Patient-controlled epidural analgesia reduces analgesic requirements compared to continuous epidural infusion after major abdominal surgery

PURPOSE: To compare the quality of pain relief and incidence of side effects between 24-hr postoperative continuous epidural infusion (CEI) and subsequent patient-controlled epidural analgesia (PCEA) with different analgesics after major abdominal surgery. METHODS: Twenty-eight women undergoing extended gynecological tumour surgery received postoperative CEI with 0.15 mL x kg(-1) x hr(-1) 0.2% ropivacaine (R: n = 14) or 0.125% bupivacaine plus 0.5 micro g x mL(-1) sufentanil (BS: n = 14) during 24 postoperative hours. Twenty-four hours later, postoperative pain management was switched to PCEA without background infusion and 5 mL single bolus application of R or BS every 20 min at most. Visual analogue scales (VAS; 1-100 mm) were assessed by patients at rest and on coughing after 24 hr of CEI and PCEA. Side effects, doses of local anesthetics and opioids were recorded and plasma concentrations of total and unbound ropivacaine and bupivacaine were measured. RESULTS: Patients required lower doses of each respective analgesic medication with PCEA (R: 108 +/- 30 mL; BS: 110 +/- 28 mL) than with CEI (R: 234 +/- 40; BS: 260 +/- 45; P < 0.01). Ropivacaine plasma concentrations were lower 24 hr after PCEA when compared with CEI (P < 0.01). No patient after PCEA but two after CEI (n = 4; NS) presented motor block. PCEA with R provided better postoperative pain relief than CEI (37 +/- 32 vs 59+/-27, P < 0.05). No difference in parenteral opioid rescue medication between CEI and PCEA was seen. CONCLUSION: PCEA in comparison to preceding CEI provides equivalent analgesia with lower local anesthetic doses and plasma levels, and without motor blocking side effects, irrespective of the applied drug regimen.     

Patient supplemented epidural analgesia after major abdominal surgery with bupivacaine/fentanyl or ropivacaine/fentanyl

PURPOSE: To compare analgesic efficacy and occurrence of motor block and other side effects during patient supplemented epidural analgesia (PSEA) with either ropivacaine/fentanyl or bupivacaine/fentanyl mixtures. METHODS: In a prospective, randomized, double-blind study, 32 ASAI-III patients undergoing major abdominal surgery received an epidural catheter at the T8- T10, followed by integrated general epidural anesthesia. Postoperative epidural analgesia was provided using a patient controlled pump with either ropivacaine 0.2%/2 microg x ml(-1) fentanyl (group Ropivacaine, n = 16) or bupivacaine 0.125%/2 microg x ml(-1) fentanyl (group Bupivacaine, n = 16) [background infusion 4-6 ml x hr(-1), 1.5 ml Incremental Doses and 20 min lock out]. Verbal pain rating score, number of incremental doses, consumption of epidural analgesic solution and rescue analgesics, sedation (four-point scale), and pulse oximetry were recorded by a blind observer for 48 hr after surgery. RESULTS: No differences in pain relief, motor block, degree of sedation, pulse oximetry and other side effects were observed between the two groups. The number of incremental doses and the volume of analgesic solution infused epidurally were higher in patients receiving the bupivacaine/fentanyl mixture (10 [0-52] I.D. and 236 [204-340] ml) than in patients receiving the ropivacaine/fentanyl solution (5 [0-50] I.D. and 208 [148-260] ml) (P = 0.03 and P = 0.05, respectively). CONCLUSION: Using a ropivacaine 0.2%/2 microg x ml(-1) fentanyl mixture for patient supplemented epidural analgesia after major abdominal surgery provided similar successful pain relief as bupivacaine 0.125%/2 microg x ml(-1) fentanyl, but patients receiving bupivacaine/fentanyl requested more supplemental.     

Epidural levobupivacaine 0.1% or ropivacaine 0.1% combined with morphine provides comparable analgesia after abdominal surgery

Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 +/- 178 mg levobupivacaine versus 347 +/- 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects. IMPLICATIONS: Small concentrations (0.1%) of epidural levobupivacaine and ropivacaine combined with morphine (0.1 mg/h) produce comparable analgesia and have similar side effects for similar dose requirements.     

Comparison of ropivacaine and bupivacaine for epidural analgesia during labor]

OBJECTIVES: To compare the analgesic efficacy and level of motor block using two local anesthetics, ropivacaine and bupivacaine, during labor. MATERIAL AND METHODS: Sixty nulliparous women were enrolled during labor after full-term pregnancies. They were randomly assigned to receive epidural analgesia with ropivacaine (group R) or bupivacaine (group B). Group R patients received 10 ml of 0.18% ropivacaine with 5 microgram/ml of fentanyl followed by continuous epidural infusion of 0.1% ropivacaine with 2 microgram/ml of fentanyl at a rate of 10 ml/h. Group B patients received 10 ml of 0.15% bupivacaine with 5 microgram/ml of fentanyl followed by continuous epidural perfusion of 0.0625% bupivacaine with 2 microgram/ml of fentanyl at the same rate. Pain intensity was assessed on a visual analog scale, motor blockade on a Bromage scale, and level of sensory block at different moments. We also recorded total doses of local anesthetic employed during continuous epidural infusion, manner of final delivery, Apgar score, degree of maternal satisfaction and side effects. RESULTS: The demographic and delivery characteristics were similar in both groups. We found no statistically significant differences between the two groups for level of motor blockade, which was nil for 29 patients (96.66%) in group R and 28 patients (93.33%) in group B. No differences in degree of pain or level of sensory block (T8-T10 in both groups) were observed.The total doses of local anesthetic used were similar at 23.7 +/- 11.6 mg in group R and 16.5 +/- 7.3 mg in group B (non-significant difference). Nor did we find differences in manner of delivery, neonatal Apgar scores, degree of maternal satisfaction or side effects. CONCLUSION: Ropivacaine and bupivacaine are equally effective for epidural analgesia during labor at the doses used and they do not cause a relevant level of motor blockade.     

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

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

0.2% ropivacaine with or without sufentanil for patient-controlled epidural analgesia after anterior cruciate ligament repair

AIM: The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia (PCEA) on the quality of postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: Twenty ASA physical status I-II patients, scheduled to have elective ACL repair were studied. Combined spinal-epidural anesthesia was performed at the L3-L4 or L4-L5 interspace using a needle-through-needle technique. Spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine. Postoperative epidural analgesia was started at the end of surgery using a continuous epidural infusion of 0.2% ropivacaine alone (n=10) or 0.2% ropivacaine/0.5 mg mL(-1) sufentanil (n=10). The degree of pain was evaluated at 1, 8, 16, 24 and 48 hours after surgery; at the same observation times the degree of motor block, sedation, oxygen saturation, total consumption of PCEA solution and incremental doses given to the patient were also recorded. RESULTS: No differences in the quality of intraoperative anesthesia was observed, and in no case general anesthesia was required to complete surgery. Patients receiving the combination of ropivacaine and sufentanil showed lower levels of VAS from 16 hours after surgery as compared with ropivacaine group (P=0.02). However, no differences in the degree of pain were observed between the 2 groups during continuous passive mobilization. CONCLUSION: Adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia improved pain control at rest but did not result in significant improvement of postoperative analgesia during continuous passive mobilization.     

A comparison of ropivacaine with fentanyl to bupivacaine with fentanyl for postoperative patient-controlled epidural analgesia

Ropivacaine for patient-controlled epidural analgesia (PCEA) may facilitate postoperative patient mobilization because it causes less motor block than bupivacaine. Forty patients undergoing abdominal surgery were randomized in a double-blinded manner to the following: 0.05% bupivacaine/4 microg fentanyl, 0.1% bupivacaine/fentanyl, 0.05% ropivacaine/fentanyl, or 0.1% ropivacaine/fentanyl for standardized PCEA. We measured pain scores, side effects, and PCEA consumption for 42 h. Lower-extremity motor function was assessed with electromyography and isometric force dynamometry. Analgesia was equivalent among groups. Local anesthetic use was more in the 0.1% Ropivacaine and 0.1% Bupivacaine groups (77% increase, P = 0.001). Motor function decreased during PCEA (10%-35% decrease from preoperative, P < 0.001) and was equivalent among groups. Eight patients were transiently unable to ambulate. These patients used more local anesthetic (45 vs 33 mg mean, P < 0.05) with additional decrease in motor function (32%, P < 0.004) compared with ambulating patients. Other side effects were mild and equivalent among solutions. PCEA with bupivacaine/fentanyl and ropivacaine/fentanyl as 0.05% or 0.1% solutions appears clinically equipotent. Lower-extremity motor function decreases, but is unlikely to result in prolonged inability to ambulate. Use of a 0.05% solution may be advantageous to decrease local anesthetic use and prevent transient motor block. IMPLICATIONS: Patient-controlled epidural analgesia with bupivacaine/fentanyl and ropivacaine/fentanyl as either 0.05% or 0.1% solutions are clinically similar. Lower-extremity motor function will decrease with the use of any of these combinations, but is unlikely to result in the inability to walk.     

A comparison of epidural analgesia with 0.125% ropivacaine with fentanyl versus 0.125% bupivacaine with fentanyl during labor

We previously found that the extent of an epidural motor block produced by 0.125% ropivacaine was clinically indistinguishable from 0.125% bupivacaine in laboring patients. By adding fentanyl to the 0. 125% ropivacaine and bupivacaine solutions in an attempt to reduce hourly local anesthetic requirements, we hypothesized that differences in motor block produced by the two drugs may become apparent. Fifty laboring women were randomized to receive either 0. 125% ropivacaine with fentanyl 2 microg/mL or an equivalent concentration of bupivacaine/fentanyl using patient-controlled epidural analgesia (PCEA) with settings of: 6-mL/hr basal rate, 5-mL bolus, 10-min lockout, 30-mL/h dose limit. Analgesia, local anesthetic use, motor block, patient satisfaction, and side effects were assessed until the time of delivery. No differences in verbal pain scores, local anesthetic use, patient satisfaction, or side effects between groups were observed; however, patients administered ropivacaine/fentanyl developed significantly less motor block than patients administered bupivacaine/fentanyl. Ropivacaine 0.125% with fentanyl 2 microg/mL produces similar labor analgesia with significantly less motor block than an equivalent concentration of bupivacaine/fentanyl. Whether this statistical reduction in motor block improves clinical outcome or is applicable to anesthesia practices which do not use the PCEA technique remains to be determined. Implications: By using a patient-controlled epidural analgesia technique, ropivacaine 0.125% with fentanyl 2 microg/mL produces similar analgesia with significantly less motor block than a similar concentration of bupivacaine with fentanyl during labor. Whether this statistical reduction in motor block improves clinical outcome or is applicable to anesthesia practices which do not use the patient-controlled epidural analgesia technique remains to be determined.     

Ropivacaine for postoperative epidural analgesia

Ropivacaine is a long-acting local anesthetic that has lower toxicity than bupivacaine and causes less motor block when given via the epidural route in low concentrations. This makes it a potentially useful drug for postoperative epidural analgesia. Studies with epidural infusions of plain ropivacaine for 24 to 72 hours have shown that a large proportion of patients (up to 50%) required supplemental analgesics or were withdrawn from the study because of inadequate analgesia. This is not surprising and is consistent with earlier experience with bupivacaine because clinical experience shows more rapid segmental regression with ropivacaine than bupivacaine; however, when combined with fentanyl (2 to 4 μg/mL), ropivacaine 0.2% provides a similar quality of analgesia to bupivacaine (0.1% to 0.2%) with fentanyl (2 to 4 μg/mL), although there are few direct comparisons. The use of patient-controlled epidural analgesia with ropivacaine also is effective provided it is combined with an opioid. Initial studies with levobupivacaine show a similar need for admixture with adjuvants (eg, fentanyl) for effective postoperative analgesia. The incidence of motor block in the lower limbs is low with thoracic epidural infusions, and no difference has been consistently shown between ropivacaine and bupivacaine. There is evidence, however, that with lumbar epidural infusions, less motor block occurs in patients receiving ropivacaine than similar concentrations of bupivacaine. Acute toxicity is highly unusual in the postoperative setting. Both ropivacaine and bupivacaine show no significant increase in free plasma levels during prolonged (up to 72 hours) epidural infusion. There is a theoretical advantage of ropivacaine, and possibly levobupivacaine, in the circumstance of massive epidural overdose because of more rapid block regression than bupivacaine and less systemic toxicity. Copyright © 2001 by W.B. Saunders Company     

Double-blind evaluation of patient-controlled epidural analgesia during labor

A double-blind randomized study was designed to compare the efficacy of patient-controlled epidural analgesia (PCEA) with continuous epidural analgesia (CEA) with regards to patient satisfaction with analgesia, analgesic efficacy, and local anesthetic usage. After establishing effective epidural analgesia with 8 ml of 0.25% bupivacaine, 39 parturients were randomized to 1 of 2 groups. The CEA group received a continuous infusion of 12 ml/h of 0.125% bupivacaine. The PCEA group received a background infusion of 4 ml/h of 0.125% bupivacaine and were able to self-administer additional boluses of 3 ml of 0.25% bupivacaine every 10 min up to 15 ml/h. In both groups, when patients complained of inadequate analgesia, supplemental doses of 5 ml of 0.25% bupivacaine were administered by a physician. The 2 groups were similar in age, height, weight, gravidity, labor duration, motor block, sensory block, and infant Apgar scores. The 2 groups also did not differ significantly in terms of patient satisfaction, pain assessment, or total drug usage. However, the PCEA group required significantly fewer supplemental doses (15%) compared with the CEA group (40%). The decreased need for supplemental doses in the PCEA group may suggest a potential advantage in consistency of analgesia and possibly decreased man-power needs.     

Advantage of ropivacaine for postoperative epidural analgesia following leg orthopedic surgery

BACKGROUND: Epidural administration of local anesthetics may lead to effective pain relief. However, tachyphylaxis or other problems following prolonged epidural anesthesia may develop and in many cases difficulties exist in the maintenance of the similar degree of sensory blockade. The present study was therefore performed to investigate the analgesic effect of continuous postoperative epidural infusion of ropivacaine with fentanyl in comparison with that of bupivacaine or ropivacaine alone. METHODS: After leg orthopedic surgery with lumbar combined spinal-epidural anesthesia, thirty-six patients were randomized to one of the three postoperative epidural infusion groups: bupivacaine 0.125%, ropivacaine 0.2%, or ropivacaine 0.2% with 2.2 microg x ml(-1) (400 microg x 180 ml(-1)) of fentanyl. Continuous epidural infusion was started at a rate of 6 ml x h(-1) with possibility of an additional bolus injection of 3 ml at least every 60 min. Pain was assessed using a 10-cm visual analog scale (VAS) just before and 15 min after epidural bolus injections, and 15-20 h after the start of continuous epidural infusion as the severe at pain through the observation. The spread of analgesia (loss of sharpness in pinprick perception) and motor block (Bromage scale) were evaluated bilaterally. Systolic and diastolic blood pressure and heart rate were also measured. RESULTS: The epidural bolus infusion was associated with a significant decrease of VAS (P < 0.001) and stable blood pressure and heart rate in all groups. The maximal VAS in patients receiving 0.2% ropivacaine+fentanyl was significantly less compared to that in the other two groups. The regression of sensory blockade was significantly prolonged in patients treated with ropivacaine+fentanyl. There was no significant difference in the spread of sensory analgesia between 20 min and 15-20 h after the continuous epidural anesthesia in this group. None of the patients developed adverse effects such as respiratory depression, nausea, and pruritis. CONCLUSIONS: Epidural injection of ropivacaine with fentanyl decreased postoperative pain with stable vital signs in patients undergoing leg orthopedic surgery, as compared to bupivacaine or ropivacaine alone, possibly because of the maintenance of sensory blockade by ropivacaine and enhancement of this sensory blockade by fentanyl.     

Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty

BACKGROUND: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. METHODS: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. RESULTS: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. CONCLUSION: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.     

Pharmacokinetics and clinical effect during continuous epidural infusion with ropivacaine 2.5 mg/ml or bupivacaine 2.5 mg/ml for labour pain relief

Background: Ropivacaine has shown less systemic toxicity than bupivacaine, and comparatively low muscle-blocking properties could constitute another advantage when used epidurally for obstetric pain relief. We aimed primarily to compare maternal and foetal drug disposition following continuous epidural infusion of ropivacaine or bupivacaine.
Methods: Twenty-four full-term, nulliparous women were randomized to continuous epidural infusion (10 ml/h) of ropivacaine 2.5 mg/ml or bupivacaine 2.5 mg/ml for labour pain relief in a double-blind, parallel-group design. Maternal blood samples were collected up to 24 h after the end of infusion as well as taken from the umbilical cord at the time of delivery. Sensory and motor block as well as analgesia were assessed. All the women were monitored by cardiotocography and neonatal assessment was performed.
Results: The sensory block was adequate for both drugs. Higher plasma levels (total and free) were seen with ropivacaine, although the infusion with bupivacaine continued on average for about 2 hours longer. However, the ratios between maternal and umbilical blood concentrations were similar for both drugs. Normal neonatal Apgar and neonatal adaptive capacity scores (NACS) were found in both groups.
Conclusion: A continuous epidural infusion of 25 mg/h ropivacaine or bupivacaine both produced good labour pain relief. Higher total and free plasma concentrations were seen for ropivacaine. The ratios between maternal and umbilical plasma levels were similar for both drugs.     

Postoperative analgesia using continuous lumbar epidural infusion of ropivacaine in comparison with bupivacaine

BACKGROUND: Epidural bupivacaine infusion is a commonly used technique for postoperative analgesia because of its motor-sparing properties. Recently a new long acting local anesthetic, ropivacaine, has become available. The aim of this study was to investigate the efficacy of ropivacaine and bupivacaine with regard to postoperative analgesia when administered continuously into the lumbar epidural space. METHODS: All patients were ASA I II and undergoing ipsi-lateral leg orthopedic surgery with epidural or combined spinal-epidural anesthesia. Patients were randomly assigned to following three groups: 0.1% ropivacaine (0.1 R); 0.2% ropivacaine (0.2 R); 0.125% bupivacaine (0.125 B). At the end of surgery, continuous infusion was begun at a rate of 6 ml.hr 1 after a bolus epidural administration of 5 ml of 0.2% ropivacaine in R groups and 0.25% bupivacaine in B group. Sensory and motor block, blood pressure, pulse rate, verbal pain score (VPS), analgesic consumption were assessed at 20 min, 1, 3, 10-20 hrs following the beginning of continuous infusion. RESULTS: Vital signs were stable at every measuring point in all groups. In 0.1 R group (n = 20), the spread of sensory block at 3 hrs after infusion was lower than 0.2 R group (n = 19), and VPS during the study was higher than 0.125 B group (n = 17). Bromage scale after 3 hrs was higher in 0.2 R group compared with 0.125 B group. The degree of sensory and motor block gradually decreased, resulting in little difference between the groups. When epidural anesthesia was spread over the surgical area throughout the study, 0.2 R or 0.125 B was sufficiently relieved from postoperative pain. CONCLUSIONS: After leg orthopedic surgery, 6 ml.hr-1 of 0.2 R or 0.125 B provided enough postoperative analgesia when the spread of anesthesia covered the operated area. 0.2 R would be better compared to 0.125 B in continuous epidural infusion for postoperative analgesia due to less systemic toxicity, even though it accompanies a little more intense motor block.     

Ropivacaine 2 mg/mL vs. bupivacaine 1.25 mg/mL with sufentanil using patient-controlled epidural analgesia in labour

BACKGROUND: In recent studies, minimum local analgesic concentrations have been defined as 0.93 mg/mL for bupivacaine and 1.56 mg/mL for ropivacaine for epidural analgesia for the first stage of labour, resulting in an analgesic potency ratio of 1 : 0.6. In the current study we compared ropivacaine and bupivacaine in a PCEA system (combined with sufentanil) taking this potency ratio into account but administering drug doses providing sufficient analgesia for all stages of labour. METHODS: In a prospective, double-blinded study 114 parturients were randomised to receive either ropivacaine 2 mg/mL with sufentanil 0.75 microg/mL or bupivacaine 1.25 mg/with sufentanil 0.75 microg/mL. After epidural catheter placement, PCEA was available with boluses of 4 mL, a lock-out time of 20 min and no basal infusion rate. We evaluated pain intensity during contractions, sensory and motor function, duration of labour, mode of delivery and neonatal outcome. Consumption of local anaesthetic and opioid drugs and PCEA system variables were recorded. RESULTS: Mean total consumption as well as mean hourly drug consumption was significantly increased in the ropivacaine-sufentanil group. No differences in analgesic quality, sensory or motor blocking potencies or neonatal outcome variables between groups were detected. Frequency of instrumental deliveries was significantly increased in the ropivacaine-sufentanil group. CONCLUSIONS: The results support the findings of previously published studies postulating ropivacaine to be 40-50% less potent for labour epidural analgesia compared to bupivacaine. However, we observed an increased frequency of instrumental deliveries with ropivacaine. To evaluate the clinical relevance of these findings, further investigations are warranted.     

Patient-controlled epidural analgesia versus continuous epidural infusion with ropivacaine for postoperative analgesia in children

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 +/- 0.08 mg x kg(-1) x h(-1) versus 0.40 +/- 0.08 mg x kg(-1) x h(-1); P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA. IMPLICATIONS: We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.     

PCEA compared to continuous epidural infusion in an ultra-low-dose regimen for labor pain relief: a randomized study

BACKGROUND: Patient-controlled epidural analgesia, PCEA, has been introduced in obstetric analgesia during the past decade. Many studies have shown that the consumption of analgesic is reduced when the parturient requests her own doses. This study investigates whether this is also true when using an ultra-low-dose regimen. METHODS: Eighty parturients were prospectively randomized to have either continuous epidural infusion (CEI) with ropivacaine 1 mg ml-1 and sufentanil 0.5 micro g ml-1, 6 ml h-1, or patient-controlled epidural analgesia (PCEA) with 4 ml demand doses with 20 min' lockout. The epidural start dose was the same for the two groups, 8 ml of the study solution. Rescue bolus doses were given when needed and the continuous infusion could be increased, which gave the two groups the same maximum possible dose. The consumption of local ropivacaine in combination with sufentanil during labor was registered. Hourly assessments made throughout labor included pain intensity documented with visual analog score, VAS, the patient's opinion on epidural efficacy, motor block, pruritus and need for nitrous oxide. RESULTS: The PCEA group consumed 33% less of the study solution than the CEI group. Mean total consumption was 35 ml (SD 18.0) and 52 ml (SD 19.6), respectively. Mean hourly consumption was 5.2 ml h-1 (SD 2.54) in the PCEA group and 6.9 ml h-1 (SD 1.31) in the CEI group. There were no significant differences between the two groups in pain relief, epidural efficacy, side-effects or obstetric outcome. CONCLUSION: PCEA reduces doses compared to continuous infusion even when ultra-low-dose local anesthetic with opioid is used. The PCEA technique provides individual titration of doses to an acceptable degree of pain relief.     

Patient-controlled epidural analgesia for labor pain: effect on labor, delivery and neonatal outcome of 0.125% bupivacaine vs 0.2% ropivacaine

The objective was to evaluate the influence of patient-controlled epidural analgesia (PCEA) using low doses of bupivacaine vs. ropivacaine, on labor pain, motor blockade, progression of labor, delivery and neonatal outcome. This randomized double blind study included 565 parturients. All received a 5-mL/h infusion and PCEA (5-mL boluses with a 20-min lockout, maximum volume 20 mL/h) of either 0.125% bupivacaine (n = 313: 165 nulliparous, 148 parous) or 0.2% ropivacaine (n = 252: 113 nulliparous, 139 parous). Pain score, lower limb motor block, sensory levels, local analgesic doses required, hemodynamic parameters, side effects and complications were assessed. Obstetric variables included cervical dilation at epidural insertion, incidence of ruptured membranes and their duration, use of oxytocin, fetal heart rate changes, duration of labor, mode and outcome of delivery, and use of invasive and non-invasive fetal monitoring. Neonatal characteristics included birth weight, Apgar scores, umbilical artery pH, serum bilirubin, hypoglycemia, need for assisted ventilation, sepsis or sepsis study, feeding difficulties and respiratory distress syndrome. Ropivacaine 0.2% was equianalgesic with 0.125% bupivacaine, but produced less motor block (P < 0.0001). There were no significant differences, however, in duration of labor, delivery type or neonatal outcome.     

Patient-controlled epidural analgesia during labor: a comparison of three solutions with a continuous infusion control

This study examined the efficacy of patient-controlled epidural analgesia (PCEA) during labor and compared the suitability of three different PCEA solutions. After establishing effective epidural analgesia with 12 ml of 0.25% bupivacaine, 72 parturients in active labor were randomly assigned to one of four groups: physician-controlled continuous epidural infusion using 0.125% bupivacaine (CEI); PCEA using 0.125% bupivacaine (B); PCEA using 0.125% bupivacaine with fentanyl 1 micrograms/ml (BF); and PCEA using 0.125% bupivacaine with fentanyl 1 micrograms/ml and 1:400,000 epinephrine (BFE). The CEI infusion was begun at 12-16 ml/h and adjusted to maintain a T10 sensory level and adequate pain relief. PCEA pumps were programmed to deliver a 6 ml/h basal infusion, 4 ml on-demand boluses, 10-min lockout intervals between doses, and a 20 ml hourly limit. Hemodynamic parameters, sensory level, quality of analgesia, duration of labor, overall satisfaction, and Apgar scores did not differ among groups. Compared with CEI, PCEA with plain bupivacaine did not decrease total local anesthetic usage or average hourly infusion rates during labor. However, addition of fentanyl (groups BF and BFE) decreased hourly infusion requirements. Average hourly infusion rates were 13.0 +/- 1.1 ml/h (B), 10.6 +/- 0.6 ml/h (BF), and 9.6 +/- 0.5 ml/h (BFE); group B differs from others (P less than 0.05). No instance of respiratory depression or complication secondary to PCEA was observed. Mild pruritus occurred only with fentanyl-containing solutions, whereas dense motor block developed more frequently with the epinephrine-containing solution.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patient-controlled epidural analgesia combined with patient-controlled intravenous analgesia for postoperative analgesia after Miles' operation for rectal cancer

A 69-year-old woman (156 cm, 53 kg) underwent a Miles' operation, total hysterectomy, resection of vagina, and thigh flap to vulva for rectal cancer. Before general anesthesia, an epidural catheter was inserted at T11-12 interspace, and 1.5% mepivacaine 7ml was administered. Sensory block level spread from T4 to L1. Anesthesia was induced with propofol and maintained with sevoflurane in air oxygen mixture. Operation was performed uneventfully. After the operation, postoperative analgesia was achieved with patient-controlled epidural analgesia (PCEA). The epidural solution of 0.06% ropivacaine with 4 microg x ml(-1) fentanyl and 20 microg x ml(-1) was connected to a PCA pump (i-Fuser, JMS, Japan) that was programmed as an 8 ml initial bolus, 4 ml x hr(-1) basal infusion, 2 ml bolus dose, and 10-min lockout interval. Although abdominal pain was well controlled by PCEA, intractable pain in the pelvic nerve region existed. Patient-controlled intravenous analgesia (IV-PCA) with fentanyl, ketamine, and lidocaine was added to PCEA. Then excellent pain relief was obtained without any side effects such as nausea, vomiting, drowsiness, and respiratory depression. It could be useful to use IV-PCA together with PCEA when wide spread postoperative analgesia is necessary.