Effects of continuous epidural administration of fentanyl and morphine on postcesarean pain

We studied the effects of continuous epidural administration of fentanyl and morphine with bupivacaine for management of postcesarean pain. Eighteen patients received either bolus epidural administration of fentanyl 100 micrograms or morphine 3 mg with 0.5% bupivacaine 4 ml, followed by continuous infusion of fentanyl 33 micrograms.ml-1 with 0.17% bupivacaine or morphine 0.21 mg.ml-1 with 0.17% bupivacaine for 48 hours, respectively. Pain score was assessed at 0 h, 12h, 24h and 48h after leaving the operating room. Pain score increased significantly and progressively in the fentanyl group. In all cases pruritus was noted. Severe pruritus was observed in the morphine group significantly more than in the fentanyl group. The current results indicate that morphine may be preferable to fentanyl for postcesarean pain control using the present opioid doses.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomised, double-blind, cross-over study with and without adrenaline

BACKGROUND: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. METHODS: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml.h-1 of bupivacaine 1 mg.ml-1, fentanyl 2 micrograms.ml-1, and adrenaline 2 micrograms.ml-1 were included. On the 1st and 2nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. RESULTS: The number of hypaesthetic dermatomal segments decreased (P < 0.001) and pain intensity at rest and when coughing increased (P < 0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15-20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng.ml-1 (P < 0.01), and there was more sedation during the period without adrenaline. CONCLUSIONS: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Determination of provitamin A of green leafy vegetables by high performance liquid chromatography and open column chromatography

AIM OF STUDY: Intrathecal sufentanil has recently been used in labour as part of a combined spinal epidural technique. This study was conducted to compare its use in combination with bupivacaine for caesarean section with fentanyl added to bupivacaine and bupivacaine alone. METHODS: Sixty ASA I and II patients for non-emergency caesarean section under spinal anaesthesia were divided into three groups to receive 15 micrograms fentanyl added to 7.5 mg bupivacaine, 10 micrograms sufentanil added to 7.5 mg bupivacaine and 7.5 mg bupivacaine. Onset time of sensory blockade, side effects, surgical conditions, neonatal outcome and quality of the anaesthetic was assessed. On the first postoperative day, duration of effective analgesia, side effects and patient satisfaction were noted. RESULTS: The duration of effective analgesia of bupivacaine alone was prolonged with the addition of sufentanil and fentanyl by 358% and 256% respectively. No patient in the sufentanil and fentanyl groups required additional intra-operative analgesics compared with 17.6% of patients in the bupivacaine alone group. There was an increase in incidence of desaturation in the sufentanil group (45%) and fentanyl group (5.6%) compared with the bupivacaine only group (0%). The incidence of pruritus was 35% with sufentanil, 27.8% with fentanyl against 0% with bupivacaine alone. CONCLUSION: The addition of 10 micrograms of sufentanil and 15 micrograms of fentanyl to 7.5 mg of bupivacaine prolonged the duration of effective analgesia and improved intra-operative analgesia. However, the incidence of pruritus and episodes of desaturation were increased more with 10 micrograms sufentanil than with 15 micrograms fentanyl.     

The influence of epidural administration of fentanyl infusion on gastric emptying in labour

The effect of epidural infusions containing fentanyl on maternal gastric emptying in labour was examined using the rate of paracetamol absorption. Women were randomly allocated to receive one of two epidural infusions, bupivacaine 0.125% alone or bupivacaine 0.0625% with fentanyl 2.5 micrograms.ml-1 at a rate of 10-12 ml.h-1. Paracetamol 1.5 g was given orally to women after either 30 ml of the infusion solution had been given (mean time 2.5 h, study A) or 40-50 ml (mean time 4.5 h. study B). Six venous blood samples were taken over the next 90 min for measurement of plasma paracetamol concentration. There were no significant differences in maximum plasma paracetamol concentration, time to maximum paracetamol concentration and area under the concentration-time curve between the two groups for study A. In study B the time to maximum plasma paracetamol concentration was significantly delayed in women receiving > 100 micrograms fentanyl compared with controls (p < 0.05). We conclude that the dose of fentanyl that may delay gastric emptying when given by epidural infusion is greater than 100 micrograms.     

Intrathecal fentanyl prolongs sensory bupivacaine spinal block

The purpose of investigation was to study the effect of intrathecal fentanyl on the onset and duration of hyperbaric bupivacaine-induced spinal block in adult male patients. Forty-three patients undergoing lower extremity or genitourinary surgery were enrolled to receive either 13.5 mg hyperbaric bupivacaine 0.75% + 0.5 ml CSF it, (Group I) or 13.5 mg hyperbaric bupivacaine 0.75% + 25 micrograms fentanyl it, (Group II) according to a randomized assessor-blind protocol. The onset and duration of sensory block were assessed by pinching the skin with forceps in the midclavicular line bilaterally every two minutes for first twenty minutes and then every five to ten minutes. Similarly, the onset and duration of motor block were assessed and graded at the same time intervals using the criteria described by Bromage. The time required for two sensory segment regression and sensory regression to L1 dermatome was 74 +/- 18 and 110 +/- 33 min vs 93 +/- 22 and 141 +/- 37 min in Groups I and II, respectively (P < 0.05). Intrathecal fentanyl did not enhance the onset of sensory or motor block, or prolong the duration of bupivacaine-induced motor spinal block. Fewer patients demanded pain relief in the fentanyl-treated group than in the control group in the early postoperative period (19% vs 59%; P < 0.05). Episodes of hypotension were more frequent in the fentanyl-treated group than in the control group (43% vs 14%; P < 0.05). We conclude that fentanyl, 25 micrograms it, prolonged the duration of bupivacaine-induced sensory block (sensory regression to L1 dermatone) by 28% and reduced the analgesic requirement in the early postoperative period following bupivacaine spinal block.     

Influence of anesthetic technique in postoperative analgesia in thoracic surgery

OBJECTIVE: To compare the intensity of postoperative pain after thoracotomy with 2 anesthetic techniques: 1) thoracic epidural block with bupivacaine administered before surgery (combined anesthesia with isoflurane) and 2) conventional balanced anesthesia with isoflurane and endovenous fentanyl. PATIENTS AND METHODS: Thirty patients scheduled for thoracotomy by lateral incision (T5-T6) were randomly divided into 2 groups of 15. Group A received 8 ml of 0.5% bupivacaine with adrenalin 1:200.000 30 min before start of surgery while group B received 8 ml saline solution through an epidural catheter inserted to T4-T8. Combined anesthesia (4 ml 0.5% bupivacaine through an epidural catheter 150 min after the first dose and isoflurane in 100% oxygen) was used in group A. Group B received balanced anesthesia with endovenous fentanyl 2.5 micrograms/kg and isoflurane in 100% oxygen. The difference in pain intensity during postoperative recovery was assessed by way of the following variables: number of boluses administered by epidural patient-controlled analgesia (bupivacaine 0.0625% and fentanyl 6 micrograms/ml); score on a visual analog scale of 10 at baseline and at 1, 3, 7, 11, 19 and 43 hours after surgery; and need for additional analgesia (diclofenac) during the 43 hours of study. Arterial gases were measured during the preoperative period and at 1, 3, 7, 19 and 43 hours after surgery. RESULTS: No significant differences in pain intensity measured on the visual analog scale, by the number of boluses per patients or by need for additional analgesia were found between the 2 groups. The total number of boluses administered and additional analgesic requirements were greater in the group receiving bupivacaine, although the difference was not significant (p = 0.095 and p = 0.056, respectively). Nor were there significant differences in pH and PaCO2 levels for the 2 groups. CONCLUSIONS: Analgesic efficacy after thoracotomy was similar for our 2 groups receiving either combined anesthesia (epidural bupivacaine at 0.5% and isoflurane) or balanced anesthesia with isoflurane and endovenous fentanyl.     

Epidural fentanyl produces labor analgesia by a spinal mechanism

BACKGROUND: The purpose of this study was to determine if epidural fentanyl produces analgesia in laboring patients by a primary spinal or supraspinal action. METHODS: Fifty-four parturients were randomized to receive epidural 0.125% bupivacaine plus one of three treatments: epidural saline-intravenous saline, epidural fentanyl (20 microg/h)-intravenous saline, or epidural saline-intravenous fentanyl (20 microg/h). The study treatments were administered by continuous infusion, whereas epidural bupivacaine use was patient controlled. RESULTS: Epidural bupivacaine use was significantly reduced by epidural (11.5+/-4.6 ml/h) but not by intravenous fentanyl (15.9+/-4.5 ml/h) compared with saline control (16+/-5.9 ml/ h). Analgesia characteristics and side effects were similar among groups. CONCLUSIONS: Low-dose epidural infusions of fentanyl produce labor analgesia by a primary spinal action.     

Experimental fetal transesophageal and intracardiac echocardiography utilizing intravascular ultrasound technology

The effects of epidural fentanyl on the incidence of maternal hypoxaemia during labour and on neonatal welfare were examined. Women were randomly allocated to receive one of two epidural infusions, bupivacaine 0.125% alone or bupivacaine 0.0625% with 2.5 micrograms.ml-1 fentanyl, and maternal arterial oxygen saturation was monitored continuously until delivery. The median incidence of desaturation (SpO2 < 95%) during the active phase of the second stage of labour was significantly greater in the fentanyl group than in controls (2.9 versus 0.6 min.h-1, p = 0.02). Similarly, the incidence of desaturation to SpO2 < or = 90% was greater in the fentanyl group than in controls (p = 0.02). There was no correlation between maternal oxygenation or plasma fentanyl concentration and neonatal welfare as measured by umbilical arterial and venous blood gas and acid base status, Apgar score and Neurologic and Adaptive Capacity Score.     

Epidural opioid analgesia after caesarean section: a comparison of patient-controlled analgesia with meperidine and single bolus injection of morphine

The quality of analgesia, patient satisfaction and incidence of side effects following a single bolus of epidural morphine were compared with patient-controlled epidural analgesia (PCEA) with meperidine during the first 24 hr after elective Caesarean section. Seventy-five women were randomly assigned to three equal groups. Group I received 30 mg epidural meperidine after delivery and PCEA with meperidine; Group 2 received 3 mg epidural morphine after delivery and PCEA with saline in a double-blind fashion. Group 3 received 3 mg epidural morphine after delivery without saline PCEA. Visual analogue pain scores (VAS) were higher with PCEA meperidine from 8-16 hr post-operatively (P < 0.05) than in both epidural morphine groups. Two patients in Group 1 and one in Group 3 required supplemental parental analgesia. The incidence of nausea was 16% in Group 1, compared with 52% in Group 2 and 56% in Group 3 (P < 0.01). Pruritus occurred in 24% of Group 1 patients, 84% of patients in Group 2 and 68% of patients in Group 3 (P < 0.001). Forty-six percent of patients in Group 1 were very satisfied with pain management, compared with 77% in Group 2 and 79% in Group 3. Nurse workload was higher in the PCEA study groups than in Group 3 (P < 0.05). A single bolus of epidural morphine provides superior analgesia and satisfaction at low cost, but with a higher incidence of nausea and pruritus than PCEA with meperidine.     

Phosphatidylcholine-associated aspirin accelerates healing of gastric ulcers in rats

In this double-blind study, we administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. One hundred patients (ASA physical class I or II) scheduled for lower abdominal surgery were randomly assigned to one of four groups. Group 1 received 10 mL of 0.5% epidural bupivacaine injected 15 min before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 2 received 10 mL of epidural normal saline injected before incision, followed by 10 mL of 0.5% epidural bupivacaine 30 min after incision. Group 3 received 10 mL of 0.5% epidural bupivacaine plus 5 mg of verapamil injected before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 4 received the same drugs as Group 3, in the reverse order. Pain and mood numeric rating scores, sedation scores, Prince Henry scores, patient-controlled cumulative postoperative analgesic consumption, and the incidence of side effects were assessed 2, 6, 12, 24, and 48 h after the operation in each group. Cumulative postoperative analgesic consumption in Groups 3 and 4 was significantly lower (P < 0.05) than that in Groups 1 and 2 24 and 48 h after surgery. There were no differences in the pain, mood, and sedation scores and the incidence of side effects among the four groups. We conclude that epidural verapamil decreases postoperative pain, possibly by interfering with normal sensory processing and by preventing the establishment of central sensitization. Implications: Calcium plays an important role in pain physiology at the spinal cord level. We examined the effect of bupivacaine plus verapamil (calcium channel blocker) and of bupivacaine alone. We demonstrated that the combination, administered epidurally, resulted in less postoperative analgesic consumption than bupivacaine alone.     

The effect of supervision of residents on quality of care in five university-affiliated emergency departments

BACKGROUND: The purpose of the study was to compare the analgesic and side effects of two epidurally administered mixtures of bupivacaine and fentanyl with the same drug ratios. METHODS: One hundred patients scheduled for colorectal surgery were randomized to receive a thoracic epidural infusion of either bupivacaine 0.12% with fentanyl 2 micrograms/ml or bupivacaine 0.24% with fentanyl 4 micrograms/ml during 48 h postoperatively. The pumps were adjusted to keep the visual analogue scale (VAS) pain score at 3 or less (on a scale of 0-10) with a minimum of adverse effects. RESULTS: There were no statistically significantly differences between the two groups in VAS pain scores. The average VAS pain score resting varied between 0.5 and 1, and coughing between 1.9 and 3.4. One case of respiratory depression with breathing frequency 7 occurred in each group, but none of the patients required naloxone. One patient in the low concentration group developed partial motor weakness in both legs 36 h postoperatively. Equal drug amounts--bupivacaine 10.8-11 mg/h and fentanyl 18-18.4 micrograms/h--were given in both groups throughout the study. CONCLUSIONS: Both groups had low pain scores with few and comparable adverse effects. It thus seems that the volume is not important when mixtures of bupivacaine and fentanyl in the studies concentrations are infused epidurally at a low thoracic level. Practical reasons favour the higher concentration mixture.     

Obstetric analgesia using continuous epidural perfusion of bupivacaine, adrenaline, and fentanyl

OBJECTIVES: To determine the efficacy and complications of continuous epidural perfusion of bupivacaine, adrenaline and fentanyl in the relief of pain during first and second stage labour during vaginal birth. PATIENTS AND METHODS: Between January 1990 and March 1993 we used continuous epidural perfusion for control of pain during labor in 1307 women. The solution administered through an epidural catheter and maintained until expulsion was one 10 ml bolus of bupivacaine 0.25% with adrenaline 1:200,000 and fentanyl 25 micrograms followed by continuous perfusion of bupivacaine 0.0625% with adrenaline 1:200,000 and fentanyl 2 micrograms/ml at an infusion rate of 12 ml/h. When analgesia was insufficient, a bolus of local anesthetic was administered or a pudendal block was carried out. RESULTS: Ninety-two percent of the birthing women reported good analgesic effect during the first stage; for 7% the effect was fair and for 0.55% it was poor. During the second stage 88% reported satisfactory analgesia, and 8% fair or poor. Assessment was not possible for the remaining women, who underwent cesarean sections. Complications were few and easily controllable. CONCLUSIONS: Maintenance of epidural perfusion with 0.0625% bupivacaine with adrenaline 1:200,000 and fentanyl 2 micrograms/ml provides sufficient analgesia during all stages of childbirth.     

Survival after massive ecstasy overdose

This study was designed to evaluate the potential advantages of combined epidural and light general anesthesia over the commonly employed general anesthesia during open heart surgery. Twenty-four patients undergoing mitral valve replacement were thus studied. General anesthesia was maintained with an isoflurane-nitrous oxide-oxygen was mixture and morphine sulfate (0.4 mg/kg i.v. initially) followed by postoperative pain control with morphine in 12 patients (group GA). The remaining 12 patients (group EAA) received continuous epidural bupivacaine (0.125%)-morphine (50 micrograms/ml) supplemented with the same gas mixture as group GA. Epidural infusion was continued until the third postoperative day. Changes in the serum cortisol and beta-endorphin levels together with postoperative pain relief defined as good (scale 0-2), fair (3-4), or poor (5-10) were observed serially. Lower cortisol levels were observed in group EAA than in group GA (P < 0.05) just before skin closure, on the second and the third postoperative day. The beta-endorphin levels were substantially lower in group EAA than in group GA throughout the observation. The pain scores were good in 2 patients (17%), fair in 6 (50%), and poor in 4 (33%) for group GA, and good in 8 (67%), fair in 3 (25%), and poor in 1 (8%) for group EAA. We thus conclude that a combined epidural and light general anesthesia is considered to attenuate the stress response and thereby provides a better quality of postoperative pain control.     

Postoperative hypoxaemia: continuous extradural infusion of bupivacaine and morphine vs patient-controlled analgesia with intravenous morphine

We carried out a randomized prospective study in 60 patients who had undergone major abdominal surgery for cancer. For postoperative pain control, 30 patients received continuous extradural infusion of 0.125% bupivacaine 12.5 mg h-1 and morphine 0.25 mg h-1 (EXI group) and 30 received patient-controlled analgesia (PCA) with intravenous morphine (1 mg bolus, 5-min lock-out and maximum dose 20 mg 4h-1). Both groups had general anaesthesia. The two groups were compared for postoperative pain scores, satisfaction, sedation and oxygen saturation. Oxygen saturation was recorded continuously the night before surgery and for two consecutive postoperative nights. Episodes of moderate desaturation (90% > SpO2 85%) were more frequent in the EXI group than in the PCA group (P < 0.05). Pain scores were lower in the EXI group compared with the PCA group at rest and while coughing (P < 0.05). No significant difference was found for patient sedation and satisfaction.     

Caudal clonidine and bupivacaine for combined epidural and general anaesthesia in children

BACKGROUND: Clonidine produces analgesia by actions on alpha 2-adrenoceptors and enhances both sensory and motor blockade from epidural injection of local anaesthetics. Low-dose clonidine has been used so far for caudal injection in children. Our aim was to study the perioperative effects of high-dose caudal clonidine when added to low concentration of bupivacaine for combined epidural and general anaesthesia in children. METHODS: After induction of general anaesthesia caudal block was performed either with 1 ml.kg-1 bupivacaine 0.175% with the addition of clonidine 5 micrograms.kg-1 (n = 20), or with 1 ml.kg-1 bupivacaine 0.175% (n = 20). The intraoperative anaesthetic requirements, the perioperative haemodynamic effects, respiratory rate, sedation score, postoperative pain scores and side effects were assessed by a blinded observer. A patient-controlled analgesia system was used for postoperative pain relief. The quality of postoperative pain relief was assessed using Smiley's pain analogue scale. RESULTS: Intraoperative haemodynamic responses did not differ between the groups. However, during emergence from general anaesthesia children in the clonidine group had significantly lower heart rates and blood pressure compared to children in the control group. In addition, heart rates and blood pressures were also lower in the clonidine group in the early postoperative period (P < 0.05). Postoperative analgesia was significantly better in the clonidine group as evidenced by the total number of requests (3 vs 12, P < 0.05) and the total amount of tramadol (20.5 mg vs 72.8 mg, P < 0.05) administered. The duration of the caudal analgesia was significantly longer in the clonidine group (20.9 +/- 7.4 h vs 14.4 +/- 10.9 h, P < 0.05). CONCLUSION: Our results suggest that caudal clonidine 5 micrograms.kg-1 enhances and prolongs caudal blockade with bupivacaine (1.175% in children. It also blocks sympathoadrenergic responses during emergence from anaesthesia. Sedation and cardiovascular effects are observed up to 3 h into the postoperative period.     

Comparison of caudal block using bupivacaine and ketamine with ilioinguinal nerve block for orchidopexy in children

Forty boys weighing less than 25 kg undergoing unilateral orchidopexy were randomly allocated to receive one of two analgesic regimens. Group C received a caudal epidural block with 0.25% bupivacaine 1 ml.kg-1 and preservative-free ketamine 0.5 mg.kg-1; Group L received an ilioinguinal nerve block with 0.25% bupivacaine 0.5 ml.kg-1 and infiltration of the wound with 0.25% bupivacaine 0.5 ml.kg-1. All subjects received diclofenac sodium 1-2 mg.kg-1 as a rectal suppository. Postoperative pain was assessed by means of a modified Objective Pain Score and analgesia was administered if this exceeded a value of 4. The median duration of analgesia was 10 h (range 2.6 to > 24 h) in Group C and 2.9 h (range 0.7 to > 24 h) in Group L (p < 0.05). There were no differences between groups in the incidence of motor block, urinary retention, postoperative vomiting or postoperative sedation. Subjects in Group L required significantly more doses of postoperative analgesia than those in Group C (p < 0.05).     

Effectiveness, side effects and costs of postoperative pain therapy: intravenous and epidural patient-controlled analgesia (PCA)

PURPOSE: Improvement of the quality of analgesia, reduction of side effects and costs by application of epidural (PCEA) in comparison to intravenous patient-controlled analgesia (PCA) in postoperative pain treatment. METHODS: 62 patients with upper abdominal surgery took part in this randomised prospective study which was approved by the local ethics committee. Epidural catheters were inserted at T 8/9 (group PCEA). General anaesthesia was performed with propofol, sufentanil 2 micrograms/kg, pancuronium, enflurane and O2:N2O = 1:2. Postoperative analgesia consisted of epidural bupivacaine 0.25% + sufentanil 2 micrograms/ml (BS). (bolus 0.05 ml/kg, lockout 10 min) in group PCEA, or of intravenous morphine (bolus 2 mg. lockout 10 min) in group PCA. The following parameters were recorded until the evening of postoperative day 4: pain intensity at rest (VASR, 1-10) and on coughing (VASH, 1-10), blood pressure, heart rate, blood gas analysis, ability to ambulate, pruritus, nausea/vomiting (PONV), patient satisfaction (0-4), time and expenses for postoperative pain treatment. RESULTS: Median VASR (1 vs 2) and VASH (3 vs 4.5) were lower, cough intensity (2 vs 1) and patient satisfaction score (4 vs 3) were higher in PCEA compared to PCA. Ability to ambulate, pruritus, PONV, haemodynamics, paO2 and paCO2 were comparable. Postoperative pain treatment with PCEA was more time-consuming (407 vs 299 min) and expensive (71 vs 40 S/day) than PCA. CONCLUSION: PCEA in comparison to PCA after major abdominal surgery provides superior analgesia with comparable side effects at approximately 80% higher costs.     

Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. IMPLICATIONS: Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.     

Measurement of pulmonary status and surfactant protein levels during dexamethasone treatment of neonatal respiratory distress syndrome

PURPOSE: To study the effect of epidural buprenorphine on minimum alveolar concentration (MAC) of volatile anaesthetics, duration of analgesia and respiratory function in the perioperative period. METHODS: One hundred and twenty patients, ASA I-II undergoing gynaecological surgery were randomly divided into three studies. The forty patients in each study were randomly divided into four groups depending on the dosage; Group I (control), Group II (80 micrograms. kg-1 morphine), Group III (4 micrograms. kg-1 buprenorphine), Group IV (8 micrograms. kg-1 buprenorphine). The MAC of halothane was measured following epidural administration of the agents in each group. The duration of analgesia was assessed by the first request for pentazocine. Postoperative analgesic effects were assessed by the total dosage of pentazocine required for the 48 hr after surgery. Respiratory rate (RR), minute volume (MV), and PaCO2 were measured during surgery and the postoperative period. The MAC of halothane was reduced in Group IV (P < 0.01). The duration of analgesia was 10.0 +/- 5.1 hr (Mean +/- SE) in Group I, 37.7 +/- 4.7 hr in Group II, 27.1 +/- 7.1 hr in Group III, and 44.4 +/- 4.1 hr in Group IV. Total dosage of pentazocine was lower in Group IV (P < 0.05) than in the other groups. The decrease of RR, MV and the increase of PaCO2 were observed within 60 min in Group III and IV dose dependently. CONCLUSION: Epidural buprenorphine administered in a dose of 4 or 8 micrograms. kg-1 provides postoperative analgesia that is no less effective than that of morphine.     

Midazolam for caudal analgesia in children: comparison with caudal bupivacaine

In a randomized, double-blind study we have examined the analgesic efficacy of caudal administration of midazolam, bupivacaine, or a mixture of both drugs in 45 children, undergoing inguinal herniotomy. They were allocated randomly into three groups (n = 15 in each) to receive a caudal injection of either 0.25% bupivacaine 1 ml.kg-1 with or without midazolam 50 micrograms.kg-1 or midazolam 50 micrograms.kg-1 with normal saline 1 ml.kg-1. There were no differences in quality of pain relief, postoperative behaviour or analgesic requirements between the midazolam group and the other two groups. Times to first analgesic administration (paracetamol suppositories) were longer (P < 0.001) in the bupivacaine-midazolam group than in the other two groups. Further, the bupivacaine-midazolam group received fewer (P < 0.05) doses of paracetamol than the bupivacaine group. Side effects such as motor weakness, respiratory depression or prolonged sedation were not observed in patients who received caudal epidural midazolam only. We conclude that caudal midazolam in a dose of 50 micrograms.kg-1 provides equivalent analgesia to bupivacaine 0.25%, when administered postoperatively in a volume of 1 ml.kg-1 for children following unilateral inguinal herniotomy.