Epidural Administration Of Local Anesthetics Research Articles

Effects of epidurally administered dexmedetomidine and dexamethasone on postoperative pain, analgesic requirements, inflammation, and oxidative stress in thoracic surgery.

The aim of this study was to compare the effects of dexmedetomidine and dexamethasone as adjuvants to preoperative epidural administration of local anesthetic (ropivacaine) in thoracic surgery on the postoperative level of pain, use of analgesics, inflammation, and oxidative stress. The study enrolled 42 patients who underwent elective thoracic surgery in a one-year period at the University Hospital Dubrava (Zagreb, Croatia). Based on a computer-generated randomization list the patients were assigned to the dexmedetomidine (n = 18) or dexamethasone (n = 24) group. Postoperatively, patients of dexmedetomidine group reported lower pain (VAS value 1 h post surgery, 3.4 ± 2.7 vs. 5.4 ± 1.8, dexmedetomidine vs. dexamethasone, p < 0.01) and had lower anal-gesic requirements in comparison with dexamethasone group. Thus, dexmedetomidine in comparison with dexamethasone was more efficient in lowering pain and analgesia requirements 24 h after the surgery. On the contrary, dexamethasone had better anti-inflammatory properties (CRP level 24 h post surgery, 131.9 ± 90.7 vs. 26.0 ± 55.2 mg L-1, dexmedetomidine vs. dexamethasone, p < 0.01). Both dexmedetomidine and dexamethasone exhibited antioxidant effects, however, their antioxidant properties should be further explored. The results of this study improve current knowledge of pain control in thoracic surgery.

Metamorphosis of a herniated lumbar disc

Compression of nerve roots by herniated intervertebral discs (IVD) is a major cause of lumbosacral radiculopathy and often causes problems in patient management. We present a case report of a patient whose initial pain was axial discogenic in nature, probably due to a fissure of the annulus fibrosus, and who later developed LIII–IV radiculopathy. The timing of formation of a sequestered IVD hernia was recorded on MRI. There was no prolonged gradual formation of IVD hernia (bulging, fissure, protrusion, extrusion/sequestration), an acute formation of disc herniation occurred. Conservative treatment, including nonpharmacological (McKenzie gymnastics, educational program) and drug treatment (nonsteroidal anti-inflammatory drugs, anticonvulsants), as well as minimally invasive measures (epidural administration of local anesthetics and glucorticoids), allowed rapid regression of clinical symptoms and improvement of functional and emotional status. MRI of the lumbar spine performed six months after onset showed complete resorption of the IVD hernia. The patient follows ergonomic recommendations and performs therapeutic exercises (Nordic walking); no deterioration was observed within 9 months.

Pain management during labor: use of intermittent drug delivery devices for improvement of obstetric and neonatal outcome and reduction of healthcare burden: A large non-inferiority randomized clinical trial

BackgroundAutomated continuous epidural administration of local anesthetics provides a more stable analgesic block with decreasing of healthcare staff compared to manual boluses administration (TOP-UP) but is associated to high rate of operative vaginal delivery. We hypothesized that the use of programmed intermittent automated boluses (PIEB) is able to provide a good quality of analgesia and decreasing of anesthesiologic workload without increasing the rate of instrumental vaginal birth in comparison with TOP-UP technique. Laboring nulliparous woman aged between 18 and 46 years were randomized to epidural analgesia with 0.0625% levobupivacaine and sufentanil administered by PIEB or by TOP-UP techniques. Primary outcome was instrumental vaginal delivery rate and secondary outcomes were quality of analgesia, total and time-related drugs doses used, motor block, newborn outcome, and anesthesiologic workload.ResultsSix hundred twenty-nine were randomized, and 628 were included in the intention-to-treat analysis. The rate of instrumental vaginal delivery was similar in the PIEB and TOP-UP groups (13.2% vs 9.7%, OR 1.4 95% CI 0.8 to 2.5; p 0.21). There was no difference between groups regarding mode of delivery (cesarean section vs vaginal birth), newborn outcome, and motor block. Patients in the PIEB group received more total and time-related drugs doses and a better quality of analgesia. Anesthesiological workload was significantly reduced in the PIEB group.ConclusionsOur study demonstrated that epidural anesthesia with programmed intermittent epidural boluses by an automated device provides an effective and safe management of labor analgesia with improvement of pain control and sparing of man workload compared to manual top-up protocols.

ROUX-IN-Y GASTROJEJUNAL BYPASS: WHICH ANESTHETIC TECHNIQUE HAS BEST RESULTS?

Nausea and vomiting groups x moments. As the number of bariatric operations increases, there is a greater interest in knowledge, experience and skills in the operative and anesthetic management of obese people. Anesthetic recovery is an important point in the therapeutic approach and less adverse effects delaying discharge of these patients are necessary to be kept in mind by the surgical team. To compare anesthetic-analgesic techniques in the opioid-sparing era through epidural administration of local anesthetic associated with low-dose morphine vs. clonidine and analyze the impact of analgesia on the effectiveness of postoperative recovery by comparing these two techniques. Randomized, double-blind clinical trial with 66 patients candidates for Roux-en-Y gastrojejunal bypass divided into two groups: morphine group and clonidine group. Multimodal analgesia included epidural anesthesia with 0.375% ropivacaine 20 ml at the eighth thoracic vertebra with the association of morphine (morphine group) at a dose of 15 mcg / kg or clonidine (clonidine group) at a dose of 1 mcg / kg. The groups were homogeneous and statistical significance was found when analyzing the difference in pain between them in the first postoperative period. The pain was higher in the clonidine group, as in this period, analgesic rescue was also better in this group. In the other times, there was no significance in the differences regarding pain and rescue. The return of intestinal motility in the morphine group was earlier in the first postoperative period. Nausea, vomiting and hospital discharge did not show significant differences between groups. Epidural anesthesia with low-dose morphine allowed less pain during the entire hospital stay, with a positive impact on patient recovery.

Discogenic lumbosacral radiculopathy. Recommendations of the Russian Association for the Study of Pain (RSSP)

When examining a patient with lumbosacral pain, it is necessary to rule out the specific cause of the disease. The diagnosis of discogenic lumbosacral radiculopathy (DLSR) is based on clinical examination; magnetic resonance imaging (MRI) is of informative value in excluding other causes of radiculopathy and in evaluating disk herniation. If the signs of cauda equina and spinal cord compression are absent, and no epidural glucocorticoid injection or urgent surgical treatment is scheduled, there is no reason for early (within the first 4 weeks) MRI.It is recommended to inform the patient with DLSR about the possibility of disk herniation regression and natural recovery and about the advisability of maintaining physical activity. Epidural administration of local anesthetics and glucocorticoids and use of non-steroidal anti-inflammatory drugs are advisable to relieve acute pain. Anticonvulsants (pregabalin and gabapentin), muscle relaxants, and B vitamins can be used as additional methods for acute DLSR; psychological therapies (cognitive behavioral therapy), antidepressants, therapeutic exercises (kinesiotherapy), manual therapy, and acupuncture are effective in chronic DLSR. Consultation with a neurosurgeon for possible microdiscectomy is indicated in the presence of cauda equina syndrome (urgently) and in the absence of medical therapy effects within 4–8 weeks.Therapeutic exercises (kinesitherapy) with an educational program for prevention of strenuous physical activity and static and uncomfortable positions for a long time, as well as for teaching how to lift weights properly, etc. are recommended for preventive purposes.

СОДЕРЖАНИЕ МОЧЕВОЙ КИСЛОТЫ, КОНЦЕНТРАЦИЯ РЕНИНА У ПАЦИЕНТОК С ПРЕЭКЛАМПСИЕЙ В ЗАВИСИМОСТИ ОТ УРОВНЯ ВИТАМИНА D И ОСОБЕННОСТИ ЭПИДУРАЛЬНОЙ АНАЛЬГЕЗИИ РОДОВ

The objective: to investigate the correlation of renin concentration and uric acid content in pregnant women with pre-eclampsia and vitamin D deficiency and their impact on the course of pregnancy, childbirth, and infant status. Subjects and methods . The content of uric acid, vitamin D, endothelin and renin concentration were studied in pregnant women with pre-eclampsia and the control group; enzyme immunoassay and spectrophotometric tests were used. Venous blood was used as a specimen for tests. Results . Hyperuricemia (435.61 ± 24.05 μmol/l) and a 10-fold increase of renin concentration were observed in patients with severe pre-eclampsia and vitamin D deficiency (11.23 ± 1.60 ng/ml). Vitamin D deficiency is associated with a higher need for epidural administration of local anesthetics during labor analgesia in patients with pre-eclampsia versus the control group; it is also associated with unfavorable perinatal outcomes. Conclusions . The following was detected in the patients with pre-eclampsia: low levels of vitamin D, hyperuricemia, elevated blood renin concentration, which was associated with the severity of pain and increased blood pressure. For adequate analgesia and blood pressure control during labor, they needed a higher rate of local anesthetic administration. Perhaps, replenishing vitamin deficiencies during pregnancy may improve perinatal outcomes.

Doppler sonographic examination of uterine and placental perfusion in cows in the last month of gestation and effects of epidural anesthesia and isoxsuprine

The massive increase in size of the fetus and uterus in the last trimester is accompanied by an increasing demand for nutrients and oxygen, and it is assumed that this demand is met by increasing uterine and fetal perfusion. The goals of this study were to measure the perfusion of the uterine arteries and the placentomes in the last month of gestation and to investigate the effect of epidural anesthesia and isoxsuprine on perfusion. During the last month of gestation, eight Braunvieh cows underwent nine color Doppler sonographic examinations of the uterine arteries to determine diameter (DM), pulse rate (PR), resistance index, time-averaged maximum blood flow velocity (TAMV), and blood flow volume (BFV), and power-mode Doppler sonography was used to determine perfusion of placentomes. The PR increased (P < 0.001), and the BFV and TAMV of the ipsilateral uterine artery decreased between 4.5 and 0.5 weeks prepartum (BFV, 236.8 ± 65.80 and 208 ± 41.52 cm3/s, P < 0.01; TAMV, 140.0 ± 26.53 cm/s and 125.2 ± 18.46 cm/s, P < 0.05). After sonographic examination, the cows received epidural administration of local anesthetic (100-mg lidocaine) in the sacrococcygeal space or isoxsuprine (200 mg/cow, iv), and the sonographic measurements were repeated 30 minutes later. After epidural anesthesia, the TAMV and BFV of the contralateral uterine artery increased by 5.4% (P < 0.05) and 7.9% (P < 0.01). In the placentomes of the gravid uterine horn, the relative placentome perfusion and the color pixel grading (Cp) increased by 10.1% (P < 0.05) and 11.5% (P < 0.01) after epidural anesthesia. After isoxsuprine, the DM, PR, and BFV increased by 4.7%, 49.3%, and 16.9% in the ipsilateral uterine artery and by 10.8%, 48.7%, and 22.8%, respectively in the contralateral uterine artery. The TAMV of the ipsilateral uterine artery increased by 7.1% (P < 0.01), and the resistance index decreased in both uterine arteries (ipsilateral 24.2%, contralateral 14.9%, both P < 0.00001). Isoxsuprine increased the relative placentome perfusion and the Cp of the placentomes by 18.1% and 18.3% in the gravid horn and by 10.2% and 24.2% in the nongravid horn. Blood flow variables changed little in the last month of gestation. However, epidural anesthesia and isoxsuprine caused changes in uterine and placentome perfusion that suggest improvement of placental nutrient and oxygen supply to the fetus.

Spinal Cord Compression due to an Iatrogenic Lumbar Epidural Abscess

The development of epidural abscess after intermittent epidural administration of local anesthetics and steroids is a rare condition with an unknown incidence. Magnetic Resonance Images (MRI) offers the appropriate approach to determine its effects on the spinal canal. A 60-year-old woman with a diagnosis of central disc at L4-L5, with sciatic pain in the left leg, was treated by means of two consecutive single-shot epidural injections of local anesthetic and depo-steroids with a time span of one week between them, 72 hours after the second injection, local infection developed, but after 17 days of antibiotic therapy the back pain worsened, with weakness and areflexia in both legs, as well as fever and normocytic anemia. At this stage, the patient was referred to our hospital where emergency MRI revealed an epidural abscess at L2- L3 level, and was taken to the emergency operating room where a laminectomy for emergent decompression and drainage of the abscess was performed. Symptoms improved in the immediate postoperative period, with 4/5-knee flexion, but sciatic pain persisted. Conclusion: Epidural abscess is rare condition if correct methodology is applied, but failure to promptly diagnose and treat it may be associated with a poor outcome, Magnetic Resonance Images being the diagnostic method of choice.

Prediction of Effective Post-Operative Epidural Anesthesia Using Hemodynamic Changes Detected by Endotracheal Cardiac Output Monitor (ECOM)

Background: Epidural anesthesia after abdominal surgery results in improved postoperative pain relief but has up to a 30% failure rate. Hemodynamic changes after epidural administration of local anesthetics may provide parameters to predict dermatomal blockade and effective pain control in the postoperative period. The Endotracheal Cardiac Output Monitor (ECOM) provides continuous measurements of stroke volume (SV), cardiac output (CO) cardiac index (CI) and systemic vascular resistance (SVR). We hypothesized that the changes in hemodynamic parameters measured by the ECOM monitor along with changes in systolic (SBP), diastolic (DBP) and mean arterial pressure (MAP) would predict effective epidural anesthesia. Methods: 19 patients undergoing intra-abdominal surgery were enrolled. After placement of an epidural catheter and establishment of general anesthesia hemodynamics were recorded in 15-minute intervals using the ECOM monitor. At the start of abdominal closure epidural catheters were loaded with two 5 ml boluses of 0.25% bupivacaine in ten-minute intervals. Hemodynamic parameters where then recorded at five-minute intervals until conclusion of surgery. The number of dermatomes blocked, post anesthesia care unit (PACU) pain scores, average 24-hour pain scores, and patient satisfaction were recorded.Results: Significant reduction was observed in SBP, DBP, MAP and in SVR, and increases were seen in CO and CI after starting epidural anesthesia. From the parameters measured, only a significant reduction of SVR accompanied with higher level of dermatomes blocked, and lower average 24-hour pain scores. At the sane time patients without significant SVR change had relatively low pain scores, high patient satisfaction and required the same amount of pain medications. Conclusion: Changes in SVR detected by the ECOM monitor might help to predict an effective epidural system but its clinical relevance needs to be further evaluated.

Accidental epidural injection of rocuronium

Epidural administration of local anesthetics or opioid during general anesthesia is a widespread method for postoperative analgesia. Despite the availability of this technique, inadvertent administration of nonepidural medications into the epidural space can be associated with serious neurological complications. We report a case of accidental epidural rocuronium injection.

Injection therapy and denervation procedures for chronic low back pain: a systematic review—clinical value?

“Injection therapy and denervation procedures for chronic low back pain: a systematic review” [1] evaluates the effect of two broadly defined treatment options for chronic low back pain. This forms indeed a burden to patients, society and physicians. Lack of knowledge of the causes of chronic pain and poor understanding of patient heterogeneity in pathophysiologic mechanisms and treatment response are a major explanation for unsuccessful trials [2]. Clinical research reaches the conclusion that a “mechanism-based” treatment approach in which therapeutic interventions target the specific mechanisms of a patient’s pain is recommended [2]. Low back pain is divided into specific form due to fracture tumor, infection, etc and the aspecific form. We generally differentiate between degenerative diseases of the facet joints or of the intervertebral disc and radicular pain. The described inclusion and exclusion criteria for the studies to be withheld in this systematic review [1]; however, suggest that the research group lacks the input of a clinical experts who can provide information regarding the clinical diagnoses and the potential underlying mechanisms. In contrast, instead of following recent recommendations, pain syndromes with different underlying mechanisms are clearly mixed in the expectation to draw clinically relevant information on a therapeutic intervention. Moreover, also treatments with no indication in a clinical setting are analyzed, which troubles even more the evidence. Under the heading injection therapy, injections of medication and proteolytic agents are considered and it is for the clinician strange to have epidural and facet joint injections discussed in the same line as local injections in spinal muscles. Moreover, the epidural injections are recommended for the management of subacute low back pain radiating into the leg. This means pain of a duration between 6 weeks and 3 months. Obviously because of the predefined criteria for inclusion of studies on patients with pain of duration of more than 3 months, the authors eliminate the most important trials on this treatment option. Of the three studies that are maintained for further analysis only the trial on targetted steroid placement deals with patients suffering radicular pain. Evidence-based practice guidelines [3] clearly indicate that the only indication for epidural corticosteroid administration is the management of subacute radicular pain. Epidural administration of local anesthetic may be used in surgery and postoperative pain control, but is not recommended for the management of chronic pain, mainly because of the short duration of action of the local anesthetic and the lack of mechanism/cause oriented mode of action. The authors suggest a lack of clinical understanding and differentiation between degenerative disease of the facet joints and lumbosacral radicular pain because under the heading “zygapophysial joints (facet joints)” they also list the RCT comparing radiofrequency treatment adjacent to the dorsal root ganglion with sham intervention. This study was performed in patients suffering chronic lumbosacral radicular pain. In a recent letter to the editor [4], a plea was made to include clinicians in the definition of the research question before starting a systematic review to obtain more clinically relevant information.

Pitfalls in Chronobiology

The duration of analgesia from epidural administration of local anesthetics to parturients has been shown to follow a rhythmic pattern according to the time of drug administration. We studied whether there was a similar pattern after intrathecal administration of bupivacaine in parturients. In the course of the analysis, we came to believe that some data points coincident with provider shift changes were influenced by nonbiological, health care system factors, thus incorrectly suggesting a periodic signal in duration of labor analgesia. We developed graphical and analytical tools to help assess the influence of individual points on the chronobiological analysis. Women with singleton term pregnancies in vertex presentation, cervical dilation 3 to 5 cm, pain score >50 mm (of 100 mm), and requesting labor analgesia were enrolled in this study. Patients received 2.5 mg of intrathecal bupivacaine in 2 mL using a combined spinal-epidural technique. Analgesia duration was the time from intrathecal injection until the first request for additional analgesia. The duration of analgesia was analyzed by visual inspection of the data, application of smoothing functions (Supersmoother; LOWESS and LOESS [locally weighted scatterplot smoothing functions]), analysis of variance, Cosinor (Chronos-Fit), Excel, and NONMEM (nonlinear mixed effect modeling). Confidence intervals (CIs) were determined by bootstrap analysis (1000 replications with replacement) using PLT Tools. Eighty-two women were included in the study. Examination of the raw data using 3 smoothing functions revealed a bimodal pattern, with a peak at approximately 0630 and a subsequent peak in the afternoon or evening, depending on the smoother. Analysis of variance did not identify any statistically significant difference between the duration of analgesia when intrathecal injection was given from midnight to 0600 compared with the duration of analgesia after intrathecal injection at other times. Chronos-Fit, Excel, and NONMEM produced identical results, with a mean duration of analgesia of 38.4 minutes (95% CI: 35.4-41.6 minutes), an 8-hour periodic waveform with an amplitude of 5.8 minutes (95% CI: 2.1-10.7 minutes), and a phase offset of 6.5 hours (95% CI: 5.4-8.0 hours) relative to midnight. The 8-hour periodic model did not reach statistical significance in 40% of bootstrap analyses, implying that statistical significance of the 8-hour periodic model was dependent on a subset of the data. Two data points before the change of shift at 0700 contributed most strongly to the statistical significance of the periodic waveform. Without these data points, there was no evidence of an 8-hour periodic waveform for intrathecal bupivacaine analgesia. Chronobiology includes the influence of external daily rhythms in the environment (e.g., nursing shifts) as well as human biological rhythms. We were able to distinguish the influence of an external rhythm by combining several novel analyses: (1) graphical presentation superimposing the raw data, external rhythms (e.g., nursing and anesthesia provider shifts), and smoothing functions; (2) graphical display of the contribution of each data point to the statistical significance; and (3) bootstrap analysis to identify whether the statistical significance was highly dependent on a data subset. These approaches suggested that 2 data points were likely artifacts of the change in nursing and anesthesia shifts. When these points were removed, there was no suggestion of biological rhythm in the duration of intrathecal bupivacaine analgesia.

Epidural anesthesia and pulmonary function

The epidural administration of local anesthetics can provide anesthesia without the need for respiratory support or mechanical ventilation. Nevertheless, because of the additional effects of epidural anesthesia on motor function and sympathetic innervation, epidural anesthesia does affect lung function. These effects, i.e., a reduction in vital capacity (VC) and forced expiratory volume in 1 s (FEV(1.0)), are negligible under lumbar and low thoracic epidural anesthesia. Going higher up the vertebral column, these effects can increase up to 20% or 30% of baseline. However, compared with postoperative lung function following abdominal or thoracic surgery without epidural anesthesia, these effects are so small that the beneficial effects still lead to an improvement in postoperative lung function. These results can be explained by an improvement in pain therapy and diaphragmatic function, and by early extubation. In chronic obstructive pulmonary disease (COPD) patients, the use of thoracic epidural anesthesia has raised concerns about respiratory insufficiency due to motor blockade, and the risk of bronchial constriction due to sympathetic blockade. However, even in patients with severe asthma, thoracic epidural anesthesia leads to a decrease of about 10% in VC and FEV(1.0) and no increase in bronchial reactivity. Overall, epidural administration of local anesthetics not only provides excellent anesthesia and analgesia but also improves postoperative outcome and reduces postoperative pulmonary complications compared with anesthesia and analgesia without epidural anesthesia.

Epidural Local Anesthetics: A Novel Treatment for Fetal Growth Retardation?

Background: Chronically compromised uterine perfusion may lead to placental insufficiency and subsequent intrauterine growth restriction (IUGR). Various therapeutic approaches (e.g. vasodilators, low-dose aspirin, intravenous glucose infusion, and hemodilution) are often of limited efficacy. Local anesthetics have been shown to improve placental blood flow in pre-eclamptic women. We hypothesized that epidural administration of local anesthetics might improve outcome in IUGR independent of the underlying cause. In preparation for a clinical trial to test this hypothesis, we performed a pilot study in 10 patients. Methods: After approval of the study protocol, 10 pregnant women presenting with oligohydramnios and IUGR were included in the study. In addition to our standard protocol (magnesium, glucose, betamethasone), each patient received an epidural catheter (T10/T12) with continuous infusion of bupivacaine 0.175% at a rate of 5 ml/h. Uteroplacental circulation was monitored by Doppler sonography and the amount of amniotic fluid was estimated daily. Results: Epidural insertion and infusion was performed without complications. Four patients continued to deteriorate rapidly, amniotic fluid volume did not change and uterine artery pulsatility index (PI) tended to increase. In the remaining 6 patients the clinical status stabilized, amniotic fluid volume tended to increase and uterine artery PI tended to decrease during treatment. This improvement was associated with a prolonged interval to cesarean section and increased infant birth weight. Conclusion: Our data suggest that, even if the underlying cause of IUGR is not pre-eclampsia, epidural local anesthetic administration might improve placental blood flow and be beneficial in a subgroup of patients. A clinical trial to test this hypothesis appears warranted.

Epidural blockade suppresses lipolysis during major abdominal surgery

Background and Objectives: The purpose of the study was to investigate the effect of thoracic epidural administration of local anesthetic, i.e., epidural block on perioperative lipolysis. Methods: Fourteen patients undergoing elective colorectal surgery were randomly assigned to receive either general anesthesia combined with epidural block (EDA, n = 7) or general anesthesia alone (control, n = 7). The rates of glycerol appearance (Ra glycerol), i.e., lipolysis, were assessed by the stable isotope tracer [1,1,2,3,3-2H5]glycerol before, during, and 2 hours after the operation. Plasma concentrations of metabolic substrates (glycerol, free fatty acids [FFA], lactate) and hormones (insulin, glucagon, cortisol) were also determined. Results: In the EDA group, Ra glycerol decreased to lower intra- and postoperative values than in the control group (P < .05). Perioperative plasma concentrations of glycerol, FFA, lactate, and insulin remained unaltered with both anesthetic techniques. Intraoperative plasma glucagon and cortisol concentrations were lower in the EDA group than in the control group (P < .05). Conclusions: Epidural block suppresses lipolysis during and 2 hours after major abdominal surgery without affecting plasma glycerol or FFA concentrations. Reg Anesth Pain Med 2002;27:469-475.

Patient-controlled epidural analgesia with fentanyl-bupivacaine: Influence of prior dural puncture

Background and Objectives: Combined spinal epidural anesthesia (CSEA) involves the epidural administration of local anesthetic and opioid solutions adjacent to the prior dural puncture, potentially increasing their diffusion into the subarachnoid space. This study was designed to evaluate the influence of dural puncture on the adequacy and extent of analgesia, and drugs requirements of patient-controlled epidural analgesia (PCEA) in the postoperative period. Methods: In this prospective double-blind study, 40 patients undergoing major abdominal surgery under general anesthesia followed with PCEA were randomly assigned to either group I (preoperative insertion of an epidural catheter) or group II (preoperative dural puncture with a 25-g Quincke needle + insertion of an epidural catheter). Postoperatively, a PCEA pump delivered an infusion of 0.1% bupivacaine + fentanyl (3 μg/mL) at 5 mL/h. Participants were allowed to self-administer 5-mL boluses of the same solution with a 15-minute lock-out interval. Hourly epidural solution requirements were recorded for 40 hours. Sensory and motor block, and pain scores were also analyzed. Results: There was no difference between groups with regard to epidural solution requirements, pain scores, spread of sensory blockade, or intensity of motor block. Conclusion: Dural puncture with a 25-gauge Quincke needle, performed as part of CSEA, does not influence the drug requirements when a combination of 0.1% bupivacaine and fentanyl (3 μg/mL) is used for PCEA after major abdominal surgery. Reg Anesth Pain Med 2000;25:254–258.

Endoscopic Thoracic Sympathectomy for Primary Erythromelalgia in the Upper Extremities

Endoscopic Thoracic Sympathectomy for Primary Erythromelalgia in the Upper Extremities

Plasma levels of clonidine following epidural bolus injection in children.

The use of clonidine as an adjunct to epidural administration of local anesthetics in children has been reported to substantially improve the duration and quality of postoperative analgesia. The aims of the present study were to determine the pharmacokinetic profile and to investigate the interaction between postoperative sedation and analgesia after epidurally administered clonidine in children. Plasma levels of clonidine (0-10 h postop) and assessment of postoperative analgesia and sedation (0-24 h postop) were performed at predetermined intervals following lumbar epidural administration of bupivacaine 2.0 mg/kg and clonidine 2 mg/kg in 8 children undergoing ureteral re-implantation surgery using general anesthesia (age range: 1-9 yr, weight range: 9-41 kg). Plasma levels of clonidine were analyzed by radioimmunoassay, and sedation and analgesia were assessed by previously described scoring systems. The venous plasma pharmacokinetics of clonidine following epidural administration showed a considerable interindividual variation. Cmax and Tmax values of clonidine were found to be within the 0.45-0.77 ng/mL and 48-193 min range, respectively. The time to absorb 95% of the clonidine dose from the epidural space into plasma varied between 36 min and 7.6 h. In 6 of the 8 patients postoperative analgesia substantially outlasted the duration of sedation (> or = 2 h). Sedation could not be detected in any patients at plasma concentrations below 0.3 ng/mL. The pharmacokinetic profile associated with epidural clonidine administration in children (1-9 y) was similar to that previously reported in adults. The postoperative analgesia seen after administration of epidural bupivacaine-clonidine during general anesthesia in children cannot only be explained by residual postoperative sedation.

The NMDA-receptor antagonist ketamine abolishes neuropathic pain after epidural administration in a clinical case

A 14-year-old male patient developed severe right limb pain after traumatic sciatic nerve injury. His pain was diagnosed as neuropathic pain (complex regional pain syndrome, type II). He did not respond to any conventional therapy for limb pain including non-steroidal anti-inflammatory drugs, antidepressants, anticonvulsants, continuous epidural administration of local anesthetics and psychotherapy. Following continuous epidural administration of a very low dose of ketamine, an N-methyl- d-aspartic acid (NMDA) receptor antagonist, 25 μg/kg per h for 10 days, complete pain relief was obtained without any side-effects. There has been no recurrence of pain for 8 months after discontinuation of epidural ketamine. The symptoms related to dysfunction of the sympathetic nervous system still remained after complete pain relief. We discuss pain mechanisms, pain relief and the use of ketamine in this case.

Management of Nonobstetric Pain During Pregnancy and Lactation

Management of Nonobstetric Pain During Pregnancy and Lactation