Continuous Infusion Epidural Analgesia Research Articles

An ultrasound-guided serratus anterior plane block with continuous local anaesthetic infusion and epidural analgesia for rib fracture pain.

We compared analgesia with an ultrasound (US)-guided serratus anterior plane block (SAPB) to thoracic epidural analgesia (EA) with continuous local anaesthetic infusion in patients with unilateral multiple traumatic rib fractures. EA often carries contraindications in patients with multiple rib fractures (MRFs), whereby having alternative effective methods to treat rib fracture pain remains important to patient care. Thus, we hypothesised that both regional anaesthetic techniques would provide effective pain relief. In this study, we included 59 patients with unilateral MRFs and a numerical rating scale (NRS) pain score ≥4 at rest or upon movement. Patients were randomised to receive a US-guided SAPB or continuous infusion EA with 2 mg/mL ropivacaine. Patients were given a patient-controlled analgesia (PCA) device with intravenous oxycodone boluses for rescue medication. The primary outcome was a change in the NRS score at rest and upon movement from baseline to Day 2 following the block. We also measured the forced expiratory volume in 1 s of expiration (FEV1) and FEV1% at the same time points when NRS was measured. The total consumption of oxycodone with PCA was measured at 24 and 48 h after the block. We detected a significant reduction (≥2) in NRS for both groups; however, EA associated with a greater reduction in NRS upon movement after block initiation. The mean reduction in NRS upon movement within 1 h was 3 (1.8, p < .01) in the SAPB group versus 4.7 (2.4, p < .01) in the EA group. We found no significant difference between groups in pain scores on Days 1 and 2 following the block. In the EA group, FEV1% increase in the first 12 h from baseline. Finally, PCA oxycodone consumption did not differ between groups. SAPB with continuous local anaesthetic infusion is an effective alternative to treat rib fracture pain when EA is contraindicated. We found that SABP significantly reduces pain in patients with unilateral MRFs, although EA achieves better analgesia over the first 12 h following the block.

Epidural bolus versus continuous epidural infusion analgesia on optic nerve sheath diameter in paediatric patients: A prospective, double-blind, randomised trial

The use of programmed intermittent epidural bolus for postoperative analgesia may have greater analgesic efficacy than continuous epidural infusion. However, the rapid delivery speed used with an epidural bolus is more likely to increase intracranial pressure. We compared the effects of lumbar epidural bolus versus continuous infusion epidural analgesia on intracranial pressure in children using optic nerve sheath diameter as a marker. We randomly assigned 40 paediatric patients to bolus or infusion groups. Epidural analgesia (0.15% ropivacaine 0.3 ml·kg−1) was administered via bolus or infusion. Ultrasonography was used to measure the optic nerve sheath diameter before (T0), at 3 min (T1), 10 min (T2), and 70 min (T3) after starting the pump. There were statistically significant between-group differences in optic nerve sheath diameter over time (PGroup x Time = 0.045). From T0–T3, the area under the curve values were similar between the two groups. Although there were differences in the patterns of optic nerve sheath diameter change according to the delivery mode, the use of lumbar epidural bolus did not increase the risk of intracranial pressure increase over that of continuous infusion. Further research is needed to investigate intracranial pressure changes after continuous application of each delivery mode.

A prospective randomized comparative study of postoperative pain control using an epidural catheter in patients undergoing posterior lumbar interbody fusion.

To assess the efficacy of continuous epidural infusion analgesia (ED) with 0.2% Ropivacaine versus IV PCA (Fentanyl) in spinal fusion surgery patients. A prospective randomized comparative clinical trial. Patients were randomized into one of two groups-the epidural group (ED-51 patients) and the IV PCA group (IV-43 patients). The epidural catheter tip was placed one level cephalad to the level of the PLIF in patients in the ED group. Patients were assessed by determining the pain score, cumulative opioid requirement, adverse effects, and satisfaction. Pain score comparisons between the ED group and the IV group, respectively, were as follows: immediate postoperative status: 2.1±1.5 vs. 7.2±2.1, p=0.01; postoperative day 1: 2.3±1.9 vs. 6.8±2.3, p=0.02; postoperative day 2: 1.9±1.8 vs. 5.4±2.1, p=0.02; postoperative day 3: 1.5±1.6 vs. 3.9±1.9, p=0.03; postoperative day 4: 3.8±2.1 vs. 3.1±1.9, p=0.4. Lower levels of opioids were required in the ED group, and fewer opioid-related complications developed in the patients in this group. Complications related to the use of epidural catheters were comparable between the two groups. Patient satisfaction with postoperative pain control was higher in the ED group. In comparison with the use of IV PCA only, continuous epidural infusion of Ropivacaine resulted in lower pain scores and opioid consumption and higher patient satisfaction levels after posterior lumbar interbody fusion.

Patient safety in continuous infusion epidural analgesia: prospective analysis of indicators in a general hospital

Patient safety in continuous infusion epidural analgesia: prospective analysis of indicators in a general hospital

The incidence of motor block following continuous epidural infusion analgesia (EIA) in children at a UK tertiary paediatric hospital

The incidence of motor block following continuous epidural infusion analgesia (EIA) in children at a UK tertiary paediatric hospital

16. Complex Regional Pain Syndrome

AbstractComplex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered.Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred.Therefore this technique receives a negative recommendation (2 A–). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).

Comparison of obstetric outcome following the introduction of patient-controlled epidural analgesia with background infusion compared with continuous epidural infusion technique

PATIENT-CONTROLLED EPIDURAL ANALGESIA WITH BACKGROUND INFUSION COMPARED WITH CONTINUOUS EPIDURAL INFUSION TECHNIQUE AOIFE O’NEILL, NIAMH HAYES, EVE GAUGHAN, JOHN LOUGHREY, MICHAEL GEARY, Rotunda Hospital, Dublin, Ireland OBJECTIVE: Patient controlled epidural analgesia (PCEA) with low-dose background infusion has been shown in one study to result in fewer epidural rescue interventions, but this has not been a universal finding.PCEA techniques have been associated with reduced analgesic requirements, which may decrease instrumental delivery rates. We compared the effect of PCEA (5 ml bolus every 15 min/as required) with background infusion (6 ml/hour), versus continuous infusion epidural analgesia (CIEA) at 10 mls/hr with the same solution (bupivacaine 0.1% and fentanyl 2 mcg/ml) for nulliparous women. Our outcome measures were instrumental delivery rates, analgesic consumption and the frequency of rescue epidural reinforcement. STUDY DESIGN: A retrospective review of the hospital database prior to and after the introduction of PCEA with background infusion was conducted to assess major obstetric outcomes. A chart review for a sample of parturients in each group was also conducted to examine analgesic consumption and rates of rescue intervention between PCEA with background infusion and CIEA. RESULTS: The groups were demographically similar. There was no statistically significant difference in obstetric outcome between PCEA and CIEA (table). There was a reduction in the frequency of rescue reinforcement by anaesthetic and midwifery staff and a trend towards reduction in the average hourly dose of bupivacaine. CONCLUSION: Decreasing the number of rescue interventions reduces anaesthetic and midwifery workload in maintaining acceptable epidural analgesia on a busy labour ward. However, this technique has not reduced instrumental delivery rates in nulliparous women at our hospital. We conclude that PCEA with background infusion is an acceptable method of epidural analgesia maintenance.

Efficacy of Postoperative Patient-controlled and Continuous Infusion Epidural Analgesia versus Intravenous Patient-controlled Analgesia with Opioids

The authors performed a meta-analysis and found that epidural analgesia overall provided superior postoperative analgesia compared with intravenous patient-controlled analgesia. For all types of surgery and pain assessments, all forms of epidural analgesia (both continuous epidural infusion and patient-controlled epidural analgesia) provided significantly superior postoperative analgesia compared with intravenous patient-controlled analgesia, with the exception of hydrophilic opioid-only epidural regimens. Continuous epidural infusion provided statistically significantly superior analgesia versus patient-controlled epidural analgesia for overall pain, pain at rest, and pain with activity; however, patients receiving continuous epidural infusion had a significantly higher incidence of nausea-vomiting and motor block but lower incidence of pruritus. In summary, almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provided superior postoperative analgesia compared to intravenous patient-controlled analgesia.

Ropivacaine 0.33% versus a ropivacaine 0.2% combined with 0.05mg/ml morphine regimen administered as a continuous epidural infusion analgesia after Cesarean section delivery

Ropivacaine 0.33% versus a ropivacaine 0.2% combined with 0.05mg/ml morphine regimen administered as a continuous epidural infusion analgesia after Cesarean section delivery

Patient-Controlled Epidural Analgesia Versus Continuous Epidural Infusion with Ropivacaine for Postoperative Analgesia in Children

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 +/- 0.08 mg x kg(-1) x h(-1) versus 0.40 +/- 0.08 mg x kg(-1) x h(-1); P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA. We studied patient-controlled epidural analgesia (PCEA) and continuous epidural infusion analgesia (CEA) with 0.2% ropivacaine during the postoperative period in children. We found that either PCEA or CEA with plain ropivacaine 0.2% provided adequate pain relief in children during the first 48-h postoperative course. However, adequate analgesia was obtained with 50% less volume infused with PCEA compared with CEA.

Patient-controlled epidural analgesia for labor and delivery: a novelty or a practical method?

Patient-controlled analgesia, familiar worldwide as “PCA” and derived from a conceptual framework designed to improve standards of pain relief, developed rapidly from an experimental paradigm to the gold standard of modern acute pain management. While PCA has been universally adopted for postoperative parenteral drug administration, as an approach to epidural drug delivery during childbirth, its acceptance has been slow and characterized by isolated flourishes of energy and pockets of clinical activity. Once largely confined to academic or tertiary maternity units, patient-controlled epidural analgesia (PCEA) now seems to be more widely used, although new survey data are awaited before this impression can be affirmed or refuted. World wide, the clinical use of PCEA during labor and delivery varies widely. In parts of North America and Western Europe, PCEA has firmly established a place in the provision of epidural analgesia for parturition, partly accounted for by regional practice patterns, by requirements with respect to epidural management by medical and nursing staff, and by remuneration issues. In other countries and institutions, a variety of factors, not least of which is cost-containment, finds PCEA rarely considered as an alternative to continuous infusion epidural analgesia (CIEA) or intermittent bolus epidural analgesia (IBEA). Consumer-focused epidural services placing emphasis on choice or satisfaction frequently offer PCEA as an option or have adopted PCEA as the routine approach. Nevertheless, while there is strengthening evidence for several advantages of PCEA compared with the alternatives methods of drug delivery, assessing and documenting maternal satisfaction is difficult and any general benefit of PCEA in this respect is largely theoretical. This chapter reviews the literature pertaining to the efficacy and safety of PCEA during labor and delivery, especially in comparison with CIEA and IBEA.

Sequential sensory testing during continuous infusion epidural analgesia in parturients

Sequential sensory testing during continuous infusion epidural analgesia in parturients

Sequential sensory testing during continuous infusion epidural analgesia in parturients

Sequential sensory testing during continuous infusion epidural analgesia in parturients

Combined spinal-epidural analgesia for labor

Combined spinal-epidural analgesia is a technique that provides rapid-onset, profound epidural analgesia for laboring parturients at almost any stage of labor. The most commonly used technique is a needle-through-needle technique in which the epidural space is identified with an epidural needle, and then a long spinal needle is inserted through the epidural needle and into the cerebrospinal fluid. Intrathecal fentanyl, 15 to 25 μg ± 1 to 2.5 mg of bupivacaine, or 2.5 to 5 μg of sufentanil ± 1 to 2.5 mg of bupivacaine are injected to produce analgesia. The epidural needle is removed and an epidural catheter inserted. Analgesia is maintained by low-dose, patient-controlled epidural analgesia; continuous infusion epidural analgesia; or intermittent top-ups. Pruritus is a very common side effect. Respiratory depression is rare but of great concern. Current literature favors low-dose epidural analgesia in labor as leading to the best patient and obstetric outcomes. Both low-dose conventional epidural analgesia and combined spinal-epidural analgesia produce similar outcomes. The main advantage of combined spinal-epidural analgesia is its predictable profound analgesia in parturients during late labor or when labor is progressing rapidly. Copyright © 2001 by W.B. Saunders Company

Epidural opioid delivery methods: bolus, continuous infusion, and patient-controlled epidural analgesia.

Multiple methods of delivery of epidural opioids are acceptable, including bolus injection, continuous infusion, and patient-controlled infusion. The incidence of side effects appears to be reduced with the use of continuous infusion techniques, especially with the liquid-soluble opioids, although these appear to be most effective when infused near the center of the dermatomal pain site. with more distant catheters, the water-soluble opioids are more effective, but there use is associated with more frequent side effects. The lowest dose requirement appears to be associated with PCEA, but further study is needed to confirm the theoretical safety and efficacy of this modality, especially if a constant background infusion is used along with the PCEA. At present, significant advantages appear to be obtainable by adding local anesthetic to the opioid infusion, but the ideal drug and dosage are yet to be determined.

Comparison of Patient-Assisted Epidural Analgesia with Continuous-Infusion Epidural Analgesia for Postoperative Patients

Background and Objectives. Patient-assisted epidural analgesia, a mode of epidural analgesic delivery in which self-administered epidural boluses supplement a baseline continuous epidural infusion, was compared to continuous epidural infusion in 62 postsurgical patients. Methods. Patients were randomly assigned to receive continuous epidural infusion (n = 31) or patient-assisted epidural analgesia (n = 31) consisting of fentanyl 10 mcg/mL and bupivacaine 1 mg/mL for the first 2 days after the operation. Variables examined included the adequacy of analgesia, amount of epidural infusion solution used, use of supplemental opioids, as well as incidence of side effects including nausea, pruritus, sedation, urinary retention, and respiratory depression. Results. Visual analog pain scores on days 1 and 2 after the operation, mean total epidural fentanyl consumption, and use of supplemental opioids were all significantly (P Conclusions. Patient-assisted epidural analgesia can provide superior pain control as compared to continuous epidural infusions while also reducing opioid dosages. Despite the reduction in total analgesic administered no reduction in side effects was seen with this mode of administration.

Patient‐controlled epidural analgesia following post‐traumatic pelvic construction

Summary A randomised, single-blinded study was conducted to compare patient-controlled epidural analgesia with continuous infusion epidural analgesia for the treatment of pain following post-traumatic pelvic reconstruction. The patient-controlled group (n = 11) received a background infusion of 4 ml.h−1 of bupivacaine 0.125% with fentanyl 1 μg.ml−1, and 3–6 ml bolus doses, self administered, as required (with a 15 min lockout interval). The continuous infusion group (n = 12) received a continuous infusion of the same solution through an identical apparatus, but with the demand button deactivated. This was started at 10 ml.h−1 and adjusted by the anaesthetist, as required, up to a maximum of 25 ml.h−1. Pain scores, side effects, and the volumes of drug infused were recorded over the first 3 postoperative days. One patient from each group was withdrawn because of catheter-related problems. Pain scores were similar and the incidence of nausea and pruritus was low in both groups. There was no recorded instance of respiratory depression or hypotension and there was no significant difference between the groups in the volumes of drug solution received. Patient satisfaction was equally very good in both groups. Patient-controlled epidural analgesia is an effective means of providing pain relief after post-traumatic pelvic reconstruction, but did not significantly reduce analgesic requirements in comparison with continuous infusion epidural analgesia.

A comparison of two epidural analgesic techniques with respect to the outcome of labour

SummaryA prospective controlled trial was undertaken to investigate the efficacy of continuous infusion epidural analgesia in labour compared to conventional 'topped-up' epidurals. There were 70 patients with continuous infusions and 79 in the 'topped-up' group. Clinical parameters and duration of labour did not differ between the groups. More patients having continuous infusions (49 per cent) delivered normally than in those who were topped-up (30 per cent, P < 005). The incidence of low cavity instrumental delivery was correspondingly higher in the 'topped-up' patients (65 versus 45 per cent). The incidence of obstetric intervention for maternal distress was higher (P < 0-001) in the 'topped-up' patients. There was no difference between the groups with regard to perinatal outcome although the infusion patients had a higher mean cord artery pH level. A reduced workload for the anaesthetist was confirmed with the infusion technique.

Continuous infusion epidural analgesia for obstetrics: bupivacaine versus bupivacaine-fentanyl mixture

Continuous infusion epidural analgesia (CIEA) using a mixture of bupivacaine and fentanyl was evaluated in this randomized, double-blind study involving 75 nulliparous women by comparing the mixture (Group I, Bupivacaine 0.125% and fentanyl 4 micrograms.ml-1 -24 patients) with two concentrations of bupivacaine alone (Group II, bupivacaine 0.25% - 24 patients; and Group III, bupivacaine 0.125% - 27 patients). Epidural anaesthesia was established in Group I with 6 ml 0.125% bupivacaine with fentanyl 50 micrograms and in both Groups II and III with 6 ml 0.25% bupivacaine. In the women whose pain score (Visual Analogue Scale) decreased by at least 50% within 15 min, CIEA was given until delivery. The initial infusion rate in all three groups was set at 7 ml.hr-1, but was decreased in the event of motor block or excessive sensory level. For inadequate analgesia, bupivacaine 0.25% in 3 ml supplements was given every 30 min, as required. During the first stage of labour, 88% of women in Group I reported excellent or good analgesia compared with 92% of women in Group II (NS) and with 59% in Group III (P less than 0.05). The proportion of women reporting excellent/good analgesia during the second stage was approximately 65% in all three groups. The total cumulative dose of bupivacaine in Group I was 54 +/- 36 mg, compared with 107 +/- 47 mg for Group II (P = 0.001), and 71 +/- 41 mg for Group III (NS). Group I patients required less supplementation with bupivacaine than either Group II or III patients during the first stage but only with Group III patients during the second stage.(ABSTRACT TRUNCATED AT 250 WORDS)

Alteration of Maternal Posture and Its Immediate Effect on Epidural Pressure

Summary A study was undertaken to investigate the changes in pressure inside the epidural space in parturients in the first stage of labour. The purpose was to see whether acute local pressure changes in the epidural space were consistent with the hypothesis that there is physical movement of cerebrospinal fluid with certain changes in maternal posture. Pressure changes were measured via the epidural catheter through which continuous infusion epidural analgesia was administered, using a pressure transducer kept at the level of the lumbar spine. The mothers moved through a series of postures that rejected those expected during the course of labour and delivery. The pressure within the catheter was recorded during these manoeuvres. The pressure changes which were found, taken in conjunction with the associated investigations of others, are consistent with the hypothesis.