An intravenous fluid bolus is not necessary before administration of intrathecal fentanyl for labor analgesia

The acute phase response to inflammation is mediated in part by the endogenous production of pro-inflammatory cytokines. Interleukin 6 (IL-6) and members of its superfamily, including ciliary neurotrophic factor (CNTF) and leukaemia inhibitory factor (LIF) have been implicated as primary mediators of the hepatic acute phase response. In the present report, mice suffering a turpentine-induced myositis were passively immunized with antibodies against either IL-6, CNTF or LIF. Passive immunization against IL-6 attenuated the anorexia and completely prevented the hypoalbuminaemia, and increases in the serum concentration of the acute phase reactants, amyloid P, amyloid A and seromucoid. In contrast, passive immunization against either CNTF or LIF failed to modulate the anorexia, weight loss or hepatic acute phase protein responses. The findings suggest that IL-6, but not other members of its superfamily, is primarily responsible for the hepatic acute phase response, and contributes to the anorexia, associated with turpentine-induced myositis.     

Comparison of patient-controlled epidural analgesia with patient-controlled intravenous analgesia using pethidine or fentanyl

OBJECTIVE: To investigate the relationship between physical activity, leisure time activities and dietary habits in adolescents. PATIENTS AND METHODS: We have studied 541 girls and 537 boys from 24 schools. Physical activity, leisure time activities and dietary habits were assessed by 3 different questionnaires, taking into account one week of normal activity and diet. RESULTS: Foods such as milk, fish, meat, egg, fruits, vegetables, pasta and snacks were consumed more frequently in children who spent more time doing sport, but difference were not statistically significant. Boys who spent more time watching T.V. ate greater amounts of almost all foods (p < 0.05). In girls, we have observed the same results, but differences were not statistically significant. CONCLUSIONS: Sports and T.V. watching are both related to a greater amount of food intake From our results we can deduce that in order to prevent obesity, and other cardiovascular risk factors, we must improve food intake related with sedentary habits.     

Hemodynamic effects of intrathecal fentanyl in nonlaboring term parturients

220 cases of gastric cancer were selected from Dakar Hospitals during seven years (1984-1991). This retrospective study confirms that gastric cancer is the most common cancer of the Gastro-intestinal tract (48.4%). The sex ratio was 2.7 (M/F) with mean age of 50 years. However, a steady progression of gastric cancer was noticed beginning at 40 years. Despite the introduction of upper gastro-intestinal endoscopy the classical evolved form was the most commonly found (83.2%). The associated lesions known to be premalignant were found in 22.7% of cases. The patients were seen with a long delay after the first symptoms. This is why we have long delays of diagnosis in our centers. 61.7% of them are seen 3 to 12 months after their first symptoms. In 70% of cases, lesions were found on antropyloric region. The most common histological type remain adenocarcinoma (90% of cases). Even though endoscopy has contributed to increase the incidence of gastric cancer, it did not allow to discover early gastric carcinoma.     

Synergistic antinociceptive interaction between sevoflurane and intrathecal fentanyl in dogs

This study determined the nature of the antinociceptive interaction between sevoflurane and intrathecal fentanyl on somatosympathetic reflexes in anaesthetized dogs. Afferent A delta- and C-fibre-mediated somatosympathetic reflexes, evoked by supramaximal electrical stimulation of tibial nerves, were recorded from renal sympathetic nerves. The effect of fentanyl alone, administered intrathecally (i.t.) in incremental doses from 2 to 64 micrograms, was compared with the effect of the same doses during the administration of 1.5% sevoflurane. The mean ED50s for the depressant effect of fentanyl (i.t.) on A delta and C reflexes were 35.6 micrograms and 14.2 micrograms while 1.5% sevoflurane, when administered alone, depressed them by 15.5% (P < 0.05) and 27.5% (P < 0.01) respectively. During the administration of 1.5% sevoflurane, the mean ED50s of fentanyl (i.t.) for the depression of A delta and C reflexes were reduced by 76% and 75%, to 8.5 micrograms and 3.5 micrograms respectively. The combined antinociceptive effects of sevoflurane and intrathecal fentanyl were not additive but exhibited a high degree of synergistic interaction.     

Dose-response relationship of intrathecal morphine for postcesarean analgesia

BACKGROUND: This series investigated the quality of analgesia and the incidence and severity of side effects of intrathecal morphine for post-cesarean analgesia administered over a dose range of 0.0-0.5 mg. METHODS: ONE hundred eight term parturients undergoing cesarean delivery at term and given spinal anesthesia were randomized to receive a single dose of intrathecal morphine (0.0, 0.025, 0.05, 0.075, 0.1, 0.2, 0.3, 0.4, or 0.5 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. PCA morphine use, incidence and severity of side effects, and need for treatment interventions were recorded for 24 h. Data were analyzed with analysis of variance and linear regression analysis for trends among groups. RESULTS: Patient-controlled analgesia use differed significantly between groups; PCA use was higher in the control group than in groups receiving 0.075, 0.1, 0.3, 0.4, or 0.5 mg. Twenty-four-hour PCA morphine use was 45.7 mg lower (95% CI, 4.8-86.6 mg lower) in the 0.075-mg group than the control group. There was no difference in PCA morphine use between the 0.075- and 0.5-mg groups (95% CI, 36.8 mg lower to 45.0 mg higher); despite a fivefold increase in intrathecal morphine dose, PCA morphine use remained constant. There was no difference between control and treatment groups or among treatment groups with respect to nausea and vomiting. Pruritus and the need for treatment interventions increased in direct proportion to the dose of intrathecal morphine (linear regression, P = 0.001 and P = 0.0002, respectively). CONCLUSIONS: These data indicate there is little justification for use of more than 0.1 mg for post-cesarean analgesia. For optimal analgesia, augmentation [corrected] of intrathecal morphine with systemic opioids may be necessary.     

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.     

Comparative study of postoperative analgesia with methadone and fentanyl in continuous peridural perfusion

OBJECTIVE: To determine whether continuous epidural perfusion of fentanyl, which is more liposoluble than methadone, provides a similar level of analgesia with fewer side effects than methadone administered by the same route for postoperative pain. PATIENTS AND METHODS: Prospective double blind study of 40 patients, randomly assigned to two groups. Group F (n = 20) received 300 micrograms-1200 micrograms/24 h in epidural perfusion. Group M (n = 20) received 9 mg-18 mg/24 h in epidural perfusion. In both cases treatment was for pain in the first 72 h after abdominal surgery. Analgesia quality was evaluated on a visual analog (VAS) scale from 1 to 10 at rest and moving. Need for complementary analgesia was also recorded, as were side effects related to the technique. RESULTS: Quality of analgesia was good and similar which both drugs. Postoperative pain did not surpass 3 on the VAS at rest or 4.5 while moving, although group F patients' need for complementary analgesia was significantly greater (p < 0.05). The incidence of hypoxemia was greater in group M than in group F (p = 0.05). CONCLUSIONS: Continuous epidural perfusion of fentanyl provides good analgesia and is associated with less hypoxemia than is methadone.     

Comparison of morphine with and without fentanyl for epidural analgesia after major abdominal surgery

Expression of fusion proteins between prepro-alpha-factor and somatostatin (SRIF) in yeast, resulted in the correct processing and secretion of the heterologous 14-amino acid SRIF peptide (1). When the chimeric genes were placed under the control of yeast acid phosphatase (PHO5) promoter, significant amount of an unglycosylated form of the fusion precursor molecule accumulated intracellularly, suggesting disruption of an endoplasmic reticulum-mediated function. We report here that the appearance of the precursor is due to an alteration in the three amino terminal residues of the chimera, i.e., Met-Arg-Phe in native prepro-alpha-factor is changed to Met-Phe-Lys in the hybrids. The unglycosylated precursor represents a population of molecules that are disrupted at an early stage of targeting to or translocation across the endoplasmic reticulum membrane. Our data demonstrate that the N-terminus plays an important role in topogenesis. Furthermore, these results show that translocation and glycosylation can be uncoupled from protein synthesis in vivo, and therefore can be posttranslational events in yeast.     

The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20), or 15 micrograms (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra-operatively was similar. Fentanyl significantly improved the quality of intra-operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 micrograms fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra-operative anaesthesia for Caesarean section.     

The effect of intrathecal and epidural narcotic analgesia on the length of labor

OBJECTIVE: Long-term results after different types of operations for urinary stress incontinence (minimum follow-up: 18 months) as well as multiple risk factors for the pelvic floor were analysed in a retrospective study. STUDY DESIGN: Between 1980 and 1992 1283 patients underwent surgery because of urinary stress incontinence at the University Women's Hospital in Heidelberg. The data of 478 patients, 430 of these after primary and 48 after recurrent surgery, were evaluated by questionnaires with regard to the long-term-results. RESULTS: 57% of patients after primary surgical therapy and 37% after recurrent surgery were cured for longer than 5 years or since the operation. A cure or improvement of the incontinence could be observed in 80% after primary and in 73% after recurrent surgery. Among the vaginal approaches for primary surgery the hysterectomy combined with colporrhaphy was most successful (60% cured or more than 5 years continent, 80.5% at least improved). The Burch colposuspension revealed even better results among the abdominal approaches (64% cured or longer than 5 years continent, 86% at least improved) compared to the Marshall-Marchetti-Krantz procedure with a cure rate of 33%. For therapy of the recurrent urinary incontinence the abdominal Burch colposuspension showed the best results with cure rates of 50% and cure or improvement in 75%. Therefore the abdominal approach seems to be superior to vaginal techniques such as sling operations (33% cure rate, 67% at least improved) or only re-colporrhaphy (27% cure rate, 78% at least improved). CONCLUSION: For primary incontinence the hysterectomy with vaginal repair or the Burch colposuspension have proved to be most successful. For recurrent urinary incontinence the abdominal colposuspension (Burch procedure) seems to be superior to other approaches.     

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.     

Epidural fentanyl, adrenaline and clonidine as adjuvants to local anaesthetics for surgical analgesia: meta-analyses of analgesia and side-effects

BACKGROUND: The risk/benefit ratio of adding fentanyl, adrenaline and clonidine to epidural local anaesthetics for improving intraoperative analgesia is unclear. This meta-analysis was performed to clarify this issue. METHODS: Trials retrieved by search were considered if they were prospective, controlled, epidural analgesia (without combining general anaesthesia) was planned and occurrence of pain during surgery or side-effects were reported. Papers entered meta-analysis if they reached a predefined minimum quality score. Pooled odds ratios (OR) and confidence intervals (CI) were computed. P < 0.05 was considered as significant. RESULTS: Eighteen trials were included in the analysis for fentanyl. Fentanyl decreased the likelihood of pain (OR = 0.21, 95% CI = 0.15-0.30, P < 0.001) and increased the incidence of pruritus (OR = 5.59, 95% CI = 3.12-10.05, P < 0.001) and sedation (OR = 1.88, 95% CI = 1.19-2.98, P = 0.003), compared to control (local anaesthetic without fentanyl). Fentanyl had no effect on respiratory depression, nausea, vomiting and Apgar score. One case of respiratory depression of a newborn was observed. Because of the very low number of trials selected, evaluation of adrenaline and clonidine was not feasible. CONCLUSION: The analysis of current literature shows that the addition of fentanyl to local anaesthetics for intraoperative epidural analgesia is safe and advantageous. The reduction in the incidence of pain during surgery is quantitatively high and therefore clinically significant. Side-effects are mild. Randomized, controlled trials have to be performed in order to clarify the role of adrenaline and clonidine as epidural adjuvants for surgical analgesia.     

A comparison of morphine, pethidine and fentanyl in the postsurgical patient-controlled analgesia environment

Oncogene and tumor suppressor gene mutations are candidate biomarkers for cancer risk assessment and lesion detection. The K-ras oncogene has previously been associated with non-small cell lung cancer (NSCLC), particularly adenocarcinomas in which reported rates of mutation have approached 30-40%. We have analyzed non-malignant lung tissue from patients with lung cancer and primary lung cancers for K-ras gene mutations. Mutations were detected in 32% cancers and 29% non-malignant lung tissue from patients with cancer. The majority of tumors testing positive were adenocarcinoma of the lung. Normal DNA controls, including peripheral blood lymphocytes and normal lung from non-smokers, were negative. The ability to detect genetic alterations in non-malignant lung tissues is consistent with the concept that genetic alterations are involved in field cancerization of the aerodigestive tract.     

Comfortable labor with intrathecal narcotics

Aggressive pursuit of high-quality health care had guided the Health Service of the United States Army to establish a labor analgesia program within its hospitals. A dedicated Labor Epidural Service can be quite expensive, especially from the manpower standpoint. Therefore, the Anesthesia Service at Reynolds Army Community Hospital, Fort Sill, Oklahoma, implemented a program of intrathecal narcotic injection as an alternative to costly labor epidural analgesia. After reviewing a patient fact sheet, 150 laboring patients volunteered for labor intrathecal analgesia (LIA). Once active labor began, the patient received intrathecal morphine (0.25 mg) and fentanyl (25 micrograms). The pain level before and after the LIA was evaluated by the visual analog schedule method. At 2 weeks follow-up the intrathecal narcotic-assisted labor was subjectively reported by the patients. Ninety-four percent of the patients agreed that the LIA worked well and that they would do it again. LIA was found to be a well-accepted, cost-saving, very effective approach to labor analgesia.     

Postoperative analgesia after co-administration of clonidine and morphine by the intrathecal route in patients undergoing hip replacement

Postoperative analgesia after intrathecal co-administration of clonidine hydrochloride (75 micrograms) and morphine sulfate (0.5 mg) was compared with analgesia produced after either intrathecal morphine (0.5 mg) or 0.9% sodium chloride in 90 patients undergoing total hip replacement under bupivacaine spinal anesthesia. Patient-controlled morphine requirements were significantly reduced (P < 0.001) postoperation by both clonidine/morphine (median 5 mg/24 h) and morphine (median 7 mg/24 h) compared with control (saline) (median 28 mg/24 h). However, no significant additional reduction in postoperative analgesic requirements was shown with the clonidine/morphine combination compared with morphine alone. Visual analog pain scores, although good in all groups at all times, were significantly poorer in the control group at 2 h (P < 0.04) and 4 h (P < 0.001) after operation compared with both treatment groups, and significantly poorer than the clonidine/morphine group at 6 h (P < 0.002) and 24 h (P < 0.009) postoperation. Mean arterial blood pressure was significantly lower in the clonidine/morphine group than in the two other groups (P < 0.001) between 2 and 5 h after operation. The incidence of emesis was similar in the clonidine/morphine and morphine groups and was significantly more than in the control group.     

Bupivacaine 0.01% and/or epinephrine 0.5 microg/ml improve epidural fentanyl analgesia after cesarean section

The Pollution Effects on Asthmatic Children in Europe (PEACE) study is a multicentre study of the acute effects of particles with a 50% cut-off aerodynamic diameter of 10 microm (PM10), black smoke (BS), sulphur dioxide (SO2) and nitrogen dioxide (NO2) on the respiratory health of children with chronic respiratory symptoms. The study was conducted in the winter of 1993/1994 by 14 research centres in Europe. A total of 2,010 children, divided over 28 panels in urban and suburban locations, was followed for at least 2 months. Exposure to air pollution was monitored on a daily basis. Health status was monitored by daily peak expiratory flow (PEF) measurements and a symptom diary. The association between respiratory health and air pollution levels was calculated with time series analysis. Combined effect estimates of air pollution on PEF or the daily prevalence of respiratory symptoms and bronchodilator use were calculated from the panel-specific effect estimates. Fixed effect models were used and, in cases of heterogeneity, random effect models. No clear associations between PM10, BS, SO2 or NO2 and morning PEF, evening PEF, prevalence of respiratory symptoms or bronchodilator use could be detected. Only previous day PM10 was negatively associated with evening PEF, but only in locations where BS was high compared to PM10 concentrations. There were no consistent differences in effect estimates between subgroups based on urban versus suburban, geographical location or mean levels of PM10, BS, SO2 and NO2. The lack of association could not be attributed to a lack of statistical power, low levels of exposure or incorrect trend specifications. In conclusion, the PEACE project did not show effects of particles with a 50% cut-off aerodynamic diameter of 10 microm, black smoke, sulphur dioxide or nitrogen dioxide on morning or evening peak expiratory flow or the daily prevalence of respiratory symptoms and bronchodilator use.     

Maternal respiratory arrests, severe hypotension, and fetal distress after administration of intrathecal, sufentanil, and bupivacaine after intravenous fentanyl

The transjugular intrahepatic portosystemic shunt procedure is an effective intervention for patients with bleeding esophageal varices. Potential complications are numerous but rarely serious. A case of hemopericardium, cardiac tamponade, and death caused by perforation of the right atrium and aorta by a stent after embolization from the liver during stent placement is reported.