Form Of Analgesia Research Articles

Single‐shot spinal block for labour analgesia in multiparous parturients*

Intrathecal analgesia (ITA) is effective in late, rapidly progressing labour. In 1998, our hospital implemented the use of single-shot spinal block for pain relief in multiparous parturients. As part of a quality assurance programme, we assessed the analgesic efficacy, obstetric and neonatal outcomes and maternal satisfaction after this form of analgesia now in routine use in our labour ward. Two hundred and twenty-nine consecutive multiparous parturients presenting for vaginal delivery and requesting analgesia were asked to participate in this prospective study. All parturients received our standard ITA: 2.5 mg bupivacaine (1 ml) + 25 microg fentanyl (0.5 ml) inserted via the L2-3 or L3-4 interspace. Routine monitoring included maternal vital signs, uterine contraction and fetal heart rate tracing. Pain scores (visual analogue scale (VAS) 0-10), sensory levels, motor block, side-effects and maternal satisfaction were recorded. Satisfactory analgesia was defined as a decrease in pain scores to three or less within 20 min after injection. The number of parturients requesting additional analgesia and the duration of spinal block (time from injection until request for additional medication after satisfactory analgesia had worn off) were recorded. Two hundred and nine parturients were included in the study. Satisfactory analgesia was achieved in 153 (73%) parturients. Fifty-five (26%) women requested additional analgesia: 38 (18%) because of unsatisfactory analgesia and 17 (8%) because analgesia ended before delivery. The duration of spinal block was 101 +/- 34 min. Pruritus occurred in 64%, fetal bradycardia in 7% and hypotension in 2% of deliveries. Pain relief was rated excellent by 65%, moderate by 20% and inadequate by 14% of the parturients. One hundred and sixty-nine (81%) women stated that they would like to have spinal analgesia again for pain relief during delivery. The majority of multiparous parturients found ITA adequate for pain relief during delivery. However, modifications are required in terms of improved timing, reliability and duration of analgesia.

Hand-assisted Thoracoscopic Surgery Causes Less Postoperative Pain than Limited Thoracotomy after Cessation of Epidural Analgesia

Hand-assisted Thoracoscopic Surgery (HATS) is a novel minimally invasive technique for performing procedures conventionally performed by posterolateral thoracotomy. HATS overcomes a major drawback of thoracoscopic surgery in allowing full manual palpation of the lungs via a subcostal (mini-Kocher's) incision under videoscopic guidance, avoiding a thoracotomy, when the indication is pulmonary metastasectomy with curative intent or resection of undiagnosed lung nodules. It is postulated HATS may produce improved postoperative quality of life outcomes compared to thoracotomy. To determine if HATS compared to limited posterolateral thoracotomy causes less postoperative pain after cessation of epidural anaesthesia. Fifty-two patients were prospectively randomised to receive a limited thoracotomy (n=26) or HATS (n=26). Pain scores, measured on a visual analogue scale, were recorded during standard nursing observations and after analgesia demands in the 24h after epidural removal. Pain scores were significantly lower after HATS compared to limited thoracotomy (3.8 versus 5.2, p=0.04). There was no difference in postoperative respiratory function. HATS results in lower postoperative pain after cessation of epidural analgesia. This form of analgesia may therefore not be required, reducing the management complexity, complications and hospital stay associated with its use. SHORT ABSTRACT: Hand-assisted Thoracoscopic Surgery (HATS) is a novel technique allowing full manual lung palpation as an adjunct to Video-assisted Thoracoscopic Surgery (VATS). Fifty-two patients were prospectively randomised to receive limited thoracotomy or HATS. Pain scores were significantly lower after HATS compared to thoracotomy, indicating epidural analgesia may not be required.

Analgesia in labour: inhalational and parenteral

In the USA and Europe, systemic medications are the most commonly used form of analgesia in labour, despite being less efficacious then epidural analgesia. Systemic analgesics are popular because they are readily available, simple to administer and can be used earlier in labour than an epidural or when an epidural is unavailable or contraindicated. The inhalational analgesics considered here are Entonox, isoflurane, desflurane and sevoflurane. Entonox (50% nitrous oxide, 50% oxygen) is the most widely available inhalational analgesic in the UK and is used by 60% of parturients. Isoflurane 0.2–0.25% has been added to Entonox to improve its analgesic efficacy; pain relief scores and patient satisfaction were found to be superior. The parenteral opioids pethidine, morphine, diamorphine, fentanyl and remifentanil are discussed and compared. Pethidine remains the most widely available, used and investigated opioid in labour.

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial

Background context Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated. Purpose To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach. Study design/setting Randomized, double-blinded and controlled clinical trial. Patient sample Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42). Methods Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia. Outcome measures Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted. Results The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization. Conclusions Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial*1

<h2>Abstract</h2><h3>Background context</h3> Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated. <h3>Purpose</h3> To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach. <h3>Study design/setting</h3> Randomized, double-blinded and controlled clinical trial. <h3>Patient sample</h3> Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42). <h3>Methods</h3> Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia. <h3>Outcome measures</h3> Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted. <h3>Results</h3> The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization. <h3>Conclusions</h3> Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.

Survey of epidural analgesia management in general intensive care units in England

The management of epidural analgesia is controversial. Many intensive care unit (ICU) patients may benefit from this form of analgesia but have one or more contraindications to its use. Sepsis, coagulopathy, insertion in a sedated, ventilated patient, and lack of consent are common problems in ICU patients. Little has been published to help guide practice in this area. I wished to establish the current practice of the management of epidural analgesia in general ICUs in England when relative or absolute contraindications occur, in order to determine the current standard of care for placement and use of epidural analgesia in ICU patients. A postal questionnaire survey of the management of epidural analgesia in critically ill patients was sent to the named clinical director of all (216) general ICUs in England. Responses were received from 159 (75%) units: 89% of responding units use epidural analgesia but only 51(32%) have a written policy covering its use. Anesthetists or intensivists with an anesthetic background sited all epidural catheters; 68% of units would not site an epidural in a patient with positive blood cultures; but only 52% considered culture negative sepsis (systemic signs of sepsis with no organism isolated) to be a contraindication. Neither lack of consent nor the need for anticoagulation after the catheter had been sited were considered contraindications to inserting an epidural catheter by the majority of respondents. Although 71% of the units would remove an epidural catheter if a patient developed positive blood cultures after it had been sited, the majority of the ICUs did not consider culture negative sepsis and the need for anticoagulation contraindications to maintain a previously sited epidural. Practice varied considerably with little consensus. Although all the respondents use epidural analgesia in critically ill patients, the indications and contraindications to epidural analgesia remain controversial, and further research is required to help define the role of epidural analgesia in this high-risk group.

Incidence of long term backache was similar between women receiving epidural analgesia during labour and those who did not

(2001) BJOG 108, 27. Howell CJ, Kidd C, Roberts W, et al. . A randomised controlled trial of epidural compared with non-epidural analgesia in labour. . Jan; . : ....

Nitrous oxide in obstetric and gynaecological practice

Nitrous oxide (N2O) has been used for obstetric analgesia for over a century, although there is wide regional variation. In the UK, it remains one of the most commonly used forms of analgesia in labour despite little objective evidence of its efficacy. Most of its side effects are theoretical and transient and this has contributed to its popularity. N2O forms part of the routine general anaesthetic technique for Caesarean section and gynaecological surgery although there are theoretical risks in its usage for the latter. Despite the decline in use of N2O for anaesthesia generally, there appears to be no obvious replacement for N2O analgesia for labour.

Analgesia with femoral nerve block for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction is performed routinely as an outpatient surgical procedure despite few studies of patient acceptance or postoperative patient analgesia. This study reports the first series of postoperative femoral nerve blocks as analgesia for outpatient anterior cruciate ligament reconstruction. The authors retrospectively reviewed 161 patients undergoing two incision arthroscopically assisted autograft middle 1/3 patellar tendon anterior cruciate ligament reconstruction on an out-patient basis at the authors' institution during a period of 30 months. Hospital and anesthesia records were reviewed, and 83% of patients were contacted retrospectively to survey their perceptions of the procedure and its outcome. Ninety-eight percent of the patients were discharged from the ambulatory surgery center, with 51% discharged the same day as the surgery and 47% discharged by 7:00 AM the next day. As the study progressed, the number of patients staying overnight was reduced by 50%. Ninety-eight percent of patients surveyed found femoral nerve block to be beneficial, and the same percentage thought the discharge time was appropriate. However, 69% of patients staying overnight cited reasons other than pain as factors in their stay. No significant complications were reported. Based on these results, the administration of a femoral nerve block is recommended for patients undergoing outpatient anterior cruciate ligament reconstruction because it is a highly effective form of analgesia with an excellent degree of patient satisfaction.

UPDATE ON SOME ASPECTS OF THE USE OF EPIDURAL ANALGESIA IN LABOUR

SUMMARYThe aim of the study was to investigate the effect of epidural analgesia on blood pressure, duration of the second stage and mode of delivery. In a prospective controlled study carried out in a district general hospital, 122 parturients made up the study population; 81 had epidural blocks and 41 had other forms of analgesia during labour. Data were collated using questionnaires within 48 hours of delivery: 58/81 (71.6%) of those who chose epidural were Primigravidae compared with 14/41 (34%) in the non‐epidural group (p&lt;0.001). During labour, minimum diastolic blood pressure was significantly lower in the epidural group: 65.8 versus 72.4 mmHg (p=0.003). Mean duration of the second stage of labour was significantly longer in the epidural group: 108.3 versus 41.6 minutes (p&lt;0.0001); 28/81 (34.6%) of the epidural group had operative vaginal deliveries compared with 6/41 (14.6%) of the non‐epidural group (p=0.0004). Epidural analgesia provides an effective form of pain relief in labour, which has a particularly strong appeal to Primigravidae. It has a hypotensive effect which can be put to beneficial effect in hypertensive disease of pregnancy, but is significantly associated with a lengthened second stage of labour, resulting in an increased operative vaginal delivery rate.

Epidural versus non-epidural analgesia for pain relief in labour.

Epidural analgesia is effective in reducing labour pain, but the possible adverse effects are not clear. The objective of this review was to assess the effects of epidural analgesia on pain relief and adverse effects in labour. The Cochrane Pregnancy and Childbirth Group trials register was searched. Randomised trials comparing epidural analgesia with other forms of analgesia not involving regional blockade, or no intervention. Eligibility and trial quality were assessed by one reviewer. Study authors were contacted for additional information. Eleven studies involving 3157 women were included. Epidural analgesia was associated with greater pain relief than non-epidural methods, but also with longer first and second stages of labour, an increased incidence of fetal malposition, and increased use of oxytocin and instrumental vaginal deliveries. With new trial data included, no statistically significant effect on caesarean section rates could be identified. Epidural analgesia appears to be very effective in reducing pain during labour, although there appear to be some potentially adverse effects. Further research is needed to investigate adverse effects and to evaluate the different techniques used in epidural analgesia.

Hypnosis for pediatric fracture reduction

Hypnosis can diminish pain and anxiety for many emergency patients during examinations and procedures. While hypnosis has been used for millennia and was demonstrated to be of use in clinical medicine more than a century ago, modern physicians have been reluctant to adopt this technique in clinical practice. This article describes four children with angulated forearm fractures who had no possible access to other forms of analgesia during reduction, and in whom hypnosis was used successfully. A simple method for hypnotic induction is described.

Immediate and delayed complications of epidural analgesia in labour and delivery

A prospective controlled, longitudinal study investigated the immediate and delayed complications of epidural analgesia in labour. One hundred and twenty-two parturients were studied: 81 had epidurals in labour and 41 had other forms of analgesia. Each parturient was studied over a period of 6 weeks. Epidural analgesia in labour and delivery is generally safe. Although the epidural group recorded more complications, they tended to be minor ones such as backache, headaches, shoulder and neck pain. Epidural blocks have an added advantage of being helpful in complicated labours like breech presentations, multiple pregnancies, pre-eclampsia, in situations where caesarean section is anticipated and in manual removal of the placenta.

Modulation of endomorphin-2-induced analgesia by dipeptidyl peptidase IV

The tetrapeptide, endomorphin-2 (Tyr-Pro-Phe-PheNH 2) possesses high affinity for μ opioid receptors, and produces potent analgesia in mice. Its structure appears to satisfy the substrate requirements of the proteinase, dipeptidyl peptidase IV which removes dipeptides from the amino terminus of peptides containing proline as the penultimate amino acid. A potent, stable and specific inhibitor of this enzyme, Ala-Pyrrolidonyl-2-nitrile, has been described which should potentiate endomorphin-2-induced analgesia. Further, since dipeptidyl peptidase IV has an absolute requirement for l-Pro, a more metabolically-stable d-Pro 2-endomorphin-2 analog should produce longer analgesic actions at lower doses. The present study found that endomorphin-2 was degraded approximately twice as fast than the chromogenic substrate, Ala-Pro-2naphthylamide, by dipeptidyl peptidase IV, whereas d-Pro 2-endomorphin-2 was totally resistant to this enzyme's action. d-Pro 2-endomorphin-2 (ED 50=0.05 μg) was more potent than endomorphin-2 (ED 50=30 μg) in significantly increasing tail-flick latencies with longer durations of action. Both the peptide and analogue were equipotent (ED 50=0.5 μg) in significantly increasing jump thresholds. Ala-Pyrrolidonyl-2-nitrile (10–75 nmol) elicited a dose-dependent analgesia, and potentiated the analgesic actions of endomorphin-2, particularly on the tail-flick test. Whereas systemic naltrexone (2.5, 10 mg/kg) dose-dependently eliminated each of the three forms of analgesia on the jump test as well as the peak (15 min) effect on the tail-flick test, analgesia elicited by either endomorphin-2, d-Pro 2-endomorphin-2 or Ala-Pyrrolidonyl-2-nitrile returned after 30–60 min in naltrexone-treated rats on the tail-flick test. These data strongly suggest that dipeptidyl peptidase IV plays a role in the inactivation of endomorphin-2 in vivo, and thereby modulates its central analgesic actions.

History of Tumescent Anesthesia, Part I: From American Surgical Textbooks of the 1920s and 1930s

The current technique of “tumescent anesthesia,” popularized by Dr. Jeffrey A. Klein, has evolved from the developments of local anesthetic agents and various infusion devices over the last 110 years. “Tumescent anesthesia” is really a variation of a much older technique known as “massive infiltration” or “hard infiltration.” By 1915 “massive infiltration analgesia with weak analgesic solutions” was a well-developed and widely used form of analgesia. Various pressurized or motorized devices for the propulsion of the solutions, flexible needles, multiple formulas, and many applications of the technique were described and illustrated in several standard American surgical textbooks of the 1920s and 1930s. The goal was to render a large field anesthetic and relatively bloodless by use of only regionally injected solutions. In our current era, Dr. Ed Hamacher et al. and Dr. Klein deserve credit for reintroducing this old technique and for establishing new parameters for lidocaine toxicity. It is important for us to remember that the current technique of “tumescent anesthesia” really evolved over the last 110 years as the synthesis of the ideas of many individuals throughout the world.

Outcome Analysis of the Modified Mathieu Hypospadias Repair: Comparison of Stented and Unstented Repairs

Purpose We compared surgical outcomes of stented and unstented Mathieu repairs in boys with primary distal hypospadias, and evaluated the efficacy and safety of caudal analgesia relative to other forms of analgesia (penile block and epidural analgesia). Materials and Methods We retrospectively reviewed the records of 336 consecutive boys who underwent the modified Mathieu repair for primary distal hypospadias. A urethral stent was placed in 114 patients and nonstented repair was performed in 222. Adjunct caudal analgesia was given in 136 cases, a penile block in 158 and continuous epidural analgesia in 42. Results None of the unstented cases had urinary retention. Analysis of surgical outcomes revealed no difference in fistula formation between patients with and without stents (2.63 versus 2.70 percent, respectively, p greater than 0.999). Overall complication rates in the stented and unstented groups were not significantly different (2.63 versus 3.60 percent, respectively, p = 0.756). The fistula rate in patients who received adjunct caudal analgesia was no different than in those who received other forms of adjunct analgesia (2.21 versus 3.0 percent, respectively, p greater than 0.999). Conclusions These data suggest that successful Mathieu hypospadias repair is independent of the use of a stent. Caudal analgesia, a penile block and epidural analgesia provided effective postoperative pain control with no difference in complication rates. To our knowledge our report represents the largest observational study reported to date comparing stented and unstented repairs. However, because of the small number of complications in each group, a much larger study is required to determine statistically significant differences among these groups.

Water immersion and water birth

Water immersion in the first stage of labour in an uncomplicated pregnancy would appear to be safe, providing there are no signs of fetal compromise and the water temperature is not allowed to rise above 37° C. It is possible that it may reduce the need for other forms of analgesia, but this has yet to be proved by a randomised trial. Claims have been made for a more rapid progress in labour, but there is no good evidence for this. No study has demonstrated any benefit to the fetus for underwater birth, and on rare occasions it could lead to serious complications, such as fresh water drowning or neonatal sepsis and add to difficulties in obstetric emergencies such as shoulder dystocia.

Obstetrical anaesthesia in Ontario

The purpose of this study was to determine the availability of regional anaesthesia for Caesarean section, of epidural opioids and patient-controlled analgesia after Caesarean section, and of epidural and other forms of analgesia in labour. A mail survey was sent to the "Head Nurse, Department of Obstetrics" at each of the 142 hospitals in Ontario with designated obstetric beds. Responses were obtained from 100% of hospitals. For Caesarean Section, general anaesthesia was used in all hospitals, and was the only option in seven. Epidural anaesthesia was used in 93% of hospitals, and spinal anaesthesia in 48%. Postoperatively, patient-controlled analgesia was used in 31% of hospitals and spinal opioids in 28%. In 66 hospitals, im or iv opioids were the only types of analgesia available. For analgesia in labour, im or iv opioids were used in 96% of hospitals, nitrous oxide was used in 75%, epidural analgesia in 75%, transcutaneous electrical nerve stimulation in 52% and patient-controlled analgesia in 10%. The overall epidural rate was 38%. Although the average rate in the 73 hospitals with fewer than 500 births per year was only 6%, 14 large hospitals had an epidural rate of 60% or higher. It is concluded that regional techniques for peripartum analgesia have been widely accepted. Analgesia after Caesarean section could be improved. Epidural analgesia should be more widely available, especially in the many small hospitals in Ontario.

A survey of current obstetric anaesthesia practice in Switzerland

INTRODUCTION The practice of obstetric anaesthesia and analgesia has been surveyed nationally and regionally in parts of Canada] ,2 the USA, 3 the UK 4 and various constituent parts, s-7 Sweden, 8,9 Finland 1° and Western Australia.ll The main purpose of our investigation was to obtain information regarding the availability and organization of epidural services in obstetric units throughout Switzerland. Institutional guidelines, per- sonnel resources and professional groups involved in providing epidural analgesia as well as other forms of analgesia were also recorded. METHODS In the summer of 1992, a confidential questionnaire (see Appendix) was sent to all university, public and private hospitals listed in the

Blood pressure changes during labour and whilst ambulating with combined spinal epidural analgesia

To determine the influence of combined spinal epidural analgesia with fentanyl and low dose bupivacaine on maternal blood pressure and pulse rate in labour. Also, to evaluate the maternal cardiovascular response to mobilising with this form of analgesia in labour. Finally, to define the changes that occur in blood pressure and pulse rate during the second stage of labour and immediately postpartum when using combined spinal epidural analgesia. A prospective observational study. Blood pressure and pulse measurements were made at least every 10 minutes, using the SpaceLabs 90207 ambulatory blood pressure monitor, on 62 women in labour with combined spinal epidural analgesia. A significant fall in systolic blood pressure (> 20%) occurred in eight women (12%), all within 30 minutes of the spinal injection. Fifty-two women subsequently received an epidural dose (mean interval 90 minutes after spinal) and none of these women had a fall in systolic blood pressure of greater than 20%. No women had symptoms related to hypotension. Thirty-five women ambulated for more than 10 minutes on 65 occasions. Average blood pressure remained unchanged while ambulating (126/79 versus 126/79), but pulse rate was significantly increased (85 to 90, P < or = 0.001). The mean blood pressure in the second stage of labour (n = 41) did not rise with pushing (134/83 versus 134/83), but the pulse rate increased significantly (94 to 108, P < or = 0.001). Blood pressure remained unchanged immediately postpartum (n = 33) (134/83 versus 134/81) following ergometrine administration. The combined spinal epidural analgesia will only result in significant falls in systolic blood pressure within 30 minutes of the spinal injection. No further important changes in blood pressure occur when mobilising or with epidural top-ups. The combined spinal epidural analgesia may modify the normal compensatory mechanisms of blood pressure control, but does not cause significant maternal hypotension once the spinal injection has been given.