Epidural Infusion Of Fentanyl Research Articles

Perioperative analgesic management in patients with bladder exstrophy: A clinical study

Background: Bladder exstrophy is a complex, rare congenital malformation with an incidence of 3.3 cases in every 100000 live births and is slightly more common in males. Primary surgical repair requires many hours of surgery with fluid and blood loss. Because of wide fluctuations in hemodynamics, a longer duration of surgery, smaller age, risk of hypothermia and post-operative intensive care may be required. We evaluated the use of continuous caudal epidural infusion of bupivacaine and fentanyl under general anesthesia for urinary bladder exstrophy-epispadias surgery in children. Aims and Objectives: Aim of the study was to evaluate the postoperative analgesia in patients undergoing surgery for bladder exstrophy. The primary objective was to assess the postoperative pain using FLACC scale and sedation score after successful caudal administration. Secondary objective was to assess the hemodynamic changes after caudal administration. Materials and Methods: A total of 13 patients aged between 9months and 13 years of either sex, weighing between 5kg to 30kg, belonging to ASA grade II to IV, underwent surgery for epispadias–exstrophy complex. Initial bolus 0.75ml/kg of 0.25% bupivacaine with fentanyl 1ug/kg was given through epidural. Postoperative analgesia was maintained by continuous infusion of 0.0625% bupivacaine @0.1ml/kg/hr in young children and 0.125% bupivacaine with fentanyl 1ug/ml in older children for 4-5 days with the help of ON-Q pump or infusion pump. Baseline hemodynamic parameters including MAP, heart rate and SpO2 was recorded at various time intervals. Postoperative pain was assessed using face, legs, activity, cry and consolability (FLACC) pain scale and sedation score was assessed by using ramsay sedation score. Results: There was a statistically significant decrease in mean pulse rate in the study group from baseline to thirty minutes after reversal (p<0.001). Similar observation was made for mean arterial pressure which also showed statistically significant decrease from baseline to thirty minutes after reversal (p<0.001). No change was observed in SpO2 from baseline to any other follow-up interval. Conclusion: Perioperative anesthetic and analgesic management of the bladder exstrophy patient can improve the success rate. Epidural bupivacaine with or without fentanyl infusions for short duration can provide safe analgesia.

Anaesthesia for Mitrofanoff Procedure in a young male patient with exstrophy-epispadias complex

Purpose: One of the most challenging tasks of an anaesthesiologist is intraoperative and postoperative pain management. The exstrophy-epispadias complex is a congenital distortion not only of the genito­urinary system but also the muscles of the wall of the abdomen and structures of the pelvis. The focus of surgical repair remains on bladder reconstruction and its surrounding structures with cosmesis and a better quality of life. Features: A twenty-year-old male, known case of exstrophy-epispadias complex, presented for Mitrofanoff repair for recurrent urinary tract infections. This case report highlights the use of lumbar epidural infusion of local anaesthetic bupivacaine and opioid fentanyl with general anaesthesia for Mitrofanoff procedure in urinary bladder exstrophy-epispadias surgery. Conclusion: Regional anaesthesia along with general anaesthesia has advantages such as decreased use of anaesthetic drugs intraoperatively, better haemodynamics, effective analgesia both intraoperatively and postoperatively. Although there have been differences in opinion on the usage of opioids in epidurals, it has been shown to facilitate early gastric motility, better analgesia and better recovery profiles.

Case Report and Literature Review: Interventional Management of Erythromelalgia.

Erythromelalgia is a rare and very difficult to treat pain syndrome that usually presents as severe bilateral burning pain in the extremities. Here we present a case of a 34-year-old female with erythromelalgia who we treated successfully with a lumbar epidural infusion of ropivacaine and fentanyl. The patient had complete relief shortly after the epidural infusion, and she remained stable with only minor pain two weeks and nine months later. With this case, we have reviewed the interventional treatments of erythromelalgia. We suggest epidural infusion as the first line interventional management, followed by sympathetic block. Spinal cord stimulation can be considered if other interventional managements fail.

Epidural Anesthesia to Effectively Manage Pain and Facilitate Rehabilitation in a Pediatric Case of Complex Regional Pain Syndrome

There is a paucity of information related to treatment of pediatric CRPS. Treatment of CRPS in pediatric patients has been guided by adult recommendations, which consist of a multidisciplinary approach involving pharmacotherapy, physical therapy, and psychotherapy, as appropriate. Patients unable to tolerate physical therapy with traditional oral pharmacotherapy may require more invasive pain management techniques such as sympathetic blocks, epidural infusion of analgesics, or spinal cord stimulation to facilitate restoration of function. This case report describes the successful use of epidural infusion of fentanyl, clonidine, and bupivacaine through a tunneled epidural lumbar catheter for pain management in an 11-year-old girl who developed complex regional pain syndrome I (CRPS I) approximately 2 months after sustaining an injury to her right knee. Following short-lasting pain relief from 3 repeated blocks, she underwent an implant of a tunneled epidural catheter (TEC) and a 4-week infusion of fentanyl (2 mcg/mL), clonidine (1 mcg/mL), and bupivacaine (0.04%). At last follow-up, approximately 3.5 months after implant of the TEC, the patient’s pain and symptoms were completely resolved, her range of motion and function were completely restored, and her physical activity had returned to pre-injury levels. Key words: Complex regional pain syndrome (CRPS), tunneled epidural catheter, pediatric, continuous regional anesthesia, epidural analgesia, continuous epidural anesthesia, interventional pain management

A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy.

Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema. We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n=21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n=21). Inotrope use was reduced by 29% in the WC group (p=0.03) and the mean intensive care stay reduced by 2.4days (p=0.03), as was reintubation rate (p=0.01) and early mobilisation (p=0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined. The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.

Comparison of Analgesic Effects of Epidural Infusion of Fentanyl and Fentanyl-bupivacaine in Spine Surgery: A Randomized Clinical Trial Study

Background & Aim: Although most patients experience severe pain after major spinal fixation surgery, little attention has been paid to control it with a multi-modal approach. The aim of this study is to select appropriate method of pain management after spinal surgery. Methods & Materials/Patients: This study was a randomized clinically controlled trial in candidates of spondylolisthesis and spinal fixation surgery under general anesthesia. 90 patients were divided into three groups, as follows: 1) Intervention group of epidural fentanyl (F): patient-controlled analgesia (PCA) pump infused 100 µg of fentanyl and 98cc of normal saline at the rate of 3-5 ml/h in the epidural space via an epidural catheter placed by surgeon 2) Intervention group of epidural fentanyl-bupivacaine (FB): PCA pump infused 100 µg of fentanyl and bupivacaine 0.125% at the rate of 3-5 ml/h in the epidural space. 3) IV morphine group (M): No medication was received epidurally. In case of visual analog scale (VAS) score more than four, one mg of IV morphine bolus was administered to patient. The blood pressure, heart rate, respiratory rate and pain severity were recorded at the moment of patient’s transfer from recovery room to the ward and compared in three groups every six hours for 24 hours. The results of this study were analyzed by statistical tests including repeated measures ANOVA, Kruskal-Wallis, Fisher’s exact test and SPSS software 16. P values less than 0.05 were considered statistically significant. Results: The results of the study showed that VAS score in fentanyl-bupivacaine group was significantly lower than that in the two other groups during the first 18 hours. However, VAS score in all groups decreased at 24th hour postoperatively (less than three) suggesting that there was no statistically significant difference between the three groups. In this study, no serious and severe complications were observed except for a few cases of nausea in the control group. Conclusion: Epidural analgesia with fentanyl-bupivacaine is a safe and effective way to postoperative pain management in listhesis and spinal surgeries.

The effect of addition of neostigmine to epidural levobupivacaine/fentanyl mixture on return of intestinal motility in postoperative ICU

Background Postoperative ileus is a major cause of morbidity and mortality. It has a direct correlation with pain and the use of narcotic analgesics. Neostigmine is an anticholine esterase. It acts as an adjuvant analgesic in the epidural space. This study aimed to demonstrate the effect of epidural neostigmine addition to levobupivacaine/fentanyl mixture on postoperative analgesia following abdominal hysterectomy. Materials and methods A total of 40 patients were divided into group N (the neostigmine group) and group C (the control group). In group N, neostigmine 1 μg/kg was added to the epidural infusion of levobupivacaine and fentanyl. Results Both groups were comparable in demographic data, surgical time, and hemodynamic data. Group N had significantly lower visual analogue scale ( P < 0.05). In addition, time to first analgesic request was significantly longer in group N (9.5+ or −1.3 vs. 8.1+ or −0.9 in group C). The number of patients requiring analgesia in group N was two (10%), whereas in group C the number was nine (45%), which was statistically significant. Total narcotic consumption was significantly less in group N (104 ± 21.6 vs. 218 ± 35.2 mg in group C) and return of intestinal sounds was significantly faster in group N (8.1 ± 0.7 vs. 10.5 ± 1.8 h in group C). Group N had less nausea and vomiting. However, the difference was nonsignificant. Conclusion Neostigmine addition to levobupivacaine and fentanyl in lumbar epidural analgesia reduces pain scores and helps early return of intestinal motility during the postoperative period following abdominal hysterectomy.

The correlation of antepartum upper extremity cuff algometry with epidural analgesic requirements for labor

Background:Individual parturients experience pain differently, and it is unknown how these differences affect their requirements for labor analgesics.Materials and Methods:Cuff algometry of the upper limb was used to determine the pain thresholds and temporal summation of pain scores in nulliparous women about to undergo induction of labor. Analgesia was provided, upon request, with a patient controlled epidural analgesia infusion of bupivacaine and fentanyl. Nurse-administered epidural boluses of bupivacaine or lidocaine were given for breakthrough pain. Partial Spearman correlations were used to correlate the cuff algometry measurements with the amount of analgesic medication required by the patient.Results:There was no significant correlation between any of the algometry measurements and the number of patient or nurse administered bupivacaine boluses. There was a correlation of 0.7 (P = 0.001) between the temporal summation scores and the hourly number of nurse-administered epidural lidocaine boluses; however, this was based on only 3 patients who required lidocaine boluses.Conclusions:The use of pre-labor cuff algometry of the upper limb does not correlate with the patient epidural analgesic requirements and subsequent analgesia administration.

Comparison of efficacy of continuous epidural infusion of morphine, fentanyl and combination of morphine and fentanyl with bupivacaine for postoperative analgesia in children

Forty-five children of ASA I & II aged 2-10 years scheduled for elective abdominal, urological and major orthopedic procedures were included in the study. They were divided into three groups of 15 each Group I children received continuous epidural infusion of morphine 6ug/kg/hr with 0.0625% bupivacaine group II patients received an epidural infusion of fentanyl 0.4 ug/kg/hr with 0.0625% bupivacaine, whereas patients in group III received continuous epidural infusion of fentanyl 0.2 ug/kg/hr and morphine 3 ug/kg/hr with 0.0625% bupivacaine.

Effect of Preincisional Epidural Fentanyl and Bupivacaine on Postthoracotomy Pain and Pulmonary Function

This study attempts to determine whether preemptive thoracic epidural analgesia (TEA) initiated before surgical incision would reduce the severity of acute post-thoracotomy pain, its effects on pulmonary function and stress response. Forty patients undergoing posterolateral thoracotomy received TEA either before (preoperative-TEA group) or after (postoperative-TEA group) surgery. Postoperative analgesia was maintained with epidural infusion of bupivacaine and fentanyl. Pain scores, pulmonary functions, arterial blood gases, plasma glucose, cortisol levels and epidural fentanyl consumption were compared for 48 hours after surgery. The preoperative-TEA group demonstrated significantly reduced pain scores at 2, 4, 8, 12, 24, and 48 hours at rest (p = 0.001, p = 0.002, p = 0.004, p = < 0.001, p = 0.006, and p = 0.001, respectively) and at 4, 8, 12, 24, 48 hours on coughing (p = 0.001, p = 0.001, p = 0.001, p = 0.001, p = 0.004, respectively), and a significant reduction in epidural fentanyl consumption (208.6 +/- 49.3 mL, versus 260 +/- 28.8 mL, p = 0.001). The preoperative-TEA group showed significant improvement in pulmonary functions as compared with the postoperative-TEA group (p < 0.05), except forced expiratory volume in one second at 24 hours (p = 0.061) and peak expiratory flow rate at 48 hours (p = 0.188). The postoperative-TEA treated patients were more likely to have a higher arterial carbon dioxide pressure at 4, 8, 12, and 24 hours (p = 0.017, p = 0.001, p = 0.003, p = 0.001), respectively. However, we could not demonstrate a statistical difference in oxygenation, cortisol, or glucose level. Though preemptive TEA appeared to reduce the severity of acute pain, preserve pulmonary function, and reduce analgesic requirements, these statistically significant differences were not enough to conclude a clinical significant difference between groups.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration.

Comparison of three doses of epidural fentanyl followed by bupivacaine and fentanyl for labor analgesia

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. 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. 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. 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.

Regression of Sensory and Motor Blockade, and Analgesia During Continuous Epidural Infusion of Ropivacaine and Fentanyl in Comparison with Other Local Anesthetics

To compare the regression of sensory and motor blockade, and the analgesia during continuous epidural infusion between ropivacaine and other local anesthetics. Two studies were conducted. Study 1: Eighty patients were scheduled for orthopedic procedures of the lower extremity under lumbar epidural anesthesia. Following the operation, continuous infusion of a randomized solution (0.2% ropivacaine, 0.125% bupivacaine, 0.5% lidocaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl) was commenced at a rate of 6 mL/h. The regression of sensory and motor blockade were compared among the groups. Study 2: After gynecologic abdominal surgery, 39 patients were randomized to one of the three epidural infusion groups: 0.2% ropivacaine, 0.125% bupivacaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl at a rate of 6 mL/h with an additional bolus injection of 3 mL, which can be used when patients have pain. Visual analog scale (VAS) was compared among the groups. Study 1: The level of sensory blockade in all the groups appeared to decrease progressively. However, the regression of sensory blockade was significantly prolonged in patients treated with ropivacaine. The addition of fentanyl to ropivacaine augmented this prolonged analgesic effect. Study 2: VAS after the bolus in the ropivacaine and the ropivacaine + fentanyl groups were significantly lower than that in the bupivacaine group. Patients in the ropivacaine + fentanyl group required significantly fewer supplemental bolus injections. Continuous epidural infusion of ropivacaine may induce a slower regression of sensory blockade compared with bupivacaine and lidocaine. The addition of fentanyl to ropivacaine can enhance this prolonged analgesic effect with little effect on motor blockade. Epidural infusion of ropivacaine with fentanyl provides effective pain relief, possibly because of the maintenance of sensory blockade by ropivacaine and fentanyl.

Epidural magnesium reduces postoperative analgesic requirement

Magnesium has antinociceptive effects in animal and human models of pain. Our hypothesis was that the addition of magnesium to postoperative epidural infusion of fentanyl may decrease the need for fentanyl. Fifty patients undergoing hip surgery were enrolled to receive either fentanyl (Group F) or fentanyl plus magnesium sulphate (Group FM) for 24 h for epidural analgesia. All patients were equipped with a patient-controlled epidural analgesia device and the initial settings of a demand bolus dose of fentanyl 25 microg. In Group FM, patients received 50 mg magnesium sulphate epidurally as an initial bolus dose followed by a continuous infusion of 100 mg day(-1). Ventilatory frequency, heart rate, blood pressure, pain assessment using a visual analogue scale (VAS), sedation scores and fentanyl consumption were recorded in the postoperative period. There was no significant difference between groups in the time to first analgesic requirement. Compared with Group F, patients in Group FM received smaller doses of epidural fentanyl (P < 0.05). The cumulative fentanyl consumption in 24 h was 437 (SD110) microg in Group F and 328 (121) microg in Group FM (P < 0.05). Patients in Group F showed a higher VAS score in the first hour of the postoperative period (P < 0.05). The groups were similar with respect to haemodynamic and respiratory variables, sedation, pruritus, and nausea. Co-administration of magnesium for postoperative epidural analgesia results in a reduction in fentanyl consumption without any side-effects.

Risk of Hematoma After Epidural Anesthesia and Analgesia for Cardiac Surgery

To the Editor: We read Dr. Chaney’s excellent review on neuraxial block for cardiac surgery (1). As he points out, the risk of neuraxial hematoma remains a great concern (1). Unfortunately, the true risk is difficult to precisely quantify (2). To help clinicians decide whether neuraxial block is worthwhile, we should report all successful cases and series, as well as occurrences of neuraxial hematoma and other major complications. To this end, we bring to your attention the following two cases: one reported in a newsletter (3) and the second in a surgical journal (4). In the first case, a 60-yr-old man underwent coronary artery bypass grafting (3). His preoperative platelet count and coagulation were normal (antiplatelet medication status not stated). Prior to surgery, an 18-G epidural catheter was inserted at T12/L1. No bleeding was noted. The patient was heparinized 1 h after induction of anesthesia. Surgery was uneventful, with normal blood loss. Protamine, 4 U of fresh-frozen plasma, and 6 U of platelets were given. An epidural infusion of fentanyl and bupivacaine was given postoperatively. The next morning, the patient’s trachea was extubated. At that time, he was able to move his upper limbs, but his legs had no movement or sensation, a condition that persisted despite discontinuation of the epidural infusion. A magnetic resonance imaging (MRI) scan that afternoon revealed a hematoma from T5 to T10 with cord displacement. Four hours later, he underwent laminectomy. The patient remained paraplegic. In the second case a 65-yr-old patient with diabetes underwent minimally invasive direct coronary artery bypass grafting under combined general-epidural anesthesia (4). Postoperative paraplegia developed after the patient presented with anterior spinal artery syndrome. The risk of catastrophic neurologic complication after neuraxial block is increased by the fact that assessing lower limb functions may be difficult and delayed. Further delay could occur if a patient needs to be kept sedated and tracheally intubated after cardiac surgery because of hemodynamic instability, bleeding, and/or surgical re-exploration. One can also imagine that it would be hazardous to place a patient in the prone position for emergency laminectomy after recent cardiac surgery. In addition, there are two reports of spontaneous epidural hematoma after cardiac surgery without epidural instrumentation (5,6). Thus, there is the possibility that hematoma can spontaneously occur at sites of epidural placement. Two other patients suffered from this complication after epidural catheters were placed before cardiac surgery scheduled for the following day (7,8). Conceivably, if surgery had immediately followed, the consequence could have been worse. There are other considerations. First, inserting an epidural catheter the night before surgery theoretically reduces the risk of hematoma, but it necessitates early admission. Second, if epidural catheterization occurs just before induction of anesthesia, theoretically the risk of hematoma increases for the rare patient who has to be put on cardiopulmonary bypass urgently due to hemodynamic instability. Furthermore, the risks to patients from postponing a case after a bloody tap are significant. Finally, 3% of catheterizations were unsuccessful in one series (9). Multiple attempts put the patient at risk of neuraxial complications, even if no catheter is inserted, and thus the patient is afforded no benefits of neuraxial block. Anthony M.-H. Ho, MS, MD, FRCPC, FCCP Peggy T. Y. Li, MB, ChB Manoj K. Karmakar, MD, FRCA Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital, Shatin, NT Hong Kong Special Administrative Region of the People’s Republic of China [email protected]

Audit of Intrathecal, Epidural and Intravenous Analgesia for Abdominal Surgery

Background: Many studies have compared epidural and intravenous postoperative analgesia. To date there are no studies comparing intrathecal with epidural and intravenous regimes. Aim: To audit standard postoperative intrathecal (incorporating midazolam), epidural and systemic intravenous analgesic regimes used at Monash Medical Centre. Method: This was a prospective nonblinded study conducted over 9 months. Data was collated for 15 patients of each of the following regimes, identified through the Acute Pain Service. • Intrathecal infusion of Morphine 10 mcg + Midazolam 100 mcg + Bupivacaine 0.5 mg per ml at 1–2 ml/hr • Epidural infusion of Fentanyl 2 mcg/ml + Bupivacaine 1.25 mg/ml at 6–12 ml/hr • Intravenous Morphine Patient Controlled Analgesia 1 mg boluses + /− background infusion and Ketamine infusion at 0.1–0.2 mg/kg/hr Inclusion criteria were: patients conversant in English and over 60 years of age, having open abdominal surgery and postoperative ventilation less than 24 hours. Results: Statistical data analysis showed a significant difference between the groups in the median number of calls to the pain service: Data on pain scores, postoperative haemodynamic stability and pyrexias were also notable: Conclusions: The intrathecal group trends towards better postoperative analgesia and less intervention required compared to epidural or intravenous regimes.

This Month in ANESTHESIOLOGY

This Month in ANESTHESIOLOGY

Anesthésie ďune parturiente en travail, atteinte ďurticaire pigmentaire

To report the anesthetic management of labour pain and Cesarean section in a patient with urticaria pigmentosa at risk for systemic mastocytosis. CLINICAL: A 37-yr-old patient with a history of urticaria pigmentosa and an allergic reaction to a local anesthetic agent was seen in consultation at 36 weeks gestation. She previously tested negative for an allergy test to lidocaine. Recommendations to avoid systemic mastocytosis included: avoidance of histamine-releasing drugs, using lidocaine for labour epidural, and regional anesthesia in case of a Cesarean section. The patient presented at term in labour. Intravenous fentanyl was used for early labour, followed by a combined spinal-epidural. The spinal contained lidocaine and fentanyl, but because of pruritus, the epidural infusion contained lidocaine only. Most likely because of tachyphylaxis to lidocaine, an epidural bolus of lidocaine with epinephrine failed to provide adequate anesthesia for a Cesarean section. The block was supplemented with nitrous oxide by mask, with fentanyl postdelivery. Postoperative pain control was managed with an epidural infusion of lidocaine and fentanyl for three days. The patient was discharged without complications four days postsurgery.Proper allergy testing prior to pregnancy is important to help the management of labour pain and anesthesia for Cesarean section in a patient at risk for systemic mastocytosis.

Anesthetic management for the minimally invasive Nuss procedure in 21 patients with pectus excavatum

The aim of this study was to assess the anesthetic management and postoperative analgesic effect of continuous epidural infusion for the minimally invasive Nuss procedure. A total of 21 operated cases were analyzed retrospectively. Thoracoscopy was used in all cases. General anesthesia with endotracheal intubation was induced and maintained with oxygen, air, sevoflurane, and fentanyl in all cases. Thoracic epidural anesthesia was performed after induction at the level between Th4 and 12. When the bar was placed via insertion under the sternum, six patients exhibited sinus tachycardia and one showed premature atrial contraction for 2-4 beats before recovering spontaneously within 1 min. Operations were uneventful. The mean operating time was 115 min and anesthetic time was 193 min. In X-ray findings, residual pneumothorax and pleural effusion were found in seven (33.3%) and eight (38.0%) patients, respectively. In all cases, these symptoms were resolved spontaneously within 5 days. Epidural fentanyl (0.3 microg.kg(-1).h(-1)) in 0.125% bupivacaine (0.15 ml.kg(-1).h(-1)) or 0.2% ropivacaine (0.15 ml.kg(-1).h(-1)) were used for 3 days to relieve postoperative pain. Postoperatively, 12 (57.1%) patients required no additional analgesics, and 4 (19.0%) patients required a single dose of dicrofenac sodium or pentazocine. Although the Nuss procedure is minimally invasive, we should pay attention to the possibility of many intra- and postoperative complications. Continuous epidural infusion of fentanyl with local anesthetics provides effective postoperative pain relief and prevents complications such as bar displacement after the Nuss procedure.

Epidural analgesia after lumbar disc surgery with ropivacaine plus fentanyl or bupivacaine plus fentanyl

AbstractWe compared the efficacy and safety of continuous epidural infusion of ropivacaine plus fentanyl versus bupivacaine plus fentanyl in the management of postoperative pain after lumbar laminectomy. Twenty-two patients who underwent elective lumbar laminectomy were randomly allocated to one of two groups. The patients were treated with ropivacaine 0.1% plus fentanyl 2 μg/ml in group 1, and with bupivacaine 0.1% plus fentanyl 2 μg/ml in group 2 via bolus epidural infusion (6–10 ml/h). General anesthesia was standardized. Postoperative pain was evaluated using VAS at 0, 1, 2, 3, 8, 20, 32, 48 hours after surgery. The amount of ropivacaine plus fentanyl or bupivacaine plus fentanyl used over the 48-h postoperative period was documented. The postoperative pain and sedation scores were not significantly different between groups throughout the study period. The total consumption of ropivacaine plus fentanyl over the 48-h period was significantly lower (p < 0.05) than that of bupivacaine plus fentanyl. Ther...