg and 2 mg, decreased postoperative nausea and vomiting.     

Effect of prophylactic ondansetron on postoperative nausea and vomiting in patients on preoperative steroids undergoing craniotomy for supratentorial tumors

The exact incidence of postoperative nausea and vomiting (PONV) in patients on steroids undergoing neurosurgical procedures is not known. This prospective randomized double-blind study was planned to know the efficacy of prophylactic ondansetron in the prevention of PONV in patients on steroids as compared with placebo. Seventy adult patients of either sex who had received preoperative steroids (dexamethasone) for at least 24 hours and were scheduled to undergo craniotomy for supratentorial tumors were included. Patients were randomly allocated using a randomization chart to 1 of the 2 groups to receive either ondansetron 4 mg (group O) or 0.9% saline (group S) intravenously at the time of dural closure. Numeric Rating Scale score for nausea and pain intensity was recorded preoperatively and till 24 hours postoperatively. The 6-hour postoperative nausea score was significantly lower in group O [median, 0; interquartile range (IQR), 0 to 20] than in group S (median, 20; IQR, 0 to 20) (P<0.05). The incidence of vomiting was lower in group O (23%) than in group S (46%) (P<0.05). The total number of emetic episodes, the number of doses of rescue antiemetics given in the first 6 postoperative hours, and the total number of rescue antiemetics given were significantly lower in group O than in group S (P<0.05). Intravenous administration of 4 mg of ondansetron at the time of dural closure was effective in reducing the incidence of PONV and the rescue antiemetics requirement in patients on preoperative steroids undergoing craniotomy for supratentorial tumors.     

Absence of an early pre-emptive effect after thoracic extradural bupivacaine in thoracic surgery

We have determined if thoracic extradural block before surgical incision for thoracotomy produces pre-emptive analgesia. Using a double- blind, placebo-controlled, crossover design, 45 patients (ASA II-III) undergoing posterolateral thoracotomy for lung resection were randomized to one of three groups: group 1 received 0.5% bupivacaine and adrenaline 1/200,000 (B+E) 8 ml through a thoracic extradural catheter (tip T3-T5) 30 min before skin incision and saline 8 ml 15 min after skin incision; group 2 received saline 8 ml extradurally before incision and B+E 8 ml after incision; group 3 received saline 8 ml extradurally before and after incision. General anaesthesia was induced and maintained with propofol, alfentanil and atracurium. The alfentanil infusion was stopped before chest closure and fentanyl 50 micrograms in saline 10 ml was given extradurally. Patient-controlled extradural analgesia (PCEA) was commenced with 0.125% bupivacaine, adrenaline 1/400,000 and fentanyl 6 micrograms ml-1 (continuous rate of 2 ml h-1 and supplementary doses of 0.5 ml per 6 min). Visual analogue scale (VAS) scores (recorded at rest, on mobilization and after cough), verbal rating scale (VRS) (recorded at rest), number of successful PCEA demands and complications were measured during the first 48 h after operation. There was no significant difference between groups, either in PCEA requirements (P > 0.21) or in VAS scores (either at rest, during mobilization of the ipsilateral arm of surgery or after cough). No significant differences between groups were found in the VRS. Thoracic extradural block with bupivacaine did not produce an early preemptive effect after thoracotomy.      

A randomised double-blind study of interpleural analgesia after cholecystectomy

Continuous interpleural analgesia provided by 4 hourly injections of 20 ml bupivacaine 0.5% with adrenaline 5 micrograms/ml was compared with placebo in a randomised, double-blind study after cholecystectomy. All patients self-administered intravenous morphine using a patient-controlled analgesia device. There was a highly significant difference in mean morphine consumption between the groups (72 mg as compared with 22 mg). Visual analogue pain scores tended to be lower in the bupivacaine group throughout and this was significant at 2 hours. Respiratory function measurements were not significantly different between the groups. The mean peak venous plasma bupivacaine concentration after the sixth dose was 3.03 micrograms/ml and no symptoms suggestive of local anaesthetic toxicity occurred. It is concluded that this regimen can provide effective and continuous analgesia after cholecystectomy and that combined administration of interpleural bupivacaine and systemic morphine is more effective than morphine alone in the immediate postoperative period. The doses of bupivacaine required for optimal use of the technique lead to significant total plasma bupivacaine concentrations within 24 hours.     

Levobupivacaine for epidural anaesthesia and postoperative analgesia in hip surgery

Background and objectives

The aim of this randomized, single blind phase IIIb study was to evaluate the efficacy of 0.5% levobupivacaine versus 0.5% bupivacaine and 0.75% ropivacaine administered as epidural anesthesia and 0.125% levobupivacaine versus 0.125% bupivacaine and 0.2% ropivacaine for postoperative analgesia. The study was designed to test the equivalence of the overall profile of levobupivacaine against bupivacaine and ropivacaine. In addition, parameters of clinical safety were assessed.

Methods

A total of 88 patients undergoing hip surgery at 12 German academic hospitals were randomly assigned to 3 different treatment groups. Criteria for drug evaluation were the required epidural volume and time until onset and offset of sensory and motor block, the quality of postoperative analgesia using a pain visual analogue scale and verbal rating scale, as well as the need for rescue medication based on statistical non-inferiority testing.

Results

With respect to onset and offset of sensory and motor blockade, 0.5% levobupivacaine, 0.5% bupivacaine and 0.75% ropivacaine showed clinically significant equivalent profiles for all primary study endpoints. However, the levobupivacaine group showed a higher demand for intraoperative anesthesia. Postoperative analgesia request and pain scales did not differ significantly between groups, but comparatively lower total drug volumes were required in the bupivacaine group. No relevant differences between the trial groups concerning safety parameters were observed.

Conclusions

The efficacy of epidural levobupivacaine for hip surgery and postoperative analgesia is equivalent and shows a comparable clinical profile to bupivacaine and 50–60% higher concentrated ropivacaine. The results of this equivalence study confirm suggestions derived from previous comparative studies.     

Paediatric postoperative analgesia A comparison of rectal diclofenac with caudal bupivacaine after inguinal herniotomy

Forty-three children for day case inguinal herniotomy under general anaesthesia were assigned randomly to receive either 1 ml/kg caudal bupivacaine 0.25% or rectal diclofenac 0.25 mg/kg intra-operatively to provide postoperative analgesia. Pain and demeanour were assessed by an observer in the early postoperative period after operation and by questionnaire for the parents over the first 24 hours. Caudal bupivacaine provided more pain-free patients at first but later the incidence of pain was similar in the two treatment groups. Rectal diclofenac is a useful alternative to caudal blockade in this group of patients.     

Analgesic effect of epidural neostigmine after abdominal hysterectomy

STUDY OBJECTIVE: To evaluate the effects of epidurally administered neostigmine on pain after abdominal hysterectomy. DESIGN: Prospective, randomized, double-blind study. SETTING: Teaching hospital. PATIENTS: 45 ASA physical status I adult patients scheduled for abdominal hysterectomy. INTERVENTIONS: All patients received identical general and epidural anesthesia. At the end of the surgery, they received epidural bupivacaine (10 mg) with either saline (control group, n = 15), 5 micro g/kg (5-micro g group, n = 15), or 10 micro g/kg neostigmine (10-micro g group, n = 15). Postoperatively, 50 mg diclofenac suppository was given for pain relief on patient demand. MEASUREMENTS AND MAIN RESULTS: The time to first diclofenac administration and the number of times diclofenac was required during the first 24 postoperative hours were recorded. Pain was assessed using a 10-cm visual analog pain scale (VAS) at rest at the first diclofenac request, and at 15 and 24 hours after surgery. The time to first diclofenac administration was significantly longer (p < 0.05) in the 10-micro g group (223 +/- 15 min) than in the control (78 +/- 17 min) or 5-micro g groups (88 +/- 18 min). However, epidural neostigmine at both doses did not reduce the number of postoperative diclofenac administrations. There were no differences in VAS among the three groups. CONCLUSIONS: Epidural neostigmine of 10 micro g/kg in bupivacaine provides a longer duration of analgesia than does bupivacaine alone or with 5 micro g/kg of neostigmine after abdominal hysterectomy.     

Propacetamol and diclofenac alone and in combination for analgesia after elective tonsillectomy

BACKGROUND: Diclofenac and paracetamol have different mechanisms and sites of action. Therefore, we tested if their combination is more effective for analgesia after tonsillectomy than either drug alone with respect to rescue analgesic consumption and visual analog scale values. METHODS: The analgesic effects of intravenously administered propacetamol (injectable pro-drug of paracetamol) and diclofenac or a combination on postoperative pain were compared in 71 adult elective tonsillectomy patients in a randomized, double-blind study. After induction of anesthesia the patients received monotherapy with 2 g propacetamol (n = 25) or 75 mg diclofenac (n = 25), or a combined treatment with 2 g propacetamol and 75 mg diclofenac (n = 21) in physiologic saline as an infusion. Postoperatively the propacetamol dosage was repeated twice and diclofenac once on the ward. Oxycodone (0.03 mg kg(-1)) was used as a rescue analgesic by patient-controlled analgesia. RESULTS: On average the patients needed oxycodone 15.3, 13.2 and 10.6 times in the propacetamol, diclofenac and combination groups, respectively (NS). A verbal rating scale and a visual analog scale were employed for assessing post-tonsillectomy pain, nausea and patient satisfaction in all groups. No statistically significant differences were found between the groups. Twelve of the 25 (48%) patients having received propacetamol complained of pain at the cannulation site. CONCLUSION: Combined treatment with propacetamol and diclofenac with the dosages used provided clinically only a minor advantage over monotherapy with propacetamol or diclofenac with respect to postoperative analgesia or the incidence of side-effects in adult tonsillectomy patients.     

上腹部手术后镇痛对儿茶酚胺的影响

选择３０例上腹部手术患者，随机分为三组，每组１０例，采用Ｎ２一Ｏ２一安氟醚（ＧＯＥ）吸入麻醉，其中镇痛两组术终采用０．２５％丁哌卡因２０ｍｌ行腹腔神经丛阻滞，术后硬膜外分别持续滴入０．１２５％丁哌卡因及０．０００２５％芬太尼生理盐水溶液，在术终及术后２、５、８小时分别采静脉血分离血浆，并同时用线性视觉模拟评分法作疼痛程度评定，标本采用反相离子对色谱一电化学检测法分析血中儿茶酚胺浓度。结果镇痛两组疼痛评分较低，与对照组相比差异显著（Ｐ＜０．０１）。多巴胺血浆浓度在组间及组内比较均无差异（Ｐ＞０．０５），而肾上腺素和去甲肾上腺素的血浆浓度术后２、５、８小时与术终相比差异非常显著（Ｐ＜０．０１），三组间比较术终无差异，而术后２、５、８小时镇痛两组与对照组比较差异显著（Ｐ＜０．０１），但镇痛两组间相比无差异（Ｐ＞０．０５）。结论：上腹部手术后在腹腔神经丛阻滞下，行硬膜外术后镇痛既能明显减轻患者的痛苦，又能有效地阻止术后疼痛应激引起儿茶酚胺的明显变化。//     

Effect of Dexmedetomidine as an adjuvant in quadratus lumborum block in patient undergoing caesarean section – A randomised controlled study

Study objectiveThis study was conducted to evaluate the effect of Dexmedetomidine as an adjuvant in quadratus lumborum block (QLB) for postoperative pain relief at rest in patients undergoing caesarean section (CS). The primary objective was to compare the time to the first request of rescue analgesia. Secondary objectives were to compare the amount of rescue analgesia, patient satisfaction, Numeric rating scale (NRS), and Ramsay sedation score (RSS) during the first 24 h.DesignA randomised, double-blinded study.SettingThe study was conducted at AIIMS Bhubaneswar from December 2019 to February 2021in the Operating Theatre complex (for the immediate postoperative follow-up) and in the Obstetric Ward (for follow-up at the later time points).PatientsA total of 70 patients were enrolled with singleton term pregnancies scheduled for CS under spinal anaesthesia after written informed consent.InterventionBilateral QLB was given in the recovery area. Group A received 30 ml of 0.25% Bupivacaine and group B received 30 ml 0.25% bupivacaine with Dexmedetomidine 1 μg/kg. They received inj. Paracetamol 15 mg/kg intravenously TDS and Inj. Tramadol 1 mg/kg as rescue analgesia (if Numeric rating scale (NRS) Score ≥ 4). We also compared the rescue analgesia in the first 24 h, patient satisfaction scores, Ramsay sedation score (RSS), and NRS scores at 2, 4, 6, 8, 12, 18, and 24 h.Main resultsThe time to request the first rescue analgesia was significantly prolonged in group B [Mean ± SD (95% CI)] 880 ± 351 (720–1040) min. vs group A 439 ± 208 (368–510) min., p < 0.001). There was a significant decrease in the amount of rescue analgesia [(Inj. Tramadol (1 mg/ kg)] used in the group with dexmedetomidine [group B Mean ± SD (95% CI) (57 ± 18 (49–65) mg. vs group A - 81 ± 25 (73–90)] mg., p < 0.001]. A significant difference was seen in patient satisfaction scores and pain scores between the groups up to 18 h. (p < 0.05) but not in RSS.ConclusionDexmedetomidine can be considered an effective adjuvant for QLB in CS in the absence of intrathecal morphine.