Epidural versus intrathecal morphine for postoperative analgesia after Caesarean section

Background. Perispinal anaesthesia for Caesarean section allowsinjection of epidural (ED) or intrathecal (i.t.) morphine toprovide long-lasting postoperative analgesia. To compare thesetwo routes, a prospective, randomized, double-blinded studyof 53 patients undergoing elective Caesarean section was performed. Methods. Combined spinal-epidural anaesthesia with 6 mg of i.t.hyperbaric bupivacaine plus sufentanil 5 µg, and additionalED lidocaine was used. Additionally, each patient received either2 mg (2 ml) of ED morphine plus 1 ml of i.t. normal saline (EDgroup, n=28), or 0.075 mg (1 ml) of i.t. morphine plus 2 mlof ED normal saline (i.t. group, n=25). Additional postoperativeanalgesia was given in the form of propacetamol and ketoprofen,plus self-administered i.v. morphine. Results. No major respiratory depression occurred. Time to firstdemand of morphine was similar in the ED (307.5 min) and i.t.(310 min) groups, as was the incidence of side-effects suchas sedation, pruritis, nausea, and vomiting. During the first24 postoperative hours, VAS pain scores were greater in thei.t. group (P=0.032), as was additional morphine consumption(4 vs 1.5 mg) (P=0.03). Conclusions. The ED protocol was more effective than the i.t.protocol, whilst side-effects were similar. Br J Anaesth 2003; 91: 690–4     

The effect of addition of intrathecal clonidine to hyperbaric bupivacaine on postoperative pain and morphine requirements after Caesarean section: a randomized controlled trial

Background. Intrathecal clonidine prolongs spinal anaesthesia.We investigated the effect of the addition of clonidine (75µg) to hyperbaric bupivacaine on postoperative morphineconsumption after Caesarean section in a randomized controlleddouble-blind trial. Methods. A group of 106 women received spinal anaesthesia usingeither bupivacaine 0.5% (2.2 ml) heavy with 0.5 ml normal saline0.9% (B) or bupivacaine 0.5% (2.2 ml) heavy with clonidine (75µg) in 0.5 ml normal saline 0.9% (BC). The primary outcomewas the total morphine consumption in the first 24 h after surgery.Secondary outcomes were the duration of postoperative analgesia,postoperative pain scores, the need for alfentanil during surgery,block regression, clonidine side-effects and morphine side-effects. Results. Total morphine consumption was similar in both studygroups. The mean time to the first analgesic request in theBC group was 129 (SD 13.8) min, compared with 55 (14.2) minin the B group [mean difference (95% CI) –75 (–106to –44) min]. In the BC group 22 (42%) patients had acomplete motor block 1 h after surgery compared with 4 (8%)patients in the B group [RR (95% CI) 0.18 (0.07–0.49)].Side-effects of intrathecal clonidine were not detected. Conclusions. The addition of clonidine (75 µg) to hyperbaricbupivacaine prolongs spinal anaesthesia after Caesarean sectionand improves early analgesia, but does not reduce the postoperativemorphine consumption during the first 24 h. No clinically relevantmaternal or neonatal side-effects were detected.     

Efficacy of augmentation of epidural analgesia for Caesarean section

Background. Extension of a labour epidural for Caesarean deliveryis thought to be successful in most cases and avoids the useof general anaesthesia. However, most previous studies thathave estimated the failure rate of pre-existing epidural catheterswere performed in small numbers of patients. Methods. Therefore, we undertook to retrospectively measurethe failure rate of indwelling epidural catheters in a largenumber of patients. Results. The anaesthetic team was available at all times andwas permanently led by a senior anaesthetist specialized inobstetrics. Extension was performed using lidocaine 2% withepinephrine (mean 18 (SD 6) ml), combined in most patients withsufentanil (9 (2.2) µg) and/or clonidine (75 µg).Among 194 consecutive extensions performed in a 1-yr period,general anaesthesia was required in five patients (2.6%) whilesedation and/or i.v. analgesia were used in 27 patients (13.9%).In three cases where general anaesthesia was required, the intervalbetween decision to incision was <10 min. No factorassociated with failure could be identified. Addition of a lipophilicopioid or of clonidine did not modify the efficacy of the block(i.e. general anaesthesia or supplementation were required ina similar proportion). Conclusions. The augmentation of labour epidurals for Caesareansection using lidocaine 2% plus epinephrine is a reliable andeffective technique. No factor associated with failure couldbe identified. Br J Anaesth 2003; 91: 532–5     

Comparison of the effects of intrathecal ropivacaine, levobupivacaine, and bupivacaine for Caesarean section

Background. This study aimed to detect if intrathecal (i.t.)ropivacaine and levobupivacaine provided anaesthesia (satisfactoryanalgesia and muscular relaxation) and postoperative analgesiaof similar quality to bupivacaine in patients undergoing Caesareansection. Methods. Ninety parturients were enrolled. A combined spinal-epiduraltechnique was used. Patients were randomly assigned to receiveone of the following isobaric i.t. solutions: bupivacaine 8mg (n=30), levobupivacaine 8 mg (n=30), or ropivacaine 12 mg(n=30), all combined with sufentanil 2.5 µg. An i.t. solutionwas considered effective if an upper sensory level to pinprickof T4 or above was achieved and if intraoperative epidural supplementationwas not required. Sensory changes and motor changes were recorded. Results. Anaesthesia was effective in 97, 80, and 87% of patientsin the bupivacaine 8 mg, levobupivacaine 8 mg, and ropivacaine12 mg groups, respectively. Bupivacaine 8 mg was associatedwith a significantly superior success rate to that observedin the levobupivacaine group (P<0.05). It also provided alonger duration of analgesia and motor block (P<0.05 vs levobupivacaineand ropivacaine). Conclusions. The racemic mixture of bupivacaine combined withsufentanil remains an appropriate choice when performing Caesareansections under spinal anaesthesia. Br J Anaesth 2003; 91: 684–9     

Sequential compression device with thigh-high sleeves supports mean arterial pressure during Caesarean section under spinal anaesthesia

Background. This study investigated the use of a SequentialCompression Device (SCD) with thigh-high sleeves and a presetpressure of 50 mm Hg that recruits blood from the lower limbsintermittently, as a method to prevent spinal hypotension duringelective Caesarean section. Possible association of arterialpressure changes with maternal, fetal, haemodynamic, and anaestheticfactors were studied. Methods. Fifty healthy parturients undergoing elective Caesareansection under spinal anaesthesia were randomly assigned to eitherSCD (n=25) or control (n=25) groups. A standardized protocolfor pre-hydration and anaesthetic technique was followed. Hypotensionwas defined as a decrease in any mean arterial pressure (MAP)measurement by more than 20% of the baseline MAP. Systolic (SAP),MAP and diastolic (DAP) arterial pressure, pulse pressure (PP),and heart rate (HR) were noted at baseline and every minuteafter the spinal block until delivery. Results. A greater than 20% decrease in MAP occurred in 52%of patients in the SCD group vs 92% in the control group (P=0.004,odds ratio 0.094, 95% CI 0.018–0.488). There were no significantdifferences in SAP, DAP, HR, and PP between the groups. Conclusion. SCD use in conjunction with vasopressor significantlyreduced the incidence of a 20% reduction of MAP. Br J Anaesth 2003; 91: 695–8     

Minimum dose of intrathecal diamorphine required to prevent intraoperative supplementation of spinal anaesthesia for Caesarean section

Background. Intraoperative discomfort during spinal anaesthesiafor Caesarean section is the commonest cited anaesthetic causeof litigation in obstetric practice. Intrathecal opioids areused to improve intraoperative comfort and postoperative analgesiafor these operations. The minimum intrathecal diamorphine dosethat prevents intraoperative supplementation requires determination. Method. After ethics committee approval, 200 ASA I, II womenwith     

Dextromethorphan and intrathecal morphine for analgesia after Caesarean section under spinal anaesthesia

Background. Dextromethorphan is an N-methyl-D-aspartic acidantagonist which can attenuate acute pain with few side-effects.In this prospective, randomized, double-blind study of dextromethorphanand intrathecal morphine, we investigated postoperative pain,pruritus, nausea and vomiting in women undergoing Caesareansection under spinal anaesthesia. Methods. Women were allocated randomly to one of six groups,to receive intrathecal morphine 0.05, 0.1 or 0.2 mg plusoral dextromethorphan 60 mg or placebo. Results. The addition of dextromethorphan did not reduce postoperativepain scores (P=0.83). Compared with women receiving intrathecalmorphine 0.05 mg, women receiving higher doses had a significantlyhigher incidence of nausea and vomiting [odds ratio for intrathecalmorphine 0.1 mg, 4.0 (95% confidence interval 1.2–14.1);for intrathecal morphine 0.2 mg, 7.9 (2.3–27.1)].Compared with women receiving intrathecal morphine 0.05 mg,women receiving higher doses also had a significantly higherincidence of pruritus [odds ratio for intrathecal morphine 0.1 mg,3.2 (95% confidence interval 1.3–8.2); for intrathecalmorphine 0.2 mg, 3.7 (1.4–9.5)]. Women receivingdextromethorphan had a lower incidence of nausea and vomiting[odds ratio 2.6 (1.1–6.3)]. Conclusions. Postoperative pain after Caesarean section underspinal anaesthesia was not reduced by the addition of oral dextromethorphanto a multimodal approach including intrathecal morphine. Br J Anaesth 2003; 90: 653–8     

Iontophoretic transdermal system using fentanyl compared with patient-controlled intravenous analgesia using morphine for postoperative pain management

Background: The fentanyl iontophoretic transdermal system (fentanyl ITS)enables needle-free, patient-controlled analgesia for postoperativepain management. This study compared the efficacy, safety, andease of care of fentanyl ITS with patient-controlled, i.v. analgesia(PCIA) with morphine for postoperative pain management. Methods: A prospective, randomized, multicentre trial enrolled patientsin Europe after abdominal or orthopaedic surgery. Patients receivedfentanyl ITS (n = 325; 40.0 µg fentanyl over 10 min) ormorphine PCIA [n = 335; bolus doses (standard at each hospital)]for 72 h. Supplemental i.v. morphine was available during thefirst 3 h. The primary efficacy measure was the patient globalassessment (PGA) of the pain control method during the first24 h. Results: PGA ratings of ‘good’ or ‘excellent’were reported by 86.2 and 87.5% of patients using fentanyl ITSor morphine PCIA, respectively (95% CI, –6.5 to 3.9%).Mean (SD) last pain intensity scores (numerical rating scale,0–10) were 1.8 (1.77) and 1.9 (1.86) in the fentanyl ITSand morphine PCIA groups, respectively (95% CI, –0.38to 0.18). More patients reported a system-related problem forfentanyl ITS than morphine PCIA (51.1 vs 17.9%, respectively).However, fewer of these problems interrupted pain control (4.4vs 41.3%, respectively). Patients, nurses, and physiotherapistsreported more favourable overall ease-of-care ratings for fentanylITS than morphine PCIA. Study termination rates and opioid-relatedside-effects were similar between groups. Conclusion: Fentanyl ITS and morphine PCIA were comparably effective andsafe.     

Comparison of intrathecal isobaric bupivacaine-morphine and ropivacaine-morphine for Caesarean delivery

Background. This study was designed to evaluate the effectsof intrathecal isobaric bupivacaine 0.5% plus morphine and isobaricropivacaine 0.5% plus morphine combinations in women undergoingCaesarean deliveries. Method. Twenty-five parturients received ropivacaine 15 mg andmorphine 150 µg (RM group) and twenty-five parturientsreceived bupivacaine 15 mg and morphine 150 µg (BM group)for spinal anaesthesia. Sensory and motor block, haemodynamics,postoperative analgesia, fetal outcomes, and side-effects wereevaluated. Results. Intrathecal bupivacaine–morphine and ropivacaine–morphineprovided effective sensory anaesthesia and motor block. Timeto reach complete motor block was shorter and time to completerecovery from motor block was longer in the BM group than theRM group (P<0.05). The time to regression of two dermatomesand time for the block to recede to the S2 dermatome were similarin both groups (P>0.05). Time to first complaint of painand the mean total consumption of tenoxicam were similar inboth groups (P>0.05). APGAR scores at 1 and 5 min were similarin the two groups, as were mean umbilical blood pH values (P>0.05).Hypotension and pruritus were the most common side-effects inboth groups during the operation. Conclusion. Intrathecal isobaric ropivacaine 0.5% 15 mg plusmorphine 150 µg provides sufficient anaesthesia for Caesareandelivery. The ropivacaine–morphine combination resultedin shorter motor block, similar sensory and postoperative analgesia. Br J Anaesth 2003; 90: 659–64     

Anaesthesia for Caesarean section in a patient with recent subarachnoid haemorrhage and severe pre-eclampsia

Subarachnoid haemorrhage is a leading 'indirect' cause of maternal death in the UK. We describe the case of a 43-year-old woman who presented with headache, photophobia and neck stiffness of sudden onset at 32 weeks' gestation. Cerebral computed tomography demonstrated subarachnoid blood in the cisterns around the midbrain, and oral nimodipine was started to prevent vasospasm. Preparations were made for endovascular coil embolisation in the event of identification of a posterior circulation aneurysm. However, angiography under general anaesthesia failed to reveal any vascular abnormality. On emergence from anaesthesia, headache persisted, and over the next 24 h severe pre-eclampsia developed. Magnesium sulphate was started, and urgent Caesarean section performed under general anaesthesia without incident. The rationale for the neuroradiological, obstetric and anaesthetic management is discussed.     

Effect of intrathecal tramadol administration on postoperative pain after transurethral resection of prostate

Background. Tramadol administered epidurally has been demonstratedto decrease postoperative analgesic requirements. However, itseffect on postoperative analgesia after intrathecal administrationhas not yet been studied. In this double-blind, placebo-controlledstudy, the effect of intrathecal tramadol administration onpain control after transurethral resection of the prostate (TURP)was studied. Methods. Sixty-four patients undergoing TURP were randomizedto receive bupivacaine 0.5% 3 ml intrathecally premixed witheither tramadol 25 mg or saline 0.5 ml. After operation, morphine5 mg i.m. every 3 h was administered as needed for analgesia.Postoperative morphine requirements, visual analogue scale forpain at rest (VAS) and sedation scores, times to first analgesicand hospital lengths of stay were recorded by a blinded observer. Results. There were no differences between the groups with regardto postoperative morphine requirements (mean (SD): 10.6 (7.9)vs 9.1 (5.5) mg, P=0.38), VAS (1.6 (1.2) vs 1.2 (0.8), P=0.18)and sedation scores (1.2 (0.3) vs 1.2 (0.2), P=0.89). Timesto first analgesic (6.3 (6.3) vs 7.6 (6.2) h, P=0.42) and lengthof hospital stay (4.7 (2.8) vs 4.4 (2.2) days, P=0.66) weresimilar in the two groups. Conclusion. Intrathecal tramadol was not different from salinein its effect on postoperative morphine requirements after TURP. Br J Anaesth 2003; 91: 536–40     

Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia

Background: This randomized, double-blind, prospective study was undertakento evaluate the effects of magnesium sulphate on anaestheticrequirements and postoperative analgesia in patients undergoingtotal i.v. anaesthesia (TIVA). Methods: Fifty patients who underwent gynaecological surgery were randomlydivided into two groups. Before induction of anaesthesia, themagnesium group (Group M) received magnesium sulphate 50 mgkg^–1 i.v. as a bolus and then 15 mg kg^–1 h^–1i.v. by continuous infusion. The control group (Group S) receivedthe same amount of isotonic saline. TIVA (propofol+remifentanil)was administered under bispectral index monitoring during anaesthesiainduction and maintenance. Rocuronium was administered beforeorotracheal intubation and during surgery when the train-of-fourcount was 2 or more. After operation, patient-controlled analgesiawith a solution of ketorolac and morphine was used and the consumptionof this solution was recorded. Pain scores at rest and uponmovement were evaluated 30 min, 4, 24, and 48 h after surgery. Results: Patients in Group M required less rocuronium than those in GroupS [mean (SD) 0.44 (0.09) vs 0.35 (0.07) µg kg^–1min^–1, P<0.05]. The total amounts of propofol and remifentaniladministered were similar in the two groups. Postoperative painscores, cumulative analgesic consumption, and shivering incidentswere significantly lower in Group M (P<0.05). Mean arterialpressure just after intubation and during the immediate postoperativeperiod was also significantly lower in Group M (P<0.05). Conclusions: I.V. magnesium sulphate during TIVA reduced rocuronium requirementand improved the quality of postoperative analgesia.     

Prevention of postoperative nausea and vomiting after spinal morphine for Caesarean section: comparison of cyclizine,dexamethasone and placebo

Background. Low-dose intrathecal (spinal) morphine (0.1–0.2mg) for Caesarean section delivers excellent postoperative analgesiabut is associated with significant nausea and vomiting. We comparedthe antiemetic efficacy of cyclizine, dexamethasone, and placeboin this clinical setting. Methods. Ninety-nine women undergoing elective Caesarean sectionunder spinal anaesthesia were allocated randomly, in a double-blindstudy design, to receive either cyclizine 50 mg, dexamethasone8 mg, or placebo as a single-dose infusion in saline 0.9%, 100ml on completion of surgery. Spinal anaesthesia consisted of:hyperbaric bupivacaine 0.5%, 2.0 ml; fentanyl 10 µg; andspinal morphine 0.2 mg. The primary outcome measure was theincidence of nausea. Results. The incidence of nausea was significantly less in patientsreceiving cyclizine compared with dexamethasone and placebo(33 vs 60 and 67%, respectively, P<0.05). Severity of nauseaand number of vomiting episodes were also less at 3–6h in cyclizine patients. Overall satisfaction with postoperativecare at 24 h, expressed on a 100 mm visual analogue scale, wasgreater in cyclizine [78 (28)] than either dexamethasone [58(31), P=0.03] or placebo [51 (28), P=0.008]. Conclusion. We conclude that following spinal morphine 0.2 mgand fentanyl 10 µg analgesia for Caesarean section, cyclizine50 mg i.v. reduces the incidence of nausea compared with dexamethasone8 mg i.v. or placebo. It also lessens the severity of nauseaand vomiting, and increases maternal satisfaction in the earlypostoperative period. Br J Anaesth 2003; 90: 665–70     

Effect of intrathecal diamorphine on block height during spinal anaesthesia for Caesarean section with bupivacaine

Background. Opioid analgesics are commonly added to intrathecalbupivacaine to improve patient comfort during Caesarean sectionunder spinal anaesthesia, and provide post-operative pain relief.We sought to discover if the addition of diamorphine influencedblock height when given with 0.5% w/v hyperbaric bupivacaine. Method. Eighty ASA I and II women of at least 37 weeks gestationand planned for elective Caesarean section under combined spinal–epiduralanaesthesia were recruited. They were randomized into two groupsto receive intrathecal hyperbaric bupivacaine 0.5% at an initialdose of 13 mg, with the next dose determined by the responseof the previous patient (dose interval 1 mg). One group alsoreceived diamorphine 400 µg intrathecally. If a blockheight of T5 to blunt light touch had been achieved after 20min, the block was deemed effective. A difference in the ED₅₀for hyperbaric bupivacaine between the groups would indicatethat diamorphine influenced block height. Intraoperative patientdiscomfort and need for analgesic supplementation was noted. Results. The median effective dose (ED₅₀) to achieve a T5 blockto light touch for Caesarean section using hyperbaric bupivacaine0.5% was 9.95 mg [95% confidence interval (CI) 9.0–10.90]and with the addition of diamorphine it was 9.3 mg (95% CI 8.15–10.40),while the ED₉₅ was 13.55 mg (95% CI 10.10–17.0) and 13.6mg (95% CI 9.15–18.05), respectively. Five women who hadreceived intrathecal diamorphine and 13 who had not receiveddiamorphine needed intraoperative supplementation (not significant). Conclusion. The addition of intrathecal diamorphine does notappear to influence block height.     

Cough reflex sensitivity after elective Caesarean section under spinal anaesthesia and after vaginal delivery

BACKGROUND: In pregnancy, airway oedema and heartburn may increase cough sensitivity, whereas spinal anaesthesia (SA) with local anaesthetics and opiates may decrease it. Decreased cough sensitivity increases the risk for pneumonia or retained secretions. The aim of this study was to determine whether cough sensitivity is increased in pregnant patients and if it is decreased after planned Caesarean section (CS) under SA. METHODS: Twenty-seven non-pregnant volunteers, 27 patients after vaginal delivery (VD group), and 28 patients after CS under SA (CS group) were studied. For SA, hyperbaric bupivacaine 8-12 mg, sufentanil 5 microg, and morphine 100 microg was given. Increasing concentrations of nebulized citric acid were delivered until eliciting cough. The concentration eliciting one (C1) and two coughs (C2) were recorded and log transformed for analysis (log C1 and log C2). RESULTS: Median (inter-quartile) log C1 was 1.3 (0.6) mg ml(-1) in the VD group, 1.6 (0.6) mg ml(-1) in the non-pregnant group (P < 0.01 vs VD group), and 2.2 (0.7) mg ml(-1) in the CS group (P < 0.0001 and P < 0.01 vs VD and non-pregnant groups, respectively). Similar results were observed with log C2. In CS group, log C1 and log C2 remained increased up to 4 h after SA. CONCLUSIONS: Cough sensitivity was increased after VD but decreased for up to 4 h after SA.     

Incremental spinal anaesthesia for elective Caesarean section in a patient with Eisenmenger's syndrome

We describe a new approach to anaesthesia for elective Caesareansection in a woman with Eisenmenger’s syndrome. Incrementalregional anaesthesia was performed using a microspinal catheterand haemodynamic monitoring included transthoracic bioimpedancecardiography. This approach allowed the disadvantages of generalanaesthesia and invasive cardiac output monitoring to be avoided. Br J Anaesth 2001; 86: 723–6     

Comparison between patient-controlled analgesia and subcutaneous morphine in elderly patients after total hip replacement

Background. The goal of this study was to evaluate the effectivenesson postoperative pain, and cognitive impact, of patient-controlledanalgesia (PCA) compared with subcutaneous (s.c.) injectionsof morphine in elderly patients undergoing total hip replacement(THR). Methods. Forty patients older than 70 yr were randomly assignedto two different postoperative analgesic techniques for 48 h:i.v. PCA morphine (dose, 1 mg; lockout interval, 8 min; PCAgroup) or regular s.c. morphine injections (SC group). Postoperativepain was assessed at rest and when moving, using a visual analoguescale (VAS) every 4 h. A Mini Mental Status (MMS) examinationwas used to assess cognitive functions before surgery, at 2h, 24 h and 48 h after surgery, and at hospital discharge. Side-effectswere also recorded systematically during the first 48 h aftersurgery. Results. The PCA group showed significantly lower pain scoresthan the SC group both at rest and during mobilization. However,the clinical significance of pain scores was weak. There wasno intergroup difference in postoperative MMS scores. The incidenceof side-effects was similar in both groups. Conclusions. We conclude that in healthy elderly subjects undergoingTHR, the flexibility of the analgesic regimen is more importantthan the route of administration with regard to efficacy, adverseeffects and recovery of cognitive function. Br J Anaesth 2003; 90: 53–7     

Prophylactic ondansetron does not improve patient satisfaction in women using PCA after Caesarean section

Eighty-one consenting women undergoing elective Caesarean sectionunder spinal anaesthesia were randomly divided into two groups.In Group O patients, ondansetron 4 mg was given intravenouslyat the end of the surgery and 8 mg added to the morphine solutionin the PCA syringe. Patients in Group P received only morphinevia PCA syringe. Analgesia and nausea were measured until PCAwas discontinued 24 h after the operation. Women in the twogroups were similar with respect to age, duration of use ofthe PCA, amount of morphine used, previous history of PONV,and incidence of motion sickness and morning sickness duringthe current pregnancy. The number of women who complained ofnausea and those needing rescue antiemetic medication was significantlyless in Group O. However, there was no statistically significantdifference between the two groups in the patient’s perceptionof the control of nausea and their overall satisfaction. Itwas noted that PONV was more frequent among women who had significantmorning sickness during early pregnancy and ondansetron wasbeneficial in reducing PONV in these women. Although the ondansetronreduced the incidence of PONV and the need for further antiemeticmedication, this did not affect patient’s satisfactionregarding their postoperative care. Br J Anaesth 2001; 87: 502–4     

Analgesic and antacid properties of i.m. tramadol given before Caesarean section under general anaesthesia

Background. Intramuscular (i.m.) tramadol increases gastricpH during anaesthesia similar to famotidine. We investigatedthe antacid analgesic value of a single dose of i.m. tramadolgiven 1 h before elective Caesarean section performed undergeneral anaesthesia. Methods. Sixty ASA I parturients undergoing elective Caesareansection were included in a randomized double-blind study. Thepatients were randomly allocated to receive i.m. tramadol 100mg (n=30) or famotidine 20 mg (n=30) 1 h before general anaesthesia. Results. At the beginning and the end of anaesthesia, patientsreceiving tramadol had a median gastric fluid pH of 6.4, whichwas not significantly different from those treated with famotidine(median 6.3). The infant well-being, as judged by Apgar score,cord blood gas analysis, and neurobehavioural assessment showedno significant difference between the two groups. Nalbuphineconsumption in the first 24 h after operation was reduced by35% in the tramadol group. Pain intensity score on sitting andsedation were significantly greater in famotidine group up to24 h after surgery. There was no significant difference in incidenceand severity of nausea and vomiting between the two groups. Conclusion. A single i.m. dose of tramadol is useful pre-treatmentto minimize the risk of acid aspiration during operation, andin improving pain relief during 24 h after surgery.     

Influence of anaesthetic and analgesic techniques on outcome after surgery

Postoperative symptoms and complications can be prevented bya suitable choice of anaesthetic and analgesic technique forspecific procedures. The aim of analgesic protocols is not onlyto reduce pain intensity but also to decrease the incidenceof side-effects from analgesic agents and to improve patientcomfort. Moreover, adequate pain control is a prerequisite forthe use of rehabilitation programmes to accelerate recoveryfrom surgery. Thus, combining opioid and/or non-opioid analgesicswith regional analgesic techniques not only improves analgesicefficacy but also reduces opioid demand and side-effects suchas nausea and vomiting, sedation, and prolongation of postoperativeileus. Although all attempts to demonstrate that regional anaesthesiaand analgesia decrease postoperative mortality are unsuccessful,there is evidence supporting a reduction in pulmonary complicationsafter major abdominal surgery, and an improvement in patientrehabilitation after orthopaedic surgery. When such techniquesare used, cost–benefit analysis should be considered todetermine suitable analgesic protocols for specific surgicalprocedures.