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Background: Paracervical block is widely used in gynaecological interventions on cervix and uterus. Many surgeons add adrenaline 100 μg or pitressin 3-5 IU in a total volume of 10-20 mL to reduce total blood loss. We wanted to examine haemodynamic stability in healthy patients given bupivacaine with and without adrenaline., Methods: In this randomised, double-blinded, controlled study, 30 healthy women scheduled for cervical conisation got a paracervical block using bupivacaine 50 mg with adrenaline 100 μg (BA-group, n = 14) or without adrenaline (B-group, n = 16) after induction of general anaesthesia. LiDCOplus was used for minimally invasive haemodynamic monitoring. Changes in cardiac output (CO) and systolic blood pressure (SBP) were the primary outcome. Changes in heart rate (HR), stroke volume (SV), and systemic vascular resistance (SVR) were secondary outcome variables. Area under the curve (AUC) ratios and change from baseline to maximal values were used as effect measures comparing the two groups., Results: The AUC-ratio for CO and SBP was 2.50 (P < 0.001) and 1.70 (P = 0.03), respectively. For HR, SV, and SVR the AUC-ratio was 1.59 (P < 0.01), 1.52 (P < 0.001), and 0.90 (P = 0.14), respectively. CO increased 68% (standard deviation (SD) 42%, P < 0.001), HR increased 41% (SD 26%, P < 0.001), and SV increased 26% (SD 17%, P < 0.001) from baseline to maximal values after 70-90 seconds in the BA-group., Conclusion: Paracervical block with bupivacaine 50 mg and adrenaline 100 μg may give haemodynamic instability in healthy females and is not recommended if haemodynamic side effects are to be avoided., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Priapism is a rare complication of epidural anaesthesia, and the pathophysiology is poorly understood. In general, 95% of all priapism episodes are ischemic because of decreased penile blood flow, and therefore requires immediate treatment. A case is reported of a 45-year-old male patient in which a clear relation is demonstrated between continuous thoracic epidural analgesia and priapism after transabdominal nephrectomy. The level of epidural anaesthesia supports the theory that the erection is a consequence of increased penile blood flow, thus a relatively harmless condition. However, confirmation by serial cavernous blood gas analysis or colour duplex ultrasonography is mandatory. Until this hypothesis is confirmed, termination of epidural infusion is advised as a primary treatment., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: This prospective, observer-blinded, randomised, multicentre study aimed at determining the non-inferiority of 50 mg of plain 1% 2-chloroprocaine vs. 10 mg of 0.5% plain bupivacaine in terms of sensory block onset time at T10 after spinal injection. The study hypothesis was that the difference in onset times of sensory block to T10 between the two drugs is ≤ 4 min., Methods: One hundred and thirty patients undergoing lower abdominal or lower limb procedures (≤ 40 min) were randomised to receive one of two treatments: 50 mg of plain 1% 2-chloroprocaine (Group C, n = 66) or 10 mg of plain 0.5% bupivacaine (Group B, n = 64). Times to sensory and motor block onsets, maximum sensory block level, readiness for surgery, regression of sensory and motor blocks, first analgesic requirements, unassisted ambulation, home discharge, and side effects after 24 h and 7 days were registered blindly., Results: Chloroprocaine was comparable with plain 0.5% bupivacaine in terms of time to sensory block at T10 level. Group C showed faster onsets of motor block (5 vs. 6 min), maximum sensory block level (8.5 vs. 14 min), resolution of sensory (105 vs. 225 min) and motor (100 vs. 210 min) blocks, unassisted ambulation (142.5 vs. 290.5 min), first analgesic requirement (120 vs. 293.5 min), and home discharge (150 vs. 325 min) (all comparisons, P < 0.05). No chloroprocaine patient developed transient neurological symptoms., Conclusion: Spinal anaesthesia with 50 mg of plain 1% 2-chloroprocaine is similar to 10 mg of plain 0.5% bupivacaine in terms of onset of sensory block at T10 but shows quicker recovery from anaesthesia than with 0.5% bupivacaine., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Dexmedetomidine (DMT) has been shown to prolong spinal anaesthesia. We evaluated the effects of intravenous DMT on low-dose bupivacaine spinal anaesthesia in elderly patients., Methods: Fifty-one elderly patients undergoing transurethral resection of the prostate were randomized into two groups receiving either 1.0 μg/kg DMT (DMT group, n = 26) or normal saline (control group n = 25) intravenously prior to spinal anaesthesia with 1.2 ml of bupivacaine, 5 mg/ml., Results: The mean time to two-segment regression (39 min vs. 78 min for cold, 41 min vs. 61 min for pinprick) and that to motor regression (23 min vs. 46 min) were longer in the DMT group than in the control group. The atropine-requiring bradycardia was more frequent in the DMT group than in the control group (24.0% vs. 3.8%). The median sedation scores (ranges) during surgery were 4 (2-6) in the DMT group and 2 (1-3) in the control group (P < 0.001). Two patients in the DMT group showed oxygen desaturation (peripheral oxygen saturation < 90%) during surgery. The duration of post-operative care unit stay was longer in the DMT group than in the control group (58 min vs. 96 min). Post-operative pain intensity was lower and the mean time to first request for post-operative analgesia was longer in the DMT group compared to the control group (6.6 h vs. 2.1 h)., Conclusion: Intravenous DMT prolonged the duration of spinal anaesthesia and improved post-operative analgesia. However, more profound sedation with desaturation was observed with more frequent bradycardia, and delayed recovery should be considered in elderly patients., (© 2012 The Authors Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: The benefits of subacromial local anesthetic infusion are controversial. The aim of this study was to evaluate the efficacy of subacromial bupivacaine infusion after arthroscopic acromionplasty and rotator cuff procedures., Methods: Ninety patients with subacromial impingement disease scheduled for elective shoulder arthroscopy were enrolled in this randomized, prospective and placebo-controlled study. The patients received subacromially either 5.0 mg/ml bupivacaine or 9.0 mg/ml saline at the rate of 2 ml/h post-operatively for 48 h. The primary outcome measure was the use of rescue oxycodone. The consumption of opioids, ibuprofen, paracetamol and codeine, and the intensity of pain were recorded., Results: Patients receiving bupivacaine infusion used significantly less oxycodone compared with patients receiving saline [15 vs. 20 mg (median) oxycodone intravenously on the day of surgery, 0 vs. 10 mg (median) perorally on the first post-operative day]. There was no significant difference in the use of ibuprofen, paracetamol and codeine, except that paracetamol was used more in patients receiving saline during the day of surgery (P = 0.009). The pain scores of patients receiving bupivacaine were lower at 18 h (P = 0.008). Average pain scores for the worst pain experienced did not differ between the groups. There were three (4%) premature discontinuations because of technical problems., Conclusions: Considering the low need of opioids, expenses and technical problems in these patients, subacromial 5.0 mg/ml bupivacaine infusion 2 ml/h confers only moderate and probably clinically insignificant efficacy compared with placebo. This efficacy might be overweighed by the disadvantages., (© 2012 The Authors Acta Anaesthesiologica Scandinavica © 2012 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Spinal bupivacaine produces a complete anaesthetic block of a longer duration than ropivacaine, which leads to a potentially increased risk of failure. A combination of sufentanil to ropivacaine may improve the block's reliability., Methods: Sixty-four patients, scheduled for varicose vein stripping or the tension-free vaginal tape procedure, were allocated to receive double-blindly, spinal bupivacaine 10 mg (Group 1) or ropivacaine 10 mg without (Group 2) or with sufentanil 2.5 mcg (Group 3), 5 mcg (Group 4). Sensory block was tested with pinprick and motor block was evaluated with the Bromage scale until full recovery. The primary endpoint was to compare the duration of sensory block evaluated by regression to S2., Results: In comparison with bupivacaine, ropivacaine produced a shorter duration sensory block (median at 68, 90 and 120 min in groups 2, 3 and 4, respectively, vs. 150 min in Group 1) and motor block (median at 90, 98 and 120 min in groups 2, 3 and 4 vs. 180 min in Group 1). Motor blockade was significantly less important in patients receiving spinal ropivacaine (median values for the Bromage scale at 3 in groups 2, 3 and 4, vs. 1 in Group 1). Pruritus was significantly more frequent in patients receiving spinal sufentanil (Groups 3 and 4 vs. Groups 1 and 2)., Conclusion: Plain bupivacaine 10 mg has a longer recovery profile than the same dose of ropivacaine with or without sufentanil., (© 2011 The Authors. Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: We studied plasma bupivacaine concentrations in patients with a continuous subacromial bupivacaine infusion after an ambulatory arthroscopic shoulder surgery to evaluate whether it is feasible to discharge patients with an on-going infusion early on the operation day., Methods: Sixteen ASA I-III patients undergoing elective arthroscopic shoulder surgery were randomized in 1:1 ratio to receive a continuous infusion of either 2.5 or 5.0 mg/ml bupivacaine subacromially for 48 h post-operatively. Before the commencement of the infusion, 20 ml of 5.0 mg/ml bupivacaine was injected subacromially in both groups. Plasma bupivacaine concentrations were defined as the primary endpoint and concentrations of its metabolites, side effects and pain scores as the secondary endpoints., Results: The mean total plasma bupivacaine concentration increased up to 48 h, the highest mean being 0.87 (SD 0.30) μg/ml during the 5.0 mg/ml treatment and 0.24 (0.10) μg/ml during the 2.5 mg/ml bupivacaine treatment. After 48 h, there was a significant difference between the groups in the plasma levels. The highest mean 4-hydroxy-bupivacaine and desbutylbupivacaine concentrations were 0.11 and 0.22 μg/ml, respectively. In the pain scores, no significant difference was found. No clear signs of toxicity were observed., Conclusions: The concentrations of total bupivacaine and its metabolites remained below toxic levels. Excluding patients with renal or liver diseases, both 2.5 and 5.0 mg/ml bupivacaine as subacromial infusion 2 ml/h for 48 h following shoulder arthroscopy seem to be well tolerated, enabling patient discharge with an on-going infusion on the operation day. Because of similar side effects and pain scores in both groups, 2.5 mg/ml may be preferable., (© 2010 The Authors. Journal compilation © 2010 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Transient neurological symptoms (TNS) after spinal anaesthesia have been reported most commonly in association with lidocaine, but have been observed with other local anaesthetics. The aim of this prospective, randomized, double-blind study was to investigate the incidence of TNS after spinal anaesthesia with either levobupivacaine or lidocaine., Methods: Patients undergoing inguinal hernia, appendectomy, varicose vein or minor orthopaedic operations were included in the study (60 patients; 47 male, 13 female, overall mean age 30 years). All patients had an American Society of Anesthesiologists score of I or II. The patients were randomly assigned to receive spinal anaesthesia with either 20 mg isobaric levobupivacaine (5 mg/ml) or 80 mg isobaric lidocaine (20 mg/ml). Onset of sensory and motor block and side effects were recorded. On post-operative days 1, 2, and 3, patients were interviewed by an investigator blinded to the spinal anaesthetic used. The patients were classified as having TNS if, following recovery from anaesthesia, there was pain in the buttocks, thighs and/or lower limbs., Results: In the levobupivacaine group, one patient (3.33%) experienced TNS, whereas in the lidocaine group, eight (26.6%) experienced TNS (P=0.002). Maximum times to arrival of sensory blocks were shorter with lidocaine (P<0.001). The levobupivacaine and lidocaine groups did not differ significantly in terms of the highest dermatome included in sensory block or motor block grade., Conclusion: After spinal anaesthesia with levobupivacaine, the incidence of TNS was much less than after lidocaine. However, it appears that TNS may occur in association with levobupivacaine.

Background: Severe pain in the head and neck is associated with a lowered quality of life and conventional pain therapy often does not provide adequate relief. The aims of this study were to investigate the efficacy, pain relief, benefits and adverse effects of intracisternal or high cervical (IHC) administration of bupivacaine in patients with severe pain in the head, neck and face regions., Methods: Between 1990 and 2005, 40 patients (age 27-84 years) were treated with continuous IHC infusions of bupivacaine for various non-cancer (n=15) or cancer-related (n=25) refractory pain conditions (duration 1 month-18 years) in the head, neck, mouth and shoulder regions., Results: Visual analogue scale scores and opioid requirements decreased markedly after the start of the treatment and remained lowered throughout the study. No tachyphylaxis for bupivacaine was observed. Major side effects were few and most often transient. Most patients showed unchanged or improved mobility. There was no mortality, neurological damage or other severe events attributable to procedures in the study protocol., Conclusion: For patients with severe and refractory pain in areas innervated by cranial and upper cervical nerves, cervical high spinal analgesia can provide safe and effective analgesia.

Background: Low-dose hyperbaric bupivacaine has been used to produce unilateral spinal anaesthesia for outpatient surgery. Unilateral spinal anaesthesia is associated with reduction of hypotension, faster recovery and increased patient satisfaction. Small doses of clonidine have shown effectiveness in intensifying spinal anaesthesia. We investigated the effect of adding 15 microg of clonidine to 5 mg hyperbaric bupivacaine on unilaterality., Methods: Sixty patients undergoing outpatient knee arthroscopy were randomly allocated to receive either 1.2 ml (6 mg) of hyperbaric bupivacaine or a 1.2 ml solution containing 1.0 ml (5 mg) hyperbaric bupivacaine, 0.1 ml (75 microg) clonidine and 0.1 ml sterile water. The motor block was assessed by a modified Bromage scale and the sensory block by a pinprick., Results: There was a significant difference in the spread of anaesthesia between the operated and contralateral sides in both groups. Seventy-seven per cent of the blocks were unilateral in group B and 73% in group B-C. There was no significant difference between the groups, in unilaterality. The motor block was prolonged in group B-C but it did not affect home-readiness. Patients receiving clonidine needed more vasopressors. There was a significant difference in blood pressures between the groups, being lower in group B-C after 1 h 45 min., Conclusion: Using 5 mg hyperbaric bupivacaine with 15 microg of clonidine, the unilaterality can be achieved and spinal anaesthesia intensified without affecting home-readiness. More vasopressors are needed in the beginning, but after the surgery patients experienced less pain.

Background: Epidural fentanyl 100 microg after lidocaine-epinephrine test dose has been shown to provide adequate analgesia in early labor. This investigation determines the effect of three different bolus doses of epidural fentanyl on duration and quality of analgesia during early first stage of labor., Methods: In this prospective, double-blind study, 103 laboring nulliparous at cervical dilation <5 cm were enrolled. After an epidural test dose of lidocaine (60 mg) with epinephrine (15 microg), parturients received, randomly, bolus of epidural fentanyl 50, 75, or 100 microg, followed by a continuous infusion of epidural bupivacaine 0.0625% and fentanyl 3 microg/ml at a rate of 10 ml/h. Pain scores and maternal sedation, pruritus, nausea, and vomiting were recorded 10, 20, and 30 min after fentanyl, and every 30 min thereafter until first request for additional analgesia., Results: Adequate analgesia was achieved in 87% (28/32), 94% (35/38), and 94% (31/33) in the fentanyl 50, 75, and 100 microg groups within 20 min. Mean duration of analgesia before re-dosing was significantly longer in fentanyl 100 and 75 microg groups (185.6+/-82.9 and 188.5+/-82.2 min, respectively) as compared with fentanyl 50 microg group (133.6+/-46.2 min, P<0.016). There was no difference in the incidence of maternal side effects or neonatal Apgar scores among the three groups., Conclusion: After a test dose of lidocaine-epinephrine, the three epidural fentanyl doses produced similar effective labor analgesia. However, epidural fentanyl 75 microg followed by epidural infusion of dilute bupivacaine and fentanyl produced longer duration of analgesia than fentanyl 50 microg followed by the same infusion, with no further prolongation when the dose of fentanyl was increased up to 100 microg.

Background: A selective ankle block, blocking the tibial, deep and superficial peroneal nerves, can be used successfully for great toe surgery. No comparative information is available on selective ankle block using ropivacaine and levobupivacaine., Methods: We compared the onset time and success rate of a selective ankle block using low volumes (12 ml) of ropivacaine 10 mg/ml and levobupivacaine 7.5 mg/ml in 40 patients undergoing elective repair of bilateral hallux valgus. Each patient received an ankle block induced in one foot with ropivacaine and in the contralateral foot with levobupivacaine., Results: The success rate was higher [90% vs. 75%, hazard ratio (95% CI) 0.39 (0.23-0.64)] and anesthesia onset time was shorter (median, 10 vs. 20 min) after ropivacaine than after levobupivacaine. In successful ankle blocks, post-operative pain was similar in the two groups., Conclusion: In this study, ropivacaine 10 mg/ml had a shorter anesthesia onset time and a higher success rate than levobupivacaine 7.5 mg/ml for selective ankle block.

Background: Although the use of continuous epidural infusion (CEI) and patient-controlled epidural analgesia (PCEA) has become commonplace in pain management, there is still controversy regarding the relative effects of mass, volume and concentration of the local anaesthetic. This prospective study evaluated the influence of two concentrations of levobupivacaine on the quality of analgesia in two modes of delivery after lower abdominal surgery., Methods: Eighty-two patients were randomly assigned to four groups to receive combined low thoracic epidural analgesia and general anaesthesia followed by post-operative CEI or PCEA using 1.5 or 5 mg/ml levobupivacaine (15 mg/h in CEI and bolus 5 mg, lockout 20 min in PCEA). Sensory block, pain scores, levobupivacaine and rescue morphine consumption, motor blockade, haemodynamics, side-effects and patient satisfaction were registered within 48 h., Results: The four groups were similar with regard to demographics, quality of analgesia, morphine consumption and satisfaction rate. No difference in the quality of analgesia was observed for the two modes of delivery with regard to the concentration of levobupivacaine, but the consumption of the local anaesthetic was higher in the CEI groups. The Bromage scores in the PCEA groups were reduced to zero for all except one patient, whereas eight patients presented scores of one or more in the CEI population., Conclusion: Levobupivacaine in thoracic epidurals provides an equal quality of post-operative analgesia in low and high volume independent of the delivery mode, i.e. CEI or PCEA. This is in accordance with the assumption that the total dose of the local anaesthetic determines the quality of analgesia.

Background: The purpose of this study was to determine whether intra-articular injection of bupivacaine prior to surgery provided better pain control after arthroscopic meniscectomy as compared with post-operative administration of bupivacaine., Methods: Forty patients of American Society of Anesthesiologists (ASA) class I or II undergoing arthroscopic meniscectomy were assigned in a randomized, double-blinded manner into two groups: Group I received 20 ml of 2.5 mg/ml bupivacaine without epinephrine 30 min before skin incision and 20 ml of saline immediately after skin closure. Group II received identical injections in reverse order. All patients received total intravenous anesthesia. Post-operative pain scores were evaluated at 1, 2, 4, 6, 8, 12 and 24 h at rest and movement of the knee, using a 10-cm visual analog scale (VAS). The time to first analgesic use and 24-h analgesic consumption were recorded., Results: Pain scores were lower in Group I compared with Group II at 1, 2, 4 and 6 h at rest and on movement (P < 0.05). The time to first analgesic use was longer in Group I, but there was no statistically significant difference in 24-h analgesic consumption., Conclusion: Intra-articular bupivacaine administered before surgery provided a statistically significant reduction in post-operative pain scores compared with post-operative bupivacaine administration.

The interpleural block (IPB) is a relatively safe procedure and is commonly practised to provide analgesia. A local anaesthetic injected into the interpleural space spreads widely to block various neural structures. The IPB can initiate bronchospasm by interrupting the sympathetic outflow but sparing the parasympathetic outflow to the lungs. In addition, unilateral reduction of intercostal muscle tone with consequential selective reduction of the functional residual capacity of that lung may also mimic airflow obstruction. We report a case of unilateral bronchospasm encountered following IPB.

Background: Hip fracture is common in the geriatric population. Patients in this group are often at high risk for perioperative complications from concurrent diseases. Conventional spinal anesthesia can be associated with hypotension but has a better postoperative outcome compared to general anesthesia. We judged that a reduced dose of bupivacaine in combination with sufentanil could give reliable blocks with minimal hypotension., Methods: Fifty elderly patients were randomized into two groups. The study group received spinal anesthesia as a combination of hyperbaric bupivacaine 7.5 mg and sufentanil 5 microg while the control group received hyperbaric bupivacaine 15 mg. The hemodynamic stability of the patients and the quality of the blocks were compared., Results: All patients had adequate duration of reliable blocks. More control group patients than study group patients required ephedrine due to hypotension., Conclusion: A reduced dose of hyperbaric bupivacaine (7.5 mg) in combination with sufentanil (5 microg) provides reliable spinal anesthesia for the repair of hip fracture in aged patients with few events of hypotension and little need for vasopressor support of blood pressure.

Background: The new local anesthetic IQB-9302 is an amide derivative bearing a cyclopropyl group, with remarkable long duration of action and relative low toxicity. In trying to characterize further its safety profile, the current study compared the hemodynamic effects of different concentrations of bupivacaine and IQB-9302 with saline., Methods: Two groups of eight anesthetized Sprague-Dawley rats were given 0.1, 0.3, 1, 3, and 10 mg/kg of intravenous (i.v.) IQB-9302 or bupivacaine at 20-min intervals; control animals received saline only. Arterial blood pressure and heart rate were monitored during the following 20 min., Results: Both bupivacaine and IQB-9302 reduced heart rate: for bupivacaine, -73.8 beats per min (bpm) (SD: 103.8) and -132.5 bpm (SD: 140.7) at 1 and 3 mg/kg, respectively; for IQB-9302, the reduction amounted to -40.8 bpm (SD: 14.2) and -113.5 bpm (SD: 94.2) at 1 and 3 mg/kg, respectively (baseline range, 318.7-438.2 bpm). The two drugs also produced a comparable increase in the mean arterial blood pressure; bupivacaine increased it by 8.7 mmHg (SD: 6.6) and 12.6 mmHg (SD: 15.4) at 1 and 3 mg/kg, respectively, and IQB-9302, 18.7 mmHg (SD: 21.1) and 20.7 mmHg (SD: 20.5) at 1 and 3 mg/kg, respectively (baseline range, 47.4-134.1 mmHg). All rats treated with 10 mg/kg of either drug died after a drop in heart rate and mean arterial blood pressure., Conclusion: IQB-9302 had hemodynamic effects similar to those of bupivacaine in anesthetized rats. The clinical relevance of these effects warrants further investigation.

Background and Objective: The purpose of the study was to compare the effects of adding 50 microg of morphine, 25 microg of fentanyl or saline to 6 mg of hyperbaric bupivacaine on postoperative analgesia and time to urination in patients undergoing arthroscopic knee surgery under spinal anesthesia., Methods: The study was designed in a prospective, randomized, double-blinded and placebo-controlled manner. Sixty ASA I-II patients were randomized into the following three groups: Group BM: 6 mg of bupivacaine and 50 microg of morphine, Group BF: 6 mg of bupivacaine and 25 microg of fentanyl, and Group BS: 6 mg of bupivacaine and saline. Selective spinal anesthesia was performed in a lateral decubitus position, with the operative knee dependent for 10 min., Results: In all groups satisfactory anesthesia was provided during the operation. There was a statistically significant difference between all the groups in times to voiding [Group BM 422 +/- 161 min; Group BF 244 +/- 163 min; Group BS 183 +/- 54 min (mean +/- SD)]. The incidence of pruritus was significantly greater in Group BM (80%) and BF (65%) in comparison with Group BS (no pruritus) (P < 0.05). The incidence of nausea was significantly increased in Group BM (35%) in comparison with Group BF (10%) and Group BS (P < 0.05). Analgesic consumption was significantly greater in Group BS in comparison with Groups BM and BF (P < 0.01)., Conclusions: We conclude that during spinal anesthesia even mini-dose intrathecal morphine is not acceptable for outpatient surgery due to side-effects, especially severely prolonged time to urination.

Background: In total hip replacement surgery several anesthesiological techniques can be used. In this study we compared continuous spinal anesthesia (CSA) and postoperative analgesia vs. single-shot spinal anesthesia (SPA) and postoperative patient-controlled intravenous analgesia with morphine (SPA)., Methods: In a prospective randomized study, 68 patients, ASA I-III, between 50 and 85 years of age were allocated to these two groups. Quality of analgesia, hemodynamic stability and technical difficulties, as well as incidence of postoperative nausea and vomiting (PONV) and post dural puncture headache (PDPH), were recorded during a 24-h period., Results: Visual analog scale (VAS) scores were significantly lower in the CSA group from 3 h post operation (P < 0.05). Mean arterial pressure dropped by 21 +/- 11 mmHg in the CSA group and 29 +/- 14 in the SPA group during induction (P < 0.05). Technical difficulties and incidence of PDPH were similar in both groups. Postoperative nausea and vomiting was lower in the CSA group (P < 0.05)., Conclusions: Continuous spinal anesthesia/analgesia is a very practicable method providing better postoperative analgesia and better hemodynamic stability during anesthesia induction than SPA followed by morphine PCA analgesia after total hip replacement surgery.

Background: The relative effects of the mass, volume and concentration of local anaesthetic solution used for epidural anaesthesia and analgesia are still under debate. Clinical studies have shown discrepancies, probably because of limited consideration of total dose., Methods: This prospective, randomized and blinded study evaluated the spread, the quality of post-operative analgesia and the incidence of side-effects of continuous thoracic epidural levobupivacaine 15 mg/h in three different concentrations: 1.5 mg/ml, 10 ml/h (n = 26), 5 mg/ml, 3 ml/h (n = 33) or 7.5 mg/ml, 2 ml/h (n = 31). The following variables were registered within 48 h: sensory block, pain scores, rescue morphine consumption, motor blockade, haemodynamics, sedation, nausea and vomiting, and patient satisfaction., Results: The three groups were similar with regard to demographics, quality of analgesia, morphine consumption, and satisfaction rate. The upper level of sensory block was two segments higher in the 1.5 mg/ml group. Motor blockade in the lower limbs was low in the three groups. Haemodynamic profile was more stable in the higher concentration groups compared with the 1.5 mg/ml patient group (P < 0.001). Nausea was more frequent in the 1.5 mg/ml group (P = 0.02)., Conclusion: The same dose of levobupivacaine provides an equal quality of analgesia in low or high volume continuous thoracic epidural infusion with reduced haemodynamic instability and nausea in the low volume/high concentration groups.

Background: Adverse effects may still limit the use of continuous epidural and intravenous analgesia in surgical wards. This study postulated that postoperative epidural analgesia was more efficient, and had fewer side-effects than intravenous morphine. The aim was to investigate efficacy, adverse effects and safety of the treatments in a large patient population., Methods: During a five-year period 2696 patients undergoing major surgery, received either epidural or intravenous analgesia for postoperative pain relief. The patients were prospectively monitored in surgical wards. Pain was evaluated with a numeric rating scale (0-10) at rest/mobilization. Treatment duration, respiratory depression, sedation/hallucinations/nightmares/confusion, nausea/vomiting, pruritus, orthostatism/leg weakness, and insufficient pain relief were registered. Pain relief for all patients aimed at a pain scoring of less than 4 at rest., Results: Epidural analgesia was used in 1670 patients, and intravenous morphine in 1026 patients. Patients with epidural analgesia experienced less pain both at rest and during mobilization. Insufficient treatment effects such as dose adjustments, orthostatism/leg weakness, and pruritus were more common in the epidural group. Respiratory depression and sedation/hallucinations/nightmares/confusion occurred more often in the intravenous group. Thoracic epidural catheters caused a lower incidence of motor blockade compared to lumbar catheter placements., Conclusion: In a large patient population the use of epidural and intravenous postoperative analgesia was considered safe in surgical wards, and the incidence of adverse effects was low. Patients with epidural analgesia experienced overall less pain, while opioid related side-effects were more common with intravenous morphine analgesia.

Background: Combination of local anesthetic and opioid enables the use of less spinal anesthetic and increases the success of anesthesia. Intrathecal opioid does not prolong motor recovery and thus should not delay discharge home. We hypothesized that 3 mg of hyperbaric bupivacaine with 10 microg of fentanyl permits fast-tracking or shorter stay in post anesthesia care unit (PACU), and earlier discharge home, compared with 4 mg of hyperbaric bupivacaine., Methods: In this double-blind study, 100 outpatients undergoing knee arthroscopy received randomly either 4 mg of bupivacaine (B4) or 3 mg of bupivacaine + 10 microg fentanyl (B3F) intrathecally. The volume of 0.8 ml was injected at the L2/3 interspace over a 2-min period. A lateral decubitus position was maintained for 10 min. The sensory block was recorded by using thermal stimuli, and motor block was assessed according to a modified Bromage scale. Fast-tracking criteria were complete recovery of motor block, sensory block Th12 or lower and stable vital signs., Results: One block (1%) failed. Motor recovery was faster in the B3F group: 60% of the patients recovered in 80 min or less compared with 28% in group B4 (P = 0.002). The PACU-time was shorter: 36 (10-103) vs. 55 (10-140) min, respectively (P = 0.005). Seventeen (B3F) vs. nine patients (B4) could bypass PACU (NS). Time to discharge home was similar in both groups. In the B3F group, 75% of the patients developed pruritus., Conclusion: Both solutions produced reliable spinal anesthesia for outpatient knee arthroscopy. The PACU-time was shorter in the bupivacaine-fentanyl group, but both groups reached home-readiness equally.

Background: Inguinal herniorrhaphy is commonly performed as an outpatient procedure. Spinal anesthesia offers some advantages over general anesthesia in this setting., Methods: Forty patients were randomly divided into two groups according to a double-blind protocol: Group L had spinal anesthesia with bupivacaine 6.0 mg and Group H with bupivacaine 7.5 mg; in both groups, fentanyl 25 micro g was added to the spinal anesthetic. The sensory block was measured by 'pin-prick' and the motor block was evaluated by a modified Bromage scale., Results: No differences were seen in the spread, duration and regression of sensory block between the groups on the operated side. A greater number of patients required analgesics during the operation in Group L (6) compared with Group H (1) (P<0.05). The return of the modified Bromage scale to grade 0 was earlier in Group L than in Group H (P<0.05) but the time to mobilization and discharge was similar. Seven patients (17%) needed to be catheterized and two had the catheter retained overnight. Times to home discharge (median) were 350 and 445 min, respectively, in Groups L and H. Postoperatively and during the first week, visual analog pain scores, analgesic requirements and side-effects were similar between the groups. In Group H, 95% of the patients and in Group L 85% would have the same anesthetic again if operated upon for a similar procedure., Conclusions: Spinal anesthesia with bupivacaine 7.5 mg and fentanyl offers an alternative to general or local anesthesia for ambulatory inguinal herniorrhaphy. However, the long discharge times and risk for urinary retention restrict its routine use in all patients.

Reduction of postoperative pain is an important goal in the perioperative management of tonsillectomy patients. This is particularly the case for children, who often exhibit resistance to intramuscular or rectal administration of drugs. Peritonsillar bupivacaine infiltration, a relatively safe method of pain control, is in some centers frequently used by otolaryngologists for pain relief. We present the case of a 5-year-old girl who developed bilateral vocal cord paralysis following preoperative peritonsillar bupivacaine infiltration. After an uneventful tonsillectomy and extubation, stridor and respiratory distress developed. Bilateral vocal cord paralysis was seen on laryngoscopy. The patient was reintubated and five hours later was successfully extubated without further sequelae. Anesthesiologists and surgeons should be aware of this uncommon complication than can occur with the use of peritonsillar bupivacaine infiltration for pain control in tonsil surgery.

Background: Administration of bupivacaine caudally has been used for postoperative analgesia after urogenital, rectal and lower abdominal surgery in children. Caudal opioids may offer analgesic advantages over bupivacaine alone but have been associated with side effects such as respiratory depression. Tramadol is an analgesic assumed to lack a respiratory depressant effect and has been shown to provide effective, long-lasting analgesia after epidural administration in adults and children. The aim of this study was to determine whether the addition of tramadol to bupivacaine caudally prolongs the duration of analgesia compared with bupivacaine alone, with respect to side effects, and whether caudal tramadol alone provides satisfactory analgesia., Methods: Sixty boys, aged 12-84 months, undergoing unilateral herniorrhaphy, were allocated randomly to three groups. Children in group B received 0.25% plain bupivacaine 1 ml kg(-1), group BT received an identical local anesthetic dose mixed with tramadol 1.5 mg kg(-1) and group T received caudal tramadol 1.5 mg kg(-1) in 0.9% sodium chloride in the same total volume (1 ml kg(-1)). Pain and demeanour assessments were made 1, 2, 3, 4, 6, 12 and 24 h after recovery from anesthesia with reference to a three-point scale., Results: Analgesia time (time between caudal injection and first administration of analgesic) in group BT (13.5+/-2.2 h) was significantly longer than in the other two groups (P<0.05). In group T, more patients required additional analgesia after surgery than in the other two groups (P<0.05). Pain scores in the three groups were similar up to 4 h after operation but the mean score in group T was higher than groups B and BT 4 and 6 h after operation (P<0.05). Significantly more patients who had received caudal bupivacaine alone or with tramadol had lower pain and demeanour scores during the first 24 h after operation compared with those in the tramadol group., Conclusion: Caudal administration of bupivacaine with the addition of tramadol resulted in superior analgesia with a longer period without demand for additional analgesics compared with caudal bupivacaine and tramadol alone without an increase of side effects.

Background: The aim of this study was to compare the effects on intraocular pressure (IOP) of ropivacaine and bupivacaine in peribulbar block., Methods: The study involved 40 patients with ASA physical status I, II or III undergoing cataract surgery under peribulbar block. Patients were allocated to two groups according to the local anesthetic used: Group R (n=20), 1.0% ropivacaine and Group B (n=20) 0.75% bupivacaine, both associated with 50 IU. ml-1 hyaluronidase, in peribulbar double injection technique. IOP was measured at four time points: 0=before block (control); 1=1 min after block; 2=5 min after block; 3=15 min after block., Results: Mean values of IOP (mm Hg) after block were significantly lower in Group R in comparison to Group B: time point 1=13.4+/-3.2 vs 20.8+/-4.7; time point 2=10.9+/-3.7 vs 14.4+/-3.8; time point 3=7.7+/-4.0 vs 10.5+/-3.1. The variation of IOP was different in each group. In Group R, the mean values obtained at the three time points after block were significantly lower than the control; in Group B, the mean value of IOP rose significantly 1 min after block and was lower than control only at time point 3., Conclusions: Ropivacaine 1.0% associated with hyaluronidase in peribulbar block is better than 0.75% bupivacaine under the same standard conditions for lowering IOP in intraocular surgery. This effect is probably due to relaxation of the extraocular muscles after the block with both anesthetics, and possibly to a smaller intraocular blood volume due to vasoconstriction in the case of ropivacaine.

Background: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty., Methods: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded., Results: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus., Conclusion: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.

Background: The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief, and side effects when removing fentanyl from an optimally titrated epidural infusion consisting of bupivacaine, fentanyl and adrenaline., Methods: A prospective, randomized, double-blind, crossover study was carried out in 20 patients after major upper abdominal surgery requiring a large longitudinal incision. Patients with only mild pain when coughing during thoracic epidural infusion of about 10 ml per hour of bupivacaine 1 mg x ml(-1), fentanyl 2 microg x ml(-1), and adrenaline 2 microg x 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 fentanyl. The effects were observed for 6 h or until pain when coughing became unacceptable in spite of rescue analgesia. Rescue analgesia consisted of up to two patient-controlled epidural bolus injections (4 ml) per hour and intravenous morphine if necessary., Results: Main outcome measures, i.e. pain intensity when coughing and at rest, increased (P<0.001) when fentanyl (19.2+/-5.2 microg x h(-1)) was omitted from the epidural infusion: after 6 h pain intensity when coughing had increased to unacceptable levels in spite of increased consumption of rescue bupivacaine and adrenaline (P<0.001). Within 15-20 min after restarting the triple epidural mixture with fentanyl, pain intensity was again reduced to mild pain when coughing., Conclusions: A low dose of epidural fentanyl (20 microg x h(-1)) markedly improved the pain-relieving effect of bupivacaine and adrenaline infused epidurally at a thoracic level after major upper abdominal surgery. This dose of fentanyl is much too small to relieve severe dynamic pain when given systemically. Therefore, this study indirectly supports the view that a low-dose thoracic epidural infusion of fentanyl has a spinal analgesic site of action.

Background: Because pregnancy increases the sensitivity of nervous tissue to local anaesthetics, pregnant patients may be at higher risk of developing neurologic deficits after spinal block than non-pregnant patients. Therefore, we evaluated prospectively the incidence and type of neurologic symptoms after spinal anaesthesia with hyperbaric bupivacaine for caesarean section., Methods: In this prospective follow-up study we recorded neurologic complications during anaesthesia and postoperatively until discharge from the hospital of 219 patients, who underwent caesarean section under spinal anaesthesia with hyperbaric bupivacaine (5 mg/ml, mean 13 mg). The patients filled in a questionnaire on the first and fifth postoperative days. In the case of complaints typical of neurologic symptoms they were checked first by the anaesthesiologist and, in the case of persistent symptoms, afterwards additionally by a neurologist., Results: Twenty-six of 219 patients were not included in the further evaluation because of incomplete return of their questionnaires. Seventeen mothers (8.8%) complained of transient neurologic symptoms (TNSs), lasting mostly 1-2 days, in the buttocks and/or legs during the first three postoperative days. Eleven patients (5.7%) complained of postdural puncture headache. Two patients (emergency caesarean section because of protracted labour in one and elective caesarean section because of previous caesarean section in the other) complained of persisting pain or sensory abnormalities. Neither of them felt paraesthesia during lumbar puncture., Conclusion: Women after caesarean section under a spinal block seem to suffer more often from TNSs than non-pregnant women. The conclusions are, however, uncertain since we had no control group operated on under other than spinal anaesthesia. The persisting neurologic symptoms in two patients might also be due to the obstetric procedure itself. To find out about the validity and possible underlying causes of our results, we need randomised studies with control groups receiving epidural or general anaesthesia.

Background: Sufentanil is now frequently added to local anaesthetic in labour epidural analgesia. However, this opioid has some side effects such as pruritus, and in higher doses could harm the neonate. The purpose of this study was to compare three doses of sufentanil combined with low-dose bupivacaine, to determine the lowest appropriate dose., Method: In a prospective, randomized, double-blind study, 243 parturients were randomized, to receive A--0.5 microg/ml, or B--0.75 microg/ml or C--1 microg/ml sufentanil, in addition to bupivacaine 0.625 mg/ml+adrenaline 1.25 microg/ml. All were given an 8 ml bolus of the study solution, followed by continuous infusion at 6 ml/h. The analgetic effect was scored on a visual analogue scale (VAS). Onset quality was measured as VAS after 20 min, the total effect as VAS maximum during the first stage of labour. Overall maternal satisfaction was recorded within two hours post partum. Side effects were noted., Results: There were no differences between groups in VAS assessments after 20 min or in maximum registered VAS. In group A, 83% had VAS 0-4 after 20 min, in group B 77% and in group C 71%. Maximum VAS during the first stage was 0-4 for 60% of group A, 68% of group B and 61% of group C. Maternal satisfaction was also the same in the three groups. In group A, 70% reported excellent effect and 22% good effect. The corresponding figures in group B were 68% and 24% respectively, and in group C 62% and 24% respectively. Group A received a mean total dose of 21 microg sufentanil, group B 30 microg and group C 44 microg. Pruritus occurred in 51% of group A, 53% of group B and 65% of group C., Conclusion: We found no difference in the analgesic effect between three different concentrations of sufentanil. We conclude that the lowest dose may be used. This should decrease the risk of adverse effects on mother and child.

Background: The incidence of TNS after spinal anaesthesia is a problem. Especially the use of hyperbaric lidocaine in patients placed in the lithotomy position during surgery has been associated with a high incidence of TNS. The present study was performed to investigate whether TNS is present more frequently in patients undergoing surgery in the supine position with use of hyperbaric lidocaine compared with hyperbaric bupivacaine., Method: Seventy patients were included and randomised to receive either hyperbaric lidocaine or hyperbaric bupivacaine. All patients were contacted on the first and third postoperative days by an anaesthesiologist blinded to the local anaesthetic used. The patients were asked about symptoms of TNS, pain not associated with the operation area, and asked to grade the complaints after a verbal analogue score from 0 to 10., Results: We found a total of ten patients who showed signs of TNS. There were nine patients in the lidocaine group (26%) who showed signs of TNS compared to only one patient in the bupivacaine group (3%) (P<0.01). The average score of TNS complaints was 3.5. A total of 13 patients (19%) complained of back pain. There were no significant differences with regard to which local anaesthetic was used. The average score of back pain was 3.3., Conclusion: TNS is a significant problem in patients having spinal anaesthesia with hyperbaric lidocaine compared to hyperbaric bupivacaine, both in the supine position. For day-case surgery, TNS would start after dismissal from hospital. The use of hyperbaric lidocaine is therefore questionable, even though these problems are of an order that the majority of patients would still choose spinal anaesthesia for future operations.

Background: Ropivacaine is less cardiotoxic than bupivacaine and may be used in higher doses in order to increase the quality of a block. The aim of this study was to compare the efficacy and safety of 40 ml ropivacaine 7.5 mg/ml (300 mg) and 40 ml bupivacaine 5 mg/ml (200 mg) for axillary plexus block., Methods: One hundred and four adult patients were included in a prospective, double-blind study. Sensory and motor block were tested for the five main terminal nerves of the arm at 10-min intervals until start of surgery and every second hour there-after until full resolution of the block., Results: The overall evaluation of the block by the surgeon and the anesthesiologist showed a significantly better quality in the ropivacaine patients, regarding both anesthesia and motor block. There were no differences in the time to onset and duration of the block. Except for one patient, who had seizures after an accidental IV injection of ropivacaine, there were no major side effects., Conclusion: Ropivacaine 7.5 mg/ml, 40 ml, produces axillary plexus block of similar onset and duration but better quality than 40 ml of bupivacaine 5.0 mg/ml.

Background: Ropivacaine is a new local anesthetic with alleged lower systemic toxicity and slightly lower potency as compared with bupivacaine. The present study aimed to evaluate the efficacy of ropivacaine in peribulbar block, as compared with that of bupivacaine., Methods: Eighty patients aged 45-92 years with physical status ASA I, II, or III were randomized to Group R (n=40) or Group B (n=40). Group R received 8.0 ml of 1.0% ropivacaine and Group B received 8.0 ml of 0.75% bupivacaine, both solutions with 50 IU/ml hyaluronidase, to induce peribulbar block according to the double-injection technique. Decreased ocular motility was the only criterion of successful block., Results: The percentage of patients with decreased ocular motility showing successful block was higher in Group R 1 and 5 min after injection. A score indicating successful peribulbar block was found in all patients 10 min after injection. While no patient complained of a burning sensation during ropivacaine injection, 22.5% of the patients given bupivacaine reported this symptom., Conclusion: Both local anesthetics were effective in inducing peribulbar block for intraocular surgery. A tendency was noted to a faster onset of peribulbar block with ropivacaine; nevertheless, both drugs had a high degree of success for this block.

Background: Ropivacaine is a new local anaesthetic drug known to be less cardiotoxic than bupivacaine. The aims of this comparative study with bupivacaine were to evaluate efficacy, safety and tolerability for the mother and the neonate when using ropivacaine 7.5 mg/ml for epidural anaesthesia for elective Caesarean section., Methods: In a double-blind, multicentre trial the patients were randomised to receive 20 ml of either ropivacaine 7.5 mg/ml or bupivacaine 5 mg/ml. The quality of the peroperative analgesia and abdominal muscle relaxation as well as tolerability and safety in both the mother and the neonate were evaluated., Results: A total of 122 patients were evaluated for efficacy and tolerability. There were no significant differences in the onset time and the extent of the sensory spread or motor block. The peroperative quality of anaesthesia and muscle relaxation was similar in both groups. No significant side effects were observed, except for a more profound drop in systolic blood pressure in the ropivacaine group. The anaesthetics were well tolerated by the neonate in both groups, evaluated by Apgar and NACS scores., Conclusion: Ropivacaine 7.5 mg/ml administered epidurally resulted in equally effective anaesthesia for Caesarean section as bupivacaine 5 mg/ml. Because of the lower cardiotoxicity of ropivacaine, the new amide has a potential in replacing bupivacaine when used epidurally for Caesarean section.

Methemoglobinemia may occur after the administration of various drugs, including some local anesthetics. We report a patient with chronic renal failure and ischemic heart disease who developed clinically significant methemoglobinemia after an axillary block with bupivacaine and additional injection of lidocaine in the operative field. Although the two local anesthetics usually do not cause methemoglobinemia, we suspect that the displacement of lidocaine from protein binding by bupivacaine, in combination with metabolic acidosis and treatment with other oxidants, was the reason for the development of methemoglobinemia.

Background: In patients scheduled for vascular surgery, atherosclerotic disease is highly prevalent. Haemodynamic reactions are often aggravated when spinal analgesia is used in this population. No randomized studies have been conducted comparing single shot (SS) with continuous spinal analgesia (CSA) for vascular patients. We did a prospective randomized study comparing haemodynamics when SS versus CSA was performed., Methods: Sixty patients were randomized to have SS or CSA. The power of the study was 0.90. Patients in the SS group received 17.5 mg bupivacaine and in the CSA group 5 mg was given initially and incremental doses of 2.5 mg were given until an analgesic level of T-11 was reached. Mean arterial pressures (MAP) were measured invasively. ST-analysis was done continuously. Postoperatively, the patients were interviewed using a standardized questionnaire. Back pain, neurologic sequelae and post-dural puncture headache (PDPH) were investigated., Results: There was no significant difference between the analgesic levels (T-7/T-8), the decrease in MAP, the number of patients needing ephedrine and the total amount of ephedrine given in the two groups. The motor blockade was more pronounced in the SS group (P < 0.001) and the total amount of bupivacaine used was 17.5 mg compared to 7.5 mg (5-17.5) in the CSA group (P < 0.001). One patient suffered PDPH which was slight and responded to a nonsteroidal anti-inflammatory drug. Two patients in each group had transient paraesthesias in the legs. There were technical problems with the spinal catheter in 4 patients, and these were excluded from the study., Conclusion: In this study we found no difference in the haemodynamic response to SS or CSA in patients scheduled for vascular surgery of the legs. SS is easier to apply and is recommended when the duration of surgery allows for it.

Background: Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra-articular administration of buprenorphine after knee arthroscopy., Methods: In a double-blind randomised trial, 48 patients were assigned to four groups: group A patients received buprenorphine 100 micrograms i.a. and NaCl 0.9% i.m., group B patients received bupivacaine 0.25% 50 mg i.a. and NaCl 0.9% i.m., group C patients received NaCl 0.9% i.a. and buprenorphine 100 micrograms i.m., and group D patients received NaCl 0.9% i.a. and NaCl 0.9% i.m. Intensity of postoperative pain was evaluated by VAS at recovery (T0) and 1, 3, 6, 12, 24 h after operation (T1, T2, T3, T4, T5), at rest and during passive 10 degrees knee flexion. Total analgesic requirements and side effects related to study drugs were recorded., Results: The VAS scores were significantly higher in groups C and D than in group A and B patients. The differences were significant at T0, T1, T2 and T3. At T1, group C and D patients had greater analgesic requirement than groups A and B. No patients developed side effects., Conclusion: Intra-articular buprenorphine and i.a. bupivacaine, both produced equally good postoperative pain control and allowed a significant reduction of analgesic requirement after knee arthroscopy.

Background: Patient-controlled analgesia (PCA) with intravenous piritramide and subarachnoid bupivacaine was studied during postoperative pain management in comparison with nurse-administered bolus injections., Methods: Following general anaesthesia (n = 60) patients randomly received either 3.75-7.5 mg i.v. piritramide on demand (group P-Bolus) or via PCA (group P-PCA; initial bolus: 3.75 mg i.v. piritramide, baseline rate: 1 mg/h, demand-dose 1.5 mg, lockout time: 20 min). Following continuous spinal anaesthesia (n = 60; CSA; 28-G spinal catheter) patients randomly received a subarachnoid injection of 1.5 ml bupivacaine 0.25% every 2-4 h (group B-Bolus) or a baseline infusion of 0.5 ml/h bupivacaine 0.125% plus 0.5 ml bupivacaine 0.125% on demand via PCA (group B-PCA; lockout time: 30 min). Pain ratings were assessed hourly by patients using a visual analogue scale (0 = no pain, 100 mm = unbearable pain)., Statistics: multivariate analysis of variance., Results: While pain scores did not differ between group P-Bolus and P-PCA, group B-PCA showed the lowest pain ratings (18 +/- 22 mm) differing significantly from group B-Bolus (41 +/- 32 mm; P < 0.001). Group P-PCA required more piritramide than group P-Bolus (46 +/- 15 mg vs. 31 +/- 13 mg, P = 0.001). In contrast group B-PCA required less bupivacaine than group B-Bolus (18 +/- 4 vs. 23 +/- 7 mg, P = 0.002)., Conclusion: PCA with CSA was more effective than nurse-administered bolus-administration of bupivacaine, while the present study failed to show superiority of i.v. PCA over i.v. bolus-administration of piritramide. PCA using the subarachnoid route is a promising concept for treatment of postoperative pain in orthopaedic patients, while the PCA piritramide regime of this study warrants improvement.

Background: Transient radicular irritation (TRI) is common after spinal anesthesia induced with hyperbaric lidocaine 50 mg/ml. The purpose of this study was to determine the incidence of TRI after spinal anesthesia with hyperbaric lidocaine 50 mg/ml diluted with cerebrospinal fluid (CSF) 1:1 and hyperbaric mepivacaine 40 mg/ml and hyperbaric bupivacaine 5 mg/ml., Methods: Ninety ASA class I-IV patients undergoing mostly brief urological procedures under spinal anesthesia were randomly allocated to receive either hyperbaric lidocaine 50 mg/ml diluted with CSF 1:1 (Group L), hyperbaric mepivacaine 40 mg/ml (Group M) or hyperbaric bupivacaine 5 mg/ml (Group B). Characteristics of the patients and details of the surgical procedures and spinal anesthesias were similar in all groups except for the intensity of motor block. The patients were evaluated on the first postoperative day by an anesthesiologist who did not know which spinal anesthetic agent had been used., Results: Six patients (20%) in group L, 11 patients (37%) in Group M and none (0%) in Group B experienced pain in the legs and/or back (TRI) after spinal anesthesia., Conclusion: TRI is frequent after spinal anesthesia induced with hyperbaric lidocaine 50 mg/ml diluted with CSF 1:1. The incidence of TRI after hyperbaric mepivacaine 40 mg/ml is of the same magnitude. TRI could not be observed after bupivacaine spinal anesthesia.

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.