Postoperative nausea and vomiting in children using patient-controlled analgesia: the effect of prophylactic intravenous dixyrazine

BACKGROUND: Although patient-controlled analgesia (PCA) with morphine provides a high degree of satisfactory postoperative analgesia in children, it is often associated with a high incidence of postoperative nausea and vomiting (PONV). Our aim in this study was to evaluate the prophylactic effect of dixyrazine, a phenothiazine with proven anti-emetic properties. METHODS: The incidence of nausea and vomiting was studied in 60 children using PCA after major surgery. The patients were randomised to receive either dixyrazine 0.25 mg kg-1 or placebo on the induction of anaesthesia in a double-blind, placebo-controlled design. The anaesthetic technique was standardised. The PCA pump was programmed to deliver bolus doses of morphine of 20 micrograms kg-1 with a continuous background infusion of 8-10 micrograms kg-1 h-1. Nausea, vomiting, sedation and pain scores were noted every 3 h for a period of 24 h. RESULTS: The morphine consumption of morphine was the same in both groups. During the stay in the recovery room the incidence of vomiting was 3% in the dixyrazine group compared to 30% in the placebo group (P < 0.05). On the ward, 57% versus 83% of the children vomited (P < 0.05). Rescue antiemetics were significantly lower, 30%, in the dixyrazine group compared to 60% in the placebo group (P < 0.05). Higher sedation scores were recorded for the dixyrazine group in the recovery room. No other adverse effects were found. CONCLUSION: A significant number of children using PCA with morphine after major surgery experience PONV. Although prophylactic dixyrazine reduces the incidence and severity of vomiting, the incidence still remains high.     

Paraplegia after thoracotomy--not caused by the epidural catheter

BACKGROUND: Paraplegia and peripheral nerve injuries may arise after general anaesthesia from many causes but are easily ascribed to central block if the latter has been used. CASE REPORT: A 56-yr-old woman, with Bechterev disease but otherwise healthy, was operated with left-sided thoracotomy to remove a tumour in the left lower lobe. She had an epidural catheter inserted in the mid-thoracic area before general anaesthesia was started. Bupivacaine 0.5% 5 ml was injected once and the infusion of bupivacaine 0.1% with 2 micrograms/ml fentanyl and 2 micrograms/ml adrenaline (5 ml/h) started at the end of surgery. The patient woke up with total paralysis in the lower limb and sensory analgesia at the level of T8, which remained unchanged at several observations. Laminectomy, performed 17 h after the primary operation, showed a large piece of a haemostatic sponge (Surgicel) compressing the spinal cord, which was then decompressed but the motor and sensory deficit remained virtually unchanged both then and a year later. CONCLUSIONS: This case shows--once again--that although central blocks may cause serious neurological complications and paraplegia, other causes are possible and have to be considered. However, all patients with an epidural catheter must be monitored for early signs and symptoms of an intraspinal process and the appropriate treatment has to be instituted instantly.     

Focus on mobilisation after lower abdominal surgery. A double-blind randomised comparison of epidural bupivacaine with morphine vs. lidocaine with morphine for postoperative analgesia

BACKGROUND: Epidural infusion of morphine, usually with bupivacaine, for postoperative pain relief has proved to be safe and effective. Lidocaine with its short duration of action and low toxicity may be an alternative to bupivacaine. The clinical importance of the choice of local anaesthetic drug on mobilisation after lower abdominal surgery has not been studied previously. METHODS: A total of 52 patients was randomised to epidural infusion of morphine (1.6-4.4 micrograms.kg-1.h-1) with either lidocaine (0.44-0.98 mg.kg-1.h-1) or bupivacaine (0.10-0.28 mg.kg-1.h-1) in a double-blind fashion. The time to mobilisation, degree of pain relief, blood pressure, respiration and motor function were recorded at regular intervals postoperatively for 40 h. Serum concentrations of lidocaine, its main metabolite monoethylglycinexylidide (MEGX) and bupivacaine were measured at 3, 15 and 40 h. RESULTS: There were no significant differences in the clinical characteristics between the two patient groups. There were no significant differences in the time from the end of surgery to the time the patients were able to stand without support (bupivacaine: median 24 h (interquartile range (IQR): 22-31), lidocaine: median 28 h (IQR 23-40), P = 0.15) or were able to walk without support (bupivacaine: median 46 h (IQR 28-62), lidocaine: median 48 h (IQR 35-54), P = 0.78). No significant differences between the groups were recorded with respect to pain relief, blood pressure, respiration, sedation score and motor function. The plasma concentration of lidocaine and bupivacaine increased significantly during the treatment period (P < 0.01 for both drugs), but not the concentration of MEGX. The highest venous lidocaine concentration was 17.5 mumol/l and the highest bupivacaine concentration was 18.8 mumol/l. There was a significant correlation between the concentration of both lidocaine and bupivacaine and the concentration of alpha 1-acid glycoprotein (AAG) (lidocaine: r = 0.77, P < 0.001, bupivacaine: r = 0.60, P < 0.001), suggesting that the free fraction of the drugs did not increase. No patients showed serious signs of toxicity. The epidural infusion rates remained stable in both groups during the study period. CONCLUSION: There were no clinically or statistically significant differences in the postoperative course after lower abdominal surgery in patients who received an epidural infusion of morphine combined with bupivacaine as compared to patients who received morphine with lidocaine. Further clinical studies to establish the place of lidocaine in postoperative epidural analgesia should be performed.     

Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty

BACKGROUND: After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus "on-demand" intravenous analgesia to "on-demand" intravenous analgesia alone. METHODS: Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. RESULTS: No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. CONCLUSION: Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.     

Postoperative Pain Therapy After Lumbar Disc Surgery

Summary  Object. This study was undertaken to determine whether a special postoperative pain administration of tramadol and diclofenac provides any benefits in patients who underwent microsurgical lumbar discectomy.  Methods. The study consisted of 60 patients undergoing microsurgical lumbar discectomy. Patients were randomly divided into two groups based on the postoperative pain management: 1) Group A (n=30): no standardized pain therapy; these patients received on demand different analgesics and at variable dosages which were selected by the neurosurgeons; 2) Group B (n=30): standardized pain therapy with specific dosages of tramadol and diclofenac in regular time intervals during the first 48 hours after surgery. After surgery follow-up data from a special standardized questionnaire were obtained for all 60 patients during the first 48–72 postoperative hours. The patients were asked for course and intensity of pain as well as about some specific circumstances of clinical therapy after surgery.  The postoperative pain intensity of patients treated with the special combination of tramadol and diclofenac was significantly diminished (24 hours after surgery: p=0.0002, 48 h: p=0.0047, 72 h: p=0.0034) in relation to the group without standardized pain therapy. Similarly, the frequency of breakthrough pain was significantly reduced (24 h: p=0.0001, 48 h: p=0.003, 72 h: p=0.004).  Conclusions. The results suggest that the application of tramadol and diclofenac during the first 48 hours after lumbar microdiscectomy results in a reduction in postoperative pain without complications. We suggest that the use of this combination can be a beneficial adjunct to lumbar disc surgery.     

The effect of intravenous tenoxicam on pruritus in patients receiving epidural fentanyl

In this prospective randomised study, pruritus and pain were evaluated in patients undergoing abdominal surgery during which epidural fentanyl was administered. All patients had an epidural catheter inserted at the time of surgery. Epidural fentanyl 100 micrograms was administered intra-operatively and infused at a concentration of 2 micrograms.ml-1 for 48 h postoperatively. All patients received a standard anaesthetic and, in addition, the study group had a 20 mg bolus of tenoxicam intravenously, intra-operatively. Patients receiving tenoxicam demonstrated significantly lower pruritus and pain scores at 30 min, 2, 4, 8 and 24 h postoperatively as well as reduced pethidine requirements for breakthrough pain in the first 24 h. In conclusion, tenoxicam 20 mg significantly reduces the incidence and severity of postoperative pruritus in patients who received peri-operative epidural fentanyl. In addition, it significantly reduces pain and further analgesic requirements postoperatively.     

腰椎间盘突出症419例3种非手术疗法疗效分析

为比较下腰痛非手术疗效,４１９例腰椎间盘突出症患者采用腰椎牵引（甲组１９５例）、激素硬膜外注射（乙组１９２例）及经皮穿刺椎间盘切吸术或胶原酶溶解术（丙组３２例）进行治疗和随访,采用改良Ｍａｃｎａｂ标准评定。结果：优良率甲组４９％,乙组６６％,丙组８４％,Ｐ＜０．０１;甲组疗效与病程相关,病程＜６个月疗效较好（Ｐ＜０．０５）;平均治疗次数有甲组＞乙组＞丙组的倾向。结论：单纯腰椎牵引对病程较短者疗效较好;病程较长,神经根刺激症状明显者加用激素硬膜外注射可提高疗效;经腰牵、激素硬膜外注射等非手术治疗无效者,如严格掌握适应证和操作技术,采用经皮穿刺椎间盘切吸术或胶原酶溶解术可取得很好疗效     

Side effects during continuous epidural infusion of morphine and fentanyl

Respiratory effects, nausea, somnolence, and pruritus were compared during a 48-hr period of continuous epidural morphine (n = 34) and fentanyl (n = 32) infusion in 66 patients following elective total replacement of the hip or knee joint. Respiratory effects were assessed by PaCO2. Side effects were assessed by visual analogue scale and considered to be present when the score was above 30. Assessment was made at preoperative visits then 3, 6, 12, 24, 36, and 48 hr after the epidural injection. The bolus dose and subsequent infusion rate were 3,900 +/- 1,300 micrograms and 427 +/- 213 micrograms.hr-1 for morphine, and 85 +/- 46 micrograms and 56 +/- 27 micrograms.hr-1 for fentanyl. Pain relief was similar in both groups. In the morphine group, PaCO2 elevation and nausea occurred over a period of more than 12 hr (P less than 0.05). In the fentanyl group, there was no PaCO2 change, and nausea was confined to the first few hours. Nausea was more severe (P less than 0.01 at six hours and more frequent (24 hr cumulative incidence, 53 vs 28%, P less than 0.05) in the morphine group. Somnolence was prominent within several hours in two-thirds of patients in both groups. Somnolence continued to decline thereafter in the morphine group, but it was demonstrable in approximately half of the patients throughout the second day in the fentanyl group. The incidence was higher in the fentanyl group at the 48th hr (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Bupivacaine 0.1% does not improve postoperative epidural fentanyl analgesia after abdominal or thoracic surgery

Epidural infusions of fentanyl, in a 10 micrograms.ml-1 concentration, combined with bupivacaine 0.1% were compared with epidural infusions of fentanyl alone for postoperative analgesia following abdominal or thoracic surgery. There were no detectable differences between the two groups in analgesia (mean visual analogue scale pain scores ranging between 15-35 mm), average infusion rates of 7-9 ml.hr-1, and serum fentanyl concentrations which reached 1-2 ng.ml-1. There was no difference in postoperative pulmonary function (pH, PaCO2, SaO2), or bowel function (time to flatus or po fluids). The incidence of side-effects including somnolence, nausea and vomiting, pruritus and postural hypotension was also similar. Of the patients receiving fentanyl and bupivacaine 0.1%, three developed a transient unilateral sensory loss to pinprick and ice, and two of these patients had unilateral leg weakness equal to a Bromage 1 score. The addition of bupivacaine 0.1% does not improve epidural infusions of fentanyl using a 10 micrograms.ml-1 concentration following abdominal or thoracic surgery.     

A comparison of spinal and epidural anaesthesia for hip arthroplasty

Spinal and epidural anaesthesia were compared in 65 patients undergoing hip arthroplasty, with regard to the degree of sensory and motor blockade, cardiovascular effects, operating conditions, the dose of propofol required to produce satisfactory hypnosis, and complications. Epidural anaesthesia was successful in 30 patients using an initial dose of 15 ml of 0.5% bupivacaine, and spinal anaesthesia in 32 patients, using 4 ml 0.5% isobaric bupivacaine. The two techniques were similar with regard to the level of sensory blockade (T8), degree of hypotension and perioperative haemorrhage. Differences occurred in the degree of motor blockade (mean Bromage score of 1 in the spinal group vs 3.86 in the epidural group) (P less than 0.05), time to achieve maximal cephalad spread (13 min in the spinal group vs 21 min in the epidural group) (P less than 0.05) and the dose of propofol required to produce adequate hypnosis (1.95 mg.kg-1.hr-1 in the spinal group vs 2.89 mg.kg-1.hr-1 in the epidural group) (P less than 0.05). Only seven patients required urethral catheterization in this spinal group compared with 14 in the epidural group (P less than 0.05). Spinal anaesthesia also proved advantageous by providing better operating conditions for the surgeon, with a lower incidence of patient movement.