Postoperative epidural bupivacaine-morphine therapy. Experience with 4,227 surgical cancer patients

Peripheral nerve blocks with liposomal bupivacaine are associated with increased opioid use compared to thoracic epidural in patients with an epigastric incision

BACKGROUND

Thoracic epidurals are commonly recommended in enhanced recovery protocols, though they may cause hypotension and urinary retention. Peripheral nerve blocks using liposomal bupivacaine are a potential alternative, though they have not been extensively studied in major cancer operations with an epigastric incision.

METHODS

We conducted a retrospective review of prospectively collected data following the transition from thoracic epidural to liposomal peripheral nerve blocks in patients undergoing major oncologic surgery. Patients receiving peripheral nerve blocks were compared to those receiving thoracic epidural. Outcome variables included postoperative opioid use (milligram morphine equivalents [MME]), severe pain, and postoperative complications.

RESULTS

Forty-seven of 102 patients studied (46%) received peripheral nerve blocks. Opioid use was higher in the peripheral nerve block group during the 0-24 h (116 vs. 94 MME, p = 0.04) and 24-48 h postoperative period (94 vs. 23 MME, p < 0.01). There was no significant difference in severe pain, hypotension, urinary retention, or ileus. Peripheral nerve blocks were associated with earlier ambulation (1 vs. 2 days, p = 0.04), though other milestones were similar.

CONCLUSIONS

Liposomal peripheral nerve blocks were associated with increased opioid use compared to thoracic epidural. On the basis of our results, thoracic epidural might be preferred in surgical oncology patients with an epigastric incision.

Epidural Volume of Injectate Using a Dose Regimen Based on Occipito-Coccygeal Spinal Length (OCL): Randomized Clinical Study Comparing Different Ropivacaine Concentrations, with or without Morphine, in Bitches Undergoing Total Unilateral Mastectomy

A prospective, randomized clinical trial was designed to compare four epidural treatments in dogs undergoing total unilateral mastectomy. The epidural volume of injectate was based on the individual occipito-coccygeal length (OCL) aiming to reach the first thoracic vertebra (T1). The first ten dogs were allocated in a control group (C) and did not receive epidural treatment. Subsequently, forty dogs were randomly allocated in four groups of ten: epidural ropivacaine 0.5% (R0.5%); morphine 0.1 mg kg−1 plus ropivacaine 0.5% (MR0.5%); morphine 0.1 mg kg−1 plus ropivacaine 0.35% (MR0.35%); morphine 0.1 mg kg−1 plus ropivacaine 0.25% (MR0.25%). Intraoperatively, isoflurane requirement (1.3% vs. <1.1% FE’Iso) and fentanyl requirement (9.8 vs. <1.1 µg kg−1 h−1) were significantly higher in C group compared to all epidural groups. Postoperatively, methadone requirement was higher (1.8 mg kg−1 vs. <0.8 mg kg−1) for C group compared to all epidural treatment groups. The ability to walk and to urinate returned 4 h earlier in MR0.35% and MR0.25%. The mean epidural volume of ropivacaine, using a dose regimen based on OCL, to reach T1 was about 0.15 mL cm−1. The addition of morphine further reduced the methadone requirement, without affecting urinary and motor functions.

SBA 2020: Regional anesthesia safety recommendations update

The purpose of the Brazilian Society of Anesthesiology (SBA)’s Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

An Audit of Morphine versus Fentanyl as an Adjunct to Ropivacaine 0.2% for High Thoracic Epidural Analgesia

When used as an adjunct to local anaesthetic, opioid administered via the epidural route can improve the quality of analgesia. Reports of respiratory depression associated with epidural morphine use as a sole agent in the 1980s led to an increased use of lipophilic opioids, especially fentanyl. Although fentanyl is commonly used, controversy exists about its efficacy and site of action. It is possible that low-dose morphine may be more effective than fentanyl, without increasing the risk of respiratory depression.

A retrospective audit was conducted of 200 consecutive patients undergoing coronary artery bypass surgery who received high thoracic epidural analgesia.

One hundred patients who received fentanyl 2 μg/ml with 0.2% ropivacaine, prior to a change in our technique, were audited, followed by 100 patients who received 20 μg/ml morphine with 0.2% ropivacaine. Outcome measures included the incidence of Visual Analogue Score (VAS) ≥4/10; infusion rate adjustments; and side-effects. Patients receiving fentanyl were more likely to experience pain ≥4/10 (P'=0.002); the infusion rate was higher (P8=0.024); required more rate adjustments (P8=0.001); a greater need for noradrenaline (P'=0.001) and antiemetic drugs (P'=0.001). There were no significant differences between the groups for sedation scores or the incidence of respiratory depression.

This audit suggests morphine 20 μg/ml may be superior to fentanyl 2 μg/ml, as an adjunct to 0.2% ropivacaine. We found a reduced number of infusion interventions and less inadequate patient analgesia.

Protective role of LRRC3B in preventing breast cancer metastasis and recurrence post-bupivacaine

The present study aimed to investigate the potential effect of leucine-rich repeat containing 3B (LRRC3B) with respect to the inhibition of breast cancer recurrence and metastasis post-anesthesia. The mRNA expression of LRRC3B in breast MDA-MB-231 and MCF-7 cell lines was detected using reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analysis. The effect of bupivacaine on breast cancer cell invasion was analyzed using a Matrigel assay. LRRC3B specific small interfering (si)RNA was constructed and transfected into breast cancer cells using Lipofectamine^® 2000 reagent. The influence of bupivacaine on LRRC3B expression was measured based on RT-qPCR. Additionally, the effect of LRRC3B silencing on the invasion of breast cancer cells treated with bupivacaine was analyzed. Compared with the control, LRRC3B expression significantly increased in MDA-MB-231 and in MCF-7 cells as the length of time increased (P<0.05), but the expression of the gene significantly declined in 2 types of cancer cell when the cells were transfected with siRNA-LRRC3B plasma (P<0.05). The administration of 50 µg/ml bupivacaine promoted maximum breast cancer cell invasion, and suppressed LRRC3B mRNA expression in cells. However, when LRRC3B was silenced in cancer cells, 20 µg/ml bupivacaine significantly promoted cancer cell invasion, indicating that bupivacaine suppresses the expression of LRRC3B and promotes cell invasion. The present study suggested that LRRC3B serves a protective role in preventing bupivacaine-induced breast cancer recurrence and metastasis.

Practice Advisory for the Prevention, Diagnosis, and Management of Infectious Complications Associated with Neuraxial Techniques

Supplemental Digital Content is available in the text.

Management of acute postoperative pain with continuous intercostal nerve block after single port video-assisted thoracoscopic anatomic resection

BACKGROUND

Effective postoperative pain control for thoracic surgery is very important, not only because it reduces pulmonary complications but also because it accelerates the pace of recovery. Moreover, it increases patients' satisfaction with the surgery. In this study, we present a simple approach involving the safe placement of intercostal catheter (ICC) after single port video-assisted thoracoscopic surgery (VATS) anatomic resection and we evaluate postoperative analgesic function with and without it.

METHODS

We identified patients who underwent single port anatomic resection with ICC placed intraoperatively as a route for continuous postoperative levobupivacaine (0.5%) administration and retrospectively compared them with a group of single port anatomic resection patients without ICC. The operation time, postoperative day 0, 1, 2, 3 and discharge day pain score, triflow numbers, narcotic requirements, drainage duration and post-operative hospital stay were compared.

RESULTS

In total, 78 patients were enrolled in the final analysis (39 patients with ICC and 39 without). We found patients with ICC had less pain sensation numerical rating scale (NRS) on postoperative day 0, 1 (P=0.023, <0.001) and better triflow performance on postoperative day 1 and 2 (P=0.015, 0.032). In addition, lower IV form morphine usage frequency and dosage (P=0.009, 0.017), shorter chest tube drainage duration (P=0.001) and postoperative stay (P=0.005) were observed in the ICC group.

CONCLUSIONS

Continuous intercostal nerve blockade by placing an ICC intraoperatively provides effective analgesia for patients undergoing single port VATS anatomic resection. This may be considered a viable alternative for postoperative pain management.

Thoracic Epidural Analgesia

Thoracic epidural analgesia (TEA) offers a unique oppor tunity for the anesthesiologist to enhance postopera tive recovery for the thoracic surgery patient. By deliver ing analgesics to a limited dermatomal distribution, TEA can provide profound segmental analgesia and also serves to modulate neural outflow to improve cardiac and pulmonary parameters. The notable side-effects of hypotension and respiratory depression can be mini mized by using synergistic combinations of local anes thetic and opioids, and by adopting a continuous infu sion strategy. With thoughtful patient selection, careful technique, and a proactive approach to the recognition of the known hemodynamic and respiratory effects of epidural drugs, TEA can be administered safely. The significant benefits of TEA include better pain relief, increased FEV1, earlier extubation, and, perhaps, de creased morbidity and mortality.

Intrathecal morphine for postoperative pain control after laminoplasty in patients with cervical spondylotic myelopathy

OBJECTIVES

To examine the clinical efficacy of intrathecal morphine as postoperative analgesia for cervical laminoplasty.

SUMMARY OF BACKGROUND DATA

Patients who undergo posterior cervical spinal surgery frequently experience significant postoperative pain. Postoperative pain contributes to patient morbidity because of decreasing early voluntary mobilization and delayed rehabilitation. Intrathecal morphine is known to be a simple and effective analgesia. However, the effectiveness of intrathecal morphine for cervical spinal surgery has not yet been reported.

METHODS

Seventy-eight patients with cervical spondylotic myelopathy were divided into two groups prospectively, a diclofenac suppository (DS) group who received 50 mg diclofenac suppository at the end of the surgery, and an intrathecal morphine (ITM) group who were preoperatively administered 0.3 mg of morphine chloride, intrathecally, via a lumbar puncture. All patients underwent double-door laminoplasty of C3-6 or C3-7 level. Visual analog scale (VAS) of cervical pain, self-rating pain impression, supplemental analgesic usage, and complication rate were evaluated until the seventh postoperative day.

RESULTS

Thirty-one patients in the DS group and 32 patients in the ITM group were finally assessed. No baseline variable differences between the two groups were observed. The VAS was significantly lower in the ITM group at 4 h and 24 h until the seventh postoperative day. Self-rating pain impression was significantly better in the ITM group. No significant difference was observed in complication rate.

CONCLUSIONS

Intrathecal morphine was an effective and safe analgesic method for cervical laminoplasty in patients with cervical spondylotic myelopathy.

Challenges of pain control and the role of the ambulatory pain specialist in the outpatient surgery setting

Ambulatory surgery is on the rise, with an unmet need for optimum pain control in ambulatory surgery centers worldwide. It is important that there is a proportionate increase in the availability of acute pain-management services to match the rapid rise of clinical patient load with pain issues in the ambulatory surgery setting. Focus on ambulatory pain control with its special challenges is vital to achieve optimum pain control and prevent morbidity and mortality. Management of perioperative pain in the ambulatory surgery setting is becoming increasingly complex, and requires the employment of a multimodal approach and interventions facilitated by ambulatory surgery pain specialists, which is a new concept. A focused ambulatory pain specialist on site at each ambulatory surgery center, in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized, thus preventing emergency room visits, as well as readmissions for uncontrolled pain. This paper reviews methods of acute-pain management in the ambulatory setting with risk stratification, the utilization of multimodal interventions, including pharmacological and nonpharmacological options, opioids, nonopioids, and various routes with the goal of preventing delayed discharge and unexpected hospital admissions after ambulatory surgery. Continued research and investigation in the area of pain management with outcome studies in acute surgically inflicted pain in patients with underlying chronic pain treated with opioids and the pattern and predictive factors for pain in the ambulatory surgical setting is needed.

Management of post-operative pain by placement of an intraoperative intercostal catheter after single port video-assisted thoracoscopic surgery: a propensity-score matched study

BACKGROUND

The establishment of a golden standard for post-operative analgesia after thoracic surgery remains an unresolved issue. Benefiting from the rapid development of single port video-assisted thoracoscopic surgery (VATS), a good candidate for the alleviation of patients' pain is the placement of an intercostal catheter (ICC) safely after uniport VATS. We hypothesized that continual infusion through ICC could provide effective analgesia for patients with only one wound and we evaluate its postoperative analgesic function in uniport VATS patients with or without intercostal nerve blockade.

METHODS

Since March 2014, 235 patients received various kinds of single port VATS. We identified 50 patients who received single port VATS with intercostal nerve blockade and retrospectively compared them with a group of patients who had received single port VATS without intercostal nerve blockade. The operative time, post operation day 0, 1, 2, 3 and discharge day pain score, narcotic requirements, drainage duration and post-operative hospital stay were collected. In order to establish a well-balanced cohort study, we also used propensity scores matching (1:1) to compare the short term clinical outcome in two groups.

RESULTS

No operative deaths occurred in this study. The uniport VATS with intercostal nerve blockade group was associated with less post operation day 0 and day 1 pain score, and narcotic requirements in our cohort study (P<0.001, <0.001, and 0.003). After propensity scores matching, there were 50 patients in each group. Mean day 0 and day 1, day 2, day 3 pain score, drainage duration, post-operative hospital stay, and narcotic requirements were smaller in uniport VATS with intercostal nerve blockade (P<0.001, <0.001, 0.038, 0.007, 0.02, 0.042, and 0.003).

CONCLUSIONS

In conclusion, in patients post single port VATS, continual intercostal nerve block with levobupivacaine infusion appears to be a safe, effective and promising technique in our study, associated with a shorter hospital stay and less post-operative pain. Further prospective trials are needed to determine the long term outcomes.

Current evidence for spinal opioid selection in postoperative pain

Background

Spinal opioid administration is an excellent option to separate the desirable analgesic effects of opioids from their expected dose-limiting side effects to improve postoperative analgesia. Therefore, physicians must better identify either specific opioids or adequate doses and routes of administration that result in a mainly spinal site of action rather than a cerebral analgesic one.

Methods

The purpose of this topical review is to describe current available clinical evidence to determine what opioids reach high enough concentrations to produce spinally selective analgesia when given by epidural or intrathecal routes and also to make recommendations regarding their rational and safety use for the best management of postoperative pain. To this end, a search of Medline/Embase was conducted to identify all articles published up to December 2013 on this topic.

Results

Recent advances in spinal opioid bioavailability, based on both animals and humans trials support the theory that spinal opioid bioavailability is inversely proportional to the drug lipid solubility, which is higher in hydrophilic opioids like morphine, diamorphine and hydromorphone than lipophilic ones like alfentanil, fentanyl and sufentanil.

Conclusions

Results obtained from meta-analyses of RTCs is considered to be the 'highest' level and support their use. However, it's a fact that meta-analyses based on studies about treatment of postoperative pain should explore clinical surgery heterogeneity to improve patient's outcome. This observation forces physicians to use of a specific procedure surgical-based practical guideline. A vigilance protocol is also needed to achieve a good postoperative analgesia in terms of efficacy and security.

Highlights in postoperative pain treatment

Acute pain is a symptom that originates from actual ongoing or impending tissue damage. Pain is an individual subjective experience and varies markedly among individuals. For this reason, patient involvement is essential, with the most reliable indicator of severity being patient self-report. The main objective of postoperative pain management is the achievement of fast rehabilitation, recovery of all normal functions and reduction of postoperative morbidity. Sufficient evidence supports the hypothesis that effective analgesia modifies many of the adverse sequelae that accompany acute pain and assists in recovery. Nevertheless, despite the availability of drugs and techniques for its effective management, postoperative pain remains undertreated. It is now accepted that the solution to the problem of inadequate pain relief lies not only in the development of new analgesic drugs or technologies but also in the development of an appropriate organization to utilize existing expertise. Methods used to control postoperative pain are numerous; this review focuses on pharmacological and anesthetic methods.

Spinal opioid bioavailability in postoperative pain

Opioids have been used for spinal analgesia for more than a century, and their injection epidurally and intrathecally has a key role in the control of postoperative pain. Since the discovery of the endogenous opioid system, 3 decades ago, their use has become more generalized in obstetric analgesia, the management of chronic pain, and acute postoperative pain. To use opioids effectively for this type of analgesia, it is important to understand the pharmacokinetics and clinical pharmacology of these drugs, specifically those that produce analgesia by an intrinsic spinal mechanism. Evidence from animal and human experiments indicates that hydrophilic opioids (such as hydromorphone and morphine) bind more strongly to specific receptors within the dorsal horn of the spinal cord than lipophilic opioids (such as alfentanil, fentanyl, and sufentanil). This can be understood by considering the spinal cord selectivity and bioavailability of these opioids. This difference is attributable to differences in the pharmacokinetic and pharmacodynamic properties of the 2 groups. It is more difficult for lipophilic opioids to reach and remain at sufficiently high concentrations at the site of action due to their sequestration in epidural fat and rapid plasma clearance from both epidural and intrathecal spaces, resulting in analgesia with a limited spread and duration, as well as the appearance of early supraspinal side effects. In contrast, morphine has very different properties, including greater spinal bioavailability and therefore administered neuraxially, it is suitable choice for the treatment of acute postoperative pain. However, when using morphine, a greater incidence of adverse effects can be expected, and it requires careful patient selection.

Audit of complications in post-operative epidural analgesia and adherence to acute pain service protocols at an Indian cancer center

An audit of epidural anesthesia in an Indian teaching hospital is described. The authors reviewed Acute Pain Service (APS) documentation of epidural anesthesia and outcomes form the procedure over a 6-month period. Variances from established protocols were noted and reasons for these variances are discussed.

Patient-controlled Epidural Analgesia with Ropivacaine and Fentanyl: Experience with 2,276 Surgical Patients

Background

Good postoperative pain control is an important part of adequate postoperative care. Patient-controlled epidural analgesia (PCEA) provided better postoperative analgesia compared to other conventional analgesic methods, but several risks have been observed as well. We therefore surveyed the efficacy and safety of PCEA in this retrospective observational study.

Methods

We analyzed collected data on 2,276 elective surgical patients who received PCEA with ropivacaine and fentanyl. Patients were assessed by a PCA service team in the post-anesthesia care unit (PACU), at 1-6 h, 6-24 h, and 24-48 h postoperatively for adequate pain control. The presence of PCEA-related adverse events was also assessed.

Results

Numerical pain score (median [interquartile range]) were 3 [1-4], 5 [4-7], 4 [3-5], and 3 [3-5] in the PACU, at 1-6 h, 6-24 h, and 24-48 h postoperatively. Median pain scores in patients underwent major abdominal or thoracic surgery were higher than other surgical procedure in the PACU, at 1-6 h after surgery. Nausea and vomiting (20%) and numbness and motor weakness (15%) were revealed as major PCEA-related adverse events during the postoperative 48 h period. There were 329 patients (14%) for whom PCEA was ceased within 48 h following surgery.

Conclusions

Our data suggest that the use of PCEA provides proper analgesia in the postoperative 48 h period after a wide variety of surgical procedures and that is associated with few serious complications. However, more careful pain management and sustainable PCEA monitoring considering the type of surgical procedure undergone is needed in patients with PCEA.

Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery

BACKGROUND

Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques.

METHODS

A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed.

RESULTS

When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA.

CONCLUSIONS

Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.

Plasma Concentrations of Morphine during Postoperative Pain Control

Background

Morphine has been commonly used for postoperative pain control. We measured plasma concentrations of morphine and compared the efficacy and safety of continuous epidural analgesia (CEA) using morphine-bupivacaine with intravenous patient controlled analgesia (IV-PCA) with morphine for 48 hrs after the end of the operation.

Methods

Nineteen patients undergoing Mile's operation were assigned to receive a morphine loading dose of 5 mg followed by IV-PCA with 0.1% morphine (IV-PCA group, n = 9) or a morphine loading dose of 2 mg and 0.125% bupivacaine 10 ml, followed by CEA with 0.004% morphine and 0.075% bupivacaine at a rate of 5 ml/hr (CEA group, n = 10). The plasma concentrations of morphine were measured and visual analog scales (VAS) for pain were recorded at 1, 6, 12, 24, and 48 hr postoperatively and the effects on respiration and any other side effects were noted.

Results

The mean maximal and minimal levels of plasma morphine were 40.2 ± 21.2 ng/ml and 23.4 ± 9.7 ng/ml for the IV-PCA group and 11.8 ± 3.5 ng/ml and 8.2 ± 1.9 ng/ml for the CEA group, respectively. Resting and dynamic pain scores were significantly lower in the CEA group than in the IV-PCA group. There were no significant differences for the effects on respiration and for any side effects between the two groups.

Conclusions

We evaluated plasma concentrations of morphine with CEA using morphine-bupivacaine and IV-PCA using morphine for the postoperative pain control. The CEA group had better postoperative analgesia than that of the IV-PCA group and the incidence of side effects were not significantly different between the two groups.

Pharmacological strategies to reduce pruritus during postoperative epidural analgesia after lumbar fusion surgery - a prospective randomized trial in 150 patients

Background

Epidural analgesia with bupivacain, epinephrine and fentanyl provides excellent pain control after lumbar fusion surgery, but pruritus and motor block are frequent side effects. Theoretically epidural ropivacain combined with oral oxycodone could decrease the incidence of these side effects. The two regimens were compared in a prospective randomized trial.

Patients and methods

150 patients (87 women) treated with posterior instrumented lumbar fusion were included. The mean age was 51 +/- 11 years. 76 were randomized to bupivacain, epinephrine and fentanyl (group B) and 74 to ropivacain and oxycodone (group R). Pruritus, motor block and pain were measured 6 hours after surgery, thereafter 6 times per day for 5 days. Any pain breakthrough episode was registered whenever it occurred.

Results

The epidural treatment could be performed in 143 patients (72 in group B and 71 in group R). Disturbing pruritus occurred in 53 patients in group B compared to 12 in group R (p < 0.0001). Motor blockade was most frequent on day 1, occurring in 45% of the patients with no difference between the groups. Both regimes gave good pain control with average VAS under 40, but the pain relief was statistically better in group B. The number of pain breakthrough episodes did not differ between the groups.

Conclusions

Pruritus could be reduced with a combination of epidural ropivacain and oral oxycodone, at the price of a slightly higher pain level. Ropivacaine was not found to be superior to bupivacaine with regard to motor blocks.

Multiple nerve blocks after video-assisted thoracic surgery (VATS)

INTRODUCTION

Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS.

METHODS

At the end of the VATS wedge resection, two small incisions were made below and parallel to the position of the trocars, at the level of the anterior and posterior axillary line and an introducer was used to place a catheter subcutaneously. At this point, the introducer was curved, in a way to follow the anatomic shape of the costal margin of the patient, inserted into posterior incision and advanced in between the thoracic pleura and the ribs. Under direct vision from the thoracoscope and paying careful attention not to perforate the pleura, the guide was pushed toward the first rib by using a combination of blunt and hydro dissection. Once the guide reached the first rib, the introducer was removed and the catheter was left in place.

RESULTS

We evaluated 64 patients (29 patient-controlled analgesia (PCA), 35 SC). Propensity weighting produced two matched groups for further analysis. Mean total morphine dose and mean total morphine dose/body mass index (BMI) were both significantly decreased in the SC group for the 0-24 h period only (mean total morphine 38.1 vs. 27.8; P = 0.024 and mean total morphine/BMI 1.15 vs 0.79; P = 0.024). Complication rates did not differ between groups.

CONCLUSIONS

PCA narcotic analgesia with subpleural local anesthetic infusion provided similar pain control with less narcotic use in patients during the first 24 h after VATS lobectomy compared with PCA narcotic analgesia alone.

Treatment of pain in children after limb-sparing surgery: an institution's 26-year experience

A significant proportion of patients report long-term pain that is ≥5 on a 0-10 intensity scale after limb-sparing surgery for malignancies of the long bones. Patients experience several distinct types of pain after limb-sparing surgery which constitute a complex clinical entity. This retrospective study examined 26 years of experience in a pediatric institution (1981-2007) in pain management as long as 6 months after limb-sparing surgery and reviewed the historical evolution of pain interventions. One hundred fifty patients underwent 151 limb-salvage surgeries for bone cancer of the extremities in this series. Pain treatment increased progressively in complexity. Therapies included opioids, nonsteroidal antiinflammatory drugs, acetaminophen-opioid combinations, postoperative continuous epidural infusion, anticonvulsants and tricyclic antidepressants for neuropathic pain, local anesthetic wound catheters, and continuous peripheral nerve block catheters. Management of pain after limb-sparing surgery has evolved over the 26 years of this review. It currently relies on multiple "layers" of pharmacologic and nonpharmacologic strategies to address the complex mixed nociceptive and neuropathic mechanisms of pain in this patient population.

Operative anesthesia and pain control

A comprehensive understanding of operative anesthesia and postoperative pain control is essential to the practicing colon and rectal surgeon. Most of the operations performed-particularly in the perineum-cause significant patient discomfort and often result in a lengthy recovery period. A variety of factors, including patient positioning in the operating room and patient expectations, influence the choice of operative anesthesia. Postoperatively numerous modalities and agents exist for pain control. With this variety of options at hand, surgeons should be educated and decisions should be individualized, with the ultimate goals of improving the patient experience and facilitating recovery.

Continuous epidural infusion of morphine versus single epidural injection of extended-release morphine for postoperative pain control after arthroplasty: a retrospective analysis

BACKGROUND

This study retrospectively compared the continuous epidural infusion of morphine with a single epidural injection of extended-release morphine for postoperative pain control after arthroplasty.

METHODS

Medical records were reviewed for subjects who had total knee or hip arthroplasty (THA) under spinal anesthesia and received either a continuous epidural infusion of morphine (Group EPID; n = 101) or an extended-release epidural morphine (Group EREM; n = 109) for postoperative pain. Data were collected for three postoperative days (POD) on: pain scores; supplemental opioids; medications for respiratory depression, nausea, and pruritus, and distance ambulated during physical therapy.

RESULTS

Pain scores were similar until subjects were transitioned to another analgesic approach on POD 2; after that time, pain scores increased in Group EPID, although they decreased in Group EREM. Supplemental opioids were used more on POD1 in Group EREM than in Group EPID, although time to first opioid and total daily morphine equivalents were similar. Naloxone and antiemetics, not antipruritics, were used more in Group EREM. Distance ambulated after THA was greater in Group EREM than in Group EPID.

CONCLUSIONS

These results suggest that EREM is associated with better postoperative ambulation and analgesia during the transition to oral or intravenous analgesics, although a higher incidence of side-effects was evident.

Intrathecal morphine combined with intravenous patient-controlled analgesia is an effective and safe method for immediate postoperative pain control in live liver donors

The healthy condition of living donors makes their tolerance to pain particularly low, and clinicians are often challenged to come up with an analgesic technique that is effective yet ensures donor safety. This study compared, in donor right hepatectomy, the efficacy and safety of preoperative intrathecal morphine (ITM) combined with intravenous patient-controlled analgesia (IV-PCA) with IV-PCA alone. Forty adult patients were randomly allocated into 2 groups: ITM+IV-PCA group (n = 20) and IV-PCA-only group (n = 20). Patients in the ITM+IV-PCA group received morphine sulfate (400 microg). The visual analog scale (VAS) at rest and when coughing and supplementary meperidine and IV-PCA (fentanyl) consumption were assessed at 2, 4, 6, 8, 10, 12, 18, 24, 30, 36, 42, 48 56, 64, and 72 hours after surgery. Also, side effects such as sedation, dizziness, nausea, vomiting, pruritus, and respiratory depression were evaluated. The ITM+IV-PCA group showed significantly less pain at rest and when coughing for up to 30 hours and 24 hours, respectively. Cumulative postoperative consumption of meperidine and IV-PCA (fentanyl) were significantly less in the ITM+IV-PCA group. The incidence of side effects were comparable between the 2 groups except for pruritus; its incidence was significantly higher in the ITM+IV-PCA group during the first 24 hours, but no treatment was required due to its mild severity. The results of our study suggest that preoperative ITM combined with IV-PCA may be considered as an effective and safe pain management regimen in living liver donors who have characteristics of low tolerance to pain and postoperative coagulation derangement.

The safety of concurrent administration of opioids via epidural and intravenous routes for postoperative pain in pediatric oncology patients

Supplementation of epidural opioid analgesia with intravenous opioids is usually avoided because of concern about respiratory depression. However, the choice of adjunct analgesic agents for pediatric oncology patients is limited. Antipyretic drugs may mask fever in neutropenic patients, and nonsteroidal anti-inflammatory agents may exert antiplatelet effects and interact with chemotherapeutic agents. We examined the safety of concurrent use of epidural and intravenous opioids in a consecutive series of 117 epidural infusions in pediatric patients and compared our findings to those reported by other investigators. We observed a 0.85% rate of clinically significant respiratory complications. The single adverse event was associated with an error in dosage. In our experience, the supplementation of epidural opioid analgesia with intravenous opioids has been a safe method of postoperative pain control for pediatric patients with cancer.

Drugs for the perioperative control of hypertension: current issues and future directions

The management of hypertension continues to pose important challenges. Recent developments have established the importance of more rigorous blood pressure control in the community. In the perioperative setting, hypertension has long been recognised as undesirable, although the adverse impact of high blood pressure on the acute risks of elective surgery may have been previously overstated.A number of agents and techniques are available to control blood pressure perioperatively. These include principally general and regional anaesthetics, alpha(2)-adrenoceptor agonists, peripheral alpha(1)- and beta-adrenoceptor antagonists, dihydropyridine calcium channel antagonists, dopamine D(1A)-receptor agonists (fenoldopam), and nitric oxide donors. Recent years have seen important developments in the receptor selectivity of new compounds and in pharmacokinetics, particularly esterase metabolism. The future study of genomics may enable us to identify patients at risk for hypertension-related adverse events and target therapies most effectively to these high-risk groups.

Observational study on intrathecal and peridural changes after routine spinal and epidural anesthesia in patients undergoing total joint arthroplasty

Epidural bleeding from spinal anesthetics or epidural catheter placement is concerning, especially when anticoagulants are used. Little is known of the natural changes that occur subdurally or epidurally after each of these procedures. To describe the natural history and occurrence of bleeding that may result from these anesthetics with anticoagulants, we studied 16 joint arthroplasty patients who underwent spinal magnetic resonance imaging postoperatively. Seven patients had an epidural catheter, 7 had a straight spinal injection, and 2 had a general anesthetic. All patients received 5 mg of warfarin postoperatively, with dosing to an international normalized ratio of 2.0. Magnetic resonance imaging readings were blinded. No magnetic resonance image demonstrated peridural inflammation or hemorrhage. No difference was observed between the anesthetics. Warfarin did not cause abnormal bleeding. Based on these observations, one should consider bleeding or peridural inflammation to be abnormal after spinal or epidural anesthesia.

Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis

Background

To determine infection rate with use of epidural catheters in place for seven days or more.

Methods

Systematic review and pooled analysis of observational studies.

Results

Twelve studies with 4,628 patients (median 197 patients) provided information, of which nine (4,334 patients) were published after 1990. Eight studies (3,893 patients) were retrospective, and four studies (735 patients) prospective. Electronic searches identified three studies and searching reference lists nine.

There were 257 catheter-related infections in total, of which 211 were superficial and 57 deep, giving rates of 6.1%, 4.6% and 1.2% respectively. Ten of the 12 studies had deep infection rates of 2% or less. The incidence of deep infection was 1 per 2391 days of treatment, or 0.4 per 1000 catheter treatment days. In nine studies (1503 patients), predominantly in cancer, and with average catheter duration of 74 days, the deep infection rate was 2.8%. The proportion of patients with infection of any type was higher in cancer patients with longer catheter duration. Limited numbers of events meant that no reliable estimate of the impact of prospective and retrospective design could be made. There appeared to be a relationship between catheter duration and infection rate from this and other recent estimates. Four of 57 (7%) patients with deep infection died.

Conclusion

The best estimate is that one person in 35 with an epidural catheter in place for 74 days for relief of cancer pain can be expected to have a deep epidural infection, and that about 1 in 500 may die of infection-related causes. This is a most uncertain estimate given the limited nature of the evidence.

Determinants of Patient-controlled Epidural Analgesia Requirements

OBJECTIVES

Patient-controlled epidural analgesia (PCEA) has been widely used in postoperative pain management. Many factors may correlate with PCEA requirements but no previous study has ever investigated this subject. Therefore, we conducted this study to explore the relationship among patients' characteristics and total PCEA consumption during the 3-day postoperative course.

METHODS

This prospective study was conducted with surgical patients receiving postoperative PCEA and completing the 3-day course. The PCEA regimen was prepared as 0.0625% bupivacaine with fentanyl (l microg/mL). Patients' characteristics including demographic data and surgical procedures were collected. The total doses were recorded after the course terminated. Stepwise regression analyses were conducted to select significant variables, which could determine total PCEA demand. Subgroup analyses were also performed to investigate whether differences exist among distinct surgical sites.

RESULTS

There were 1753 patients (1094 men and 659 women) included in the analysis. Weight, age, height, body mass index, sex distribution, and total PCEA consumption were significantly different among various surgical sites (all P<0.001). Operational sites, procedures involving malignant disease, weight, and age are the most significant factors in sequence to determine total PCEA requirements. Height and sex have no impact on PCEA demand. The multiple correlation coefficient of our model is 0.688 and the predictive formula of the 3-day postoperative PCEA requirement was 240.1+(130.5xsite)+(66.6xmalignancy)+(1.7xweight)-(0.4xage).

CONCLUSIONS

Our study demonstrated the association between patients' characteristics and total PCEA requirements from a large-scaled clinical data. Surgical procedures have more influence on PCEA consumption than demographic variables. Background infusion rate of PCEA could be determined from our predictive model.

An Analysis of Postoperative Epidural Analgesia Failure by Computed Tomography Epidurography

In this prospective study involving 125 patients, we analyzed epidural analgesia failure after major abdominal surgery using computed tomography (CT) epidurographies to compare the incidence of dislodgement of epidural catheters and leakage of solution from the epidural space between two groups of patients: patients with successful or failed epidural analgesia. Our hypothesis was that the incidence of dislodgement and leakage should be low when epidural analgesia is successful. A thoracic epidural catheter was inserted before general anesthesia and secured by subcutaneous tunneling. Bupivacaine (0.25%) was administered during surgery followed by continuous epidural analgesia with 0.125% bupivacaine (10 mL/h) and morphine (0.25 mg/h) for 48 h. Failure was defined as a visual analog scale pain score at rest more than 30 mm and/or interruption of epidural analgesia before 48 h for any reason. When failure was not due to unintentionally withdrawn, kinked catheters or adverse events (n = 11), a CT scan with contrast injection was performed. Control CT scans were also performed in patients with adequate analgesia (i.e., the success group). The incidence of failure was 24.8% (n = 31). CT scans in the failure group (n = 20) showed seven patients with catheters outside the epidural space, nine with normal distribution, one with unilateral spread, and three with leakage of solution outside the epidural space. In the success group, CT scans (n = 19) showed 11 patients with normal distribution, five with unilateral spread, and three with leakage. We conclude that the major cause of epidural analgesia failure was dislodgment of the catheter. CT scans were mostly useful for detecting leakage of injectate, which may be the early phase of dislodgment.

The frequency and timing of respiratory depression in 1524 postoperative patients treated with systemic or neuraxial morphine

STUDY OBJECTIVE

To describe the frequency and timing of intravenous patient-controlled analgesia (IV-PCA) or neuraxial morphine-induced postoperative respiratory depression.

DESIGN

Audit of data captured by routine quality assurance of the acute pain protocols that were implemented by nurses performing routine postoperative care.

SETTING

The surgical wards of a university-affiliated, 700-bed, tertiary hospital.

PATIENTS AND INTERVENTIONS

In real time, the data of all patients enrolled into our Acute Pain Service (APS) were entered and stored in the APS database. Thereafter, patients who had received IV morphine via a PCA device or neuraxial morphine between January 1999 and December 2002 were isolated. From this subset, all patients in whom a respiratory rate (RR) less than 10 breaths per minute was recorded were retrieved.

MEASUREMENTS AND MAIN RESULTS

From a total of 4500 patients, IV or neuraxial morphine was administered to 1524 patients. Eighteen (1.2%) cases of an RR less than 10 breaths per minute were recorded (13 patients, 4 patients, and 1 patient in the IV-PCA, daily epidural morphine, and single-dose intrathecal morphine groups, respectively). A direct correlation between intraoperative fentanyl administration and postoperative respiratory depression was demonstrated between the IV-PCA (P = 0.03) and epidural groups (P = 0.05). The time from IV-PCA initiation or last neuraxial morphine administration until the diagnosis of respiratory depression ranged between 2 hours and 31.26 hours and 2 hours and 12.15 hours, respectively. Ten (55.6%) patients received naloxone.

CONCLUSION

Morphine-induced respiratory depression may occur at any time during the APS admission. However, the optimal frequency of intermittent RR monitoring is unknown. Furthermore, because multiple variables (age, sex, prior opioid administration, site of operation) may affect morphine-induced respiratory depression, further investigation must be performed to determine the ideal monitoring protocol.

Patient-controlled analgesia

One of the most common methods for providing postoperative analgesia is via patient-controlled analgesia (PCA). Although the typical approach is to administer opioids via a programmable infusion pump, other drugs and other modes of administration are available. This article reviews the history and practice of many aspects of PCA and provides extensive guidelines for the practice of PCA-administered opioids. In addition, potential adverse effects and recommendations for their monitoring and treatment are reviewed.

A Prospective Comparative Study of Two Indirect Methods for Confirming the Localization of an Epidural Catheter for Postoperative Analgesia

We prospectively evaluated, in randomized order, 2 indirect methods of confirming the localization of an epidural catheter for postoperative analgesia in 218 surgical patients: epidural stimulation test (EST) and epidural pressure waveform analysis (EPWA). The epidural space was localized by using a loss of resistance technique. All catheters were inserted 5 cm into the epidural space and primed with 5 mL of 0.9% normal saline. There were no differences between the methods: the positive predictive value and specificity were high (100% in both groups), but the sensitivity was moderate (80% for EST and 81% for EPWA) and the negative predictive value was low (16% for EST and 17% for EPWA). Combining both methods yielded better sensitivity (97%) and negative predictive value (57%) (P < 0.001). The sensitivity of EST was increased to 87% (P < 0.05) if sensory response was included as well as motor response for stimulation less than 10 mA. We suggest the inclusion of sensory response in the appropriate dermatome at a current <10 mA as a criterion for adequate epidural catheter localization for EST testing. EPWA sensitivity was significantly better with older patients: 94% for patients older than 80 yr compared with 63% for patients younger than 40, 73% for patients 40 to 60, and 85% for patients aged 60 to 80 yr (P = 0.03). We conclude that the two tests are comparable for confirming catheter placement.

Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritis, and urinary retention. Evidence from published data

This review examines the evidence from published data concerning the tolerability (indicated by the incidence of nausea, vomiting, sedation, pruritus, and urinary retention), of three analgesic techniques after major surgery; intramuscular analgesia (i.m.), patient-controlled analgesia (PCA), and epidural analgesia. A MEDLINE search of publications concerned with the management of postoperative pain and these indicators identified over 800 original papers and reviews. Of these, data were extracted from 183 studies relating to postoperative nausea and vomiting, 89 relating to sedation, 166 relating to pruritus, and 94 relating to urinary retention, giving pooled data which represent a total of more than 100,000 patients. The overall mean (95% CI) incidence of nausea was 25.2 (19.3-32.1)% and of emesis was 20.2 (17.5-23.2)% for all three analgesic techniques. PCA was associated with the highest incidence of nausea but the emesis was unaffected by analgesic technique. There was considerable variability in the criteria used for defining sedation. The overall mean for mild sedation was 23.9 (23-24.8)% and for excessive sedation was 2.6 (2.3-2.8)% for all three analgesic techniques (significantly lower with epidural analgesia). The overall mean incidence of pruritus was 14.7 (11.9-18.1)% for all three analgesic techniques (lowest with i.m. analgesia). Urinary retention occurred in 23.0 (17.3-29.9)% of patients (highest with epidural analgesia). The incidence of nausea and excessive sedation decreased over the period 1980-99, but the incidence of vomiting, pruritus, and urinary retention did not. From these published data it is possible to set standards of care after major surgery for nausea 25%, vomiting 20%, minor sedation 24%, excessive sedation 2.6%, pruritus 14.7%, and urinary retention requiring catheterization 23%. Acute Pain Services should aim for incidences less than this standard of care.

Efficacy of Methods of Intercostal Nerve Blockade for Pain Relief After Thoracotomy

Intercostal nerve blockade for postthoracotomy pain relief can be accomplished by continuous infusion of local anesthetics through a catheter in the subpleural space or through an interpleural catheter, by cryoanalgesia, and by a direct intercostal nerve block. A systematic review of randomized studies indicates that an extrapleural infusion is at least as effective as an epidural and significantly better than narcotics alone. The other techniques of intercostal blockade do not offer an advantage over narcotics alone.

Safety of mixture of morphine with ketamine for postoperative patient-controlled analgesia: an audit with 1026 patients

BACKGROUND

Adding ketamine to morphine for patient-controlled analgesia (PCA) may be useful. However, data on this drug combination have been collected on small sample sizes. In order to evaluate the safety of the combination morphine- ketamine, we conducted a prospective study on a large patient population.

METHODS

Patient-controlled analgesia was performed with 1026 patients using morphine and ketamine in a dose ratio of 1:1. All patients were treated in the ward. Prospectively collected data included incidence of complications and side-effects, verbal pain scores at rest and during mobilization (0 = no pain to 4 = very strong pain), consumption of morphine and ketamine and patient satisfaction (0 = very un-satisfied to 3 = very satisfied).

RESULTS

The study included 462 women and 564 men who underwent, on average, 71.8 h (+/-56.1) of PCA. There were 698 orthopaedic, 160 abdominal, 96 thoracic, 20 vascular, 16 plastic, 15 neurosurgical, 11 urologic and 10 other surgical procedures. No complication was observed. Incidence of side-effects was: 1.2% respiratory depression, 23.5% nausea, 6.2% vivid dreams and/or hallucinations, 21.4% sedation and 10.3% pruritus. Reasons for discontinuing the PCA were side-effects (7.0%) and other (0.5%). Mean pain scores over the whole period were 0.44 (+/-0.54) at rest and 1.36 (+/-0.62) during mobilization. Mean satisfaction score was 2.52 (+/-0.69).

CONCLUSION

Patient-controlled analgesia with morphine and ketamine is safe. It produces side-effects which, however, are infrequently a reason for discontinuing the regimen. It is also associated with low pain scores and high patient satisfaction.

Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection

BACKGROUND

Multimodal postoperative care regimens accelerate recovery after abdominal surgery. The benefit of thoracic epidural (TE) analgesia over patient-controlled analgesia (PCA) remains unproven when used with a fast-track postoperative care plan.

METHODS

Fifty-six patients undergoing major intestinal resection, and on a fast-track postoperative care plan, were randomized to preemptive TE or PCA. Patients were evaluated at standard time points for pain score, quality of life (Short Form-36), and complications. Oral analgesia was substituted for TE and PCA on the second postoperative day. Discharge criteria were identical for both groups.

RESULTS

Six patients (20.6%) had a failed epidural. There was no difference in length of stay (5.8 versus 6.2 days, TE versus PCA, P = .55), total length of stay (including readmissions), pain scores, quality of life, complications, or hospital costs at any time point.

CONCLUSION

TE offers no advantage over PCA for patients undergoing major intestinal resections who are on a fast-track postoperative care plan using PCA.

Epidural Analgesia for Postoperative Pain

Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.