Epidural clonidine or bupivacaine as the sole analgesic agent during and after abdominal surgery: a comparative study

Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, vomiting and pain after abdominal surgery

BACKGROUND

Gastrointestinal paralysis, nausea and vomiting and pain are major clinical problems following abdominal surgery. Anaesthetic and analgesic techniques that reduce pain and postoperative nausea and vomiting (PONV), while preventing or reducing postoperative ileus, may reduce postoperative morbidity, duration of hospitalization and hospital costs. This review was first published in 2001 and was updated by new review authors in 2016.

OBJECTIVES

To compare effects of postoperative epidural analgesia with local anaesthetics versus postoperative systemic or epidural opioids in terms of return of gastrointestinal transit, postoperative pain control, postoperative vomiting, incidence of anastomotic leak, length of hospital stay and costs after abdominal surgery.

SEARCH METHODS

We identified trials by conducting computerized searches of the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 12), MEDLINE (from 1950 to December 2014) and EMBASE (from 1974 to December 2014) and by checking the reference lists of trials retained. When we reran the search in February 2016, we added 16 potential new studies of interest to the list of 'Studies awaiting classification' and will incorporate these studies into formal review findings during the next review update.

SELECTION CRITERIA

We included parallel randomized controlled trials comparing effects of postoperative epidural local anaesthetic versus regimens based on systemic or epidural opioids.

DATA COLLECTION AND ANALYSIS

We rated the quality of studies by using the Cochrane 'Risk of bias' tool. Two review authors independently extracted data and judged the quality of evidence according to the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) scale.

MAIN RESULTS

We included 128 trials with 8754 participants in the review, and 94 trials with 5846 participants in the analysis. Trials included in the review were funded as follows: charity (n = 19), departmental resources (n = 8), governmental sources (n = 15) and industry (in part or in total) (n = 15). The source of funding was not specified for the other studies.Results of 22 trials including 1138 participants show that an epidural containing a local anaesthetic will decrease the time required for return of gastrointestinal transit as measured by time to first flatus after an abdominal surgery (standardized mean difference (SMD) -1.28, 95% confidence interval (CI) -1.71 to -0.86; high quality of evidence; equivalent to 17.5 hours). The effect is proportionate to the concentration of local anaesthetic used. A total of 28 trials including 1559 participants reported a decrease in time to first faeces (stool) (SMD -0.67, 95% CI -0.86 to -0.47; low quality of evidence; equivalent to 22 hours). Thirty-five trials including 2731 participants found that pain on movement at 24 hours after surgery was also reduced (SMD -0.89, 95% CI -1.08 to -0.70; moderate quality of evidence; equivalent to 2.5 on scale from 0 to 10). From findings of 22 trials including 1154 participants we did not find a difference in the incidence of vomiting within 24 hours (risk ratio (RR) 0.84, 95% CI 0.57 to 1.23; low quality of evidence). From investigators in 17 trials including 848 participants we did not find a difference in the incidence of gastrointestinal anastomotic leak (RR 0.74, 95% CI 0.41 to 1.32; low quality of evidence). Researchers in 30 trials including 2598 participants noted that epidural analgesia reduced length of hospital stay for an open surgery (SMD -0.20, 95% CI -0.35 to -0.04; very low quality of evidence; equivalent to one day). Data on costs were very limited.

AUTHORS' CONCLUSIONS

An epidural containing a local anaesthetic, with or without the addition of an opioid, accelerates the return of gastrointestinal transit (high quality of evidence). An epidural containing a local anaesthetic with an opioid decreases pain after abdominal surgery (moderate quality of evidence). We did not find a difference in the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anaesthetic would reduce the length of hospital stay (very low quality of evidence).

The analgesic effect of epidural clonidine after spinal surgery: a randomized placebo-controlled trial

BACKGROUND

Clonidine is an alpha(2) adrenoreceptor and imidazoline receptor agonist, which has analgesic, sedative, and minimum alveolar anesthetic concentration-sparing effects. It has been used orally, IV, and epidurally. In spinal surgery, there is a reluctance to use local anesthetic-based epidural analgesia postoperatively because of fears of masking important signs of nerve root or spinal cord injury.

METHODS

We randomized 66 patients undergoing uncomplicated decompressive spinal surgery to receive an epidural infusion of either clonidine (Group C) or saline placebo (Group P) postoperatively. Morphine consumption by patient-controlled analgesia device was recorded for 36 h.

RESULTS

Morphine consumption was significantly lower in Group C. The mean consumption at 36 h was 35 mg (95% confidence interval 21-50 mg) in Group C, compared with 61 mg (95% confidence interval 48-74 mg) in the control group. Nausea was significantly reduced in Group C (6.5%), when compared with placebo (38.2%).

CONCLUSION

Low-dose epidural clonidine significantly reduced the demand for morphine and reduced postoperative nausea with few side effects.

Hipotermia no período intra-operatório em pacientes submetidos a cirurgias eletivas

OBJETIVO: Analisar a temperatura corporal do paciente submetido a cirurgia eletiva no período intra-operatório. MÉTODOS: Para a coleta de dados elaborou-se um instrumento que foi submetido à validação aparente e de conteúdo e a amostra foi constituída de 70 pacientes. As variáveis mensuradas foram: temperatura e umidade da sala de cirurgia e temperatura corporal do paciente em diferentes momentos do período intra-operatório. RESULTADOS: Em relação à temperatura corporal dos pacientes observou-se que no final do procedimento anestésico-cirúrgico a média foi de 33,6º C. A temperatura média da sala na chegada dos pacientes foi de 24,6º C e na quarta hora de procedimento anestésico-cirúrgico foi de 22,4ºC. Houve correlação estatisticamente significante e positiva entre as variáveis mensuradas. CONCLUSÃO: Os resultados apontaram a necessidade de implementação de intervenções efetivas para a prevenção da hipotermia e, neste cenário, a atuação do enfermeiro é crucial para a melhoria da assistência prestada ao paciente cirúrgico.

A comparison of epidural bupivacaine-fentanyl and bupivacaine-clonidine in children undergoing the Nuss procedure

The administration of epidural opioids, though effective for producing analgesia, has severe side effects in most patients. It is unknown whether clonidine can effectively replace opioids and cause fewer side effects. We compared, in this randomized trial, the incidence of vomiting and pruritus as well as the analgesic profile of three different combinations of bupivacaine, fentanyl, and clonidine administered epidurally in patients undergoing the Nuss procedure: bupivacaine + fentanyl, bupivacaine + clonidine, bupivacaine + fentanyl + clonidine. The incidence of side effects was significantly less in the bupivacaine + clonidine group (33%) compared with the bupivacaine + fentanyl (92%) and bupivacaine + fentanyl + clonidine (73%) groups (P = 0.004). Quality of postoperative analgesia was similar in the three groups. No significant complications were observed. In conclusion, clonidine is an effective and safe alternative to epidural opioids.

The short-lasting analgesia and long-term antihyperalgesic effect of intrathecal clonidine in patients undergoing colonic surgery

In this study, we investigated the antihyperalgesic effect of clonidine after surgery. Sixty patients undergoing right colic resection were studied. Patients were randomized to receive prior to general anesthesia a 2-mL intrathecal (IT) injection of 300 microg of clonidine or saline, or 10 mg of bupivacaine. General anesthesia was achieved using a target concentration propofol infusion and monitored using bispectral index. Postoperative analgesia was provided by morphine IV given through a patient-controlled analgesia device. Postoperative analgesia was assessed by morphine requirements and visual analog scale pain scores at rest, cough, and movement during the first 72 h. Mechanical hyperalgesia was measured by von Frey filaments. Patients were questioned regarding residual pain at 2 wk,1, 6, and 12 mo. The patient-controlled analgesia morphine requirements were significantly smaller in the IT clonidine group (31.5 +/- 12 versus 91 +/- 25.5 and 43 +/- 15 mg, respectively, in groups clonidine, saline, and bupivacaine: P < 0.05 at 72 postoperative hours). The area of hyperalgesia at 72 h was 3 +/- 5 cm(2) in the clonidine group versus 90 +/- 30 and 35 +/- 20 cm(2) in the saline and bupivacaine groups (P < 0.05). At 6 mo, fewer patients in the clonidine group experienced residual pain than in the saline group (0 of 20 versus 6 of 20, P < 0.05). We conclude that both intraoperative spinal clonidine and bupivacaine improve immediate postoperative analgesia. IT clonidine was, however, more potent than IT bupivacaine to reduce postoperative secondary hyperalgesia.

IMPLICATIONS

Spinal clonidine contributes to the reduction of secondary hyperalgesia in patients recovering from abdominal surgery.

Intrathecal clonidine in the treatment of intractable pain: a phase I/II study

OBJECTIVE

Epidural clonidine has been proven effective in relieving intractable cancer pain, especially neuropathic. This phase I/II study was performed to investigate if intrathecal clonidine is well tolerated and effective for long-term treatment of intractable chronic pain.

DESIGN

Thirty-one patients, previously implanted with programmable pumps and unable to obtain adequate pain relief with opioids and adjuvant oral medications, were enrolled. Clonidine monotherapy was initiated at 1 mcg/hr and escalated to a maximum of 40 mcg/hr (960 mcg/day). Efficacy measurements included Verbal Digital Pain Ratings, and side effects were determined by physical exam and patient reports.

RESULTS

Patients achieving 50% or greater reduction in pain intensity scores in the dose-titration phase continued for long-term follow-up. Twenty-two patients (71%) entered long-term follow-up with intrathecal clonidine; nine patients (29%) did not obtain adequate pain control in the dose-titration phase. Thirteen patients were considered long-term successes with a mean follow-up of 16.7 months (range = 6.3 to 44 months). Nine patients failed to achieve adequate pain relief due to side effects or lack of efficacy. Fifty-nine percent of the patients successful in the dose-titration stage (42% of all patients considered) were considered long-term successes. Patients in the long-term phase maintained adequate pain control with minimal dose escalation.

CONCLUSIONS

This study demonstrates the tolerability and effectiveness of intrathecal clonidine in the treatment of chronic pain. The physician using clonidine for long-term intrathecal infusion should be cognizant of the risk that severe rebound systemic hypertension can occur with abrupt cessation of the intrathecal infusion of clonidine.

Epidural clonidine, bupivacaine and methadone as the sole analgesic agent after thoracotomy for lung resection

Thoracic epidural analgesia can effectively relieve post-thoracotomy pain but may also adversely affect pulmonary function. This randomised, prospective study compared the effects on pulmonary function of three different epidural analgesics (clonidine, bupivacaine and methadone). Forty-seven patients undergoing thoracotomy were treated postoperatively for 72 h with one of the study drugs. Doses were titrated to maintain visual analogue pain scale values below 4 out of 10. Throughout the postoperative period, reductions of up to 70% of the pre-operative value were observed in forced expiratory volume in 1 s, forced vital capacity and peak expiratory flow rate. Patients who received clonidine showed significantly faster recovery rates of forced expiratory variables compared to other patients, and by the third postoperative day significantly higher spirometry values (10-15%) were recorded in this group. As clonidine was the most effective drug in terms of preservation of pre-operative lung function, it may be clinically advantageous in post-thoracotomy patients.

Older people and hypothermia: the role of the anaesthetic nurse

Older clients are at increased risk during surgical intervention because of age-related system changes and comorbid conditions. However, recent advances in surgical and anaesthetic techniques, together with modern monitoring technology and the proliferation of ambulatory surgery, have reduced mortality in older patients undergoing surgery. Nevertheless, inadvertent hypothermia in older clients remains problematic. Therefore, an understanding of specific diseases prevalent in old age, coupled with a comprehensive knowledge of the physiological impact of ageing in all body systems, underpins the role of the anaesthetic nurse.

Epidural Analgesia at End of Life: Facing Empirical Contraindications

In a patient with unbearable cancer pain at the end of life, long-lasting analgesia without impairment of consciousness could only be achieved with an epidural infusion of local anesthetics combined with opioids and clonidine. Despite leptomeningeal infection during prolonged treatment, epidural analgesia at the lumbar level provided analgesia using very large doses of local anesthetics combined with clonidine and morphine. Thus, terminal sedation was avoided, allowing the patient's end-of-life planning of an "aware" death surrounded by her family. It may be useful to reconsider institutional pain management standards when unbearable pain occurs in patients with limited life expectancy.

IMPLICATIONS

We report a patient with severe visceral and neurogenic pain from metastatic carcinoma of the colon resistant to multimodal oral analgesic therapy. Although there were empirical contraindications, epidural analgesia was successful, allowing the patient's end-of-life planning of an "aware" death surrounded by the family.

Epidural infusion of clonidine or clonidine plus ropivacaine for postoperative analgesia in children undergoing major abdominal surgery

STUDY OBJECTIVE

To investigate the analgesic efficacy and safety of epidural infusion of clonidine in children undergoing major abdominal surgery.

DESIGN

Randomized open-label study.

SETTING

Postoperative anesthetic unit and pediatric ward of a metropolitan hospital.

PATIENTS

Forty children aged 0 to 3 years undergoing major abdominal surgery.

INTERVENTIONS

Children were randomly allocated to receive a 24-hour epidural infusion of clonidine 1 microg.mL(-1) at rate of 0.2 mL.kg -1.h -1 preceded by a bolus of 2 microg.kg -1 (CLON group) or a mixture of clonidine 1 microg.mL -1 and ropivacaine 0.1% at rate of 0.2 mL.kg -1.h -1. Both groups received intravenous (IV) ketoprofen 2 mg.kg -1 every 8 hours. Breakthrough pain was treated with IV tramadol 1 mg.kg(-1).

MEASUREMENTS

Tramadol requirement, sedation and respiratory and hemodynamic changes were measured.

MAIN RESULTS

Approximately 77% and 59.3% of the CLON and CLON+ROPIV groups, respectively, required no tramadol or only one dose over a 24-hour period. Except for those patients who exhibited frequent coughing during the night (4 and 5 patients in the CLON and CLON+ROPIV groups, respectively), no study patients required an analgesic and all had good sleep quality during the first night. Sedation and decreased systolic blood pressure were observed after the clonidine bolus was given.

CONCLUSION

For children undergoing major abdominal surgery, the addition of epidural infusion of clonidine or clonidine plus ropivacaine to IV ketoprofen provided good analgesia quality for postoperative rest pain.

Epidural clonidine suppresses the baroreceptor-sympathetic response depending on isoflurane concentrations in cats

Epidural administration of clonidine induces hypotension and bradycardia secondary to decreased sympathetic nerve activity. In this study, we sought to elucidate the change in baroreflex response caused by epidural clonidine. Thirty-six cats were allocated to six groups (n = 6 each) and were given either thoracic epidural clonidine 4 micro g/kg or lidocaine 2 mg/kg during 0.5, 1.0, or 1.5 minimum alveolar anesthetic concentration (MAC) isoflurane anesthesia. Heart rate (HR), mean arterial blood pressure (MAP), and cardiac sympathetic nerve activity (CSNA) were measured. Depressor and pressor responses were induced by IV nitroprusside 10 micro g/kg and phenylephrine 10 micro g/kg, respectively. Baroreflex was evaluated by the change in both CSNA and HR relative to the peak change in MAP (deltaCSNA/deltaMAP and deltaHR/deltaMAP, respectively). These measurements were performed before and 30 min after epidural drug administration. Epidural clonidine and lidocaine decreased HR, MAP, and CSNA by similar extents. deltaCSNA/deltaMAP and deltaHR/deltaMAP for depressor response were suppressed with epidural lidocaine and clonidine in all groups but the clonidine 0.5 MAC isoflurane group (0.197 +/- 0.053 to 0.063 +/- 0.014 and 0.717 +/- 0.156 to 0.177 +/- 0.038, respectively, by epidural lidocaine [P < 0.05] but 0.221 +/- 0.028 to 0.164 +/- 0.041 and 0.721 +/- 0.177 to 0.945 +/- 0.239, respectively, by epidural clonidine during 0.5 MAC isoflurane). Those for pressor response were suppressed in all groups. We conclude that thoracic epidural clonidine suppresses baroreflex gain during isoflurane anesthesia >1.0 MAC but may offer certain advantages compared with epidural lidocaine during 0.5 MAC isoflurane by virtue of preserving baroreflex sensitivity when inadvertent hypotension occurs.

Nonopioid additives to local anaesthetics for caudal blockade in children: a systematic review

BACKGROUND

Caudal epidural injection with local anaesthetics is a popular regional technique used in infants and children. A disadvantage of caudal blockade is the relatively short duration of postoperative analgesia. Opioids have traditionally been added to increase the duration of analgesia but have been associated with unacceptable side-effects. A number of nonopioid additives have been suggested to increase the duration of analgesia.

METHODS

A systematic review was conducted to identify randomized control trials comparing the use of local anaesthetic to local anaesthetic with nonopioid additives for caudal blockade in children. The increase in duration of analgesia and side-effects were compared.

RESULTS

The addition of clonidine to the local anaesthetic solution produces an increase in the duration of analgesia following caudal blockade in children (pooled weighted mean difference of 145 min with 95% confidence interval of 132-157 min). Side-effects include sedation and the potential for neonatal respiratory depression. Ketamine and midazolam further increase the duration of analgesia, however, the potential for neurotoxicity remains a concern.

CONCLUSION

The evidence examined shows an increased duration of analgesia with clonidine, ketamine and midazolam. However, we are not convinced that the routine use of these adjuvants in the setting of elective outpatient surgery shows improved patient outcome. It is unclear if the potential for neurotoxicity is outweighed by clinical benefits. Further testing, including large clinical trials, is required before recommending routine use of nonopioid additives for caudal blockade in children.

Side-effects of postoperative epidural analgesia in children: a randomized study comparing morphine and clonidine

BACKGROUND

Morphine is widely used in association with local anaesthetics for postoperative epidural analgesia. There are no data on the prolonged use of clonidine for postoperative analgesia in children. The primary outcome of this randomized, double-blind trial was to compare the incidence of side-effects after epidural infusion of clonidine or morphine, in association with ropivacaine in children.

METHODS

After institutional approval, 26 children, aged 3-12 years, who were scheduled for abdominal surgery, had an epidural catheter placed after induction of general anaesthesia. Patients were then randomized to two different groups. After an initial bolus of 2.5 mg x kg-1 0.25% ropivacaine with either 40 micro g x kg-1 morphine (group M, n = 14) or 1 micro g x kg-1 clonidine (group C, n = 12), an epidural infusion was started at a rate of 0.4 ml x kg-1 x h-1. The patients in the M group received an infusion of 0.08% ropivacaine with 10 micro g.ml-1 morphine, those in the group C an infusion of 0.08% ropivacaine with 0.6 micro g.ml-1 clonidine.

RESULTS

The two groups were similar with respect to age, sex and weight. One patient in the C group was excluded for misplacement of the epidural catheter. The incidence of vomiting and pruritus was significantly higher in the M group compared with the C group (64% and 85% versus 0%, respectively). The incidence of pain was significantly higher in the C group compared with the M group (73% versus 29%) as well as the need for rescue analgesia medications.

CONCLUSIONS

Epidural clonidine is followed by a significantly lower incidence of side-effects. However, its analgesic effects, at least at the doses used in this study, are less potent than those of epidural morphine.

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.

Epidural analgesia in a child with sickle cell disease complicated by acute abdominal pain and priapism

We describe a case of a 9-yr-old child with sickle cell disease complicated by abdominal vaso-occlusive crisis and priapism. Both complications were successfully treated with a combination of epidural local anesthetics and morphine.

[Automatic analysis of electroencephalogram: what is its value in the year 2000 for monitoring anesthesia depth?]

Spontaneous EEG has been proposed for monitoring depth of anaesthesia and adjusting anesthetic drugs doses. This review describes the main features of spontaneous EEG, the principles of EEG signal analysis used in anaesthesia, and the EEG effects of the different anesthetic drugs in adults and children. Then, the correlations between EEG parameters changes and clinical signs of anesthesia (loss of consciousness and memory, lack of movement and haemodynamic stability despite noxious stimulations) are analyzed. The best signal analysis technique available today for routine use seems to be bispectral analysis, which returns, in the available monitors, a single number called bispectral index or BIS. Based upon the recent literature, clinical uses, performances and limits of use of BIS are described and discussed.

Minimizing perioperative adverse events in the elderly

Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly.

The pharmacological basis of contemporary pain management

Pain management has become an increasingly well researched area in medicine over recent years, and there have been advances in a number of areas. While opioids remain an integral part of pain-management strategies, there is now an emphasis on the use of adjuvant drugs, such as paracetamol and anti-inflammatory agents, which through physiological or pharmacological synergism, both enhance pain control and reduce opioid use. The management of neuropathic pain continues to be a challenge. Anti-epileptics and antidepressants, together with clonidine and ketamine, provide the foundations for treatment. Another area of interest has been the widespread use of patient-controlled analgesia and the administration of some drugs, especially opioids, by means other than traditional oral and parenteral routes. The number of new drugs that have reached the stage of clinical trials has been small, yet they offer exciting possibilities. The epibatidine analogue ABT-594 and zinconitide both offer novel approaches to the management of neuropathic pain states, while selective cyclo-oxygenase-2 inhibitors and nitroaspirins may see advances in the management of nociceptive pain states.

Clonidine prolongs the effect of ropivacaine for axillary brachial plexus blockade

PURPOSE

To evaluate the effect of adding clonidine to ropivacaine, for axillary brachial plexus blockade, on the onset and duration of sensory and motor block and duration of analgesia.

METHODS

In a prospective randomised double blind placebo controlled study axillary brachial plexus blockade was performed in 50 patients using 40 ml ropivacaine 0.75%. Group (A) had 150 microg clonidine and Group (B) 1 ml normal saline added to the local anesthetic. Sensory function was tested using pinprick (sharp sensation, blunt sensation or no sensation) and temperature with an ice cube compared with the opposite arm, (cold/not cold). Motor function was assessed using a modified Bromage scale. Postoperative analgesia was standardised. Onset and duration of sensory and motor blockade, duration of analgesia, postoperative pain score, and analgesic requirement were compared.

RESULTS

The clonidine patients showed an increase in duration of sensory loss from 489 min to 628 min with a mean difference of 138 min (95% confidence interval of 90 to 187 min), motor blockade from 552 min to 721 min with a mean difference of 170 min (95% confidence interval of 117 to 222 min), and analgesia from 587 min to 828 min with mean difference of 241 min (95% confidence interval of 188 to 294 min). There was no difference in onset time. No side effects were noted.

CONCLUSION

The addition of 150 microg of clonidine to ropivacaine, for brachial plexus blockade, prolongs motor and sensory block and analgesia, without an increased incidence of side effects.

Evidence-based review of the literature on intrathecal delivery of pain medication

Evidence-based medicine depends on the existence of controlled clinical trials that establish the safety and efficacy of specific therapeutic techniques. Many interventions in clinical practice have achieved widespread acceptance despite little evidence to support them in the scientific literature; the critical appraisal of these interventions based on accumulating experience is a goal of medicine. To clarify the current state of knowledge concerning the use of various drugs for intraspinal infusion in pain management, an expert panel conducted a thorough review of the published literature. The exhaustive review included 5 different groups of compounds, with morphine and bupivacaine yielding the most citations in the literature. The need for additional large published controlled studies was highlighted by this review, especially for promising agents that have been shown to be safe and efficacious in recent clinical studies.