701
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Halonen P, Sarvela J, Saisto T, Soikkeli A, Halmesmäki E, Korttila K. Patient-controlled epidural technique improves analgesia for labor but increases cesarean delivery rate compared with the intermittent bolus technique. Acta Anaesthesiol Scand 2004; 48:732-7. [PMID: 15196106 DOI: 10.1111/j.0001-5172.2004.00413.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery. METHODS We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume. RESULTS Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups. CONCLUSION The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section.
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MESH Headings
- Adolescent
- Adult
- Analgesia, Epidural/methods
- Analgesia, Obstetrical/methods
- Analgesia, Patient-Controlled/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/therapeutic use
- Bupivacaine/administration & dosage
- Bupivacaine/therapeutic use
- Cesarean Section/statistics & numerical data
- Chi-Square Distribution
- Delivery, Obstetric/statistics & numerical data
- Female
- Fentanyl/administration & dosage
- Fentanyl/therapeutic use
- Humans
- Labor, Obstetric/drug effects
- Pain Measurement
- Patient Satisfaction/statistics & numerical data
- Pregnancy
- Statistics, Nonparametric
- Time Factors
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702
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Güneş Y, Seçen M, Ozcengiz D, Gündüz M, Balcioglu O, Işik G. Comparison of caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol administration for postoperative analgesia in children. Paediatr Anaesth 2004; 14:557-63. [PMID: 15200652 DOI: 10.1111/j.1460-9592.2004.01220.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare the effect of single-dose caudal ropivacaine, ropivacaine plus ketamine and ropivacaine plus tramadol in children for postoperative pain management. METHODS Following ethics committee approval and informed parental consent, 99 ASA PS I or II children, between 1 and 10 years of age, scheduled for elective inguinal hernia repair with general anaesthesia, were recruited. After induction of anaesthesia and placement of a laryngeal mask airway (LMATM), the patients were randomly divided into three groups to receive either caudal ropivacaine alone (0.4%, 2 mg x kg(-1)) in group R (n = 32) or ropivacaine (0.2%, 1 mg x kg(-1)) plus ketamine (0.25 mg x kg(-1)) in group RK (n = 33) or ropivacaine (0.2%, 1 mg x kg(-1)) plus tramadol (1 mg x kg(-1)) in group RT (n = 34) with a total volume of 0.5 ml x kg(-1). Systemic blood pressure (SBP and DBP), heart rate (HR), peripheral O2 saturation (SpO2), respiratory rate (RR), sedation and pain scores were recorded at 5, 10, 15 and 30 min, 1, 3, 4 and 6 h following recovery from anaesthesia. Pain was evaluated by Children's Hospital of Eastern Ontario Pain Scale, and sedation with a five-point sedation test. RESULTS No difference was found regarding age, weight and duration of operation between the groups (P > 0.05). No patient experienced hypotension, bradycardia or respiratory depression. Duration of analgesia was longer in group RT (1377 +/- 204 min) than group R (1006 +/- 506 min) (P = 0.001). In the tramadol group, fewer patients required supplementary analgesics in the first 24 h (P = 0.005). Sedation scores were below 2 in all groups. Incidence of postoperative nausea and vomiting was higher in group RT (eight patients) and group RK (seven patients) than group R (one patient, P = 0.032). CONCLUSIONS Ropivacaine (0.4%), ropivacaine (0.2%) plus ketamine (0.25 mg x kg(-1)) and ropivacaine (0.2%) plus tramadol (0.5 mg x kg(-1)) provided sufficient analgesia in children, but the duration of analgesia was longer in the RT group.
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703
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Lim Y, Sia AT, Ocampo CE. Comparison of intrathecal levobupivacaine with and without fentanyl in combined spinal epidural for labor analgesia. Med Sci Monit 2004; 10:PI87-91. [PMID: 15232517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2003] [Accepted: 01/22/2004] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The initiation of epidural infusion immediately after intrathecal (IT) injection to prolong labor analgesia has gained increasing popularity. The effect of additional intrathecal fentanyl on levobupivacaine for labor analgesia has not been fully investigated. We wished to determine if addition of IT fentanyl to IT levobupivacaine in combined spinal epidural (CSE) could prolong obstetric analgesia when epidural infusion is initiated promptly. MATERIAL/METHODS In this randomized controlled trial, 40 nulliparous parturients in labor were recruited to receive either IT 2.5 mg levobupivacaine (L) or IT 2.5 mg levobupivacaine + 25 microg fentanyl (LF). A 10 ml/h epidural infusion of 0.125% levobupivacaine and 2 microg/ml fentanyl was immediately started. The proportion of parturients who delivered without breakthrough pain and the duration of analgesia were analyzed with the x2 test and Kaplan-Meier technique (using a log-rank test), respectively. Sensory block, motor block, pain scores, and post-block side effects were also evaluated. RESULTS The percentage of parturients with "successful" blocks, i.e. parturients not requiring further analgesic supplementation, was significantly higher in LF (87.5% vs. 44%, p<0.05). The duration of analgesia was also significantly longer in group LF (mean 530 min +/- SE65 vs. 361 +/- 66, p<0.05). CONCLUSIONS The addition of 25 microg intrathecal fentanyl to 2.5 mg levobupivacaine as part of CSE for labor analgesia decreased the incidence of labor breakthrough pain and resulted in a longer duration of labor pain relief. This may decrease the need for supplemental labor pain relief and the anesthetists' workload in the delivery suite.
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704
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Vuori A, Salo M, Viljanto J, Pajulo O, Pulkki K, Nevalainen T. Effects of post-operative pain treatment using non-steroidal anti-inflammatory analgesics, opioids or epidural blockade on systemic and local immune responses in children. Acta Anaesthesiol Scand 2004; 48:738-49. [PMID: 15196107 DOI: 10.1111/j.1399-6576.2004.00404.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Many studies have been carried out on the effects of anaesthetic drugs and methods on the immune response, but pain and its relief also affect the immune response. We measured systemic immune responses in the blood circulation and local responses in the surgical wound when non-steroidal anti-inflammatory analgesics (NSAIDs), opioids or epidural blockade was used in the peri-operative treatment of pain. METHODS Responses were measured in 51 children, aged from 2 to 12 years and undergoing major surgery under balanced anaesthesia. Bolus doses of diclofenac intravenously (i.v.) and rectally (NSAID group), continuous i.v. infusion of oxycodone (opioid group) or continuous epidural infusion of bupivacaine + fentanyl (epidural group) were used peri-operatively for pain relief. RESULTS The only difference related to the analgesic method was shorter duration of post-operative leucocytosis and lower phytohaemagglutinin (PHA)-induced lymphocyte proliferative responses in peripheral blood in the opioid group than in the NSAID or epidural groups. By contrast, time-related alterations were seen overall in leucocyte and differential counts, lymphocyte and their subset counts, lymphocyte proliferative responses, and in serum cortisol, C-reactive protein, plasma interleukin-6 and group II phospholipase A2 concentrations and in the appearance of different cell types in the wound. CONCLUSIONS Post-operative pain treatments using diclofenac (NSAID), oxycodone (opioid) and epidural blockade have basically similar effects on systemic and local immune responses with only slight, probably clinically unimportant differences in children undergoing surgery under general anaesthesia.
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MESH Headings
- Analgesia, Epidural/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/immunology
- Analgesics, Opioid/therapeutic use
- Analysis of Variance
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/immunology
- Anesthetics, Local/therapeutic use
- Anti-Inflammatory Agents, Non-Steroidal/administration & dosage
- Anti-Inflammatory Agents, Non-Steroidal/immunology
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Bupivacaine/administration & dosage
- Bupivacaine/immunology
- Bupivacaine/therapeutic use
- Child
- Child, Preschool
- Diclofenac/administration & dosage
- Diclofenac/immunology
- Diclofenac/therapeutic use
- Female
- Fentanyl/administration & dosage
- Fentanyl/immunology
- Fentanyl/therapeutic use
- Finland
- Humans
- Immunity, Cellular/drug effects
- Immunity, Cellular/physiology
- Leukocyte Count
- Male
- Oxycodone/administration & dosage
- Oxycodone/immunology
- Oxycodone/therapeutic use
- Pain, Postoperative/drug therapy
- Pain, Postoperative/immunology
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705
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Akural EI, Salomäki TE, Bloigu AH, Ryhänen P, Tekay AH, Alahuhta SM, Surcel HM. The effects of pre-emptive epidural sufentanil on human immune function. Acta Anaesthesiol Scand 2004; 48:750-5. [PMID: 15196108 DOI: 10.1111/j.1399-6576.2004.00402.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Surgical stress and general anaesthesia suppress immune functions, including natural killer cell (NK) activity. This suppression could be attributed, at least in part, to the effect of opiates. METHODS Twenty patients undergoing abdominal hysterectomy received epidural sufentanil (50 microg) either before (pre-emptive) or at the end (control group) of surgery. Post-operative pain relief was provided using sufentanil from a patient-controlled epidural analgesia (PCEA) system. Systemic immunity was assessed by determining leucocyte counts, NK cell counts and activity, lymphocyte response to mitogen stimulation, and secretion of pro-inflammatory cytokines. RESULTS In the pre-emptive group there was a significant decrease in NK activity on the first and third post-operative day (P < 0.05) compared with baseline values and on the third postoperative day (P < 0.05) compared with the control group. The number of total leucocytes and neutrophiles increased in both groups post-operatively, but no differences were found in the levels of mononuclear lymphocyte populations or in their mitogen responses. Interleukin-6 (IL-6) concentration increased in both groups after the operation. In addition, at the end of the surgery the IL-6 level was greater in the control group than in the pre-emptive group. Interleukin-1 (IL-1) levels had decreased significantly at the end of surgery and 4 h later compared with baseline levels in the pre-emptive, but not in the control group. CONCLUSIONS Pre-emptive epidural sufentanil during combined propofol and isoflurane anaesthesia had minor effects on the immune response after hysterectomy. The lower production of pro-inflammatory cytokines (IL-1, IL-6) in the pre-emptive group compared with the control group is beneficial, but its clinical importance remains to be determined.
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706
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Klokocovnik T, Hollan J, Sostaric M, Pintar T, Mirkovic T. Minimally Invasive Aortic Valve Replacement under Thoracic Epidural Anesthesia in a Conscious Patient: Case Report. Heart Surg Forum 2004; 7:E196-7. [PMID: 15262601 DOI: 10.1532/hsf98.20041009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cardiopulmonary bypass and full median sternotomy have been recognized as major morbidity factors in cardiac surgery. Additional morbidity factors are general anesthesia and endotracheal intubation. Over the past several years high-thoracic epidural anesthesia (hTEA) has emerged as a potentially beneficial supplement to general anesthesia in the care of patients undergoing cardiac surgery. We report a case of ministernotomy aortic valve replacement performed with hTEA. The procedure was not converted to general anesthesia or to a conventional operation and was performed without adverse incidents. The patient was discharged from the hospital on the 2nd postoperative day. There were no complications within 30 days after surgery. This case demonstrates that thoracic epidural anesthesia without endotracheal intubation used for aortic valve replacement performed through ministernotomy is feasible. Further experience is necessary to determine the safety of this method and the effect on outcome.
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707
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Abstract
UNLABELLED Lumbar epidural analgesia has become a common mode of pain control for laboring patients. Side effects, such as hypotension, motor blockade, respiratory depression, dural puncture, and urinary retention, are well described. Although pressure sores have been thought of as a complication limited to elderly, emaciated, unconscious, or bedridden patients, we describe the occurrence of pressure sores in a young and healthy parturient after lumbar epidural analgesia. IMPLICATIONS We report a pressure sore that resulted from lumbar epidural analgesia for labor.
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708
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Bahar M, Chanimov M, Cohen ML, Friedland M, Shul I, Gofman V, Gershfeld S, Geller R, Sherman DJ. The lateral recumbent head-down position decreases the incidence of epidural venous puncture during catheter insertion in obese parturients. Can J Anaesth 2004; 51:577-80. [PMID: 15197121 DOI: 10.1007/bf03018401] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The unintentional and unrecognized cannulation of an extradural vein is a potentially serious complication of an epidural anesthetic. The present study was undertaken to assess the incidence of blood vessel puncture related to epidural catheterization in three different body positions, in a cohort of morbidly obese parturients, following the completion of a similar study published in 2001 from which such parturients were excluded. METHODS The study was conducted in 450 (three groups of 150) morbidly obese, obstetric patients undergoing continuous epidural analgesia during labour. Epidural catheterization was performed on patients randomized to the sitting, lateral recumbent horizontal, or lateral recumbent head-down position. RESULTS There was a lower incidence of vessel cannulation when this procedure was performed in the lateral recumbent head-down position [1.3%; body mass index (BMI): 37.0] than in the lateral recumbent horizontal [12.9%; BMI: 38.0] and in the sitting position [12.0%; BMI: 38.0]. The incidence of accidental subarachnoid puncture was 2%, 1.3% and 2% respectively, in these same positions. CONCLUSION Adoption of the lateral recumbent head-down position for the performance of lumbar epidural blockade, in labour at term, reduces the incidence of lumbar epidural venous puncture in these obese parturients.
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709
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Shine TSJ, Greengrass RA, Feinglass NG. Use of Continuous Paravertebral Analgesia to Facilitate Neurologic Assessment and Enhance Recovery After Thoracoabdominal Aortic Aneurysm Repair. Anesth Analg 2004; 98:1640-1643. [PMID: 15155317 DOI: 10.1213/01.ane.0000117149.87018.f2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Neurologic assessment after thoracic aortic aneurysm repair is important for detecting and treating late onset paraplegia. Traditional methods of pain control, such as patient-controlled IV analgesia and epidural analgesia, may interfere with neurologic assessment. We present a case of a patient who received continuous thoracic paravertebral analgesia that provided excellent analgesia while preserving the ability to monitor neurologic function. IMPLICATIONS We provided postoperative continuous paravertebral analgesia in a patient after thoracoabdominal aneurysm repair requiring postoperative neurologic assessment. Paravertebral analgesia provides unilateral analgesia with fewer neurologic and hemodynamic side effects than central neuraxial blockade and should be considered for management of patients undergoing thoracic aortic aneurysm repair.
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710
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Camorcia M, Capogna G, Lyons G, Columb M. Epidural test dose with levobupivacaine and ropivacaine: determination of ED 50 motor block after spinal administration. Br J Anaesth 2004; 92:850-3. [PMID: 15096445 DOI: 10.1093/bja/aeh155] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND When a test is required to detect a possible intrathecal catheter, many would seek to use the same local anaesthetic as that used for epidural analgesia. The rapid onset of inappropriate motor block after a local anaesthetic administered epidurally implies intrathecal spread. Because of claims of greater sensory-motor separation, or because of reduced potency compared with bupivacaine, the efficacy of the new local anaesthetics in intrathecal testing has been questioned. The aim of this study was to establish the feasibility of a test dose for an inadvertent intrathecal catheter using ropivacaine and levobupivacaine, and to establish the dose required. METHODS Sixty women undergoing elective Caesarean section with a combined spinal- epidural technique were enrolled into this prospective, double-blind sequential allocation study. The women were randomized to receive plain levobupivacaine 0.5% or ropivacaine 0.5% intrathecally. The dose was determined according to up-down sequential allocation. The end-point was any evidence of lower limb motor block within 5 min of injection. RESULTS The ED(50) motor block at 5 min was 4.8 mg (95% CI, 4.49, 5.28) for levobupivacaine and 5.9 mg (95% CI, 4.82, 6.98) for ropivacaine (95% CI difference, 0.052, 1.98) (P=0.04). The estimated ED(95) motor block was 5.9 mg (95% CI 5.19, 6.71) for levobupivacaine and 8.3 mg (95% CI, 6.30, 10.44) for ropivacaine. The potency ratio between the two drugs was 0.83 (95% CI, 0.69, 0.99). CONCLUSIONS Both local anaesthetics produce evidence of motor block within 5 min of intrathecal injection and could serve as tests of intrathecal administration. Derived ED(95) values suggest 10 mg doses should be effective, but this study did not measure predictive value. Ropivacaine is less potent for motor block than levobupivacaine by a factor of 0.83 (P<0.04).
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711
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Perren F, Buchser E, Chédel D, Hirt L, Maeder P, Vingerhoets F. Spinal cord lesion after long-term intrathecal clonidine and bupivacaine treatment for the management of intractable pain. Pain 2004; 109:189-94. [PMID: 15082141 DOI: 10.1016/j.pain.2003.11.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2003] [Revised: 08/18/2003] [Accepted: 11/04/2003] [Indexed: 11/30/2022]
Abstract
Long-term intrathecal drug administration using implanted pumps is increasingly used in the treatment of chronic refractory pain [Anderson and Burchiel 1999, Neurosurgery 44 (1999) 289; Krames 2002, Best Pract Res Clin Anaesthesiol 16 (2002) 619; Wallace 2002, Neurology 59 (2002) S18]. Extensive clinical experience over the last 15 years suggests that in selected cases the technique is safe, although infections, system malfunction and drug-related complications have been reported. In most cases, drug-related spinal cord injuries have resulted from the compression of a spinal inflammatory mass or abcess rather than from a direct neurotoxic effect. We report on a case of toxic spinal cord lesion occurring after more than 3 years of uneventful continuous infusion of a mixture of bupivacaine and clonidine.
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712
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Borghi B, Agnoletti V, Ricci A, van Oven H, Montone N, Casati A. A Prospective, Randomized Evaluation of the Effects of Epidural Needle Rotation on the Distribution of Epidural Block. Anesth Analg 2004; 98:1473-8, table of contents. [PMID: 15105234 DOI: 10.1213/01.ane.0000111113.45743.b8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED We evaluated the effects of turning the tip of the Tuohy needle 45 degrees toward the operative side before threading the epidural catheter (45 degrees -rotation group, n = 24) as compared to a conventional insertion technique with the tip of the Tuohy needle oriented at 90 degrees cephalad (control group, n = 24) on the distribution of 10 mL of 0.75% ropivacaine with 10 microg sufentanil in 48 patients undergoing total hip replacement. The catheter was introduced 3 to 4 cm beyond the tip of the Tuohy needle. A blinded observer recorded sensory and motor blocks on both sides, quality of analgesia, and volumes of local anesthetic used during the first 48 h of patient-controlled epidural analgesia. Readiness to surgery required 21 +/- 6 min in the control group and 17 +/- 7 min in the 45 degree-rotation group (P > 0.50). The maximum sensory level reached on the operative side was T10 (T10-7) in the control group and T9 (T10-6) in the 45 degree-rotation group (P > 0.50); whereas the maximum sensory level reached on the nonoperative side was T10 (T12-9) in the control group and L3 (L5-T12) in the 45 degree-rotation group (P = 0.0005). Complete motor blockade of the operative limb was achieved earlier in the 45 degree-rotation than in the control group, and motor block of the nonoperative side was more intense in patients in the control group. Two-segment regression of sensory level on the surgical side was similar in the two groups, but occurred earlier on the nonoperative side in the 45 degree-rotation group (94 +/- 70 min) than in the control group (178 +/- 40 min) (P = 0.0005). Postoperative analgesia was similar in the 2 groups, but the 45 degree-rotation group consumed less local anesthetic (242 +/- 35 mL) than the control group (297 +/- 60 mL) (P = 0.0005). We conclude that the rotation of the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter provides a preferential distribution of sensory and motor block toward the operative side, reducing the volume of local anesthetic solution required to maintain postoperative analgesia. IMPLICATIONS Turning the Tuohy introducer needle 45 degrees toward the operative side before threading the epidural catheter is a simple maneuver that produces a preferential distribution of epidural anesthesia and analgesia toward the operative side, minimizing the volume of local anesthetic required to provide adequate pain relief after total hip arthroplasty.
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713
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Tan CNH, Guha A, Scawn NDA, Pennefather SH, Russell GN. Optimal concentration of epidural fentanyl in bupivacaine 0.1% after thoracotomy. Br J Anaesth 2004; 92:670-4. [PMID: 15033892 DOI: 10.1093/bja/aeh129] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim of this prospective, double-blind, randomized controlled trial was to investigate the analgesic and adverse effects of three commonly used concentrations of thoracic epidural fentanyl with bupivacaine in patients undergoing thoracotomy for lung resection. METHODS We studied 99 patients who were randomized to receive fentanyl 2 microg ml(-1) (group 2), fentanyl 5 microg ml(-1) (group 5) and fentanyl 10 microg ml(-1) (group 10) in bupivacaine 0.1% via a thoracic epidural. Postoperatively, pain on coughing was assessed using a visual analogue scale (VAS) and an observer verbal rating score (OVRS) at 2, 8, 16 and 24 h. At the same times, sedation, pruritus and nausea were assessed. RESULTS Of 29, 28 and 32 patients who completed the study in groups 2, 5 and 10 respectively, there was no significant difference in baseline characteristics between the three groups. The number of patients with episodes of unsatisfactory pain, i.e. VAS scores >30 mm and OVRS >1, at each of the four assessments postoperatively was significantly (P<0.01) higher in group 2 than in groups 5 and 10. In group 10, 16 patients had sedation scores >1 compared with 10 each in groups 2 and 5. In addition, 19 patients in group 10 experienced pruritus compared with 12 each, in groups 2 and 5. These differences were not significant. Nausea was not significantly different between the three groups. CONCLUSION We conclude that thoracic epidural fentanyl 5 microg ml(-1) with bupivacaine 0.1% provides the optimum balance between pain relief and side effects following thoracotomy.
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714
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715
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Bansal S, Turtle MJ. Inadvertent subdural spread complicating cervical epidural steroid injection with local anaesthetic agent. Anaesth Intensive Care 2004; 31:570-2. [PMID: 14601282 DOI: 10.1177/0310057x0303100512] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although cervical epidural steroid injection with local anaesthetic is considered a safe technique and widely practiced, complications may occur. We report a patient experiencing unexpected delayed high block, moderate hypotension and unconsciousness eight to ten minutes after an apparently normal cervical epidural steroid injection. The most probable diagnosis was a subdural block. Anatomical peculiarities of the epidural and subdural space in the cervical region increase the risk of subdural spread during cervical epidural injection. Fluoroscopic guidance is important during cervical epidural injection to increase certainty of correct needle placement, thus minimizing the risk of complications.
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716
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Tamai H, Sawamura S, Kanamori Y, Takeda K, Chinzei M, Hanaoka K. Thoracic epidural catheter insertion using the caudal approach assisted with an electrical nerve stimulator in young children. Reg Anesth Pain Med 2004; 29:92-5. [PMID: 15029542 DOI: 10.1016/j.rapm.2003.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We evaluated whether thoracic epidural catheter placement using the caudal approach and assisted with an electrical stimulator could be performed in young children. METHODS Ten young children (1-4 years) who underwent abdominal surgeries were studied. Under general anesthesia without muscle relaxants, caudal catheter placement was performed using an 18-gauge Crawford-type needle and a 20-gauge radiopaque epidural catheter with a stainless-steel stylet. A metal adapter and a 3-way stopcock were attached to the catheter to connect to an electrical stimulator and to inject physiological saline. Electrical stimulation was performed intermittently while advancing the catheter until it reached the target length. The catheter position was confirmed on postoperative roentgenogram. RESULTS The mean age of the subjects was 32.2 +/- 10.1 months (13-48 months), and the height was 85.3 +/- 6.1 cm (72-93 cm). In 9 of 10 patients, an epidural catheter could be placed at the first insertion. In 1 patient, the catheter could be placed successfully at the second insertion. The electrical current required for muscle contraction at the target length was 5.8 +/- 1.5 mA. CONCLUSION Electrical stimulation reliably indicated the location of the catheter tip. This technique for thoracic epidural catheter insertion was easy to perform and could be used in young children.
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717
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Lee I, Yamagishi N, Oboshi K, Yamada H. Eliminating the effect of epidural fat during dorsolumbar epidural analgesia in cattle. Vet Anaesth Analg 2004; 31:86-9. [PMID: 15053745 DOI: 10.1111/j.1467-2987.2004.00150.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the distribution of new methylene blue (NMB) solution injected into either the subperiosteal space or under the epidural fat at the first and second lumbar vertebral interspace in cattle. STUDY DESIGN Prospective experimental study. SAMPLE POPULATION Nine nonpregnant cows. METHODS Needles were advanced towards the first interlumbar epidural space using a dorsal mid-line approach. Upon confirmation of successful penetration of the ligamentum flavum, group 1 received 5 mL of 0.12% NMB in 0.9% saline. In group 2, the needle was slowly advanced a further 7-10 mm to ensure injection under the epidural fat; the same dose was injected. The extent of cranial and caudal migration of dye, as indicated by staining of epidural fat and the dura mater was measured. RESULTS In group 1 (n = 4), NMB solution migrated only between the periosteum and the epidural fat. There was unilateral distribution in two cows. In contrast, there was no difference between left- and right-sided distribution in group 2 (n = 5), and the NMB solution migrated only between epidural fat and the dura mater. Although the dura mater was not penetrated in any animal of group 2, the dorsal roots were slightly stained and the overlying dura mater was heavily stained in these animals. CONCLUSIONS AND CLINICAL RELEVANCE Variation in distribution of local anaesthetic solution can probably be overcome by deeper needle penetration of the epidural fat.
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718
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Heller AR, Litz RJ, Koch T. A fine balance'one-lung ventilation in a patient with Eisenmenger syndrome. Br J Anaesth 2004; 92:587-90. [PMID: 14977800 DOI: 10.1093/bja/aeh104] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
A 38-yr-old woman with an atrial septum defect and Eisenmenger syndrome was scheduled for a lung biopsy via thoracoscopy during one-lung ventilation. Fluids were given to increase central venous pressure to 8 mm Hg, an epidural catheter was inserted at the sixth thoracic intervertebral space and ropivacaine 0.3%, 6 ml were given. Careful balance of systemic and pulmonary vascular resistance is crucial in Eisenmenger syndrome, so norepinephrine (0.14 mg kg(-1) min(-1)) was infused before general anaesthesia was started with fentanyl 4 mg kg(-1), ketamine 2 mg kg(-1), pancuronium 1 mg and succinylcholine 2 mg kg(-1). Anaesthesia was maintained with propofol 4-8 mg kg(-1) h(-1). To control pulmonary artery pressure, ventilation was performed with oxygen 100% and nitric oxide 20 ppm. Surgery and anaesthesia course were uneventful and the patient was extubated. However, pleural haemorrhage required treatment with blood components, re-intubation on the second postoperative day and removal of the haematoma by mini-thoracotomy. A step-by-step approach using a balanced combination of regional and general anaesthesia, controlled fluid administration, norepinephrine and inhaled nitric oxide preserved a stable circulation even during one-lung ventilation. The diagnostic value of lung biopsy must be weighed against the possibility of life-threatening haemorrhage.
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719
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720
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Tsui BCH, Wagner A, Cave D, Kearney R. Thoracic and lumbar epidural analgesia via the caudal approach using electrical stimulation guidance in pediatric patients: a review of 289 patients. Anesthesiology 2004; 100:683-9. [PMID: 15108986 DOI: 10.1097/00000542-200403000-00032] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nerve stimulation guidance (Tsui test) has been reported to be an effective alternative to radiographic imaging for proper catheter placement. The purpose of this study was to examine the success rate and complications of continuous caudal epidural analgesia since the implementation of routine use of the Tsui test at the authors' institution. METHODS The authors examined prospectively collected data in their pediatric pain service database from 289 children who had attempted caudal placement of a lumbar or thoracic catheter between 1999 and 2002. RESULTS In five patients (aged 5 months-1.6 yr), the catheter did not thread to the desired level and was abandoned in the operating room (technical success rate, 98.2%). Of the remaining 284 patients, the overall analgesic success rate of all caudal route epidural analgesia procedures was 84.9%. There was no significant difference in adequate pain control (success) in infants (aged 1 day-1 yr) versus older children (aged younger than 1 yr). The most common adverse effects were pruritus (26.1%) and nausea and vomiting (16.9%). Of the patients in our study, 57.7% had urinary catheters in situ; of those who did not have a catheter placed, 20.8% experienced urinary retention. The incidence of respiratory depression was 4.2%, but the administration of naloxone for severe respiratory depression was never necessary. Three percent of catheters were removed because of suspected contamination, but no epidural abscesses or systemic infection were noted. CONCLUSIONS The results of this study suggest that epidural catheter placement via the caudal approach using the Tsui test is an effective and reasonable alternative to direct lumbar and thoracic epidural analgesia in pediatric patients.
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721
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Martindale SJ, Dix P, Stoddart PA. Double-blind randomized controlled trial of caudal versus intravenous S(+)-ketamine for supplementation of caudal analgesia in children. Br J Anaesth 2004; 92:344-7. [PMID: 14742331 DOI: 10.1093/bja/aeh076] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The postoperative analgesic efficacy of S(+)-ketamine after caudal or i.v. administration following sub-umbilical surgery in children was studied to investigate its principal site of analgesic action. METHODS Sixty children undergoing caudal block during general anaesthesia for hernia repair or orchidopexy were prospectively randomized to one of three groups: the bupivicaine group received plain bupivacaine 0.25% 1 ml x kg(-1); the caudal ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) with S(+)-ketamine 0.5 mg x kg(-1); the i.v. ketamine group received caudal plain bupivacaine 0.25% 1 ml x kg(-1) plus S(+)-ketamine 0.5 mg x kg(-1) i.v. Postoperative measurements included analgesic requirements and modified objective pain score for the first 24 h. RESULTS The median time to first analgesia was significantly longer in the caudal ketamine group (10 h) than in the i.v. ketamine (4.63 h) or bupivacaine (4.75 h) groups (P=0.01). Significantly fewer doses of analgesia were required over the first postoperative 24 h by subjects in the caudal ketamine group (median 1) compared with the i.v. ketamine (median 2) or bupivacaine (median 2.5) groups (P<0.05). There was no difference between the groups in the incidence of postoperative nausea and vomiting or psychomotor reactions. CONCLUSIONS We have demonstrated that the addition of caudal S(+)-ketamine to bupivacaine prolongs the duration of postoperative analgesia. However, the same dose of i.v. S(+)-ketamine combined with a plain bupivacaine caudal provides no better analgesia than caudal bupivacaine alone, indicating that the principal analgesic effect of caudal S(+)-ketamine results from a local neuroaxial rather than a systemic effect.
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722
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Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coccydynia. Spine J 2004; 4:138-40. [PMID: 15016390 DOI: 10.1016/j.spinee.2003.07.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2002] [Accepted: 07/31/2003] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Coccydynia is a painful condition of the terminal portion of the spine often resulting from direct trauma, childbirth or unknown etiology. This is a relatively rare condition with no universally accepted treatment protocol. PURPOSE To more clearly determine the optimal treatment for patients with coccydynia and to assess the outcomes after conservative and surgical therapy. STUDY DESIGN Retrospective review of outcomes of all patients presenting with symptoms of coccydynia during a 5-year period. PATIENT SAMPLE Thirty-two patients presented to an orthopedic spine surgeon during a 5-year period with symptoms of coccydynia. OUTCOME MEASURES Patients completed visual analog pain scales (VAS) and the Oswestry (OSW) functional capacity index. METHODS Of the 32 patients in the study, 4 (13%) were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) alone, 17 (53%) were treated with NSAIDs followed by local injections and 11 (34%) underwent coccygectomy after failure of NSAIDs and local injections. Patients completed VAS and OSW forms. Pain drawings were also completed. RESULTS Patients undergoing surgery had significantly greater pretreatment VAS scores (8.3 vs 5.4, p=.002). Surgical patients also had greater OSW scores, but not significantly (36.6 vs 24.2, p=.223). Marked improvement was reported by 9 of 11 (82%) surgical patients. Three of 11 (27%) surgical patients developed wound infections and 1 (9%) wound dehiscence. All infections resolved following irrigation and debridement and a short course of oral antibiotics. CONCLUSIONS Patients with coccydynia should be managed conservatively when possible. Treatment should include NSAIDs and local steroid injections. Patients will often require repeat injections over time. Surgery can offer reasonable results for patients failing conservative treatment, but they should be warned of the high rate of infection.
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Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47:271-7; discussion 277-8. [PMID: 14991487 DOI: 10.1007/s10350-003-0055-0] [Citation(s) in RCA: 286] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND For patients undergoing colonic surgery, the postoperative hospital stay is usually 6 to 10 days, and the morbidity rate is 15 to 20 percent. Fast-track rehabilitation programs have reduced the hospital stay to 2 to 3 days. The aim of this study was to evaluate the postoperative outcome after colonic resection with conventional care compared with fast-track multimodal rehabilitation. METHODS One hundred thirty consecutive patients receiving conventional care (group 1) in one hospital were compared with 130 consecutive patients receiving multimodal, fast-track rehabilitation (group 2) in another hospital. Outcomes were time to first defecation after surgery, postoperative hospital stay, and morbidity during the first postoperative month. RESULTS Median age was 74 years (group 1) and 72 years (group 2). American Society of Anesthesiologists (ASA) score was significantly higher in group 2 ( P < 0.05). Defecation occurred on day 4.5 in group 1 and day 2 in group 2 ( P < 0.05). Median hospital stay was 8 days in group 1 and 2 days in group 2 ( P < 0.05). The use of a nasogastric tube was longer in group 1 ( P < 0.05). The overall complication rate (35 patients) was lower in group 2 ( P < 0.05), especially cardiopulmonary complications (5 patients; P < 0.01). Readmission was necessary in 12 percent of cases for group 1 and 20 percent in group 2 ( P > 0.05). CONCLUSIONS Time to first defecation, hospital stay, and morbidity may be reduced after colonic resection with fast-track multimodal rehabilitation.
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Purdie NL, McGrady EM. Comparison of patient-controlled epidural bolus administration of 0.1% ropivacaine and 0.1% levobupivacaine, both with 0.0002% fentanyl, for analgesia during labour. Anaesthesia 2004; 59:133-7. [PMID: 14725515 DOI: 10.1111/j.1365-2044.2004.03582.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of the study was to compare the relative potencies and clinical characteristics of epidural ropivacaine and levobupivacaine in labour using patient-controlled epidural analgesia (PCEA). In a randomised double-blinded study, 60 ASA I or II primigravidae requesting epidural analgesia in early labour were allocated to receive either 0.1% ropivacaine with fentanyl 0.0002% or 0.1% levobupivacaine with 0.0002% fentanyl via a patient-controlled analgesia pump. Analgesia was established with 15 ml of study solution and maintained using 5-ml boluses of study solution with a 5-min lockout interval. There were no significant differences in onset time, duration and quality of analgesia, motor and sensory blockade, local anaesthetic consumption, mode of delivery, neonatal outcome or maternal satisfaction between the groups. We conclude that 0.1% ropivacaine with 0.0002% fentanyl and 0.1% levobupivacaine with 0.0002% fentanyl are clinically indistinguishable for labour analgesia and appear pharmacologically equipotent when using PCEA.
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725
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Paterson K, Kuehne J. Intrathecal morphine vs psoas compartment block for hip surgery. Can J Anaesth 2004; 51:190; author reply 190-1. [PMID: 14766706 DOI: 10.1007/bf03018788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
MESH Headings
- Amides/administration & dosage
- Analgesia, Epidural/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthesia, General
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Arthroplasty, Replacement, Hip
- Bupivacaine/administration & dosage
- Bupivacaine/adverse effects
- Hip Joint/innervation
- Hip Joint/surgery
- Humans
- Injections, Spinal
- Morphine/administration & dosage
- Morphine/adverse effects
- Nerve Block
- Pain, Postoperative/prevention & control
- Postoperative Care/methods
- Prilocaine/administration & dosage
- Prilocaine/adverse effects
- Psoas Muscles
- Ropivacaine
- Time Factors
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