Epidural PCA Research Articles

Postoperative Infusion of Amino Acids Induces a Positive Protein Balance Independently of the Type of Analgesia Used

Net loss of body protein is a prominent feature of the catabolic response to surgical tissue trauma. Epidural analgesia with hypocaloric dextrose has been demonstrated to attenuate leucine oxidation but was unable to make protein balance positive. The current study was set to determine whether an infusion of amino acids on the second day after colon surgery would revert the catabolic state and promote protein synthesis while maintaining glucose homeostasis in patients receiving epidural analgesia as compared with patient-controlled analgesia with morphine (PCA). Sixteen patients undergoing colorectal surgery were randomly assigned to receive epidural blockade or PCA as analgesic techniques and underwent a 6-h stable isotope infusion study (3 h fasted, 3 h fed) on the second postoperative day. Whole body glucose kinetics and protein turnover were measured using [6,6-2H2]glucose and l-[1-13C]leucine as tracer. The infusion of amino acids caused a decrease in endogenous glucose rate of appearance in both groups (P < 0.05), with greater changes in the PCA group (P < 0.05). Administration of amino acids suppressed the appearance of leucine from protein breakdown in both groups (P < 0.05), although the decrease was greater in the PCA group (P < 0.05). Leucine oxidation increased in both groups (P < 0.05), with greater change in the epidural group (P < 0.05). Protein synthesis increased to the same extent in both groups (P < 0.05). Protein balance became positive after the infusion of amino acids, and the effect was greater in the PCA group (P < 0.05). Infusion of amino acids decreased the endogenous glucose production and induced a positive protein balance independent of the type of anesthesia provided, although such effects were greater in the PCA group.

Ropivacaine vs. Bupivacaine for epidural PCA. The incidence of urinary retention assesed by bladder ultrasound, a randomized controlled study

Ropivacaine vs. Bupivacaine for epidural PCA. The incidence of urinary retention assesed by bladder ultrasound, a randomized controlled study

Loss of consciousness from epidural sufentanil for labour analgesia

Loss of consciousness from epidural sufentanil for labour analgesia

Outcome of Total Knee Arthroplasty Depending on Post-operative Pain Control Methods

Background: Rehabilitation physical therapy after a total knee arthroplasy (TKA) is important for the functional prognosis of the surgery and the methods of postoperative analgesic control could have influence on physical therapy. Therefore we compared surgical outcome of TKA patients receiving intravenous patient-controlled analgesia (IPCA) and epidural patient-controlled analgesia (EPCA) for pain control. Methods: Forty four patients scheduled for a TKA were randomly allocated into two groups. The IPCA group received intravenous PCA (fentanyl 30/ml, ketorolac 3 mg/ml, 0.5 ml/15 min/0.5 ml) after general anesthesia and the EPCA group received epidural PCA (0.1% bupivacaine, fentanyl 3/ml, 3 ml/15 min/3 ml) after combined spinal epidural anesthesia for an operation. Pain score and side effects were checked at 6, 24, 48, and 72 hours after the operation. Range of motion (ROM) was evaluated at discharge, 1 and 3 months after the operation. Results: The EPCA group showed better analgesia and ROM than the IPCA group but the advantage on ROM did not last up to the 3 month follow up. Nausea/vomiting and sedation was more in the IPCA group, and backache, paresthesia and motor weakness of the lower limbs were more in the EPCA group. However, all side effects were tolerable for the patients. There was 31.8% of epidural catheter dislodgement or occlusion. Conclusions: Better analgesia with epidural PCA resulted in a better functional prognosis, but more effort would be needed to manage an epidural catheter.

Greater gain in QOL, less pain with epidural analgesia vs PCA

Greater gain in QOL, less pain with epidural analgesia vs PCA

The Effects of Three Different Analgesia Techniques on Long-Term Postthoracotomy Pain

In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain. Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%.

The Comparison of Ropivacaine and Bupivacaine in Epidural Patient Controlled Analgesia (PCA)

Background: Local anesthetics combined with an opiate are frequently used as a postoperative epidural PCA regimen. Ropivacaine is known to have a selective blockade of the sensory nerve without motor blockade. This study is designed to show advantages of ropivacaine over bupivacaine. Methods: Patients undergoing elective abdominal and orthopedic surgeries were randomly selected and divided into two groups, B and R. The patients in group B and R received 0.2% bupivacaine and 0.2% ropivacaine respectively through an epidural catheter using a PCA pump. Both local anesthetic solutions were mixed with 4g/ml of fentanyl. The PCA pumps of both groups were set in the same manner. A basal rate of 2 ml/hr was infused from 1hour after the onset of surgery. This basal rate was continued postoperatively. A bolus dose and lock out time were set at 2 ml and 20 minutes respectively. The Visual analogue pain scale (VAS), demand dose, complication and additional intramuscular analgesic requirements were checked up to 24 hours after surgery in 6-hour interval. Results: The VAS was significantly lower in group R than in group B at 6, 12, 18 and 24 hours after the surgery (P 0.05). Total additional bolus doses of the PCA pump were not significantly different in either group at 6, 12, 18 and 24 hours after surgery. The patients in group R showed more satisfaction and less additional intramuscular injections. Conclusions: 0.2% Ropivacaine, mixed with 4g/ml of fentanyl, was more effective than bupivacaine, mixed with the same concentration of fentanyl, in controlling postoperative pain using an epidural PCA pump.

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.

Cancer pain relief by epidural PCA pump infusion through tunneled epidural catheters

Cancer pain relief by epidural PCA pump infusion through tunneled epidural catheters

Cancer Pain Relief by Epidural PCA Pump Infusion through Tunneled Epidural Catheters

Cancer Pain Relief by Epidural PCA Pump Infusion through Tunneled Epidural Catheters

Epidural PCA and the progress of nulliparous labor

Epidural PCA and the progress of nulliparous labor

A MODIFIED, OPEN, LIVING-DONOR NEPHRECTOMY TECHNIQUE: IS IT BETTER THAN LAPAROSCOPIC DONOR NEPHRECTOMY?

168 Introduction: We have modified our open living-donor nephrectomty technique (ModNx) in order to reduce hospital stay, costs, and morbidity. Recent reports suggest that laparoscopic living-donor nephrectomy (LapNx) may also offer similar advantages over the standard open approach. We present our experience with the ModNx technique and compare our results to that reported in the literature for LapNx (Flowers, 1997; Ratner, 1997). Methods: Between Jan/1995 and Dec/1997, 77 consecutive ModNx were performed. Both right and left kidneys were approached retroperitoneally through an anterior sub-costal incision with the patient in a 30° decubitus position. The rectus musculature was retracted (not incised) with the internal oblique/transversalis mm. split when possible. Ribs were not transected. Epidural PCA was used in 74/77 cases for control of post-operative pain. Data was collected on operative time (ORT), length of hospital stay (LOH; includes operative day), graft function and complications. Our data was then compared to 71 patients undergoing LapNx during the same time period. An estimated cost comparison between OpenNx and LapNx is made. Results: For our ModNx patients, kidneys were removed through a 15 cm incision, ORT was 155±26 min, and LOH decreased from 4.9±1.2 days in 1995 to 3.8±0.9 in 1997 (p=0.02). In contrast, LapNx kidneys were removed through an 8 cm infra-umbilical incision, ORT was 235 min, and LOH 3.3±0.5. In the ModNx group, all grafts functioned immediately, no technical complications occurred in any recipient, and no donor had a major complication or required blood transfusion. In this same group, minor complications included atelectasis (2), stitch granulomas (3) requiring removal, and ileus (3). In contrast, major complications were reported for 60 LapNx patients and include incisional hernia requiring repair (1), blood transfusion (3), and splenic injury/splenectomy (1). Two LapNx patients required conversion to an open technique. Three LapNx grafts were lost immediately. Estimated costs of LapNx at our center is higher compared to ModNx ($10,925 vs. 4,945). Conclusion: This study demonstrates that our ModNx technique can minimize hospital stay and costs without increased risks to the donor or recipient. Although LapNx is appealing, further experience is needed to fully demonstrate the purported advantages of reduced post-operative morbidity, earlier return to full function, and increased numbers willing to volunteer as a donor. We, therefore, recommend that the ModNx technique be utilized until the benefits of LapNx have been fully elucidated.

DO OBSTETRIC OUTCOMES DIFFER BETWEEN EARLY COMBINED SPINAL-EPIDURAL AND EPIDURAL ANESTHESIA IN SPONTANEOUSLY LABORING NULLIPAROUS PATURIENTS?

S382 Introduction: Previous studies showed that combined spinal-epidural (CSE) labor anesthesia in nulliparous parturients receiving oxytocin may differ from epidural anesthesia alone (EA) by shorter 2nd stage labor, less epidural local anesthetic requirement, and possibly less instrument deliveries. This prospective double-blinded, randomized study aims to see if these same differences between CSE and EA occur in spontaneously laboring nulliparous parturients as in induced laboring parturients. Methods: After IRB approval, informed consent was obtained from 22 healthy spontaneously laboring nulliparous term parturients with singleton fetus in vertex presentation and cervical dilation less than 5 cm, who requested regional labor analgesia. Patients were randomized to receive either CSE (n=11) or EA alone (n=11). CSE group received 35 ug fentanyl intrathecally after identification of intrathecal space by return of cerebral spinal fluid via 25 G Sprotte spinal needle. An epidural catheter was inserted but not tested or dosed until patient requested for more analgesia. EA groups received epidural anesthesia in usual manner For both CSE and EA groups, and the testing of epidural catheter consisted of 3 cc of 2% lidocaine with epinephrine and then dosed with 0.25% bupivacaine to T-10 level. After testing of epidural catheter, both groups received epidural PCA (EPCA) with 0.125% bupivacaine and 2 ug/cc of fentanyl. EPCA basal rate was 4 ml/hr with demand dose of 3ml every 8 mins. Additional bolus of 0.25% bupivacaine in 5 cc increments (up to a maximum of 10 cc) were administered if needed after maximal use of the EPCA. Patients were evaluated every 10 minutes for the first 30 minutes, then hourly. Data analysis included Chi square, ANOVA and unpaired t-test. Results: Demographics were similar between groups. Our results showed that there were no difference in the progress of labor, the amount of epidural local anesthetic required and the incidence of instrument deliveries between CSE and EA groups in the spontaneously laboring nulliparous parturients. However, CSE group had a more complete analgesia and a higher patient satisfaction than EA group. Discussion: Labor requiring oxytocin is at risk for dysfunction labor and may be more susceptible to adverse effects (if any) of EA than spontaneous labor. Therefore, previously reported differences between EA and CSE in induced laboring patients are not seen in spontaneously laboring patients here. (Table 1)Table 1

Pediatric pain management: Clinical aspects for the nineties

No patient should be denied safe and effective postoperative analgesia. The well-informed pain management specialist has the opportunity to dramatically alter the perioperative pain experience of children undergoing medical procedures and surgery by making pain treatment a priority. This includes dispelling the misconception among anesthesiologist, surgeon, and nurse colleagues that pain is unimportant in the very young and that its treatment is unnecessary and unsafe. There are a variety of new and refined techniques that allow the pain management specialist to individualize the analgesic therapy based on the nature of the surgery, the patient's underlying medical condition and expectations, and the anesthesiologist's training and experience. Several regional anesthesia techniques provide safe and effective analgesia for the ambulatory pediatric patient. The availability of trained pain-management staff members 24 hours a day enables patients to receive safe and effective analgesia by means of epidural catheters or PCA. Both opioid and nonopioid agents may be used as an alternatives or supplements to regional anesthesia techniques. Psychological methods of pain relief for children and adolescents are not as widely used and understood as they might be. Both pleasant imagery and progressive muscle relaxation have been shown to decrease self-reported pain intensity and pain distress. Pain management in children and adolescents seems best addressed with an integrated multidisciplinary approach that begins in the postoperative period or initial acute phase of injury and extends through the patient's convalescence period. Hopefully, this article will enable health care providers to make more educated decisions about analgesic use and, particularly, about the need for opioid narcotics in the pediatric patient. Also, health care providers must be made more aware of the dimensions and safeness of regional anesthesia/analgesic techniques.

Is Fentanyl Appropriate for Postoperative Epidural PCA?

Is Fentanyl Appropriate for Postoperative Epidural PCA?

Is Fentanyl Appropriate for Postoperative Epidural PCA?

Is Fentanyl Appropriate for Postoperative Epidural PCA?

Comparison of Continuous Epidural Bupivacaine Infusion Plus Either Continuous Epidural Infusion or Patient-Controlled Epidural Injection of Fentanyl for Postoperative Analgesia

We compared the postoperative epidural analgesia provided by the continuous epidural infusion of bupivacaine supplemented with patient-controlled injection (PCA) of epidural fentanyl with that provided by a continuous infusion of bupivacaine supplemented with a continuous epidural infusion of fentanyl. Our patient population comprised 16 ASA physical status I or II patients undergoing laparotomy with a midline incision under general anesthesia combined with bupivacaine epidural analgesia. Post-operatively, a continuous epidural infusion of bupivacaine (0.1 mg.kg-1.h-1) was combined with epidural fentanyl given by either (a) PCA (15-micrograms bolus with a lockout interval of 12 min, n = 8) or (b) continuous infusion (1 microgram.kg-1.h-1, n = 8). In the case of inadequate pain relief in the latter group, the fentanyl infusion rate was increased by 10 micrograms/h. Analgesia evaluated by a visual analogue pain score and by a verbal pain score was similarly effective in both groups. The sedation score was also similar in both groups. The total dose of epidural fentanyl administered during the first 24 h was significantly lower in the PCA group than in the continuous infusion group (405 +/- 110 micrograms vs 1600 +/- 245 micrograms, P less than 0.001). The dose of fentanyl given during each 4-h interval ranged between 40 and 160 micrograms in the PCA group and 251 and 292 micrograms in the continuous infusion group. Clinically detectable respiratory depression was not observed in either group. In conclusion, epidural administration of 0.1 mg.kg-1.h-1 bupivacaine combined with fentanyl provides effective postoperative analgesia with a total dose of fentanyl required that is lower when fentanyl is administered by epidural PCA rather than by continuous epidural infusion.

Postcesarean Section Pain Prevention and Relief

Summary In this young and healthy group of patients, exceptional changes have occurred to improve overall maternal and infant outcome. Yet there is still room to improve individual analgesia following cesarean section, improve the satisfaction with the child-bearing experience, and augment the resumption of normal activity. Many recent advances in pain management directly benefit the parturient during labor, during delivery, and after her cesarean section. For pain relief during labor, when compared with local anesthetic alone, patients receiving both local anesthetics and low-dose opiates report a more rapid onset of analgesia, more profound analgesia, longer duration of analgesia, and less motor blockade compared with traditional local anesthetic alone. During and following cesarean section, intraspinal opiates, both epidural and intrathecal, provide superior analgesia with tolerable side effects. PCA devices reliably produce sustained pain control with fewer bothersome side effects and are at least equally satisfactory to patients compared with epidural analgesia. In the future, intravenous PCA may deliver improved labor analgesia with insignificant fetal effects accompanied with improved maternal satisfaction. Epidural PCA may receive wider application in the future, both for labor and postoperative analgesia. New drugs are currently under development. Ongoing investigative efforts aim to anatomically target the action of the drug to specific opiate receptors when administered into the intrathecal and epidural space. The future strives to achieve an intraspinal drug with strong analgesic action without production of neonatal effects, maternal respiratory depression, somnolence, nausea, or tolerance.

Oxyhemoglobin Saturation Following Cesarean Section in Patients Receiving Epidural Morphine, PCA, or IM Meperidine Analgesia

The treatment of postoperative pain with narcotics may be associated with respiratory depression, a concern recently emphasized by the increasing use of new modalities of pain control: PCA and epidural narcotics. This has led to development of special protocols for monitoring respiratory effects of these analgesic approaches. The current study evaluated the potential for problems with three modalities of narcotic pain relief after cesarean section, employing changes in oxyhemoglobin saturation (SpO2) by means of pulse oximetry.

The comparison of continuous epidural fentanyl and PCA morphine for acute postoperative pain relief: Demographic data and side effects

The comparison of continuous epidural fentanyl and PCA morphine for acute postoperative pain relief: Demographic data and side effects