Continuous Epidural Infusion Of Bupivacaine Research Articles

Successful treatment of paediatric lower limb CRPS by continuous epidural anaesthesia: a report of 2 cases.

CRPS occurs in children less frequently than in adults, but in the last two decades it has become a well-established entity in children and adolescents. The symptomatology, course, responsiveness to treatment and prognosis of the paediatric disease is also different from the "adult" form. The paper presents the successful treatment of two cases of paediatric CRPS involving the lower limb, by continuous epidural anaesthesia with bupivacaine. Both patients developed the condition after minor trauma or overuse. CRPS diagnosis was based on clinical grounds. Both patients presented a history of psychological distress, due to familial problems. In one patient, the initial treatment was lumbar sympathetic block, resulting in immediate and complete recovery. After relapse of the disease at four months, the next intervention included continuous epidural infusion of bupivacaine, with an excellent and rapid response. In the 2nd case, continuous epidural infusion was used primarily with the same, excellent and fast result. The article discusses clinical peculiarities, treatment modalities and other aspects of paediatric CRPS. Poor awareness of the condition in the paediatric community is also emphasized.

A clinical study of the effects of neonatal weight gain and breastfeeding following lower segment cesarean section under general or spinal anaesthesia with or without post-operative continuous epidural infusion of bupivacaine

Aim and Objective: We investigated the effect of continuous epidural infusion of bupivacaine following lower segment cesarean section under general or spinal anesthesia on breastfeeding and neonatal weight gain. Methods: The study enrolling 80 female patients of ASA grade I or II, age between 19-35 years were randomly allocated into 4 groups of 20 each. Group I received general anesthesia (Thiopentone sodium) + IM diclofenac 75 mg every 8 hours, post-operatively for three days. Group II received general anesthesia (Thiopentone sodium) + post-operative epidural analgesia (3-4 ml/hour of 0.125% bupivacaine for 3 days). Group III received spinal anesthesia (2.5 ml of 0.5% bupivacaine) + IM diclofenac 75 mg every 8 hours, post-operatively for three day. Group IV received spinal anesthesia (2.5 ml of 0.5% bupivacaine) + post-operative epidural analgesia (3-4 ml/hour of 0.125% bupivacaine for 3 days). The effects of anesthesia on the neonatal outcome, amount of breastfeeding and the infant weight were measured for 10 days after cesarean section. Results: The parturients who received epidural bupivacaine after the cesarean section initiated breastfeeding earlier as compared to those who received intramuscular diclofenac. The neonatal outcome was significantly better in the groups that received regional anesthesia (group III and IV) as compared to the groups that received general anesthesia. In group II and IV, the visual analog pain score after surgery was significantly lower and both the weight of milk fed by breast and the infant weight during the study were significantly more than the respective values in the group I and III.Conclusion: It is concluded that the groups that received post-cesarean analgesia with continuous epidural bupivacaine provided satisfactory pain relief which leads to increase in the frequency of breastfeeding and neonatal weight gain.

Quality of post-operative analgesia after epidural dexmedetomidine and ketamine: A comparative pilot study.

Hip fractures are intensely painful, so post-operative analgesia is an integral part of patient care for early rehabilitation and mobility.[1] Local anaesthetics with epidural additives ideally should provide stable haemodynamics and prolonged analgesia. There is limited literature comparing dexmedetomidine and ketamine as epidural additives. We conducted a study of continuous epidural infusion of bupivacaine plus dexmedetomidine comparing with bupivacaine plus preservative-free (PF) ketamine in patients undergoing hip fracture surgeries to assess the quality of post-operative analgesia.

Dexmedetomidine for anaesthetic management of phaeochromocytoma in a child with von Hippel-Lindau type 2 syndrome.

Phaeochromocytoma is a rare neoplasm in the paediatric population with fewer than 20% of diagnosed cases.[1] We describe the use of dexmedetomidine infusion for successful management of an 11-year-old male child with von Hippel-Lindau type 2 syndrome (VHL), who underwent bilateral adrenalectomy for phaeochromocytoma.

A Randomized Double Blinded Comparison of Epidural Infusion of Bupivacaine, Ropivacaine, Bupivacaine-Fentanyl, Ropivacaine-Fentanyl for Postoperative Pain Relief in Lower Limb Surgeries.

Continuous epidural infusion of Bupivacaine and Ropivacaine with or without the addition of Fentanyl has been evaluated by various researchers for effective postoperative pain relief. Studies however, depict significant variability in their results with regard to analgesic efficacy and adverse effects like hypotension, motor blockade etc. To comparatively evaluate postoperative analgesic efficacy, motor sparing effect, postoperative haemodynamic variations and total postoperative analgesic consumption in first 24 hours. A randomised double blind study was conducted on 100 adult, ASA grade I and II patients, of either sex who had undergone elective lower limb surgery under spinal anaesthesia. According to the group allocated, patients were started on epidural infusion after completion of surgery. Group I (0.2% Ropivacaine), Group II (0.1% Ropivacaine + 2μg/ml Fentanyl), Group III (0.2% Bupivacaine), Group IV (0.1% Bupivacaine + 2μg/ml Fentanyl) at the rate of 6 ml/hour. VAS scores, epidural consumption, supplemental epidural boluses, rescue analgesics, haemodynamics, motor block, sensory block regression, sedation, nausea and pruritis were recorded by a blinded observer for 24 hours. The haemodynamic parameters were stable in all the groups. Side effects including the motor block were negligible and comparable in all groups. Group I patients had significantly lower VAS scores, mean total epidural consumption, supplemental epidural bolus requirement and rescue analgesic requirement among all groups. It can be concluded that epidural analgesia using Ropivacaine 0.2% infusion is more effective than other study groups when used for postoperative pain relief in lower limb surgeries.

Addition of midazolam to continuous postoperative epidural bupivacaine infusion reduces requirement for rescue analgesia in children undergoing upper abdominal and flank surgery

Study Objective To investigate the effect of adding midazolam to continuous epidural infusion of bupivacaine for postoperative analgesia in children. Design Prospective, randomized, double-blind, controlled study. Setting Tertiary-care center. Patients 44 ASA physical status I and II children in age groups of two to 10 years, undergoing elective upper abdominal and flank surgery. Interventions At the end of surgery, patients were randomly allocated to receive epidural infusion of 0.125% bupivacaine alone (Group B) or with 20 μg/kg/hr midazolam (Group BM) for 12 hours at the rate of 0.2 mL/kg/hr. Measurements Pain, motor block, and sedation were assessed at predetermined times over 24 hours. Intravenous fentanyl was used as rescue analgesic for the first 12 hours, and tramadol for next 12 hours. Patients were followed at one week, one month, and one year for any neurological deficits. Main Results The number of patients requiring rescue analgesia during infusion was significantly lower in Group BM (7 vs. 17 in Group B; P < 0.001). Time to first rescue analgesia was significantly prolonged in Group BM compared with Group B ( P < 0.001). Frequency of fentanyl ( P < 0.001) and tramadol ( P = 0.001) administration as rescue analgesia was significantly less in Group BM. Significantly lower median pain scores were obtained in Group BM than Group B at all time intervals ( P < 0.05). Greater sedation scores were noted in Group BM at all time intervals postoperatively except at 4 hours ( P < 0.05). No motor block was observed in any child during the study. No neurological deficit was reported in any child in the one year of follow-up. Conclusion Addition of 20 μg/kg/hr of midazolam to postoperative continuous epidural infusion of 0.125% bupivacaine reduces the requirement for rescue analgesia in children following upper abdominal and flank surgery.

Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia

The introduction of fast-tracking multidisciplinary programs allows good results in postoperative outcome in many surgical specialties. We evaluated a multimodal clinical program (based on mininvasive surgery, epidural anesthesia and early mobilization and feeding) in abdominal aortic surgery. Between June 2000 and October 2005, 323 unselected patients were treated for atherosclerotic aorto-iliac occlusive disease (aorto-femoral bypass) and aortic or aorto-iliac aneurysm (aorto-aortic graft or aorto-iliac bifurcated graft). The infusion of bupivacaine 0.5% through an epidural catheter at T6-T7 interspace allowed sensory block between T4-S3. A light general anesthesia was performed using sevoflurane by a laryngeal mask in spontaneous breathing; no nasogastric tube was used. The patients were placed in dorsal decubitus; a transperitoneal access was performed with a left subcostal incision parallel to the condro-costal edge and spread from the linea alba to the edge of the rectus muscle. The bowel was maintained inside the abdominal cavity and manipulated with care. Standard surgical instrumentation was used. No drains were placed. Patients were transferred to the surgical ward at the end of surgery; they were early mobilized and enforced to drink and to eat. Analgesia was achieved with a continuous epidural infusion of bupivacaine 0.25% supplemented by oral ibuprofen on request. We observed a mortality rate of 2.5% and a low postoperative morbidity: 1.4% of cardiac complications, 3.7% of transient creatinine increase, and no pulmonary complications. All patients ambulated a mean of 536 m (95% CI: 81.4) on the day of surgery and 2544 m (95% CI: 208.9) the day after. They consumed an oral diet, 36.2% of their daily caloric requirement on the same day of surgery and 1583 Kcal (95% CI: 105.2) the day after (77% of daily caloric requirement). Median hospital stay was three days (range 2-21). All patients were discharged home. Our experience suggested that hospital stay and morbidity after abdominal aortic surgery can be decreased by performing a mininvasive surgical approach, thoracic epidural anesthesia-analgesia and an aggressive postoperative nursing on the ward. Therefore, this multidisciplinary program can be proposed to all patients undergoing aortic surgery without prior selection, major technological investments and long-term surveillance.

This Month in ANESTHESIOLOGY

This Month in ANESTHESIOLOGY

Thoracic epidural analgesia via the lumbar approach using nerve stimulation in a pediatric patient with Down syndrome

This case illustrates the threading of an epidural catheter with electrical stimulation guidance from the lumbar epidural space to the thoracic space in a pediatric patient. A 17-year-old boy with Down syndrome, weighing 48 kg, was scheduled to undergo a laparotomy for duodenal obstruction and gastrostomy tube insertion. Combined general and continuous epidural anesthesia was selected for his anesthetic. Following the induction of general anesthesia and tracheal intubation, a 17G Tuohy needle (Arrow International, Inc., Reading, PA) was inserted into the lumbar space (L3-4) using loss of resistance with air. A 20G styletted epidural catheter was then inserted and threaded cranially. As the catheter was advanced, a low electrical current (1-10mA) was applied to the catheter. Motor response was observed from the lower limb muscles to the upper abdominal muscles as the catheter advanced cranially. After 22 cm of the epidural catheter had been inserted, intercostal muscle movement (T9 - 10) was observed at 3.0 mA. Radiographical imaging later confirmed the catheter tip at T10. The patient awoke without distress and was discharged to the ward with subsequent good pain control from a continuous epidural infusion of bupivacaine 0.1% with 1 microg ml(-1) fentanyl at 4-6 ml(-1).

EFFICACY OF CONTINUOUS EPIDURAL ANALGESIA VERSUS SINGLE DOSE CAUDAL ANALGESIA IN CHILDREN AFTER INTRAVESICAL URETERONEOCYSTOSTOMY

We compared the effects of single dose caudal injection and continuous epidural infusion of bupivacaine on postoperative pain intensity and supplemental opioid analgesic requirements in children undergoing intravesical ureteroneocystostomy. Children 6 to 18 years old scheduled for ureteroneocystostomy were recruited for the study. Patients were randomized to group 1--caudal injection of 0.25% bupivacaine before approximately surgical incision and group 2--placement of an epidural catheter with injection of 0.25% bupivacaine, followed by a continuous epidural infusion upon completion of surgery. All patients received intravenous morphine patient controlled analgesic (PCA) as a rescue analgesic, and ketorolac and oxybutynin postoperatively. The epidural catheter was discontinued 48 hours after surgery, with removal of the urinary drainage catheter 4 hours later. Outcome measures included pain intensity rating, supplemental morphine requirements, presence and pain intensity of bladder spasms, analgesia related side effects, time to tolerating a regular diet, and patient and parent satisfaction. There was no statistically significant difference in average daily pain scores between the 2 groups. In the postanesthesia care unit. Significantly more patients in the caudal group required morphine than in the epidural group (56% versus 11%). The total PCA demand was significantly greater in the caudal group on days 1 and 2 postoperatively. Patients in the caudal group took significantly longer to tolerate a regular diet than those in the epidural group. Continuous epidural analgesia and single dose caudal injection of bupivacaine in conjunction with intravenous morphine PCA and ketorolac provide adequate pain control following intravesical ureteroneocystostomy. Continuous epidural analgesia reduces the need for supplemental intravenous morphine and allows children to tolerate a regular diet earlier.

Spinal analgesia: Efficacy of continuous epidural versus single-dose caudal analgesia using bupivacaine in children undergoing intravesical ureteroneocystostomy

The purpose of this RCT, with children undergoing intravesical ureteroneocystostomy, was to compare the effects of caudal injection and continuous epidural infusion of bupivacaine, on postoperative pain intensity, supplemental opioid analgesic requirements, and adverse effects. Children, ages 6 to 18 years, were randomized to receive either caudal injection of bupivacaine (0.25%, 1 ml/kg, maximum of 20 ml; n=16) or epidural catheter placement followed by bupivacaine administration (0.25%, 0.75 mg/kg, maximum of 20 ml; n=18), prior to surgical incision. Epidural infusion of 0.125% bupivacaine was initiated after surgery at 0.4ml/kg/hr for 48 hours. Intraoperative anesthetics were standardized and opioids were not given. Morphine PCA initiated in PACU included: 0.02 mg/kg/dose, 7 minute lockout, and 0.4 mg/kg 4-hour limit. IV ketorolac and oxybutynin were given postoperatively. Pain intensity was measured using a 0 to 10 numeric rating scale. Mean pain intensity scores were low (< 2/10) for children in both groups. In the PACU, 56% of patients in the caudal group required morphine versus 11% in the epidural group (p=0.009). Total PCA demands and doses delivered were significantly higher in the caudal group on day of surgery (p=0.032 and p=0.049, respectively) and on the first postoperative day (p=0.018 and p=0.018, respectively). Children in the epidural group tolerated a regular diet sooner than children in the caudal group (p=0.012). There were no group differences in opioid-related side effects. The epidural group had significantly more lower extremity numbness and motor block for the first 2 days after surgery. Both continuous epidural and single-dose caudal administration of bupivacaine, in conjunction with IV morphine PCA and ketorolac, provide adequate pain control following intravesical ureteroneocystostomy in children. Continuous epidural analgesia reduced the need for supplemental IV morphine and allowed earlier return to regular diet, but produced significant lower extremity sensory-motor block.

Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia

When used alone, lipid-soluble epidural opioids are thought to produce analgesia supraspinally via systemic absorption. However, spinal opioids and local anesthetics have been shown to act synergistically at the spinal level in animal studies. We, therefore, tested the hypothesis that sufentanil requirements will be less when given epidurally than IV in patients simultaneously given epidural bupivacaine after major abdominal surgery. Forty patients were anesthetized with isoflurane and epidural bupivacaine for major abdominal surgery. After surgery, each was given a continuous epidural infusion of bupivacaine at a rate of 5 mg/h and sufentanil patient-controlled analgesia (PCA). In a randomized, double-blinded fashion, the sufentanil was given either epidurally or IV. PCA settings were the same in each group. For 60 hrs after surgery, the following variables were measured: pain scores at rest, during mobilization, and during coughing; extension of sensory block; side effects; and sufentanil consumption. Pain scores, extension of sensory block, and the incidence of side effects did not differ between the two groups. Consumption of sufentanil in the epidural group was half that of the IV group (48 h after surgery: 107 +/- 57 microg versus 207 +/- 100 microg for the epidural and IV groups, respectively; P < 0.05). We conclude that spinal mechanisms contribute to the analgesia produced by epidural sufentanil in combination with a local anesthetic. When combined with epidural bupivacaine, the sufentanil requirement was 50% less when given epidurally than IV. Epidural sufentanil thus appears to have a spinal mechanism of action.

Acute abdomen after coronary artery bypass surgery masked by thoracic epidural analgesia

Acute abdomen after coronary artery bypass surgery masked by thoracic epidural analgesia

Fentanyl versus sufentanil: plasma concentrations during continuous epidural postoperative infusion in children

No pharmacokinetic data are available with respect to the plasma concentrations and fentanyl or sufentanil during epidural administration in children. This double-blind randomized study included 12 children (5-12 yr). Patients in group F were given an epidural loading dose of fentanyl 1.5 micrograms kg-1 and in group S sufentanil 0.6 microgram kg-1. Both groups then received a continuous epidural infusion of bupivacaine 5 mg kg-1 day-1 with either fentanyl 5 micrograms kg-1 day-1 or sufentanil 2 micrograms kg-1 day-1. An epidural PCA system was also given to the children (bolus: bupivacaine 0.2 mg kg-1 and fentanyl 0.2 microgram kg-1 or sufentanil 0.08 microgram kg-1). Maximal median concentrations of plasma (0.117-0.247 ng ml-1 for fentanyl and 0.027-0.074 ng ml-1 for sufentanil) were reached approximately 30 and 20 min respectively after the loading doses. These values were similar to those measured after 48 h.

Continuous epidural administration of midazolam and bupivacaine for postoperative analgesia.

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. 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. 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. 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.

Epidural abscess after epidural analgesia treated successfully with antibiotics

Spinal extradural abscess is an infrequent, but serious complication to extradural catheters. Early diagnosis is essential for successful treatment. An extradural abscess may develop slowly over days to several weeks and symptoms may be vague and unspecific, delaying correct diagnosis. Meticulous supervision of the patients is required and must continue as long as an epidural catheter is in place and for some time after the catheter has been withdrawn. This case report describes a patient undergoing extensive reconstructive plastic surgery after a leg trauma. For postoperative pain treatment a continuous epidural infusion of bupivacaine was given. After 10-14 days an extradural abscess developed with increasing low back pain but without any neurologic symptoms. With antibiotics a complete resolution of the extradural abscess occurred, documented by computerized tomography (CT).

Postoperative epidural analgesia with Bupivacaine-HCl 0.06%/Fentanyl 0.0002%. Experiences and physicochemical stability in infusion bags

Continuous epidural infusion of bupivacaine with the opioid fentanyl represents an effective analgesic method in the therapy of strong postoperative pain after major surgery. Preparation of the required infusion solution in syringes with a volume of 50 ml immediately prior to administration is routinely performed by nursing staff in Germany. The effort required for the preparation is associated with logistical and pharmaceutical difficulties. The preparation of a mixture of bupivacaine hydrochloride 0.06% and fentanyl 0.0002% in 250 ml infusion bags at the pharmacy of the University Hospital Mainz is described. To determine the physicochemical stability, the concentration of bupivacaine-HCl and fentanyl was assessed using HPLC over a period of 32 days; in addition the pH values were determined. After 32 days 95% of the bupivacaine hydrochloride and fentanyl baseline values were recorded. The pH baseline value had decreased from 5.48-5.52 to 0.5-0.7 units. The measured values confirm the physicochemical stability of the mixture of bupivacaine hydrochloride 0.06% and fentanyl 0.0002% over a period of 32 days. The infusion bag can be stored for 4 weeks at room temperature.

Cervical epidural analgesia for management of pain associated with digital vasculitis secondary to rheumatoid arthritis

Cutaneous vasculitis is a devastating extra-articular manifestation of rheumatoid arthritis. The potential consequences of digital vasculitis are necrosis, ischemia, infarction, and eventually gangrene. A 54-year-old woman with a long history of rheumatoid arthritis developed an acute onset of severe diffuse occlusive cutaneous vasculitis beyond the head of the metacarpals (documented by angiogram). Despite treatment with high-dose prednisone and Cytoxan, her symptoms were poorly controlled. Cervical sympatholysis via continuous epidural infusion of bupivacaine was then initiated to manage her pain as well as to treat the vasoconstrictive sequelae of the cutaneous vasculitis. The cervical epidural infusion relieved the pain and produced significant resolution of the symptoms. This case highlights the rational use of continuous cervical epidural block for the management of pain and improvement in blood flow to vasoconstricted upper extremities and digits resulting from vasculitis due to rheumatoid vasculitis.

Cervical Epidural Analgesia for Management of Pain Associated With Digital Vasculitis Secondary to Rheumatoid Arthritis

Background and ObjectivesCutaneous vasculitis is a devastating extra-articular manifestation of rheumatoid arthritis. The potential consequences of digital vasculitis are necrosis, ischemia, infarction, and eventually gangrene.MethodsA 54-year-old woman with a long history of rheumatoid arthritis developed an acute onset of severe diffuse occlusive cutaneous vasculitis beyond the head of the metacarpals (documented by angiogram). Despite treatment with high-dose prednisone and Cytoxan, her symptoms were poorly controlled. Cervical sympatholysis via continuous epidural infusion of bupivacaine was then initiated to manage her pain as well as to treat the vasoconstrictive sequelae of the cutaneous vasculitis.ResultsThe cervical epidural infusion relieved the pain and produced significant resolution of the symptoms.ConclusionsThis case highlights the rational use of continuous cervical epidural block for the management of pain and improvement in blood flow to vasoconstricted upper extremities and digits resulting from vasculitis due to rheumatoid vasculitis.

Epidural analgesia during labor: continuous infusion or patient-controlled administration?

Abstract Patient-controlled epidural analgesia (PCEA) has several advantages over continuous epidural infusion of bupivacaine during labor: it produces a good analgesia with a limited sensory spread; generally, less bupivacaine is administered and maternal satisfaction with pain control is increased. However, the quality of analgesia is similar to that obtained with other forms of epidural administration. Moreover, PCEA is only a particular form of epidural and, as such, has the same safety requirements. PCEA does not appear to reduce the workload of the anesthetic team. The cost of the PCA pump will need to be included in future evaluation of the cost/benefit ratio.