Effect of continuous epidural 0.2% ropivacaine vs 0.2% bupivacaine on postoperative pain, motor block and gastrointestinal function after abdominal hysterectomy

Postoperative complications of epidural analgesia at hysterectomy for gynecologic malignancies: an analysis of the National Surgical Quality Improvement Program

Objective

The aim of this study was to identify the rate of 30-day postoperative complications after the use of epidural in women undergoing hysterectomy for gynecologic malignancy. Secondary outcome was the impact of epidural on hospital length of stay.

Methods

A retrospective cohort study was conducted using the American College of Surgeons’ National Surgical Quality Improvement Program database. This large dataset includes perioperative risk factors and 30-day post-operative outcomes from more than 680 hospitals. Women who underwent abdominal hysterectomy for a gynecologic malignancy from January 2014 to December 2017 were included. Adult patients (18 years or older) who underwent abdominal hysterectomy were identified using common procedure terminology and international classification of diseases codes. Only laparotomy cases were included, and minimally invasive cases (laparoscopy, transvaginal) were excluded due to the small prevalence of epidural cases in this cohort. All patients received general anesthesia. If patients were noted to have “epidural anesthesia” they were included in the epidural cohort and those receiving other adjuvant techniques (regional blocks or spinal anesthesia) were excluded. The primary outcome of interest was the 30-day occurrence of a pulmonary embolism, deep-vein thrombosis, pneumonia, and urinary tract infection. Those who received epidural analgesia were matched in a 1:1 ratio with a similar group of patients who did not receive epidural analgesia using a calculated propensity score to control for confounding factors.

Results

A total of 2035 (13.8%) patients undergoing abdominal hysterectomy for a gynecologic malignancy received epidural analgesia. 1:1 propensity-matched samples included 2035 patients in both epidural and no-epidural groups. Patient characteristics between groups were similar. Overall 30-day complication rates were higher in the epidural group (75.9% vs 62.0%, P<0.01). Specific complications that were higher in the epidural group included: blood transfusion (28.9% vs 22.8%); wound disruption (2.0% vs 1.1%); surgical site infection (10.1% vs 7.2%); and delay in return of bowel function (12.3% vs 9.3%) (all P<0.05). Hospital length of stay was significantly longer in the epidural group as compared with the no-epidural group (5.69 days vs 4.79 days, P<0.01) and readmissions were higher in the epidural group (10.5% vs 9.7%, P<0.01), but there was no difference in 30-day mortality between the groups (P=0.62).

Discussion

The rate of 30-day complications and length of stay among women undergoing an abdominal hysterectomy for gynecologic malignancy was higher for those who received epidural analgesia, but there was no difference in 30-day mortality. Although epidural analgesia can provide a number of benefits when used for postoperative pain control, the possible association with increased 30-day morbidity and length of stay needs to be considered.

Comparison of Epidural Analgesia Using 0.2% Bupivacaine and 0.2% Ropivacaine for the Management of Postoperative Pain in Major Orthopedic Surgery

Introduction

Ropivacaine is preferred over racemic bupivacaine for postoperative analgesia as it is less cardiotoxic and has high selectivity for sensory fibers. We aim to compare postoperative epidural analgesia using 0.2% bupivacaine and 0.2% ropivacaine in major lower limb orthopedic surgery.

Materials and Methods

In a prospective, randomized, double-blind study, 100 patients, aged 18-70 years, undergoing elective major lower limb orthopedic surgery under spinal anesthesia, were randomly allocated to receive either 7 ml ropivacaine 0.2% (Group R) or 7 ml bupivacaine 0.2% (Group B) for postoperative analgesia through a lumbar epidural catheter. The onset and duration of epidural analgesia, total epidural dose requirement, mean number of epidural topup, rescue analgesia, incidence of motor blockade, and adverse effects were recorded.

Results

No differences were noted in demographic data and hemodynamic variables in either group. The onset time of epidural analgesia was 10.46 min ± 0.68 (Group B) and 10.52 min ± 0.71 (Group R). The duration of analgesia was 253.10 ± 17.46 min (Group B) and 251.80 ± 15.77 min (Group R). The total analgesic dose requirement was 78.40 mg ± 6.93 in Group B while in Group R, it was 78.96 mg ± 6.79. Epidural topup requirement and the need for rescue analgesia were similar in both the groups. Motor blockade, hypotension, and nausea were noted more in Group B compared to Group R.

Conclusion

In patients undergoing major lower limb orthopedic surgery under subarachnoid block, epidural ropivacaine 0.2% produces effective postoperative analgesia similar to bupivacaine 0.2% with a distinct sensory-motor dissociation resulting in analgesia without motor blockade.

Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study

OBJECTIVE

The purpose of this study was to determine the effect of early oral bowel stimulation with osmotic laxatives on gastrointestinal function, postoperative nausea and vomiting (PONV) and pain in patients who undergo fast-track abdominal hysterectomy.

STUDY DESIGN

This was a double-blind, placebo-controlled study of 53 women who were assigned randomly to either laxative (magnesium oxide + disodium phosphate) or placebo that was initiated 6 hours after the operation. Primary outcome was time to first defecation; the number of vomiting episodes; nausea and pain score were assessed on a visual analogue scale.

RESULTS

Time to first postoperative defecation was a median of 45 hours in the laxative group and a median of 69 hours in the placebo group (P < .0001). There were no significant differences between groups in pain scores, PONV and the use of morphine or antiemetics. Postoperative hospitalization was a median of 1 day in the laxative group and of 2 days in the placebo group (P = .41).

CONCLUSION

Laxative improves recovery of gastrointestinal function after fast-track hysterectomy but has no significant effect on pain and PONV.

Epidural ropivacaine -- where are the benefits? A prospective, randomized, double-blind trial in patients with retropubic prostatectomy

BACKGROUND

In comparison with bupivacaine, ropivacaine exhibits comparable anaesthetic effects but with less motor impairment and systemic toxicity. However, the analgesic potency may differ. For example, ropivacaine during obstetric epidural analgesia provides an approximately 40% lower analgesic potency than bupivacaine. Equal visual analogue pain scores require significantly higher dosages of ropivacaine, and general statements about a favourable benefit-risk profile relative to that of bupivacaine may therefore have limited clinical impact. We addressed this topic in a male pain model by evaluating the analgesic efficacy of epidural ropivacaine 0.2% vs. bupivacaine 0.125% after retropubic prostatectomy.

METHODS

Forty patients scheduled for retropubic prostatectomy were randomly assigned to two groups (20 patients per group). In a double-blind prospective design, patient-controlled lumbar epidural analgesia was provided by ropivacaine 0.2% in the ropivacaine group and by bupivacaine 0.125% in the bupivacaine group. The primary endpoint was the total amount of local anaesthetic consumption. The secondary endpoints were the numeric rating scale scores for rest and dynamic pain and the degree of motor impairment.

RESULTS

Ropivacaine consumption was 60% higher (mean +/- standard deviation, 1372.5 +/- 108.3 mg) than that of bupivacaine (852 +/- 75.2 mg) (P < 0.001). There were no significant differences in the numeric rating scale scores and motor impairment.

CONCLUSIONS

In male patients, lumbar epidural administration of ropivacaine 0.2% after retropubic prostatectomy does not appear to provide benefits over bupivacaine 0.125%. Moreover, in view of the significantly higher drug requirements, general statements focusing on the favourable therapeutic index of ropivacaine may require critical analysis, at least during epidural administration.

[Use of ropivacaine for peridural postoperative analgesia]

OBJECTIVES

To describe pharmacology and toxicology of ropivacaine. To assess the clinical efficacy of ropivacaine when used for postoperative epidural analgesia and to provide recommendations for clinical practice.

DATA SOURCES

Search in the Medline data base of original articles in French and English published since 1995, using the following key words: ropivacaine, postoperative analgesia, epidural, caudal block.

STUDY SELECTION

Prospective randomised studies in adults and children were selected. Letters to editors and editorials were excluded.

DATA EXTRACTION

Articles have been analyzed: to determine the dose of ropivacaine required for postoperative epidural analgesia, to assess the benefits of combination of epidural ropivacaine and additives (opioids or other), to compare epidural ropivacaine and bupivacaine and to assess the use of ropivacaine via caudal route for paediatric postoperative analgesia.

DATA SYNTHESIS

20 mg h-1 of ropivacaine is required to provide effective analgesia. This dose produces a motor block in a significant number of patients. Combination with an opioid allows for a reduction in ropivacaine requirement and subsequently in the incidence of motor blockade. In adults, equipotency ratio of ropivacaine and bupivacaine varies between 1.5/1 and 1/1 depending upon the concentration used. At equipotent doses, early postoperative mobilisation is facilitated with ropivacaine. In case of paediatric caudal analgesia, this ratio is close to 1.

CONCLUSIONS

Epidural ropivacaine combined with opioid provide good postoperative pain relief. Reduction in the incidence of motor blockade and safe toxicological profile make this local anaesthetic a suitable alternative of bupivacaine for postoperative epidural analgesia.

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.

Management of gastrointestinal pain

Choice of an analgesic for gastrointestinal pain requires consideration of the cause of the pain, desired duration of pain relief, need for sedation, and potential side effects and toxicity, particularly in light of other drugs being used and effects on the gastrointestinal tract. It is imperative that close monitoring be continued to ensure that surgical lesions or worsening conditions are detected. Recent research in the field may lead to new drugs, drug combinations, and avenues of treatment that minimize the side effects of these drugs while maximizing their efficacy.

Anaesthesia for minimally invasive gastric and bowel surgery

It is of great importance that anaesthetic regimens match surgical procedures in regard to surgical time, in reducing organ dysfunction elicited by the anaesthesia and surgical trauma and by providing optimal post-operative pain treatment, leaving the possibility of early mobilization. New, rapidly eliminated anaesthetic drugs are, by virtue of their pharmacodynamic and pharmacokinetic profiles, optimal for use; combined with continuous thoracic epidurals with local anaesthetics and low-dose opioids, these drugs may permit reduction of various post-operative complications. Minimally invasive surgical techniques (e.g. laparoscopy) lead to serious anaesthesiological considerations concerning changes in haemodynamic and pulmonary parameters and intra-abdominal blood flow changes caused by increased intra-abdominal pressures. Few studies have evaluated whether these changes affect surgical outcome and whether or not different anaesthetic regimens influence relevant morbidity parameters. In future documentation it is important that controlled, well-designed clinical studies evaluate how the advantages from multimodal anaesthetic techniques improve relevant surgical outcome.

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine

In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil.

IMPLICATIONS

After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.

Effect of epidural bupivacaine vs combined epidural bupivacaine and morphine on gastrointestinal function and pain after major gynaecological surgery

In a double-blind study, we investigated the effects of postoperative epidural local anaesthetic, with or without addition of epidural morphine, on postoperative pain and gastrointestinal function in patients scheduled for radical hysterectomy and pelvic lymphadenectomy. Forty patients were randomized into two study groups: 48-h postoperative epidural 0.2% bupivacaine 8 ml h(-1) (bupi group) or 48-h postoperative epidural 0.2% bupivacaine/morphine 50 microg at 4 ml h(-1) (bupi/morph group). Patients were observed for at least 96 h after surgery. No differences in pain at rest, during cough or mobilization were observed. Patients in the bupi group requested a significant greater amount of supplementary analgesics, but times to first flatus and defaecation were reduced compared with patients in the bupi/morph group. Itching was a significant problem in patients in the bupi/morph group. No differences in postoperative nausea and vomiting, mobilization or time to discharge from hospital were observed between groups. The addition of morphine to postoperative epidural bupivacaine has only limited effect on pain relief and increases time to normalization of gastrointestinal function.

Effect of peri- and postoperative epidural anaesthesia on pain and gastrointestinal function after abdominal hysterectomy

In a double blind study we have investigated the effects of epidural local anaesthesia (LA), when added to general anaesthesia (GA) and postoperative paracetamol and NSAID, on postoperative pain and gastrointestinal function in patients undergoing open hysterectomy. Sixty patients were randomized into three study groups: GA, and postoperative paracetamol and NSAID (GA, n=20); GA, paracetamol, NSAID, intraoperative epidural lidocaine and 24-h postoperative epidural saline (Saline, n=20); or GA, paracetamol, NSAID, intraoperative epidural lidocaine and 24-h postoperative epidural bupivacaine (Bupi, n=20). Patients were observed for 72 h postoperatively. Pain at rest, during cough, and mobilization, request for supplementary morphine, and time to first postoperative flatus, was reduced in patients receiving 24-h postoperative epidural anaesthesia, compared with the two other groups. However, these effects of epidural LA, were not sustained beyond the period of infusion, and no differences in PONV, time to first postoperative defecation, mobilization or time to discharge from hospital were observed between groups. A 24 h postoperative epidural infusion with bupivacaine, when added to postoperative paracetamol and NSAID, reduces pain and opioid requirements, but has only limited effects on gastrointestinal function and patient recovery.

A comparison of five solutions of local anaesthetics and/or sufentanil for continuous, postoperative epidural analgesia after major urological surgery

BACKGROUND AND OBJECTIVE

The aim of the present study was to compare and assess the quality of analgesia, the safety and the side-effects after the use of a continuous, thoracic epidural infusion of sufentanil (5 microg h(-1)), 0.25% bupivacaine (10 mL h(-1)), 0.2% ropivacaine (10 mL h(-1)) alone or in combination in patients who had undergone major urological surgery. This prospective, randomized, double-blinded study investigated the efficacy of thoracic epidural infusions after major urological surgery.

METHODS

Patients received a 72-h continuous infusion (10 mL h(-1)) of 0.25% bupivacaine (B), 0.2% ropivacaine (R), 0.25% bupivacaine with 0.5 microg mL(-1) sufentanil (BS), 0.2% ropivacaine with 0.5 microg mL(-1) sufentanil (RS) or 0.5 microg mL(-1) sufentanil only (S). The analysis included 109 patients.

RESULTS

The mean visual analogue scale (VAS) scores for pain were highest in the groups R and S (P < 0.001). The PaCO2 values were significantly higher in the groups RS and S (P = 0.003). Motor block occurred more frequently in the groups B and BS than in the other groups (P < 0.001). Sedation, nausea and pruritus were more common in the groups that received sufentanil.

CONCLUSIONS

A continuous, epidural infusion with these drugs was safe and effective in our patients. The combination of 0.2% ropivacaine plus sufentanil appeared preferable because of the low incidence of motor block.

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.

Patient-controlled interscalene analgesia with ropivacaine 0.2% versus bupivacaine 0.15% after major open shoulder surgery: the effects on hand motor function

We compared the effects of patient-controlled interscalene analgesia with ropivacaine 0.2% and patient-controlled interscalene analgesia (PCIA) with bupivacaine 0.15% on hand grip strength after major open shoulder surgery. Sixty patients scheduled for elective major shoulder surgery were prospectively randomized to receive in a double-blinded fashion either ropivacaine or bupivacaine through an interscalene catheter. Before surgery, all patients received an interscalene block (ISB) with either 40 mL of 0.6% ropivacaine or 40 mL of 0.5% bupivacaine. Six h after ISB, the patients received a continuous infusion of either 0.2% ropivacaine or 0.15% bupivacaine for 48 h. In both groups, the PCIA infusion rate was 5 mL/h plus a bolus of 4 mL with a lockout time of 20 min. Strength in the hand was assessed preoperatively, 24 h, and 48 h after ISB and 6 h after stopping the infusion of local anesthetic. The presence of paresthesia in the fingers was checked. Pain relief was assessed using a visual analog scale; side effects were noted, and the patients rated their satisfaction 54 h after the block. A significant decrease of strength in the hand was observed in the Bupivacaine group 24, 48, and 54 h after ISB (P < 0.05). Paresthesia was more frequently reported in the Bupivacaine group for the second and third fingers 48 h after ISB (P < 0.05) and in the first three fingers 6 h after discontinuation of the local anesthetic infusion (P: < 0.05). The pain score was similar in the two groups at all times, and patient satisfaction was comparable between the two groups. We conclude that the use of the PCIA technique with ropivacaine 0.2% or bupivacaine 0.15% provides a similar pain relief after major shoulder surgery. However, ropivacaine 0.2% is associated with better preservation of strength in the hand and less paresthesia in the fingers.

IMPLICATIONS

We compared the patient-controlled interscalene analgesia technique with ropivacaine 0.2% and bupivacaine 0.15% after major open shoulder surgery. For similar pain control ropivacaine is associated with better preservation of strength in the hand and less paresthesia in the fingers.