Μg Sufentanil Research Articles

Use of Dexmedetomidine as an Adjunct to Pain Control Following OPCAB: A Randomized, Double-Blind Study

Use of Dexmedetomidine as an Adjunct to Pain Control Following OPCAB: A Randomized, Double-Blind Study Jeffrey L. Horswell MD, Michael J. Mack MD, Donna A Bachand RN PhD, Luis Michelsen MD, Tina Worley RN BSN CCRC Objectives: The purpose of this study was to determine whether use of dexmedetomidine leads to improved clinical outcomes in immediately extubated, post-operative off-pump coronary artery bypass (OPCAB) patients. Patients and Methods: 24 patients scheduled for elective OPCAB consented to participate in the study. Patients who were previously selected for epidural analgesia or who had elevated serum creatinine levels were excluded. Fifteen minutes prior to extubation, patients were prospectively randomized in a double-blind fashion into one of two groups: Group 1 (n=12) received an 18 hour infusion of dexmedetomidine 0.2 to 0.7 μg/kg/hr. Group 2 (n=12) received an 18 hour infusion of normal saline. All patients received a standard anesthetic consisting of propofol, sufentanil, vecuronim, and desflurane. Post-operative pain was managed with ketorolac and morphine. Total morphine use was recorded. Hemodynamic monitoring, incentive spirometry volumes, visual analog scale pain ratings, activity, and anxiety levels were recorded every 2 hours for 18 hours post-operatively. Results are reported as mean ± standard deviation. Student’s t-test was used to test the difference in means between the two groups. Paired t-tests were used to evaluate changes across time intervals. Results: Mean narcotic use was 2.1 times greater in the placebo group (23.5 ± 20.7 mg) compared to the treatment group (11.4 ± 6.3 mg; p=.03). Time to achieving adequate pain control (VAS rating <35) was more rapid in the treatment group (6 hours vs. 8 hours). Although morphine doses were available on demand to all patients, those in the treatment group reported less pain at all time points. Patients in the treatment group were out of bed earlier (564 ± 361 vs. 292 ± 89 minutes; p=.03). There were no significant changes in heart rate, blood pressure, pulmonary artery pressure, central venous pressure, cardiac output, or systemic oxygen saturation in either group. When hemodynamic data were analyzed by subject, no significant changes could be detected. Conclusion: Dexmedetomidine provides effective post-operative pain control without untoward hemodynamic changes in immediately extubated OPCAB patients. Superior pain control can be achieved with minimal doses of narcotics. Objectives Determine whether use of dexmedetomidine leads to improved clinical outcomes in immediately extubated, post-operative off-pump coronary artery bypass (OPCAB) patients Patients and Methods • 24 patients were prospectively randomized in a double-blind fashion and scheduled for elective/urgent OPCAB. • All caregivers were blinded to treatment arm. • Patients who were previously selected for epidural analgesia or who had elevated serum creatinine levels were excluded. • Fifteen minutes prior to extubation, patients were randomly selected for one of two groups: • Group 1 (n=12) received an 18 hour infusion of dexmedetomidine 0.2 to 0.7 μg/kg/hr • Group 2 (n=12) received an 18 hour infusion of normal saline. • All patients received a standard anesthetic. Induction Maintenance Sufentanil 15-20 μg Sufentanil 10-15 μg/hr Propofol 50-100 mg Desflurane titrated to a BIS of 50-60 Vecuronium 0.1 mg/kg Vecuronium titrated to 1/4 twitch • All patients were extubated in the operating room. • For post-operative pain management, patients received ketorolac 30 mg followed by 15 mg IV every 6 hours for 6 doses. 15 minutes prior to extubation, the study infusion was begun at a dosage of 0.5 μg/kg/hr. • The study drug was adjusted within the range of 0.2 to 0.7 μg/kg/hr to achieve a visual analog scale (VAS) value < 40 on a 100 mm scale. Breakthrough pain was treated with morphine 2 mg every 5 minutes until the VAS was < 40. • Clinical monitoring recorded every 2 hours for 18 hours post-operatively • Hemodynamic values • Incentive spirometry volumes • Visual analog scale pain ratings • Activity and anxiety levels. • Results are reported as mean ± standard deviation. Student’s t-test was used to test the difference in means between the two groups. Paired t-tests were used to evaluate changes across time intervals. Results • Mean narcotic use was 2.1 times greater in the placebo group (23.5 ± 20.7 mg) compared to the treatment group (11.4 ± 6.3 mg; p=0.03) Graph 1 No difference in preoperative risk factors by treatment group

Combined spinal-epidural analgesia for labor

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

Systemic Anaphylaxis Associated with Intramammary Isosulfan Blue Injection Used for Sentinel Node Detection under General Anesthesia

IDENTIFICATION of the sentinel lymph node, a marker for metastatic disease, is used increasingly for the surgical management of melanomas and tumors of the head and neck, breast, thyroid, and genitourinary and gastrointestinal tracts. 1 Isosulfan blue (Lymphazurin; Ben Venue Laboratories, Bedford, OH) is the agent most commonly used, occasionally in conjunction with technetium sulfur colloid. Allergic reactions to this dye were reported previously during lymphangiography. 2,3 We report a systemic reaction associated with use of isosulfan blue for detection of the axillary sentinel node in breast cancer.

Acute pain management: analysis, implications and consequences after prospective experience with 6349 surgical patients

An acute pain service (APS) was set up to improve pain management after operation. We attempted to reduce the length of stay in the intensive care unit (ICU) of patients undergoing major surgery and to improve their homeostasis and rehabilitation using a multimodal approach (pain relief, stress reduction, early extubation). Patient-controlled epidural analgesia (PCEA) was a keystone of this approach. If PCEA was not applicable, patients received patient-controlled intravenous analgesia (PCIA) instead. Brachial plexus blockade (BPB) was used for surgery of the upper limbs. A computer based documentation system was used to help evaluate prospectively (a) the quality of analgesia, (b) adverse effects and risks of the special pain management techniques, and (c) cost-effectiveness. Patients receiving PCEA (n=5.602) received a patient-titrated continuous infusion into the epidural space of either bupivacaine 0.175% or ropivacaine 0.2%, with 1 μg sufentanil mL−1 added, followed by patient-controlled boluses of 2 mL (lockout time 20 min). For patients receiving PCIA (n=634) an initial bolus of 7.5-15 mg piritramide was given, and the subsequent bolus was 2 mg (lockout time 10 min). A continuous infusion of bupivacaine 0.25% was administered to patients receiving BPB (n = 113). The dose was titrated to a dynamic visual analogue scale (VAS) scores < 40. The mean treatment periods were: BPB = 4.33 days, PCEA = 5.6 days, PCIA = 5.0 days. In the case of PCEA, the quality of pain relief, vigilance and satisfaction were superior compared with the PCIA method, which resulted in greater sedation and nausea. Although personal supervision was higher for the PCEA-treated patients, cost analysis revealed final savings of €91 620 for the year 1998 obviating the need for an ICU stay totalling 433 days. Provided that PCEA is part of a fast-track protocol employing early tracheal extubation and optimal perioperative management, the associated initial higher costs will be recouped by the benefits to patients of better pain relief after surgery and fewer days subsequently spent in the ITU.

A comparison of three doses of sufentanil in combination with bupivacaine-adrenaline in continuous epidural analgesia during labour

Sufentanil is now frequently added to local anaesthetic in labour epidural analgesia. However, this opioid has some side effects such as pruritus, and in higher doses could harm the neonate. The purpose of this study was to compare three doses of sufentanil combined with low-dose bupivacaine, to determine the lowest appropriate dose. In a prospective, randomized, double-blind study, 243 parturients were randomized, to receive A--0.5 microg/ml, or B--0.75 microg/ml or C--1 microg/ml sufentanil, in addition to bupivacaine 0.625 mg/ml+adrenaline 1.25 microg/ml. All were given an 8 ml bolus of the study solution, followed by continuous infusion at 6 ml/h. The analgetic effect was scored on a visual analogue scale (VAS). Onset quality was measured as VAS after 20 min, the total effect as VAS maximum during the first stage of labour. Overall maternal satisfaction was recorded within two hours post partum. Side effects were noted. There were no differences between groups in VAS assessments after 20 min or in maximum registered VAS. In group A, 83% had VAS 0-4 after 20 min, in group B 77% and in group C 71%. Maximum VAS during the first stage was 0-4 for 60% of group A, 68% of group B and 61% of group C. Maternal satisfaction was also the same in the three groups. In group A, 70% reported excellent effect and 22% good effect. The corresponding figures in group B were 68% and 24% respectively, and in group C 62% and 24% respectively. Group A received a mean total dose of 21 microg sufentanil, group B 30 microg and group C 44 microg. Pruritus occurred in 51% of group A, 53% of group B and 65% of group C. We found no difference in the analgesic effect between three different concentrations of sufentanil. We conclude that the lowest dose may be used. This should decrease the risk of adverse effects on mother and child.

Speed of onset of analgesia in labour and maternal satisfaction: comparison of epidural and combined spinal-epidural

I read with great interest the study by Nickells et al. (Nickells et al. Anaesthesia 2000; 55: 17–20) that compared the speed of onset of analgesia of combined spinal epidural (CSE) with epidural alone (using a mixture of low-dose local anaesthetic and opioid). They also examined the incidence of side-effects of these techniques compatible with the concept of ‘walking epidural analgesia’ or ‘analgesia with minimal motor blockade’ that are thought not to adversely affect obstetric outcome. The end point was the occurrence of the first ‘comfortable contraction’, which reflects most women's wishes, but the onset time began only after the injection of the anaesthetic mixture through the epidural catheter or the spinal needle, as in other similar studies. We presume that what is really meaningful for women is the time lapse from their request to efficient analgesia. The complexity of CSE increases the time to perform the technique (needle through needle in this case), which would tend to reduce or reverse the small difference of 2 min found in this study in favour of CSE. Another cause for delay could be the recommendation to wear a sterile gown above all for the CSE technique [1]. Furthermore, there is no classical lidocaine–epinephrine ‘test dose’ of the catheter in this study. The value of this test is highly debated in low-dose epidural local analgesia with opioid or CSE [2, 3]. Consequently I propose to return to the original technique for peridural anaesthesia for surgery; that is to first inject an anaesthetic mixture through the Tuohy needle before the sometimes problematic placement of the catheter. I formerly reserved this method for painful labour, agitation or cervical dilatation greater than 6 cm, but now I use it more often. When the Tuohy needle is in the epidural space, the parturient is informed that she may experience slight lumbar discomfort during the first injection (in more than half the cases). Then 15–20 ml of bupivacaine 0.1% + 7.5–10 µg sufentanil are injected in 2–3 increments with intermittent aspiration (total dose depending of the case). Afterwards, the catheter is threaded into the epidural space, aspirated and secured in the conventional manner, while analgesia sets in. During this ‘first dose’, heart rate and blood pressure are monitored and parturients are questioned regarding symptoms of dizziness and altered sensation in the legs. This first injection always hastens the onset of analgesia, especially when, far from rarely, the epidural catheter is difficult to insert. This injection also facilitates introduction of the catheter and reduces the risks of venous cannulation [4], especially when using a soft catheter [5]. I have observed that this injection practically suppresses pain and movement that may occur during manipulation of catheters, and eliminating some inadvertent dural taps. The idea of examining this technique locally in a comparative prospective study (with a start time beginning when the anaesthetist enters the delivery suite) has been postponed because of other priorities. Personally, I am surprised by the ‘success story’ of CSE, where the bacteriological risk is real, just to try to gain a few seconds or minutes of quicker onset of analgesia compared with several hours of pain. Finally, in a recent prospective study the authors found that CSE ‘performed no better than equivalent epidural technique based on the views of the labouring women’[6] even with a first peridural injection through the catheter.

A Comparison of Intrathecal Analgesia with Fentanyl or Sufentanil After Total Hip Replacement

We designed this study to compare the postoperative analgesic effects of intrathecal fentanyl and sufentanil, the end points being onset, quality, and duration of action. A total of 42 geriatric patients, scheduled for elective total hip replacement under continuous spinal anesthesia, were randomized in two double-blinded groups as soon as they experienced a pain score higher than 3 of 10 on the visual analog scale in the recovery room. Either 7.5 μg sufentanil or 40 μg fentanyl in 2 mL normal saline were intrathecally administered. Pain scores, rescue analgesia (ketorolac and morphine), and adverse effects (respiratory depression, postoperative nausea and vomiting, and itching) were recorded for 24 h after surgery. In both groups, comparing sufentanil to fentanyl, the time to a pain score <3 (9 ± 9 vs 11 ± 8 min), the time to the lowest pain score (18 ± 6 vs 20 ± 15 min), and the time to the first systemic analgesic intervention for a pain score >3 (241 ± 102 vs 214 ± 120 min) were comparable as were the analgesic requirements during the first 24 h. We conclude that, after total hip replacement, both lipid soluble opioids produce excellent analgesia with comparable onset, duration of action, and low incidence of minor adverse effects. Implications: We compared the postoperative analgesic properties of 40 μg intrathecal fentanyl and 7.5 μg sufentanil after total hip replacement. Both opioids provided satisfactory analgesia, with comparable onset (11 ± 8 vs 9 ± 9 min) and duration of action (214 ± 120 vs 241 ± 102 min), as well as low incidence of minor side effects.

“Walking” Epidural Anesthesia: Are Test Doses Necessary? Cohen et al. (page 387)

Although the actual benefits of walking during labor are unproven, many women express the desire to walk during labor. Combined spinal–epidural analgesia performed with intrathecal opioids has gained acceptance in this application because it causes minimal motor block. Cohen et al. designed a randomized, double-blind study to evaluate analgesic effectiveness and ability to walk after receiving a bolus of either 0.0625% bupivacaine or 0.125% bupivacaine (with sufentanil), with or without previous administration of the traditional lidocaine–epinephrine test dose.Sixty healthy women in active labor, all of whom requested epidural analgesia and who expressed a desire to walk during labor, participated in the study. Visual analog pain scores were 3 or more, and cervical dilation was between 1 and 6 cm for participants. All subjects received a 3-ml epidural injection (a 1.5% lidocaine–epinephrine test dose or bupivacaine) and 3 min later, 12 ml bupivacaine with 10 μg sufentanil injected in two increments 3 min apart. Maternal blood pressure and visual analog pain scores were recorded before study drug administration and after completion of the bolus injections at 5, 10, 15, 20, 30, and 60 min, and then hourly for 4 h until delivery. Data relating to ambulation, balance, proprioception, and motor block were collected at baseline, 30 min, 1 h, and then hourly until delivery. Ability to walk with little or minimal assistance across the room was rated as either “yes” or “no.” Women who walked spent approximately 5–10 min out of bed and usually attempted to void, and then were reassessed for balance, among others.A high percentage of women in all groups (75–93%) walked at some stage during labor. The group receiving the bolus of 0.125% bupivacaine with sufentanil, without a previous test dose, experienced the best analgesia and walked earlier than women in all other groups. Fewer women walked within 1 h of block placement when they received a test dose before 0.125% bupivacaine. With or without a test dose, 0.0625% bupivacaine with sufentanil provided inadequate analgesia. Women in the two latter groups required additional bupivacaine, which in turn impaired their ability to walk. The authors suggest that, based on these results, walking during the early postblock period would be possible by omitting the lidocaine–epinephrine test dose and using 0.125% bupivacaine for the initial bolus.

Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.

SPINAL anesthesia is commonly used for cesarean section, and it has become a popular practice to add opioids to spinal solutions to enhance and prolong intraoperative and postoperative analgesia. Morphine and fentanyl are the opioids most often used for this purpose, but there is not a general consensus about the benefits of the various regimens, and the incidence of side effects with different opioids and doses is controversial. Recently, a number of systematic reviews have been published in the field of pain and perioperative medicine. The aim of a systematic review is to summarize available information from controlled clinical trials to produce evidence-based estimates of the true clinical effect of an intervention. The purpose of this systematic review was to investigate the effect of intrathecal opioids added to spinal anesthesia on intraoperative and postoperative pain and to evaluate adverse effects in patients scheduled for cesarean section, using evidence from all relevant randomized controlled and blinded trials.

Two Doses of Intrathecal Sufentanil (2.5 and 5 μg) Combined with Bupivacaine and Epinephrine for Labor Analgesia

In this study, we evaluated the effect of two doses of intrathecal sufentanil combined with bupivacaine and epinephrine on the incidence of pruritus and on the duration and quality of analgesia. One hundred five parturients were enrolled in this randomized, double-blinded, placebo-controlled study. They received either intrathecal 1.25 mg bupivacaine and 25 μg epinephrine (control group); 1.25 mg bupivacaine, 25 μg epinephrine, and 2.5 μg sufentanil (2.5-μg group); or 1.25 mg bupivacaine, 25 μg epinephrine, and 5 μg (5-μg group). Pain relief was assessed 10 min after injection, and pruritus was recorded at 30 min by a blinded observer. The study ended when the parturients requested further analgesia. There were no demographic differences among groups. Ninety of 103 parturients achieved complete pain relief with the initial dose, 11 patients in the control group (P < 0.004, control versus both sufentanil groups), and 2 patients in the 2.5-μg group needed a supplemental epidural bupivacaine. Pruritus was absent in the control group (P < 0.0001, control versus both sufentanil groups), whereas it was present in 36% of the 2.5-μg group and in 66% of the 5-μg group (P = 0.015, 2.5-μg versus 5-μg group). The mean duration of analgesia was similar in patients receiving sufentanil (2.5-μg group: 133 ± 55 min; 5-μg group: 142 ± 52 min) but was significantly higher than the control group (56 ± 32 min). Reducing the sufentanil dose from 5 μg to 2.5 μg when combined with bupivacaine and epinephrine, decreases the incidence of pruritus without impeding the quality or duration of analgesia. Implications We evaluated two different doses of intrathecal sufentanil combined with bupivacaine and epinephrine for labor analgesia. Sufentanil 2.5 μg offered an advantage over sufentanil 5 μg because, while providing the same quality and duration of analgesia, it was associated with a reduced incidence of pruritus.

Refractory Hypotension After Induction of Anesthesia in a Patient Chronically Treated with Angiotensin Receptor Antagonists

Refractory Hypotension After Induction of Anesthesia in a Patient Chronically Treated with Angiotensin Receptor Antagonists

Clonidine added to bupivacaine-epinephrine-sufentanil improves epidural analgesia during childbirth

Background and Objectives. A double-blind study was conducted to assess the efficacy and the side effects of a low dose of clonidine added to an epidural injection of bupivacaine and epinephrine, with or without sufentanil. Methods. One hundred healthy parturients (ASA 1) were randomly allocated into four groups according to the type of epidural analgesia administered. The bupivacaine/epinephrine (BE) group received a 10-mL standard injection of bupivacaine (B) 1.25 mg/mL and epinephrine (E) 1.25 μg/mL. In the bupivacaine/epinephrine/sufentanil (BES) group, 7.5 μg sufentanil (S) was added to the BE mixture. For the bupivacaine/epinephrine/clonidine (BEC) group, 50 μg clonidine (C) was added to the BE mixture, whereas for the bupivacaine/epinephrine/sufentanil/clonidine (BESC) group, both sufentanil and clonidine were added to BE. Fetal heart rate was monitored by continuous cardiotocography. Duration of analgesia, method of delivery, and neonatal outcome (measured using APGAR score, peripheral oxygen saturation, and neurologic adaptive capacity score) and side effects of clonidine were observed. The parturients were routinely asked for their global appreciation of the epidural analgesia technique by visual analog score, 2 hours postpartum. Results. The overall quality and duration of analgesia were superior in the BESC group compared with the other groups, as was the global appreciation by the parturient. The frequency of side effects in the clonidine groups was comparable, with the exception of hypotension and sedation. Hypotension was easily treated by fluids or ephedrine and caused no fetal distress. The level of sedation was mild, and all parturients aroused immediately after verbal commands. Conclusion. The addition of a low dose of clonidine to an epidural injection of bupivacaine with epinephrine and sufentanil provides better analgesia during labor, while keeping the side effects minimal and of minor clinical importance.

Intrathecal sufentanil (5 vs. 10 μg) for labor analgesia: Efficacy and side effects

Background and Objectives. Despite growing popularity, there are few studies examining the relative efficacy of different doses of intrathecal sufentanil for labor analgesia. This prospective, randomized, double-blind study compared the efficacy and side effects of 5 and 10 μg intrathecal sufentanil. Methods. Sixty-three healthy, laboring, term parturients ≤ 5 cm cervical dilation participated in this study. In a randomized, double-blind fashion, patients received 5 or 10 μg intrathecal sufentanil as part of a combined spinal epidural technique. Patients rated pain, itching, nausea, and sedation on verbal analog scales before and every 10 minutes after drug injection. We also recorded maternal blood pressure and peripheral oxygen saturation before and every 10 minutes after drug injection. Before and 30 and 60 minutes after drug injection, we measured maternal end-tidal CO 2. Results. Both doses of sufentanil provided adequate analgesia. Although 10 μg sufentanil produced slightly more profound analgesia, the duration of pain relief did not differ between the two groups. Both drug doses were associated with significant increases in itching and end-tidal CO 2. The 10-μg dose was associated with more sedation and a greater decrease in SaO 2. Conclusions. Both 5 and 10 μg intrathecal sufentanil provided adequate labor analgesia. Both doses were associated with measurable spinal (itching) and supraspinal (sedation, respiratory depression) side effects.

Spinal Anaesthesia with 0.25% Hyperbaric Bupivacaine for Cesarean Section

Comment: This carefully done study demonstrates that adequate analgesia for cesarean section can be obtained from hyperbaric 0.25% bupivacaine when doses of 10 mg or more of the drug are injected in volumes of ≥4 mL. In general, other studies using hyperbaric solutions of either 0.5% or 0.75% bupivacaine have found a minimum of 10 mg and, ideally, higher milligram doses of subarachnoid bupivacaine are required for adequate analgesia. From the data of this study, it would appear that the increased volume of doses greater than 10 mg of 0.25% bupivacaine result in very high cervical sensory levels and a higher incidence of more severe maternal hypotension. Hence, I can see absolutely no reason to use 0.25% hyperbaric bupivacaine over 0.5% or 0.75% hyperbaric bupivacaine. Our experience is that 0.75% bupivacaine in 8.25% dextrose, 15 mg (2 mL) given in the sitting position or 12.5 mg (1.7 mL) given in the lateral position, reliably results in a T2 sensory level in the average Caucasian woman who is ≥162 cm in height. It appears that the lower volume of this more concentrated solution enables a dense block, and its upper level is more controllable.1 The authors commented that their higher doses of local anesthetic resulted in more hypotension, a 70% vs. 40% incidence. Because this hypotension can be effectively treated, I consider this a lesser problem when one considers 14 (70%) patients in group 1 had pain, 4 (20%) of whom required general anesthesia compared with only 2 (10%) patients in group 3, neither of whom required general anesthesia. In addition, the objective of good or excellent analgesia was achieved in only 6 (30%) patients of group 1 compared with 15 (75%) and 18 (90%) in groups 2 and 3, respectively. Cesareans, as they are performed today using a low transverse cervical incision, require marked abdominal retraction before birth. After birth, most obstetricians exteriorize the uterus from the abdominal cavity for repair. These maneuvers require a high (≥T4), solid block if considerable maternal discomfort from visceral pain is to be avoided. With a high concentration (0.5–0.75%) of hyperbaric bupivacaine, perhaps, the addition of 25 μg of fentanyl or 7.5 μg of sufentanil appears indicated.

Severe Maternal Hypotension and Fetal Bradycardia after a Combined Spinal Epidural Anesthetic

INTRATHECAL sufentanil alone or combined with bupivacaine is commonly administered via a combined spinal epidural (CSE) technique to provide analgesia for patients in labor. Although side effects of these agents have been reported, there is debate about whether spinal sufentanil used alone or with bupivacaine is associated with clinically significant hypotension. 1-6 We describe a case of severe maternal hypotension with associated fetal bradycardia after the intrathecal administration of 7.5 μg sufentanil and 2.5 mg bupivacaine.

Post-partum urinary retention: a comparison between two methods of epidural analgesia

Objective: To compare two methods of epidural labor analgesia regarding the incidence of post-partum urinary retention. Study design: One thousand parturients who requested epidural analgesia for the relief of labor pain received, at random, either bupivacaine 0.25% with adrenaline 1:200 000 ( n = 500) or bupivacaine 0.125% with 10 μg sufentanil ( n = 500). During the same observation period all women with clinically significant urinary retention (> 500 ml, requiring indwelling catheter) were registered. Result: Altogether 30 3.364 parturients had clinically significant urinary retention. Twenty-seven of these had received epidural analgesia (EDA) (17 with bupivacaine/adrenaline and ten with bupivacaine/sufentanil, a non-significant differences). The number of parturients with urinary retention was highly increased following EDA ( 27 1000 ) as compared to those not receiving EDA ( 3 2364 ), P < 0.001 (Fisher's exact test). In patients with EDA and urinary retention there were no difference between the groups in the incidence of instrumental deliveries or vaginal/perirectal tears. All parturients regained normal bladder function. Conclusion: EDA significantly increased the risk of post-partum urinary retention but no difference was found between the two epidural techniques.

A Randomized Double-Blind Comparison of Epidural Sufentanil Versus Intravenous Sufentanil or Epidural Fentanyl Analgesia After Major Abdominal Surgery

This randomized double-blind study compared epidural sufentanil (SEPI) with intravenous sufentanil (SIV) or epidural fentanyl (FEPI) analgesia in 45 patients after major abdominal operations. On first complaint of severe postoperative pain, SIV patients were given a 15-μg bolus and then a 5 μg/h infusion of sufentanil intravenously. SEPI patients were given the same bolus and infusion, but epidurally. FEPI patients had a 60-μg bolus and 20 μg/h infusion of fentanyl epidurally. All patients also received a bolus injection and then an infusion of coded saline via the alternate route. Analgesic requirements were tailored continuously to individual needs by patient-controlled supplementary boluses of 3.1 μg of sufentanil or 12.5 μg of fentanyl, or by 50% reduction in opiate infusion rate at predetermined intervals. Pain scores, circulatory variables, and respiratory rate did not differ between groups. Mean opiate dose requirements (±SD) to maintain analgesia for 24 h were 202 ± 43 μg (SIV), 149 ± 45 μg (SEPI), and 627 ± 226 μg (FEPI). The relative analgesic potencies (AP) calculated from the equianalgesic dose requirement ratios were 1.4 for AP-sufentanilIV/EPI and 4.2 for AP-epiduralF/S. SIV patients required more supplementary boluses than SEPI patients, were more sedated during the entire treatment, and had higher PaCO2 and higher serum sufentanil concentrations within the first 3 h of treatment. In addition, severe respiratory depression occurred in four SIV patients soon after the start of treatment, despite serum sufentanil concentrations of less than 0.3 ng/mL. Although the two epidural groups required a similar number of supplementary boluses and had similar blood-gas results and equivalent serum concentrations, sedation was slightly more intense with sufentanil than with fentanyl. The authors conclude that although SIV and SEPI are almost equipotent, IV administration of an equipotent initial dose is hazardous because of the risk of respiratory depression. The higher degree of sedation observed with SIV during the entire treatment may be a point in favor of epidural administration. The equianalgesic dose of epidural sufentanil was found to be approximately four times less than the epidural fentanyl dose in pain treatment after abdominal operations. (Anesth Analg 1993;76:1243-50)

Spinal sufentanil in rats: part II: effect of adding bupivacaine to epidural sufentanil

Male Wistar rats were injected epidurally with various doses of sufentanil, bupivacaine or sufentanil combined with bupivacaine either 40 or 80 micrograms. Addition of 80 micrograms bupivacaine to sufentanil produced a 2.2- to 3-fold decrease of the lowest ED50 for a tail withdrawal reaction latency greater than 6 and greater than or equal to 10 s. The potentiation was already present at low doses. Whereas both 0.16 microgram sufentanil and 80 micrograms bupivacaine were inactive, the combination of the two drugs resulted in a deep analgesia in all animals. Because the addition of low doses of bupivacaine to sufentanil did not increase the ED50's for side-effects, higher specificity ratios were obtained as compared to sufentanil given alone. These results were discussed with regard to the potentiation of the analgesic properties of epidurally administered lipophilic opioids by local anaesthetics.

Maternal and neonatal effects of adding epidural sufentanil to 0.5% bupivacaine for cesarean delivery

Study Objective: To determine the maternal and fetal effects of the addition of epidural sufentanil to 0.5% bupivacaine for cesarean delivery. Design: Randomized, double-blind, prospective study. Setting: University Hospitals, Katholiehe Universiteit Leuven, Leuven, Belgium. Patients: Sixty women at term scheduled for elective cesarean section, all of whom had elected epidural anesthesia. Interventions: The 60 women were divided into three groups of 20, with each group receiving a different 1 ml study solution: saline (control) or sufentanil 20 μg sufentanil 30 μg added to 0.5% bupivacaine and epinephrine (1:200,000). Measurements and Main Results: In the mother, the quality of anesthesia, the duration of postoperative analgesia, the volume of anesthetic, and the frequency of side effects were examined. The neonates were evaluated at 5 and 10 minutes after birth by Apgar scores and between 60 and 120 minutes after birth by both the screening test developed by Prechtl and the Neurological and Adaptive Capacity Scoring System. Immediately after delivery, maternal and umbilical vein blood were drawn and assayed for sufentanil levels. Adding sufentanil significantly improved the quality of anesthesia without depressing the neurobehavioral status of the baby. Conclusion: The epidural injection of sufentanil added to 0.5% bupivacaine with epinephrine improved the quality of anesthesia during elective cesarean section without jeopardizing the safety of the baby.

Association sufentanil-bupivacaïne à 0,25 % par voie péridurale pour l'analgésie obstétricale. Comparaison avec le fentanyl et un placebo

The study reported was designed to determine whether 15 μg sufentanil would provide analgesia comparable in duration and quality with that given by 75 μg fentanyl, when associated with plain 0.25 % bupivacaine for extradural analgesia for labour. Patients (n = 124) in labour and at full term were randomly divided into 3 groups. Group 1 (n = 41) were given 12 ml of 0.25 % plain bupivacaine with saline, group 2 (n = 41) 12 ml of 0.25 % plain bupivacaine with 75 μg fentanyl and group 3 (n = 42) 12 ml of 0.25 % plain bupivacaine with 15 μg sufentanil. 11 cases were excluded from the study (8 Caesarean sections, 3 technical failures). The duration of analgesia obtained with the two opioids was similar (group 2 : 126.7 ± 6.5 min, p < 0.01 ; group 3 : 114.9 ± 5.8 min, p < 0.01 ; group 1 : 93.6 ± 5.4 min) as well as the quality of pain relief. There were no differences between the three groups with regard to Apgar scores. The only side-effect seen with sufentanil and fentanyl was pruritus (group 2 : 21.9 %, p < 0.05 ; group 3 : 21.4 %, p < 0.05 ; group 1 : 2.4 %). These results showed that 15 μg sufentanil could replace 75 μg fentanyl for extradural pain relief of labour with plain 0.25 % bupivacaine. However, the use of opioids with local anaesthetics would seem to be of interest only if labour is likely to be prolonged.