Chronobiology of parturients receiving neuraxial labour analgesia with ropivacaine and fentanyl: a prospective cohort study

BackgroundThe circadian variation in biologic rhythm has been known to affect labour pain. The duration of action of ropivacaine or fentanyl used in treatment of labour pain has been demonstrated to vary with different times of the day. The aim of this study is to find whether the need for epidural supplementation for breakthrough pain is significantly affected by the time of day, in patients who are on a continuous epidural infusion of these drugs.MethodsIn this prospective cohort study, parturients with spontaneous onset of labour were given a combined spinal-epidural technique with spinal ropivacaine 2 mg + fentanyl 15 μg followed by an epidural infusion of ropivacaine 0.1–0.125% with fentanyl 2 μg/mL at 10 mL/hour. A total of 1657 patients were divided into four groups: (1) morning: analgesia request: 7:01 to 13:00, delivery before 19:00; (2) afternoon: analgesia request: 13:01 to 19:00, delivery before 1:00; (3) evening: analgesia request: 19:01 to 1:00, delivery before 7:00 and (4) night: analgesia request: 1:00 to 7:00, delivery before 13:00. Pain scores before epidural analgesia, need for additional epidural supplementation, side effects and patient satisfaction scores were compared between the groups.ResultsThe pain scores before epidural analgesia were significantly higher in evening and night groups than in morning and afternoon groups (6.95 ± 2.4, 7.38 ± 2.2 compared to 6.67 ± 2.5, 6.49 ± 2.7 respectively, P < 0.001). Incidence of breakthrough pain, side effects and parturient satisfaction scores were not significantly different between groups.ConclusionParturients with labour onset and neuraxial analgesia request in the evening and night experienced higher pain scores. However, no significant differences in the incidence of breakthrough pain or the quality of analgesia were observed with the provision of commonly used concentrations of ropivacaine with fentanyl via continuous epidural infusion.     

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study

BackgroundEpisiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia.MethodsIn this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded.ResultsA total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9 h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P = 0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P = 0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8 ± 11.6, lidocaine 12.4 ± 9.7; and saline 16.2 ± 11.5, P = 0.08).ConclusionFor the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.     

Contribución del bloqueo del plano transverso abdominal guiado por ultrasonidos a la analgesia postoperatoria tras la cesárea

ObjectiveThe aim of this study was to evaluate the contribution made by ultrasound-guided transversus abdominis plane block (TAP) to the quality of the analgesia with intrathecal opioids obtained in patients undergoing elective caesarean delivery.Material and methodsA prospective, randomized study in patients submitted to elective caesarean section with spinal anaesthesia with 0.5% hyperbaric bupivacaine. The patients were randomized into 3 groups according to the added complementary drug for analgesia: group A morphine 0.1 mg; group B fentanyl 10 μg; group C 10 μg fentanyl + bilateral TAP block. The TAP block with 20 ml of 0.5% levobupivacaine on each side, after surgery. Groups A and B, were injected with 20 ml of saline. Postoperative analgesia was performed with morphine bolus through a system of patient-controlled analgesia (PCA). We studied the pain on a visual analogue scale at 12 and 24 h at rest and movement, the time elapsed to require the first bolus, and morphine bolus in 24 h. Secondary effects such as nausea, vomiting, pruritus, and drowsiness, were also evaluated. The level of patient satisfaction was also recorded.ResultsA total of 90 patients were included. At rest the 12/24 h VAS score was: group A, at 12 h 2.1 ± 1.2, at 24 h 4.7 ± 1.6; group B at 12 h 4.3 ± 2.9, at 24 h 4.8 ± 2; group C at 12 h 1.9 ± 1.09, at 24 h 2.3 ± 1.2 (P<.05). Walking improved analgesia more in group C (P≤.02). The time of asking for the first bolus was lower in group B: group A 9.3 ± 4.9 h (P=.02 compared to group C), in group B 2 ± 1.8 h (P<.001 compared to group C) and group C 13.2 ± 2.1 h. The number of bolus in 24 h in group B was 38 ± 5, in group A 10 ± 2 (P<.05), group C 5 ± 2 (P<.001). Delayed nausea was increased in group B (36.6%) and pruritus was greater in group A (36.6%).ConclusionsUltrasound (US)-guided TAP block improves spinal opioid analgesia, with a decrease in VAS scores in the first 24 h, and reduces opioid requirement and secondary effects after caesarean delivery.     

Ultrasound-guided transversus abdominis plane block for postoperative analgesia in living liver donors: A prospective,randomized, double-blinded clinical trial

BackgroundTransversus abdominis plane (TAP) block is a peripheral nerve block that reduces postoperative pain, nausea, vomiting and the need for postoperative opioids following various types of abdominal surgery. The primary aim of the present study was to evaluate the effects of TAP block on postoperative analgesia and opioid consumption in living liver donors in whom a right “J” abdominal incision was used.MethodsThis prospective, double-blinded, randomized controlled study was conducted with 50 living liver donors, aged 18–65 years, who were scheduled to undergo right hepatectomy. Patients who received ultrasonography-guided subcostal TAP block were allocated into Group 1, and patients who did not receive TAP block were allocated into Group 2. The TAP blocks were performed bilaterally at the conclusion of surgery using 1.5 mg 1 kg^− 1 bupivacaine diluted with saline to reach a total volume of 40 mL. For each patient, morphine consumption, pain scores at rest and movement, sedation scores, nausea, vomiting and the need for antiemetic medication were assessed at 0, 2, 4, 6, 12 and 24 h postoperatively by researchers who were blinded to the study groups.ResultsMorphine consumption was significantly lower in Group 1 than in Group 2 at the 2nd, 6th and 24th hours (P < 0.05). The mean total morphine consumption values after 24 h were 40 mg and 65 mg in Groups 1 and 2, respectively. The TAP block significantly reduced postoperative visual analog scale pain scores both at rest and during movement at 0, 2, 4, 6, and 24 h postoperatively (P < 0.05).ConclusionsThe TAP block reduced 24-h postoperative morphine consumption and contributed to analgesia in living liver donors who underwent upper abdominal wall incisions.     

Determination of ED50 of hydromorphone for postoperative analgesia following cesarean delivery

BackgroundMorphine is the most common opioid injected into the intrathecal space for postoperative analgesia following cesarean delivery, but ongoing medication shortages have resulted in limited availability. One proposed morphine alternative is hydromorphone. Studies investigating its use in post-cesarean analgesia are limited. This study was conducted to determine the median effective dose of intrathecal hydromorphone 12 h postpartum.MethodsTwenty healthy women undergoing elective cesarean delivery were recruited into this study. Hydromorphone doses were determined using the up-down sequential method. The study dose of hydromorphone started at 6 μg and was raised or lowered by 2 μg depending on the 12-h efficacy of the preceding participant’s dose. Pain scores of <3/10 were considered successful and the subsequent patient received a lower dose. Participants received 0.5% bupivacaine 12.5 mg, fentanyl 25 μg, and the study dose of hydromorphone as a single intrathecal injection.ResultsTen of 20 participants reported an effective hydromorphone dosage 12 h post-injection. The median effective hydromorphone dosage was 4.6 μg (95% CI 3.72 to 5.48 μg) based on participants’ reported visual analog pain scores of <3/10. No significant side effects or adverse outcomes were observed.ConclusionIntrathecal hydromorphone may be an effective alternative to morphine for post-cesarean pain management. The amount of intrathecal hydromorphone necessary to provide analgesia at 12 h postoperatively may be significantly lower than doses currently in use. Further research should be performed to identify the optimal dose of intrathecal hydromorphone for post-surgical pain relief.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.     

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

IntroductionTransversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions.MethodsSeventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA.ResultsThe cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects.ConclusionContinuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.     

Intrathecal morphine 100 and 200 μg for post-cesarean delivery analgesia: a trade-off between analgesic efficacy and side effects

IntroductionIntrathecal morphine is highly effective for post-cesarean analgesia; however, the optimal dose is yet to be established. The aim of this study was to compare analgesia and side effects after a change in institutional practice to give 200 μg rather than 100 μg.MethodsWe conducted a retrospective chart review of 241 patients who had an elective cesarean delivery and received either 100 or 200 μg of intrathecal morphine. The primary outcome variables were mean and peak verbal pain scores (0–10) and analgesic use (milligram-morphine equivalents). Postoperative administration of antiemetics, antipruritics and episodes of nausea or vomiting were recorded. Data are reported as mean ± SD or percentages with P < 0.05 considered statistically significant.ResultsWomen receiving intrathecal morphine 200 μg had lower pain scores and opioid use compared with morphine 100 μg. Mean verbal pain scores were 1.6 ± 1.1 versus 2.0 ± 1.1 (P = 0.01) and peak verbal pain scores were 4.9 ± 2.0 versus 5.6 ± 1.8, respectively (P = 0.008). The group receiving 200 μg used less opioids in the first 24 h after surgery (44 ± 35 versus 54 ± 35 milligram-morphine equivalents, respectively, P = 0.04) and received less intravenous opioids (18% versus 30%, P = 0.02). However, women receiving intrathecal morphine 200 μg had more nausea (mean number of episodes of nausea 1.9 ± 1.3 versus 1.6 ± 1.3, P = 0.037) and used more antiemetics (52% versus 24%, P < 0.0001).ConclusionsIntrathecal morphine 200 μg provided better analgesia but with more nausea compared with morphine 100 μg. Our results can be used to help guide intrathecal morphine dosing in cesarean delivery based on patient preference for analgesia versus side effects.     

Scheduled acetaminophen with as-needed opioids compared to as-needed acetaminophen plus opioids for post-cesarean pain management

BackgroundCombination opioid-acetaminophen drugs are commonly used for pain management after cesarean delivery. The aim of this study was to determine if scheduled acetaminophen decreases opioid use compared to as-needed combination acetaminophen-opioid administration.MethodsWe performed a retrospective chart review of women who underwent cesarean delivery before and after a clinical practice change. All patients received spinal anesthesia containing intrathecal morphine 200 μg and scheduled non-steroidal anti-inflammatory drugs for 48 h postoperatively. The first group (As-Needed Group, n=120) received combination oral opioid-acetaminophen analgesics as needed for breakthrough pain. The second group (Scheduled Group, n=120) received oral acetaminophen 650 mg every 6 h for 48 h postoperatively with oral oxycodone administered as needed for breakthrough pain. The primary outcome was opioid use, measured in intravenous morphine mg equivalents, in the first 48 h postoperatively.ResultsThe Scheduled Group used 9.1 ± 2.1 mg (95% CI 5.0–13.2) fewer intravenous morphine equivalents than the As-Needed Group (P <0.0001) over the study period. Fewer patients in the Scheduled Group exceeded acetaminophen 3 g daily compared to the As-Needed Group (P=0.008). Pain scores were similar between study groups.ConclusionsAfter cesarean delivery, scheduled acetaminophen results in decreased opioid use and more consistent acetaminophen intake compared to acetaminophen administered as needed via combination acetaminophen-opioid analgesics, without compromising analgesia.     

Factors influencing cesarean delivery operative times: a prospective observational cohort study

BackgroundThis study aimed to determine the distribution of operative delivery times for uncomplicated parturients undergoing elective cesarean delivery with neuraxial anesthesia. A secondary aim was to explore patient and surgical factors associated with longer cesarean delivery times.MethodsA prospective observational study of 331 parturients undergoing elective cesarean delivery with neuraxial anesthesia was conducted. Factors examined included age, body mass index, ethnicity, number of previous cesarean deliveries, stretch mark and scar severity and surgical experience.ResultsOperative times ranged from 13 to 108 min with a mean (SD) of 43.4 (±15.7) min. Only 6 (1.8%) parturients had operative times >90 min and none were converted to general anesthesia. As the number of previous cesarean deliveries increased, the mean operative time increased linearly from 39.5 (±13.0) min in subjects with no previous cesarean deliveries to 52.8 (±18.1) min in subjects with 3 or 4 previous cesarean deliveries (P < 0.0005). For parturients with previous cesarean deliveries, operative times were longer for those with scar scores ?5 than for those with scores <5 (P < 0.01). Stretch mark scores were not associated with operative times. Tubal ligation prolonged the total operative time by a mean of 7 min (P < 0.0005), and attending staff required a mean of 6 more min than residents or fellows (P < 0.01). There was no correlation between operative times, age and body mass index and little variation with ethnicity.ConclusionsThese findings identify previous cesarean deliveries, increased scar intensity, tubal ligation and surgical experience as factors that increase operative times for cesarean delivery. The data also suggest that neuraxial anesthesia lasting 90 min should provide adequate analgesia for most uncomplicated parturients undergoing elective cesarean delivery.     

Intravenous dexamethasone as an adjunct to improve labor analgesia: A randomized,double-blinded,placebo controlled clinical trial

ObjectiveTo study the role of intravenous (i.v.) dexamethasone as an analgesic adjunct in labor analgesia.DesignDouble-blinded randomized controlled trial.SettingLabor analgesia in a tertiary-care teaching hospital.PatientsEighty consenting ASA I-II parturients, age > 18 year, nulliparous, single gestation, cephalic presentation at ≥ 36 wk. of gestation, in early spontaneous labor (cervical dilatation ≤ 5 cm) requesting epidural analgesia.InterventionsThe patients were randomized to two groups. The Dexa group received 8 mg of dexamethasone i.v. in 50 ml normal saline approximately 45 min before the procedure. Placebo group patients received 50 ml normal saline only. All patients underwent epidural labor analgesia per hospital protocol. After an initial bolus, they received continuous background infusion of 5 ml/h of 0.1% of levobupivacaine with 2 μg/ml of fentanyl, with the provision of patient controlled boluses of 5 ml of the same drug combination with a lockout interval of 12 min if needed.MeasurementsPrimary outcome measure: hourly average consumption of neuraxially administered levobupivacaine-fentanyl combination. Secondary outcomes and observations: pain score, maternal satisfaction, sensory and motor block characteristics, hemodynamic parameters of mother, fetal heart rate, duration of second stage of labor, mode of delivery, Apgar scores at 1 and 5 min, and adverse effects.Main resultsAverage hourly drug consumption was significantly lower in Dexa group as compared to Placebo group (10.34 ± 1.79 ml/h vs. 11.34 ± 1.83 ml/h; mean difference 1.007, 95% CI 0.199–1.815; P = 0.015). The median number of bolus doses was 4 (interquartile-range [IQR] 3–5.75) and 5 (IQR 3–6) in the Dexa and Placebo groups, respectively (P = 0.162). There was no significant difference between groups with regard to pain scores, maternal satisfaction and hemodynamics, mode of delivery, and adverse effects.ConclusionsI.v. dexamethasone significantly decreased hourly average drug consumption of levobupivacaine-fentanyl combination through the epidural route, demonstrating the epidural drug dose sparing effect during labor analgesia.     

Ultrasound guided transversus abdominis plane block in pediatric patients undergoing laparoscopic surgery

ObjectiveTo assess safety and effectiveness of ultrasound-guided TAP block in children undergoing laparoscopic surgery for undescended testis.Subjects and methodsThis randomized controlled trial involved 108 children, 3–7 years old, randomly allocated into one of two equal groups; TAP Group and Control Group. All children received general anesthesia using propofol 1.5–2.5 mg/kg, atracurium 0.5 mg/kg and fentanyl 2 μg/kg. TAP Group received 0.5 ml/kg of ropivacaine 0.375% bilaterally under ultrasound guidance and control group received regular analgesics. Quality of analgesia was assessed using Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) and Objective behavioral pain score (OPS). The primary outcome measures were hemodynamic parameters and degree of pain. Secondary outcome measures were intraoperative fentanyl requirement, postoperative rescue analgesia (time and dose), complications, hospital stay and degree of satisfaction of patients and their parents.ResultsTAP block group had significantly lower intraoperative fentanyl dose (p < 0.001), significantly longer time to first postoperative request of analgesic (p < 0.001), lower analgesic dose during the first postoperative 24 h (p < 0.001) and lower pain scores along the whole 24 postoperative hours. Mean arterial pressure and heart rate were within the clinically accepted range in the two groups. Parents’ satisfaction was significantly higher (p < 0.001) in the TAP block group.ConclusionTAP block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing laparoscopic surgery for undescended testis.     

Bloqueo axilar ecoguiado frente a bloqueo infraclavicular ecoguiado para la cirugía de miembro superior

BackgroundMost upper limb regional anaesthesia techniques are successful, and differences in efficacy should dictate the choice of technique.MethodsThis prospective, randomised study compares ultrasound-guided infraclavicular (IB) and ultrasound-guided axillary brachial plexus blocks (AB) for upper limb surgery. Anaesthesia time (performance time and onset time) was the primary outcome measure. The success rate (surgical anaesthesia), analgesia duration, postoperative pain scores, and the incidence of complications over the following 24 h were recorded.ResultsA total of 82 patients were included in the study, and received either IB (n = 42) or AB (n = 40). No differences were observed between the 2 groups in terms of total anaesthesia-related time, performance time, success rate (90-95%), or postoperative pain scores. Compared with the infraclavicular approach, ultrasound-guided AB group required a longer onset time, 10.2 min (SD ± 1.4), than IB group, 6.35 min (SD ± 2). IB was also associated with a longer analgesia duration than that of AB; 20 h (SD ± 1.36) versus 13.70 h (SD ± 2.16), respectively. The only complications we observed were uneventful vascular punctures.ConclusionsWe can conclude that compared to ultrasound-guided AB, ultrasound-guided IB provides a similar efficacy, a shorter onset time and longer lasting analgesia.     

Optimal epidural analgesia for patients diagnosed as having gynecologic cancer undergoing interstitial brachytherapy

Study objectiveTo determine the optimal epidural analgesia for patients receiving interstitial brachytherapy (ISBT) for gynecologic cancers.DesignRetrospective analysis.SettingOperating room and hospital ward.PatientsSeventy-three patients diagnosed as having gynecologic cancer and undergoing ISBT.InterventionsTwelve patients received ropivacaine alone, 14 patients received ropivacaine with fentanyl, and 45 patients received ropivacaine with hydromorphone by epidural infusion.MeasurementsNumeric Rating Scale pain scores, amounts of nonnarcotic and narcotic pain medications used in intravenous morphine equivalents (IVMEs), and amount of antiemetic or antipruritic medications used.Main resultsPatients receiving ropivacaine alone had higher pain scores the morning of day 2 (4.2 vs 1.71 vs 0.6, P = .001), the afternoon of day 2 (4.9 vs 2.5 vs 1.7, P = .005), and the night of day 2 (2.4 vs 2.0 vs 0.6, P < .001). Patients receiving opioids in their epidural had lower pain scores on the night of placement (P = .050), the morning of day 2 (P < .001), the afternoon of day 2 (P = .002), and the night of day 2 (P < .001). Patients receiving ropivacaine alone used more oral narcotics than did those receiving ropivacaine with fentanyl or ropivacaine with hydromorphone on day 3 (5.9 vs 3.8 vs 2.8 mg IVME) and received more intravenous opioids day 1 (5.8 vs 0.0 vs 0.7 mg IVME, P = .004) and day 2 (20.6 vs 4.8 vs 1.0 mg IVME, P = .042). There were no differences in antiemetic or diphenhydramine usage at any time point. No epidural complications occurred.ConclusionsFor patients receiving ISBT for gynecologic cancer, epidural analgesia provides safe and effective pain control. Combined modality epidural analgesia improves pain control and lessens oral and intravenous opioid requirements without increased risk of adverse effects compared with epidural analgesia with local anesthetic alone.     

Pharmacokinetics of bupivacaine after bilateral ultrasound-guided transversus abdominis plane block following cesarean delivery under spinal anesthesia

BackgroundTransversus abdominis plane block is an effective method of post-cesarean analgesia. There are no data available about plasma bupivacaine levels after this block in adults. This study aimed to assess bupivacaine pharmacokinetic parameters after ultrasound-guided transversus abdominis plane blocks following cesarean delivery under spinal anesthesia.MethodsA prospective observational study in parturients undergoing elective cesarean delivery under hyperbaric bupivacaine spinal anesthesia was conducted. After surgery, patients received bilateral transversus abdominis plane block (50 mg bupivacaine each side). Venous blood samples were collected immediately before performing the block and at 10, 20, 30, 45, 60, 90, 120, 180, 240, 720 and 1440 minutes. High performance liquid chromatography was used to measure total plasma bupivacaine concentrations. Mean bupivacaine area under the curve (AUC) was calculated from 0 to 24 hours.ResultsData were collected from 17 parturients. Mean age and body mass index were 31 ± 6 y and 30 ± 4 kg/m² respectively. Mean plasma bupivacaine concentration before the block was 171 ng/mL. Mean peak concentration was 802.36 ng/mL (range 231.8 to 3504.5 ng/mL). Mean time to peak concentration was 30 min and mean area-under-the-curve (0–24 h) was 4505.4 h.ng/mL. Mean elimination half-life was 8.75 h. Three subjects had concentrations above the quoted toxic threshold and mild symptoms suggestive of neurotoxicity were reported by two subjects, but no treatment was required.ConclusionSingle-dose bilateral transversus abdominis plane block using 100 mg of bupivacaine, after spinal anesthesia for cesarean delivery, can result in toxic plasma bupivacaine concentrations.     

Pencil-point needle bevel direction influences ED50 of isobaric ropivacaine with fentanyl in spinal anesthesia for cesarean delivery: a prospective,double-blind sequential allocation study

BackgroundThere is little evidence on the influence of bevel direction of a pencil-point needle on the median effective dose (ED50) of isobaric ropivacaine and fentanyl in spinal anesthesia for cesarean delivery.MethodsIn this prospective, double-blind, sequential allocation study, 82 parturients scheduled for elective cesarean delivery under combined spinal-epidural anesthesia were included. We sought to determine the median effective dose of intrathecal 0.75% isobaric ropivacaine plus fentanyl 15 μg with two different bevel directions of a 26-gauge Whitacre needle using up-down sequential allocation. Parturients were randomly allocated to either Group Ce (needle aperture oriented in a cephalad direction) or Group Ca (aperture directed caudally). The initial dose was 0.75% ropivacaine 11.25 mg plus fentanyl 15 μg in both groups. Each dose was classified as effective if, after 15 min and during the next 60 min, there was inability to appreciate pin-prick as sharp at T4, a visual analogue pain score <2 and no requirement for an epidural rescue bolus.ResultsEighty patients were included in the analysis. The ED50 in group Ca was significantly higher (13.09 mg, 95% CI 12.19–14.00) than in group Ce (10.10 mg, 95% CI 9.54–10.65, P <0.001).ConclusionThe orientation of the distal aperture of a 26-gauge Whitacre needle during induction of spinal anesthesia for cesarean delivery influences the ED50 of 0.75% ropivacaine.     

Quadratus lumborum block for postoperative analgesia after cesarean delivery: A systematic review with meta-analysis and trial-sequential analysis

Study objectiveThe aim of this study was to investigate the analgesic efficacy of Quadratus lumborum block (QLB) versus controls, transversus abdominis plane (TAP) block and neuraxial morphine, or when added to neuraxial morphine in women undergoing cesarean delivery.DesignSystematic review and meta-analysis with trial sequential analysis.PatientsParturients undergoing cesarean delivery.InterventionQuadratus lumborum block for postoperative analgesia.MeasurementsThe primary outcomes were dynamic and static pain scores and cumulative opioid consumption at 24 h. Secondary outcomes were dynamic and static pain scores and opioid consumption at 6 and 12 h. Certainty of evidence was assessed using the GRADE system. Trial sequential analyses (TSA) were performed to determine if the results are supported by sufficient data.Main resultsTen studies involving 761 parturients were included. Compared to controls, no difference in dynamic (MD -6; 95%CI -17 to 5) or static (MD -5; 95%CI -14 to 3) pain scores were noted with QLB at 24 h (moderate certainty), although opioid consumption (MD −10.64 mg morphine equivalents; −16.01 to −5.27) was reduced (high certainty), supported by sufficient data. QLB reduced dynamic pain at 6 h, and static pain and opioid consumption at 6 and 12 h compared to controls. Compared to neuraxial morphine, QLB did not alter opioid consumption or pain scores at 24 h (low certainty), although TSA suggests insufficient data. Due to limited data, meta-analysis and TSA were not performed to compare QLB and TAP blocks. Addition of QLB to neuraxial morphine did not alter dynamic and static pain scores at 24 h (moderate certainty, supported by sufficient data).ConclusionsQLB improves post-cesarean delivery analgesia in parturients not receiving neuraxial morphine. Addition of QLB to parturients receiving neuraxial morphine has no significant analgesic benefit. Insufficient data are available to draw firm conclusions of QLB compared to TAP blocks or neuraxial morphine.     

Efficacy of ultrasound-guided oblique subcostal transversus abdominis plane block after laparoscopic sleeve gastrectomy: A double blind,randomized, placebo controlled study

IntroductionPain control in the morbidly obese can be especially challenging because of increased sensitivity to opioid-induced respiratory depression. The subcostal transversus abdominis plane block is associated with a large area of spread (T7-L1). The aim of the study was to test the hypothesis that US-guided TAP blocks can reduce opioid consumption during the first 24 h after of laparoscopic sleeve gastrectomy in comparison with port site local anesthetic infiltration and systemic analgesia.MethodSixty-three ASA II/III adult patients listed for elective laparoscopic sleeve gastrectomy were randomly allocated in one of three groups: Group I (OSTAP) received bilateral OSTAP block. Group II (Local) received local anesthetic infiltration at trocar port sites. Group III (Control) placebo group received TAP block and port site infiltration by same volumes of sterile normal saline. Twenty-four hours postopetrative morphine consumption, the dose of fentanyl (μg) required during surgery, equivalent morphine dose in the recovery unit (PACU) and first morphine dose were recorded. The quality of analgesia is assessed by Visual Analogue Scale for 24 h at rest and movement.ResultsThe mean opioid consumptions in PACU showed significant difference between the three groups, P = 0.02. The mean 24 h morphine consumption showed statistically significant difference between groups (P value < 0.001). Significant differences were found between both OSTAP and Local groups with control group (P < 0.001) and also between OSTAP and Local groups (P = 0.02). Pain score of OSTAP group was significantly lower than local infiltration group at 6 and 4 h at rest and movement respectively. OSTAP group had faster extubation time than other groups. Postoperative nausea and vomiting were not significant between groups. No signs or symptoms of local anesthetic systemic toxicity or complications were detected.ConclusionOblique subcostal TAP block is a good alternative for providing analgesia during the postoperative period. The block is easily performed using ultrasound guidance. It is safe, provides effective analgesia with significant morphine-sparing effect with reduced side-effects of opioids.     

A randomized comparison of onset of anesthesia between spinal bupivacaine 5 mg with immediate epidural 2% lidocaine 5 mL and bupivacaine 10 mg for cesarean delivery

BackgroundPrevious studies using low-dose spinal anesthesia for cesarean delivery have focused on hypotension and efficacy. This study evaluated whether, using a combined spinal–epidural technique, there was a difference in onset of anesthesia for cesarean delivery between low-dose spinal with an immediate epidural local anesthetic bolus, and conventional-dose spinal anesthesia.MethodsForty healthy term nulliparous women undergoing elective cesarean delivery with a combined spinal–epidural technique were enrolled into this prospective, randomized, double-blind study. Patients were randomly allocated to the low-dose (Group L) or conventional-dose group (Group C). Patients in Group L received intrathecal isobaric bupivacaine 5 mg with sufentanil 2.5 μg followed by epidural 2% lidocaine 5 mL; patients in Group C received intrathecal isobaric bupivacaine 10 mg with sufentanil 2.5 μg followed by epidural saline 5 mL. The onset of anesthesia (defined as the time from spinal injection to a block to T6), incidence of hypotension, maximal sensory block, epidural supplementation and side effects were recorded.ResultsAll blocks reached T6 within 11 min except for one patient in Group L. There were no differences in onset of anesthesia (9.9 ± 3.2 min in Group L vs. 8.5 ± 1.2 min in Group C, P = 0.08), maximal block level and the number of patients who required epidural supplementation in both groups. Hypotension occurred in 8 patients (40%) in Group L and 15 patients (75%) in Group C (P = 0.02).ConclusionsIntrathecal bupivacaine 5 mg with immediate 2% epidural lidocaine 5 mL provided comparable onset and efficacy of anesthesia as bupivacaine 10 mg with immediate epidural normal saline 5 mL for cesarean delivery.     

Preemptive analgesia by peritonsillar ketamine versus ropivacaine for post-tonsillectomy pain in children

BackgroundPostoperative pain relief is a desired goal after tonsillectomy. Respiratory depression from opioid, bleeding from nonsteroidal antiinflammatory drugs, and airway edema all these factors make pain control is judges. Peritonsillar infiltration of a local anesthetic has been used for reduction of post-tonsillectomy pain.ObjectiveThis study aims to compare the postoperative analgesic efficacy and side-effects of preincisional peritonsillar infiltration of either ketamine or ropivacaine in children undergoing tonsillectomy.MethodsIn this prospective randomized double blind study, 60 children 7–12 years scheduled to tonsillectomy were divided into three groups: the tonsils were infiltrated by 0.2 ml kg⁻¹ ropivacaine, 0.75% in ropivacaine group R (=21), group 0.5 mg kg⁻¹ ketamine in the ketamine group K (n = 20), and 0.2 ml kg⁻¹ normal saline in the control group S (n = 19). All drugs were prepared in normal saline (3 ml per tonsil) infiltrated 3 min after induction of anesthesia and before surgical incision. Surgery was performed by a single otolaryngology fellow using the same dissection and snare technique. Postoperative pain was compared during 8-h period using a visual analog scale (VAS). The fast-tracking score was used to determine the post-anesthesia care unit discharge criteria. Patients were evaluated for: time of first request and the total analgesic requirement, time of first oral intake, nausea, vomiting, bleeding, and hallucination.ResultsIn the post-anesthesia care unit, groups K and R had comparable pain scores that were significantly lower than S group (P < 0.04). Pain scores in the postoperative ward at 2, 6, and 8 h were significantly higher in group S than in K and R groups (P < 0.05). The time of first analgesic demand was significantly longer in R group (5.52 ± 1.7) h than in K group (3.83 ± 0.16) h p = 0.003. It was the shortest in S group (2.57 ± 0.84) h p = 0.001. The time of first oral intake was significantly longer in S than in R and K groups (5 ± 1.72 versus 3.2 ± 1.97 and 3.65 ± 1.72 h) respectively = 0.006. Total analgesic consumption (mg) was significantly higher in S group than in R and K (12. ± 5.3 versus 8, 2 ± 2.3 and 8.6 ± 3.1) p = 0.004. There were no significant differences between groups regarding nausea, vomiting, or bleeding, and there was no other side-effect recorded.ConclusionPerincisional peritonsillar infiltration of both ropivacaine and ketamine was effective in reduction of post-tonsillectomy pain. Ropivacaine was superior to ketamine in reduction of time to first analgesic demand.