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Background: Thoracic epidural analgesia (TEDA) was offered to patients with refractory angina pectoris. Our primary objectives were to evaluate TEDAs´ influence on quality of life (QoL, base for power analysis), and hypothesising that TEDA with bupivacaine during 1 month counteracts exercise-induced myocardial hypoperfusion and increase physical performance., Methods: Patients with refractory angina and exercise inducible hypoperfusion, as demonstrated by myocardial perfusion imaging (MPI), were randomised to 1-month treatment with TEDA with bupivacaine (B-group, n = 9) or saline (P-group, n = 10) in a double-blind fashion. MPI and bicycle ergometry were performed before TEDA and after 1 month while subjective QoL on a visual analogue scale (VAS) reported by the patients was checked weekly., Results: During this month VAS (mean [95%CI]) increased similarly in both groups (B-group from 33 [18-50] to 54 [30-78] P < 0.05; P-group from 40 [19-61] to 48 [25-70] P < 0.05). The B-group reduced their exertional-induced myocardial hypoperfusion (from 32% [12-52] to 21% [3-39]; n = 9; P < 0.05), while the P-group showed no significant change (before 21% [6-35]; at 1 month 23% [6-40]; n = 10). MPI at rest did not change and no improvement in physical performance was detected in neither of the groups., Conclusions: In refractory angina, TEDA with bupivacaine inhibits myocardial ischaemia in contrast to TEDA with saline. Regardless of whether bupivacaine or saline is applied intermittently every day, TEDA during 1 month improves the quality of life and reduces angina, even when physical performance remains low. A significant placebo effect has to be considered., (© 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Recently, local infiltration analgesia (LIA) has been promoted for pain control after total hip arthroplasty (THA). We hypothesized that LIA would offer equal analgesic efficacy but less adverse effects, e.g., nausea and vomiting, when compared with an established regimen [intrathecal morphine (it-M)] after THA., Methods: This randomized controlled trial comprised 60 patients undergoing THA under spinal anaesthesia. For LIA, the surgeon administered levobupivacaine, ketorolac and epinephrine at the surgical site intraoperatively. LIA patients received a LIA top-up through a wound catheter on the morning of the 1st post-operative day (POD). In group it-M, 0.1 mg morphine was given together with the spinal anaesthetic. Study parameters included pain scores, vital parameters and side effects, e.g., post-operative nausea and vomiting (PONV). Besides, levobupivacaine plasma concentrations were determined in 10 LIA patients., Results: The median (25th/75th percentiles) rescue oxycodone demand differed significantly with LIA 15 (10/25) mg vs. 8.5 (1.5/15) mg with it-M (P < 0.006) during the day of surgery, but not anymore on 1st or 2nd POD. The LIA top-up had no effect. However, both analgesic regimens resulted in comparable pain scores and patient satisfaction. PONV incidence and medication did not vary significantly. LIA offered certain advantages regarding early post-operative mobilization. Maximum levobupivacaine plasma concentrations (229-580 ng/ml) remained under the toxic level., Conclusions: While LIA might enable earlier mobilization after THA, it was not associated with less nausea as compared with it-M. Less rescue oxycodone was given early after it-M, but urinary retention was more common in that group., (© 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: When using epidural anaesthesia (EDA) for pain relief after major surgery, a failure rate of 10% is common. A crucial step in improving the care of patients with EDA is to define the position of the epidural catheter. The aim of this study was to investigate how much time it takes to determine whether the block is sufficient by assessing the extent of loss of cold sensation before induction of anaesthesia., Methods: One hundred patients listed for abdominal surgery were included in the study. After an epidural catheter had been inserted and an intrathecal or an intravenous position had been made unlikely by the use of a test dose, the patient was given a bolus dose of local anaesthetic plus an opioid in the epidural catheter. The epidural block was tested every 2 min, starting at 5 min and ending at 15 min. When at least four segments were blocked bilaterally, the testing was stopped, the time was noted and the patient was anaesthetised., Results: An epidural block was demonstrated after 5-6 min in 37 patients, after 7-8 min in 43 additional patients and after 9-10 min in 15 patients. In one patient, it took 12 min and in three patients, it took 15 min. In two patients, no epidural block could be demonstrated., Conclusion: Testing an epidural anaesthetic before the induction of anaesthesia takes only 5-10 extra minutes. Knowing whether the catheter is correctly placed means better quality of care, giving the anaesthetist better prerequisites for taking care of the patient post-operatively.

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: 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: We hypothesised that intravenous patient-controlled analgesia (IV PCA) with remifentanil could provide as satisfactory pain relief for labour as epidural analgesia., Methods: Fifty-two parturients with singleton uncomplicated pregnancies were randomised to receive either IV PCA with remifentanil or epidural analgesia with 20 ml levobupivacaine 0.625 mg/ml and fentanyl 2 microg/ml in saline. The PCA dose of remifentanil was given over 1 min with a lockout time of 1 min. The dose was increased starting from the bolus of 0.1 microg/kg and following a dose escalation scheme up until the individual-effective dose was reached. The parturients assessed contraction pain (0-10), pain relief (0-4), sedation and nausea during 60 min., Results: Forty-five parturients were included in the analysis. The median cervical opening was 4 cm before the study and 7 cm after the study. The median pain scores were 7.3 and 5.2 during remifentanil and epidural analgesia, respectively (P=0.009). The median pain relief scores were 2.5 and 2.8 (P=0.17). There was no difference between the groups in the proportion of parturients who discontinued due to ineffective analgesia, nor in the proportion of parturients who would have liked to continue the given medication at the end of the study. Sedation and low haemoglobin oxygen saturation were observed more often during remifentanil analgesia. Foetal heart rate tracing abnormalities were as common in both groups., Conclusions: In terms of pain scores, epidural analgesia is superior to that provided by IV remifentanil. However, there was no difference in the pain relief scores between the treatments.

Background: Continuous spinal anaesthesia with spinal catheters allows incremental dosing of the local anaesthetic and, consequently, less haemodynamic change. However, little is known about the required doses. Therefore, we designed a study to assess the local anaesthetic doses of isobaric bupivacaine which were effective in 50% (ED50) and 95% (ED95) of patients undergoing hip replacement surgery., Methods: Forty-eight patients undergoing hip replacement surgery were randomly allocated to one of six possible groups of eight patients to receive 6, 7, 8, 9, 10 or 12 mg of isobaric bupivacaine in a double-blind manner. The ED50 and ED95 values were calculated by a logistic regression model. The position of the spinal catheter tip was confirmed by X-rays., Results: The ED50 and ED95 values were 7.1 mg (95% confidence interval, 6.0-8.4) and 12.3 mg (95% confidence interval, 8.9-15.7), respectively. The location of the tip of the intrathecal catheter had no effect on local anaesthetic requirements. Eight patients required ephedrine after anaesthesia induction and a further 11 patients required ephedrine for correction of hypotension during surgery., Conclusion: The observed ED50 and ED95 values may guide us to use small doses of isobaric bupivacaine for hip replacement surgery. Hypotension is still possible even if low doses of isobaric bupivacaine are used.

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.

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: We tested the hypothesis that patient-controlled epidural analgesia for labor (PCEA) provides better analgesia and satisfaction than the intermittent bolus technique (bolus) without affecting the mode of delivery., Methods: We randomized 187 parturients to receive labor analgesia using either the PCEA or bolus technique. The PCEA group received a starting bolus of 14 mg of bupivacaine and 60 micro g of fentanyl in a 15-ml volume, followed by a background infusion (bupivacaine 0.08% and fentanyl 2 microg ml(-1)) 5 ml h(-1) with a 5-ml bolus and 15-min lock-out interval. The bolus group received boluses of 20 mg of bupivacaine and 75 micro g of fentanyl in a 15-ml volume., Results: Parturients in the PCEA group had significantly (P < 0.05-0.01) less pain during the first and second stages of labor. There was no difference in the spontaneous delivery rate between the groups, but the cesarean delivery rate was significantly (P < 0.05) higher (16.3% vs. 6.7%) in the PCEA group than in the bolus group. Bupivacaine consumption was significantly (P < 0.01) higher (11.2 mg h(-1) vs. 9.6 mg h(-1)) and the second stage of labor was significantly (P < 0.01) longer (70 min vs. 54 min) in the PCEA group than in the bolus group. Patient satisfaction was equally good in both groups., Conclusion: The PCEA technique provided better pain relief. This was associated with higher bupivacaine consumption, prolongation of the second stage of labor, and an increased rate of cesarean section., (Copyright 2004 Acta Anaesthesiologica Scandinavica)

Background: Many studies have been carried out on the effects of anaesthetic drugs and methods on the immune response, but pain and its relief also affect the immune response. We measured systemic immune responses in the blood circulation and local responses in the surgical wound when non-steroidal anti-inflammatory analgesics (NSAIDs), opioids or epidural blockade was used in the peri-operative treatment of pain., Methods: Responses were measured in 51 children, aged from 2 to 12 years and undergoing major surgery under balanced anaesthesia. Bolus doses of diclofenac intravenously (i.v.) and rectally (NSAID group), continuous i.v. infusion of oxycodone (opioid group) or continuous epidural infusion of bupivacaine + fentanyl (epidural group) were used peri-operatively for pain relief., Results: The only difference related to the analgesic method was shorter duration of post-operative leucocytosis and lower phytohaemagglutinin (PHA)-induced lymphocyte proliferative responses in peripheral blood in the opioid group than in the NSAID or epidural groups. By contrast, time-related alterations were seen overall in leucocyte and differential counts, lymphocyte and their subset counts, lymphocyte proliferative responses, and in serum cortisol, C-reactive protein, plasma interleukin-6 and group II phospholipase A2 concentrations and in the appearance of different cell types in the wound., Conclusions: Post-operative pain treatments using diclofenac (NSAID), oxycodone (opioid) and epidural blockade have basically similar effects on systemic and local immune responses with only slight, probably clinically unimportant differences in children undergoing surgery under general anaesthesia., (Copyright 2004 Acta Anaesthesiologica Scandinavica)

Background: Racemic bupivacaine is clinically similar to levobupivacaine, or ropivacaine. The drugs were compared in brachial plexus block for the first time in the same randomized and double-blind study., Methods: In 90 patients scheduled for hand and forearm surgery, a perivascular axillary brachial plexus block was performed with 45 ml of 5 mg ml(-1) of either racemic bupivacaine-HCl, levobupivacaine-HCl, or ropivacaine-HCl. Sensory (cold) and motor (hand clasp, and movement of elbow) block were scored, and the patient was interviewed in the postoperative evening and the following morning. Time to normal function of the arm was registered., Results: After similar onsets of sensory block, the sum of completely anaesthetized innervation areas of the four main nerves at 45 min was greater in the ropivacaine group than in the levobupivacaine group (P < 0.01). Simultaneously, complete motor block at the elbow was more frequent in the ropivacaine group (67%) than in the bupivacaine (47%) and levobupivacaine groups (30%) (P < 0.01). In the hand, the corresponding results were 83%, 77%, and 57%, respectively (NS). Two patients in the levobupivacaine and one in the ropivacaine group needed general anaesthesia. Mean duration of the blocks was similar in the bupivacaine, levobupivacaine and ropivacaine groups at 19.3 h, 19.5 h, and 17.3 h, respectively (NS). Two patients were dissatisfied with the long block duration., Conclusion: Ropivacaine-HCl 5 mg ml(-1) produced slightly better sensory and motor block intensity than the same dose of levobupivacaine-HCl. General success in relation to surgery and in the duration of the blocks was similar in the three groups.

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: Preincisional ilioinguinal and iliohypogastric nerve block (IINB) reduces postoperative analgesics after inguinal herniorrhaphy. The effect of an IINB on postoperative pain and discharge profile was therefore studied in day-surgery patients undergoing inguinal herniorrhaphy with general or spinal anaesthesia., Methods: Seventy ASA I-II adult patients scheduled for inguinal herniorrhaphy received an IINB before the surgical incision with 15 ml of 0.5% bupivacaine. In a randomized fashion half of them received general anaesthesia with spontaneous breathing via a laryngeal mask (GA-group) and the other half received spinal anaesthesia with 5 mg of bupivacaine diluted with sterile water to 2.5-ml volume (SPIN-group). In the postanaesthesia care unit (PACU), pain was assessed on a scale from 0 to 10 (VAS) and ketorolac 30 mg i.v. (VAS < 5), or fentanyl 0.05 mg i.v. (VAS > or = 5) was administered as scheduled. In the day surgery unit and at home the analgesic was a tablet of ibuprofen 200 mg + codeine 30 mg (VAS > or = 3)., Results: Patients in the SPIN-group reported lower postoperative pain scores at 30, 60 min (P < 0.0001) and 120 min (P < 0.05) after surgery, and longer time to first analgesic use (P < 0.0001). Patients in the GA-group had a shorter time to discharge without voiding (P < 0.001) and with voiding (P < 0.05). After discharge, there were no significant differences between the groups regarding pain scores at rest and at walking, or the doses of analgesic. Adverse events were rare in both groups., Conclusion: Only a relatively short immediate analgesic benefit could be demonstrated by a combination of IINB with spinal anaesthesia compared with IINB combined with general anaesthesia. The use of general anaesthesia facilitated an earlier postoperative discharge than spinal anaesthesia.

Kartagener's syndrome is a rare disorder characterized by the triad of situs inversus, including dextrocardia, bronchiectasis and paranasal sinusitis. We report the anaesthetic management of a patient with Kartagener's syndrome and postrenal transplant immunosuppression, presenting for repair of uterovaginal prolapse. Combined spinal epidural anaesthesia was administered to this patient. The anaesthetic considerations of this rare disorder and the relative advantages of the regional technique over general anaesthesia in this situation are discussed.

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: The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications., Methods: Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery., Results: The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications., Conclusion: The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery

This case report demonstrates the anesthetic management of a 41-year-old primiparous parturient with massive ascites due to advanced Krukenberg tumors, undergoing Cesarean section. We chose a combined intrathecal-epidural technique, using intrathecal hypobaric fentanyl and hyperbaric meperidine, and a low dose of epidural bupivacaine in order to avoid hemodynamic instability in this critically ill patient. Surgery was carried out without difficulty under adequate regional anesthesia. The blood pressure was maintained with low doses of phenylephrine and dopamine. Opioid-related complications such as nausea-vomiting, pruritus, drowsiness, and respiratory depression were not observed in this patient. Therefore, intrathecal opioids combined with a low dose of epidural local anesthetics for Cesarean section is suitable for critically ill patients with malignant abdominal tumors, such as a Krukenberg tumor, complicated by massive ascites.

Combined spinal epidural anesthesia (CSEA) has become an increasingly popular anesthetic technique for repeat cesarean section. However, the advantages of this technique have not routinely been available to morbidly obese patients because of the lack of an appropriately long needle. We present a case of a morbidly obese parturient who underwent repeat cesarean section under CSEA conducted with the recently introduced (and commercially available) CSEA needle set, specifically designed for morbidly obese patients.

Background: Local anesthetics are not free from potentially fatal complications. Therefore every new local anesthetic should be tested to demonstrate a lower, or at least similar, degree of toxicity over clinically used analogs. Most toxic effects from local anesthetics affect the cardiac electrophysiologic function, so the aim of this study was to characterize the electrophysiologic effects of a new long-acting local anesthetic (IQB-9302, Ciprocaine), and compare them with those of bupivacaine in the anesthetized dog., Methods: Eight Beagle dogs received three increasing infusion doses of either IQB-9302 or bupivacaine. Under isoflurane anesthesia, dogs were instrumented to monitor cardiovascular (cardiac output, arterial and venous blood pressures) and cardiac electrophysiologic data (sinus and atrioventricular (AV) node function, atrial, nodal and ventricular conduction times, and refractoriness)., Results: Only the highest dose of both drugs induced hemodynamic or electrophysiologic alterations: cardiac output and heart rate were reduced while blood pressures remained unchanged. Atrial and intranodal conduction times and atrial refractoriness increased similarly with both anesthetics, but to a slightly lesser extent with IQB-9302. Significant increases in His-Purkinje and intraventricular conduction times were the most severe noxious effects and occurred only with large doses of either drug. IQB-9302 was slightly less toxic than bupivacaine and, unlike this latter drug, potentially fatal arrhythmias were not induced., Conclusion: IQB-9302 has hemodynamic and cardiac electrophysiologic effects similar to those caused by bupivacaine. Nevertheless, slightly less toxic effects were derived from IQB-9302 administration than with bupivacaine, and, unlike the latter, the former might be less proarrhytmogenic. The new long-acting local anesthetic IQB-9302 may offer clinical advantages compared with bupivacaine.

Background: : Postarthroscopy analgesia has been provided with intra-articular bupivacaine, but reported results are conflicting regarding efficacy and the duration of analgesia. The immediate and long-term effects of intra-articular bupivacaine with epinephrine after arthroscopic knee surgery were therefore studied in a day surgery setting., Methods: : 120 ASA I-II patients scheduled for arthroscopic knee surgery were given general anesthesia with spontaneous breathing via a laryngeal mask. In a randomized and blinded fashion half of them received, at the end of surgery, intra-articularly 20 mL 0.5% bupivacaine with epinephrine (B + E-group) and the other half 20 mL saline with epinephrine (S + E-group). All patients received ketoprofen 100 mg i.v. during surgery and another 100 mg 2-3 h postoperatively. The patients were observed for about 4.5 h in the day surgery unit before discharge., Results: : The results showed that in comparison with the S + E-group, significantly fewer patients in the B + E-group needed analgesics (P < 0.0001) and the amount required was also significantly less postoperatively, before discharge (about 4.5 h postoperatively) (P < 0.0001). The latency to the need for the first postoperative analgesic was shorter in the S + E-group patients (P < 0.0001). At home, during seven days after discharge, the need for analgesic (oral ketoprofen 100 mg) was greater in the B + E-group (P < 0.05), especially only during the second postoperative day, but the visual analoque pain scale (VAPS) scores were low with no differences between the groups. No complication occurred., Conclusion: : It is concluded that a good postoperative pain control of intra-articular bupivacaine with epinephrine was found only in the immediate postoperative period (i.e. before discharge) in a day-surgery arthroscopic knee surgery patients.

Background: Ropivacaine is a new local anaesthetic, which compared to bupivacaine is less toxic and shows greater sensory and motor block dissociation. We hypothesised that treatment of postoperative pain with a combined regimen of continuous epidural infusion and Patient-Controlled Epidural Analgesia (PCEA) using ropivacaine could have given better results compared with those we had obtained using bupivacaine., Methods: Patients undergoing total hip replacement were randomly assigned to two groups. They received epidural analgesia for postoperative pain treatment using ropivacaine, 2 mg x ml(-1) or bupivacaine 2 mg x ml(-1). Both drugs were administered as a constant infusion of 6 ml x h(-1) supplemented by PCEA bolus doses of 2 ml. Patients in both groups received morphine intravenously on demand from a patient-controlled analgesia (PCA) device. An independent observer recorded pain scores, intensity of motor block and morphine consumption at regular intervals during the first 24 h after surgery., Results: Fifty-one patients were evaluated. Ropivacaine and bupivacaine, in similar amounts, provided similar results assessed as adequate to very good postoperative analgesia, whereas motor block was significantly more intense in patients treated with bupivacaine., Conclusions: Despite similar analgesic effects, epidural infusion of ropivacaine combined with PCEA provides higher patient satisfaction than equal doses of bupivacaine due to lack of motor block.

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: Femoral and sciatic nerve block may improve post-operative analgesia following total knee replacement., Objectives: To compare the post-operative analgesia following primary total knee replacement provided by spinal anaesthesia alone or in combination with femoral and sciatic nerve block with bupivacaine or ropivacaine., Methods: Seventy-five patients were randomised into one of three groups: spinal anaesthesia only; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) bupivacaine 7.5 mg x ml(-1) to each nerve; spinal anaesthesia and combined femoral and sciatic nerve block with 1 mg x kg(-1) ropivacaine 7.5 mg x ml(-1) to each nerve., Results: The mean (SD) time to first morphine request was significantly prolonged for both groups receiving combined femoral and sciatic block, 912 (489) min for the bupivacaine group and 781 (394) min for the ropivacaine group (P<0.001) compared with 413 (208) min for the group receiving spinal anaesthesia alone. Morphine consumption was significantly reduced in both groups receiving combined femoral and sciatic block. There were no systemic or neurological sequelae in any of the groups., Conclusions: Femoral and sciatic blockade following intrathecal bupivacaine/diamorphine provided superior analgesia when compared with intrathecal bupivacaine/diamorphine alone. There were no significant clinical differences between the group receiving bupivacaine 7.5 mg x ml(-1) and the group receiving ropivacaine 7.5 mg x ml(-1).

Background: Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery. The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture., Methods: After hospital admission and written consent, patients were randomised to conventional analgesic regimen (intramuscular oxycodone, OPI group) or continuous epidural infusion of bupivacaine/fentanyl (EPI group). The analgesic regimens were started preoperatively. Patients were operated under spinal anaesthesia and the treatments were continued three days postoperatively. ECG was continuously recorded. ST segment depression of > or = 0.1 mV or elevation of > or = 0.2 mV lasting > or = 1 min were considered as ischaemic episodes. Nocturnal arterial oxygen saturation (SaO2) was recorded perioperatively, and subjective pain was assessed every morning using a visual analogue scale (VAS)., Results: Fifty-nine (OPI 30, EPI 29) patients were evaluable for efficacy. Thirteen patients (43%) in the OPI and 12 patients (41%) in the EPI group had ischaemic episodes (NS). However, significantly more patients in the OPI group had ischaemic episodes during the surgery (8 vs. 0 in the EPI group, P=0.005). The median (quartal deviation) total ischaemic burden (i.e. integral of ST-change vs. time) in patients with ischaemic episodes was ten times larger in the OPI group (340 [342] mm x min) compared with the EPI group (30 [36] mm x min) (P=0.002). There were no significant differences between the groups in average heart rates or in heart rates at the start of ischaemic episodes or in maximal heart rates during the attacks. Average nocturnal SaO2 was similar in the two groups and there were no differences in the number of hypoxaemic (SaO2<90%) episodes. Preoperatively there were no differences in subjective pain, but postoperative and average perioperative VAS scores for pain were almost 40% lower in the EPI group (P=0.006). Perioperative myocardial infarctions were not detected., Conclusions: Continuous epidural bupivacaine/fentanyl analgesic regimen, started preoperatively, reduces the amount of myocardial ischaemia in elderly patients with hip fracture.

Background: The study was aimed to evaluate the analgesic efficacy, postoperative comfort, recovery characteristics and side effects of three different analgesic agents administered prophylactically., Methods: Eighty patients undergoing day-case minor operative laparoscopy were randomly allocated into four groups to receive tenoxicam 20 mg i.v. (Group T), fentanyl 100 microg i.v. (Group F), 5 ml of bupivacaine 2.5 mg/ml for infiltration of trocar sites (Group B), 30, 10 and 5 min before incision respectively. Bupivacaine, 35 ml, 2.5 mg/ml was also administered into the pelvic cavity in Group B. Group P received only placebo. Postoperative pain, analgesic requirements, first response to verbal stimulus, first analgesic requirement, ability to walk without help, to drink and to void, blood pressures, SpO2 and respiration rates were recorded in the PACU. Postoperative pain was evaluated by verbal rating scale. Pain scores, analgesic requirements and side effects were evaluated by telephone calls until the 48th postoperative hour., Results: Postoperative pain scores were lower and time to requirement of rescue analgesics was longer in groups F and B compared to Group P. In the PACU, analgesic requirements were lower in Group B, compared to Group P. Nausea and vomiting were increased in Group F., Conclusion: Tenoxicam 20 mg i.v. was found to be ineffective whereas bupivacaine was superior to other groups in reducing pain and analgesic requirements. Bupivacaine also increased time to first analgesics and obtained better recovery characteristics, underlining its value in prophylactic pain management compared to the other two agents.

Background: The efficacy of postoperative epidural pain treatment has been well documented in controlled studies. However, the literature concerning results of daily routine use of this method often only emphasises certain aspects of it., Methods: A prospective study of 168 patients scheduled for major surgery with transabdominal access was performed in order to evaluate efficacy, side effects, complications and rate of acceptance of postoperative epidural pain treatment. The epidural catheter was placed before surgery and the patients received epidural analgesia by a bupivacaine/morphine mixture for 3 days postoperatively, continued by another 3 days with bolus injections of morphine only., Results: Only few complications followed the insertion of the epidural catheter, but in about 16% of the patients the epidural catheter or the drugs administered by it made reinsertion or change in the type of analgesia necessary during the first 3 post-operative days. Despite the possibility for individualising the treatment and p.r.n. analgesics, pain relief when coughing and moving during day 1-3 was insufficient in 30-50% of the patients. Serious side effects were rare, but pruritus was frequent, as were the symptoms of nausea and vomiting. The patients were generally satisfied with the treatment; however, a small group had unacceptable pain when the epidural catheter was inserted., Conclusion: Analgesia was insufficient when coughing and moving in an unacceptably large number of the patients. Also the number of epidural catheter related problems was high. In order to make early intervention possible, the patients and epidural catheters should be observed daily and systematically by members of the staff competent to detect possible problems.

Background: Epidural opioid analgesia has become more popular for postoperative pain treatment in children. Epidural opioids are associated with adverse effects such as respiratory depression, excessive sedation, protracted vomiting, urinary retention and pruritus. Following minor surgery, ketoprofen has a synergistic effect with opioids, resulting in an improved analgesia without increase in incidence of adverse effects. To see whether this is also true following major surgery, we compared the effect of i.v. ketoprofen and placebo as an adjuvant to epidural sufentanil analgesia., Methods: A prospective, randomised, double-blind, placebo-controlled, parallel-group study design was used in 58 children, aged 1-15 years, receiving a standardised combined spinal-epidural anaesthesia. Intravenous ketoprofen or saline was provided as a bolus and a continuous infusion in addition to epidural sufentanil infusion, which was adjusted as clinically required. Epidural bupivacaine was used for rescue analgesia. The study drug infusion was discontinued when pain scores were <3 on a 0-10 scale for 6 h with an epidural sufentanil infusion rate of 0.03 microg kg(-1) h(-1)., Results: Children in the ketoprofen group received less rescue analgesia (none/29 vs. 8/29 children in the placebo group). In the ketoprofen group, criteria to discontinue epidural sufentanil were achieved more often (14 vs. 6 children) before the end of the 72 h study period. Less children in the ketoprofen group suffered pruritus (13 vs. 4). The incidence of nausea/retching and vomiting was similar (11 vs. 12) in both groups., Conclusion: In this study, ketoprofen as a background analgesic to epidural sufentanil provided improved postoperative analgesia and reduced incidence of adverse effects of the epidural opioid.

Background: Midazolam has been reported to have a spinally mediated analgesic effect. Clinically, single-shot epidural or spinal administration of midazolam has been shown to have an analgesic effect on perioperative pain. In this study, we investigated the analgesic effect of continuous epidural administration of midazolam with bupivacaine on postoperative pain., Methods: Four groups of 20 patients who underwent gastrectomy or cholecystectomy were studied. Continuous epidural infusion of bupivacaine 100 mg (Group C), bupivacaine 100 mg + midazolam 10 mg (Group M10), or bupivacaine 100 mg + midazolam 20 mg (Group M20) in 40 ml per 12 h was started after surgery using the balloon infuser. Group I received intermittent epidural bupivacaine (2.5 mg.ml-1) 6 ml every 2 h. When necessary, an indomethacin suppository and then a single epidural shot of bupivacaine (2.5 mg.ml-1) 6 ml was administered. Blood pressure, heart rate, respiratory rate, analgesic area, analgesia score, and sedation score were monitored for 12 h postoperatively. Memory and frequencies of supplemental analgesia (indomethacin suppositories and epidural bupivacaine) were also checked., Results: Group M20 showed a significantly wider area of pinprick analgesia and better analgesia scores than other groups. The need for rescue analgesics were significantly less in Group M20. Sedation and amnesia were more pronounced in Group M20 than the other groups., Conclusion: Adding midazolam (10 to 20 mg per 12 h) to continuous epidural infusion of bupivacaine for postoperative pain can provide a better analgesia, amnesia and sedation than bupivacaine alone.

Background: Epidural infusion of morphine, usually with bupivacaine, for postoperative pain relief has proved to be safe and effective. Lidocaine with its short duration of action and low toxicity may be an alternative to bupivacaine. The clinical importance of the choice of local anaesthetic drug on mobilisation after lower abdominal surgery has not been studied previously., Methods: A total of 52 patients was randomised to epidural infusion of morphine (1.6-4.4 micrograms.kg-1.h-1) with either lidocaine (0.44-0.98 mg.kg-1.h-1) or bupivacaine (0.10-0.28 mg.kg-1.h-1) in a double-blind fashion. The time to mobilisation, degree of pain relief, blood pressure, respiration and motor function were recorded at regular intervals postoperatively for 40 h. Serum concentrations of lidocaine, its main metabolite monoethylglycinexylidide (MEGX) and bupivacaine were measured at 3, 15 and 40 h., Results: There were no significant differences in the clinical characteristics between the two patient groups. There were no significant differences in the time from the end of surgery to the time the patients were able to stand without support (bupivacaine: median 24 h (interquartile range (IQR): 22-31), lidocaine: median 28 h (IQR 23-40), P = 0.15) or were able to walk without support (bupivacaine: median 46 h (IQR 28-62), lidocaine: median 48 h (IQR 35-54), P = 0.78). No significant differences between the groups were recorded with respect to pain relief, blood pressure, respiration, sedation score and motor function. The plasma concentration of lidocaine and bupivacaine increased significantly during the treatment period (P < 0.01 for both drugs), but not the concentration of MEGX. The highest venous lidocaine concentration was 17.5 mumol/l and the highest bupivacaine concentration was 18.8 mumol/l. There was a significant correlation between the concentration of both lidocaine and bupivacaine and the concentration of alpha 1-acid glycoprotein (AAG) (lidocaine: r = 0.77, P < 0.001, bupivacaine: r = 0.60, P < 0.001), suggesting that the free fraction of the drugs did not increase. No patients showed serious signs of toxicity. The epidural infusion rates remained stable in both groups during the study period., Conclusion: There were no clinically or statistically significant differences in the postoperative course after lower abdominal surgery in patients who received an epidural infusion of morphine combined with bupivacaine as compared to patients who received morphine with lidocaine. Further clinical studies to establish the place of lidocaine in postoperative epidural analgesia should be performed.

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: Accurate proprioception is critical while walking, yet an ambulatory epidural regimen that provides adequate analgesia for labour while simultaneously preserving proprioceptive input has not been described., Methods: Sixty primigravidae in established labour received bupivacaine 15 mg (15 ml of 0.1% w/v) and fentanyl 100 micrograms through a lumbar epidural catheter. Clinical assessment of dorsal column sensory function included: vibration sense, distal proprioception and the Romberg test, and were all performed before catheter insertion and 30 min after the study bolus. Sensory modalities were also tested compared to an unblocked dermatome. Pain was scored on a 0-10 cm visual analogue scale (VAS) before and 30 min after induction. Intensity of the motor block was tested using a modified Bromage score (grade 1-6)., Results: The study bolus provided reliable analgesia with 43 parturients attaining a VAS pain score of zero. Mean duration of analgesia was 67.5 min (SD 22.85). All parturients retained the ability to perform a partial knee bend while standing (grade 6). No mothers exhibited impaired distal proprioception, altered vibration sense or a positive Romberg sign., Conclusion: This study confirms that the addition of lumbar epidural fentanyl 100 micrograms to 15 mg of epidural bupivacaine provides good control of labour pain with no motor block and establishes that this combination preserves dorsal column sensory function.

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: There is no reliable treatment for "refractory" pain from unstable angina pectoris (UAP) when epidural infusion of bupivacaine has failed to relieve it. In two such cases we explored the potential of intrathecal (i.t.) bupivacaine infusion to provide pain relief., Patients and Methods: Two female patients, 70 and 67 years. An 18-G nylon catheter was inserted intrathecally through a 17-G Tuohy needle via the T2-T3 interspace and its tip located at the height of C6-C7 vertebrae. The catheter was connected to a portable, programmable electronic pump filled with bupivacaine 5 mg/ml. The infusion started at rates of 0.1-0.2 ml/h, with optional bolus doses of 0.1-0.2 ml, 4-2 times/h, respectively, by PCA (Patients-Controlled Analgesia), and then adjusted to give the patients satisfactory (80%-100%) pain relief., Results: Pain relief was obtained with doses of i.t.-bupivacaine ranging from 17 to 45 (mean = 25) mg/d. The pain intensity decreased from VAS (Visual Analogue Score) 9-10 to 0-2 out of 10. The nocturnal sleep improved from 2-4 to 6-7 h. The patients could now ambulate, walking or in a wheel-chair. The i.t.-treatment lasted 700 and 437 d, of which 540 and 343 d (respectively) were spent at home, and was terminated by: (a) the patient's death due to intracranial bleeding (1st case); (b) progressive aggravation of the unstable angina that could not be fully countered by increasing the bupivacaine dose above 1.0 mg/h due to occurrence of cerebral transient ischemic attacks, usually not correlated with orthostatic arterial hypotension but apparently facilitated by microembolization of the cerebral arteries (2nd case)., Conclusion: I.t.-bupivacaine infusion may alleviate "refractory" pain in patients with unstable angina pectoris when epidural bupivacaine failed to do so. Its use is apparently limited by the IT-bupivacaine critical dosage (in these patients = 1.0-1.5 mg/h).

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.

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.

The cerebrospinal fluid (CSF) levels of the opioid peptides met-enkephalin (ME), beta-endorphin (BE) and dynorphin (DYN) as well as the putative sensory neuropeptides substance P (SP), somatostatin (SOM), calcitonin gene related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) were determined in 10 patients with severe nociceptive pain due to malignancy, before and after initiation of spinal opioid therapy, and in 10 control patients. Pain intensity, evaluated by means of a 100-mm visual analog scale (VAS), was reduced from 39 +/- 9 to 18 +/- 10 for continuous pain and from 70 +/- 10 to 10 +/- 8 for intermittent pain (means +/- s.e.mean). Lumbar CSF immunoreactive ME and DYN concentrations were significantly increased (P = 0.05) and BE and VIP were significantly decreased (P < or = 0.05) in the pain patients. A slight, but non-significant (P = 0.06) decrease in SP-like immunoreactivity was found after initiation of spinal opioid therapy. Visceral pain seemed to be associated with low immunoreactive SP and ME concentrations compared to somatic pain. A highly significant correlation was found between SP and ME (P < 0.001) and to a lesser extent also between other peptides. We conclude that the concentrations of the endogenous opioids were more affected by nociceptive pain states than the non-opioid peptides. The origin of pain may also influence the results. The postulated inhibition of peptide release by spinal opioid application seemed to be present for SP, but could otherwise not be confirmed.

The ability of interpleural analgesia to reduce the pain caused by an indwelling chest drain was evaluated in 22 patients treated for spontaneous pneumothorax. Intermittent 8-hourly bolus injections of 20 ml bupivacaine 0.5% with epinephrine were compared with placebo in a randomized double-blind fashion. Visual analogue pain scale (VAS) scores were registered after the 1st, 2nd, 4th, 7th and 10th injections. The scores were significantly lower in the bupivacaine group at 5, 15, 30 and 60 min after the first injection. No significant differences in pain scores were found after 4 or 8 h. Pain scores in the bupivacaine group were also reduced after the 2nd, 4th, 7th and 10th injections, but compared with placebo the differences were significant only after the 2nd and 7th injections. Parenteral morphine consumption was not significantly lower in the bupivacaine group. Arterial blood gases were unaffected by the treatment in both groups. It is concluded that interpleural analgesia using bupivacaine given as bolus injections at 8-h intervals significantly reduces the pain caused by a chest drain within 5 min of injection, but the duration of pain relief is less than 4 h.

Twenty-eight patients scheduled for lung resection with lateral thoracotomy and postoperative chest drains during combined thoracic epidural bupivacaine plus morphine and general anaesthesia were studied. Postoperative pain treatment was continuous epidural infusion of bupivacaine 0.25% 5 ml h-1 plus morphine 0.2 mg h-1 for 48 h and, in addition, the patients received rectal piroxicam 40 mg randomly and double-blind 12 h and 1 h before surgery and 20 mg 24 h-1 postoperatively or placebo. Pain was evaluated at rest, during cough and mobilisation, together with pulmonary function (FEV1, FVC, PEFR) and sensory level of analgesia repeatedly for 48 h. The results showed efficient pain relief, but without differences in pain scores or need for supplementary analgesics between the two groups. Pulmonary function decreased similarly in the two groups. Thus we were unable to show enhanced analgesia by supplementing an otherwise effective low-dose epidural bupivacaine and morphine treatment with piroxicam after thoracic surgery with chest drains.

In this double-blind trial, we observed the effect of intermittent wound infiltration with local anaesthetic plus continuous coeliac plexus blockade on postoperative pain relief, pulmonary function, the neuroendocrine and acute phase protein response following upper abdominal surgery. In Group A (n = 10) patients received bupivacaine intermittently into the wound and continuously into the coeliac plexus following an initial bolus. A total of 862.5 mg of bupivacaine was used over 12 h with no observed toxicity. Group B (n = 10) received equal volumes of saline. Although pain relief was poor in both groups, the bupivacaine group used less morphine postoperatively and had lower pain scores than the saline group 4 h after operation (P less than 0.05). Pulmonary function was significantly reduced in both groups with no statistical difference between the two. Significant reductions in serum glucose and cortisol were achieved (P less than 0.05), suggesting that afferent neural blockade was partially effective in attenuating the neuroendocrine response. However, the postoperative rise in interleukin-6 was not affected by this technique. It is concluded that total afferent neural blockade cannot be achieved with peripheral wound and coeliac plexus administration of relatively large doses of local anaesthetic during upper abdominal surgery.

Analgesia with epidural bupivacaine, sufentanil or the combination was studied in 50 patients who had undergone thoracotomy. During operation all patients received an initial dose of bupivacaine 0.5% with adrenaline 5 micrograms.ml-1 (5-10 ml) by thoracic epidural catheter. One hour later the patients were divided into three groups: the bupivacaine group (bupivacaine 0.125%), the sufentanil group (50 micrograms sufentanil in 60 ml normal saline) and the combination group (50 micrograms sufentanil in 60 ml bupivacaine 0.125%). Analgesia in the three groups was provided by a continuous epidural infusion (5-10 ml.h-1) for 3 days. The mean dose of bupivacaine was significantly higher (P less than 0.05) in the bupivacaine group (12.07 mg.h-1 (s.e.mean 0.97 mg.h-1)), compared with the combination group (9.82 mg.h-1 (s.e.mean 0.43 mg.h-1)). The mean dose of sufentanil in the sufentanil group was similar to the combination group (6.37 micrograms.h-1 (s.e.mean 0.23 micrograms.h-1) and 6.52 micrograms.h-1 (s.e.mean 0.28 micrograms.h-1), respectively. The pain scores on the inverse visual analogue scale of most patients in the bupivacaine group were unacceptably low. The sufentanil group had much better pain scores, but on exercise these patients experienced more pain than the combination group. The combination group had, overall, better pain scores. In the combination group, there were better respiratory results.

Inhalation anaesthetic agents are known to depress phagocytic functions such as mobilization, attachment, chemotactic motility, engulfment and intracellular killing. Mannose-specific sugar receptors on the surface of leukocytes are involved in a series of phagocytosis-related activities. To investigate the effect of anaesthesia on the expression of this type of sugar receptor, mice were anaesthetized with halothane, enflurane and isoflurane. The presence of mannose-binding receptors on peripheral blood polymorphonuclear leukocytes was examined glycocytochemically using the biotinylated neoglycoprotein mannosylated bovine serum albumin. Prolonged administration of inhalation anaesthetic agents, especially halothane, markedly depressed expression of mannose-specific receptors. This reduction may possibly contribute to postoperative immunodepression, resulting from the impaired cellular interaction which is involved in the phagocytic function of granulocytes.

Twenty-one patients were given interpleural analgesia for postoperative pain relief after cholecystectomy, or renal or breast surgery. The patients were classified randomly into two groups: an interpleural injection of 20 ml of 0.375% bupivacaine mixed with 10 ml contrast medium was given to 11 patients in the supine position, and 10 in the lateral position. The patients remained in this position for 1 h. There was no significant difference in the rostrocaudal distribution of the contrast on computerized tomography taken 20 min later: Th3-L1 in the supine group vs. Th5-L1 in the lateral group. In the supine group the mean level of contrast medium reached significantly higher medially along the mediastinum (51 +/- 11 mm) than laterally (27 +/- 11 mm).

This study comprised 12 patients admitted for interpleural catheter treatment of chronic pancreatic pain. After the insertion of a left-sided interpleural catheter, 20 ml of bupivacaine 0.5% plain was given, followed by top-ups of 10-20 ml bupivacaine 0.5% as needed. Catheters were left in situ for 12-30 h. Immediate pain relief was achieved in all patients. Five patients had only a single blockade offering pain relief for a median of 33 days. One patient suffering from pancreatic carcinoma remained pain-free until death 45 days later. Seven patients returned for a second blockade after a median of 10 days. After this second blockade long-lasting pain relief was achieved in three patients for 70, 105 and 145 days. Two patients experienced pain relief lasting 11-14 days, while in two patients only a short-lived effect was observed, 3-8 days. Unimportant pneumothorax occurred in one patient. No cardiovascular or respiratory side-effects were recorded. We consider interpleural blockade an alternative worth further investigations in the future in the treatment of patients suffering from chronic pancreatic pain.

Twenty-one patients who underwent elective cholecystectomy were studied with regard to the effect of intrapleural administration of bupivacaine-adrenaline solution on postoperative pain and ventilatory capacity. Administration of 10 or 20 ml of 2.5 mg/ml or 5 mg/ml bupivacaine solution resulted in complete analgesia in 143 of 159 administrations. Most patients experienced the maximal pain-relieving effect within 1-2 min and analgesia persisted as a rule for 3-5 h. Forced vital capacity and forced expiratory volume in 1 s increased after intrapleural analgesia on average by 56% and 46%, respectively, on the first postoperative day and by 35% and 51%, respectively, on the second day. There was no significant difference in the analgesic effect or in the effect on the ventilatory capacity between the 2.5 mg/ml or the 5 mg/ml solution, in either the 10 ml or the 20 ml dose. Placebo (NaCl) given intrapleurally had no effect on pain or on the ventilatory capacity. The plasma concentration of bupivacaine after intrapleural administration showed a wide interindividual variation, with considerably higher average values when the 5 mg/ml solution had been used than for the 2.5 mg/ml solution. Although no toxic effects were noted, a 2.5 mg/ml solution, which can be given in an initial dose of 20 ml and top-up doses of 10 ml at 3-6 h intervals, is recommended. In four patients minor pneumothorax developed when the catheter was introduced. The pneumothorax was easily evacuated, but underlines the need for great care when introducing the catheter.