Patient-controlled Analgesia Group Research Articles

The Influence of Patient Controlled Analgesia on the Recovery of Muscle Power and Respiratory Function following Intraoperative Muscle Relaxants

Residual muscle paralysis after anesthesia is reduced with the advent of intermediate-acting neuromuscular blocking drugs, yet the incidence is as high as about 10 percent. Opioids in patient-controlled analgesia (PCA) may cause respiratory depression and other problems after anesthesia. The purpose of this study is to evaluate the influence of PCA on the , TOF ratio, head-lift and tongue protrusion during recovery room stay following intraoperative muscle relaxants. Methods: 120 patients aged from 20 to 65 in ASA class I and II were divided into control or PCA groups. All patients received rocuronium (0.9 mg/kg) or atracurium (0.5 mg/kg) for tracheal intubation, and maintenance of relaxation was done with atracurium 0.2 mg/kg/hr during inhalation anesthesia. Reversal of block was done with pyridostigmine 0.15 mg/kg and glycopyrrolate 0.2 mg. SpO2, TOF ratio, 5 sec-head lift, tongue protrusion tests were evaluated in the recovery room. Results: IV-PCA did not influence the incidence of residual block, SPO2, TOF ratio during recovery room stay for 20 minutes, but influenced negatively 5 sec-head lift test, tongue protrusion test only immediately after arrival at the recovery room. Conclusions: Since IV-PCA decreased the ability to perform head-lift and tongue protrusion early postoperatively, it is recommended that patients with IV-PCA should be carefully managed against the risk of aspiration or upper respiratory obstruction during their early recovery room stay.

A Randomized Controlled Trial of Patient Controlled Analgesia Versus Continuous Infusion of Morphine during Vaso-Occlusive Crisis in Sickle Cell Disease.

Pain during vaso-occlusive crisis (VOC) in sickle cell disease (SCD) is commonly treated with continuous intravenous infusion (CI) of morphine. During CI the treating physician titrates the dose of morphine until adequate relief of pain has been established. Patient controlled analgesia (PCA) allows the patient to self-administer doses of morphine for the relief of pain and has shown to be equianalgesic in post surgical patients with lower morphine consumption than with CI of morphine. Morphine has many dose-related side-effects and high plasma levels of morphine are associated with serious complications. Therefore, we conducted the first randomized controlled trial to compare the administration of morphine with PCA versus CI in sickle cell patients with VOC. 26 consecutive episodes of VOC in 21 patients with SCD were included. Patients were randomized between PCA and CI of morphine within 24 hours after hospital admission. Endpoints of the study were: the mean and cumulative morphine dose, pain intensity and quality of life (QoL). Pain intensity was measured daily using a ten-point-scale verbal pain score. Reduction of pain intensity was measured by subtracting a pain score on a ten point visual analogue scale (VAS) before randomization from the same measurement two days after randomization. QoL was measured using the Medical Outcomes Study 36-item Short Form Healthy Survey (SF36).Patients with PCA demonstrated to have significant lower morphine consumption as compared to patients randomized to CI. The mean and total cumulative morphine dose was 0.5 mg/h and 33 mg in the PCA-group versus 2.3 mg/h and 275 mg in the CI-group, respectively (p=0.02 and p<0.001). The pain intensity was not different between the groups. The mean daily ten-point-scale verbal pain score was 5.1 in the PCA group versus 5.3 in the CI-group (p=0.20). Reduction in pain intensity (VAS) two days after randomization was −2.4 in the PCA-group versus −3.8 in the CI-group (p=1.00). Also no difference in QoL was found.We conclude that the use of PCA in sickle cell patients with VOC results in adequate pain relief at a significant lower morphine dose as compared to morphine administration by continuous infusion. [Display omitted]

Patient Controlled Intravenous Opioid Analgesia Versus Continuous Epidural Analgesia for Pain After Intra-Abdominal Surgery

Background There are two common techniques for postoperative pain control after intra-abdominal surgery: patient-controlled analgesia (PCA) with intravenous opioids and continuous epidural analgesia (CEA). It is uncertain which method has better pain control and fewer adverse effects. Objectives The objective of this review was to compare PCA opioid therapy with CEA for pain control after intra-abdominal surgery in terms of analgesic efficacy, side effects, patient satisfaction and surgical outcome by meta-analysis of the relevant trials. Search methods We searched CENTRAL (The Cochrane Library Issue 4, 2002), MEDLINE (January 1966 to October 2002), EMBASE (January 1988 to October 2002), and reference lists of articles. We also contacted researchers in the field. Selection criteria Randomized controlled trials of adult patients after intra-abdominal surgery comparing the effect of two pain control regimens in terms of analgesic efficacy and side effects. In the patient-controlled analgesia (PCA) group the patient should be able to operate the device himself. In the continuous epidural analgesia group there was no PCA device. Data collection and analysis Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials. Main results Nine studies involving 711 participants were included. The PCA group had a higher pain visual analogue scale than the CEA group during 6, 24 and 72 hour periods. The weighted mean difference and 95% confidence interval of resting pain was 1.74 (95% CI 1.30 to 2.19), 0.99 (95% CI 0.65 to 1.33), and 0.63 (95% CI 0.24 to 1.01), respectively. The length of hospital stay and other adverse effects were not statistically different except that the incidence of pruritus was lower in the PCA group, odds ratio of 0.27 (95% CI 0.11 to 0.64). Authors' conclusions CEA is superior to opioid PCA in relieving postoperative pain for up to 72 hours in patients undergoing intra-abdominal surgery, but it is associated with a higher incidence of pruritus. There is insufficient evidence to draw comparisons about the other advantages and disadvantages of these two methods of pain relief.

Postoperative Analgesia Following Surgical Correction for Adolescent Idiopathic Scoliosis: A Comparison of Continuous Epidural Analgesia and Patient-Controlled Analgesia

A retrospective comparison of postoperative continuous epidural analgesia and patient-controlled analgesia following surgical treatment for adolescent idiopathic scoliosis. To compare the safety and efficacy of continuous epidural analgesia and patient-controlled analgesia following adolescent idiopathic scoliosis surgery. The most commonly used pain management techniques are continuous epidural analgesia and patient-controlled analgesia. However, no large published reports compare them following adolescent idiopathic scoliosis surgery. A review was performed from 1990 to 2001 of patients undergoing primary surgery for adolescent idiopathic scoliosis. Visual analog scale scores were recorded postoperatively at multiple time periods. Adverse effects related to each pain management technique were noted. The average of all pain scores (1.3 vs. 1.9) (P < 0.0001) and scores at 2, 4, 6, 8, 12, 24, 36, and 48 hours (p < 0.001) was significantly better in the continuous epidural analgesia group when compared to the patient-controlled analgesia group. The range of pain scores (2.3 vs. 2.7) (P < 0.05) and the average maximum score was less in the continuous epidural analgesia group (2.6 vs. 3.2) (P < 0.05). The need to temporarily stop and then restart the pain management (12.3% vs. 7.0%) (P = 0.04) and premature permanent discontinuation (13.1% vs. 0.0%) (P < 0.001) was greater in the continuous epidural analgesia group than the patient-controlled analgesia group. No neurologic injuries occurred. Although both continuous epidural analgesia and patient-controlled analgesia provide effective pain control following surgery for adolescent idiopathic scoliosis, patients with continuous epidural analgesia had significantly better pain scores for all time periods, less fluctuations in pain, and lower maximum pain levels during the postoperative period.

Randomised controlled trial of patient controlled analgesia compared with nurse delivered analgesia in an emergency department

Objective: To compare effectiveness, safety, and patient satisfaction of patient controlled analgesia (PCA) with titrated, intravenous opioid injections for the management of acute traumatic pain in the emergency department (ED)....

A hospital-sponsored quality improvement study of pain management after cesarean delivery*1

Objective We undertook this study to systematically assess prevailing pain management regimes used at our hospital in women after cesarean delivery. Study design Between August 1999 and July 2000, all women delivered by cesarean section at Parkland Hospital were assigned to 1 of 4 different pain management strategies: (1) intramuscular (IM) meperidine, (2) patient-controlled analgesia (PCA) meperidine, (3) IM morphine sulfate, and (4) PCA morphine sulfate. A combination of methods were used to compare these different pain management strategies. A survey questionnaire, using Likert scale responses, was administered to evaluate maternal satisfaction with pain control. Visual Analog Scale (VAS) scores and information regarding breastfeeding and rooming-in were also collected. Results A total of 1256 women were allocated to the 4 analgesia study groups. The median meperidine dosages for the IM and PCA groups were 350 mg and 600 mg, respectively (P ≤ .01). Conversely, the median IM morphine dose (65 mg) was significantly higher than that for the PCA group (60 mg). The percentage of women reporting moderate or worse pain (VAS scores 4 or more) was significantly lower in those women who received PCA meperidine compared with IM meperidine. Women who received morphine reported less severe pain compared with meperidine, regardless of route of administration. The patients' subjective report of satisfaction with pain management was not related to the method or drug used for pain control (P = .13). Fewer women assigned to morphine therapy stopped breastfeeding (P = .02) and more roomed-in with their infants (P<.01). Conclusion Pain relief was superior with the morphine regimens used and was positively associated with breastfeeding and infant rooming-in.

A hospital-sponsored quality improvement study of pain management after cesarean delivery

Objective We undertook this study to systematically assess prevailing pain management regimes used at our hospital in women after cesarean delivery. Study design Between August 1999 and July 2000, all women delivered by cesarean section at Parkland Hospital were assigned to 1 of 4 different pain management strategies: (1) intramuscular (IM) meperidine, (2) patient-controlled analgesia (PCA) meperidine, (3) IM morphine sulfate, and (4) PCA morphine sulfate. A combination of methods were used to compare these different pain management strategies. A survey questionnaire, using Likert scale responses, was administered to evaluate maternal satisfaction with pain control. Visual Analog Scale (VAS) scores and information regarding breastfeeding and rooming-in were also collected. Results A total of 1256 women were allocated to the 4 analgesia study groups. The median meperidine dosages for the IM and PCA groups were 350 mg and 600 mg, respectively ( P ≤ .01). Conversely, the median IM morphine dose (65 mg) was significantly higher than that for the PCA group (60 mg). The percentage of women reporting moderate or worse pain (VAS scores 4 or more) was significantly lower in those women who received PCA meperidine compared with IM meperidine. Women who received morphine reported less severe pain compared with meperidine, regardless of route of administration. The patients' subjective report of satisfaction with pain management was not related to the method or drug used for pain control ( P = .13). Fewer women assigned to morphine therapy stopped breastfeeding ( P = .02) and more roomed-in with their infants ( P<.01). Conclusion Pain relief was superior with the morphine regimens used and was positively associated with breastfeeding and infant rooming-in.

Ultra-fast-track anesthesia in off-pump coronary artery bypass grafting: a prospective audit comparing opioid-based anesthesia vs thoracic epiduralbased anesthesia

To examine the feasibility of immediate extubation after off-pump coronary artery bypass grafting (OPCAB) using opioid based analgesia or high thoracic epidural analgesia (TEA) and compare postoperative analgesia with continuous TEA vs patient-controlled analgesia (PCA). One hundred consecutive patients undergoing OPCAB were included in this prospective audit. After induction of anesthesia using fentanyl 2 to 5 microg.kg(-1), propofol 1 to 2 mg.kg(-1) and endotracheal intubation facilitated by rocuronium, anesthesia was maintained using sevoflurane titrated according to bispectral index monitoring. Perioperative analgesia was provided by TEA (n = 63) at the T3/T4 interspace or T4/T5 interspace using bupivacaine 0.125% 8 to 14 mL.hr(-1) and repetitive boluses of bupivacaine 0.25% during surgery. In patients who were fully anticoagulated or refused TEA, perioperative analgesia was achieved by i.v. fentanyl boluses (up to 15 microg.kg(-1)) and remifentanil 0.1 to 0.2 microg.kg(-1).min(-1), followed by morphine PCA after surgery (n = 37). Maintenance of body temperature was achieved by a heated operating room and forced-air warming blankets. Ninety-five patients were extubated within 25 min after surgery (PCA, n = 33; TEA, n = 62). Five patients were not extubated immediately because their core temperature was lower than 35 degrees C. One patient was re-intubated because of agitation (TEA group); one was re-intubated because of severe pain and morphine-induced respiratory depression (PCA group). Pain scores were low after surgery, with pain scores in the TEA group being significantly lower immediately, at six hours, 24 hr and 48 hr after surgery (P < 0.05). Immediate extubation is possible after OPCAB using either opioid-based analgesia or TEA. TEA provides significantly lower pain scores after surgery in comparison to morphine PCA.

The Effects of High Thoracic Epidural Patient Controlled Analgesia after Open Heart Surgery

Background: Postoperative pain may be severe after open heart surgery (OHS). High thoracic epidural analgesia may reduce postoperative pain and improve the pulmonary function. We investigated the effect of epidural analgesia after median sternotomy Methods: Fifty-six patients were randomized to epidural patient controlled analgesia (PCA) or conventional analgesia (control). Patients received OHS with standardized general anesthetic technique. The day before surgery, patients allocated to the PCA group had an epidural catheter inserted at level T4-5. Proper placement was tested with small dose of lidocaine and epinephrine. Epidural catheter was removed 3 days after surgery. Patients in control group received conventional nurse controlled analgesia. Postoperative assessment included daily visual analog scoring (VAS) and pulmonary function test 3 days after surgery. Complication and patients satisfaction were also evaluated. Results: The VAS scores did not significantly differ between the groups, except 12 hours after surgery during coughing. Patients with PCA awoke and were extubated significantly earlier than patients in control group. Significantly higher forced expiratory volume in 1s and peak expiratory flow rate were seen in PCA group than in control group. No significant thoracic epidural related complications occurred. Conclusions: Thoracic epidural PCA provided better analgesia and allowed earlier extubation. Thoracic epidural PCA yields a slight, but significant, improvement in pulmonary function.

Comparison of the effects of intravenous and thoracic epidural patient-controlled analgesia with morphine after upper abdominal surgery

AbstractOur purpose was to compare the effects of patient-controlled analgesia (PCA) with intravenous (i.v.) and epidural morphine on pulmonary function and their analgesic efficacy and side effects after upper abdominal surgery. In a prospective study, patients were randomly allocated to receive either thoracic epidural (n = 20) or intravenous (n = 20) patient-controlled analgesia with morphine. Preoperatively and at 24 and 48 h after surgery, arterial blood-gas analysis, forced vital capacity (FVC), and forced expiratory volume in 1s (FEV1) were measured, and chest X-ray films were taken from all patients. Pain (at rest), morphine consumption, nausea and vomiting, pruritus, and respiratory rate were recorded during the first 48 postoperative hours. In this period, the amount of morphine that was used in the epidural PCA group (28.5 ± 7.4 mg) was significantly lower than in the i.v. PCA group (49.4 ± 27.0 mg). Pain scores were similar in the two groups. Throughout the study no differences were found in p...

Prospective Randomized Clinical Trial Comparing Patient-Controlled Intravenous Analgesia With Patient-Controlled Epidural Analgesia After Lumbar Spinal Fusion

A prospective, randomized, double-blind clinical trial was conducted. To compare the efficacy of patient-controlled analgesia (PCA) with that of patient-controlled epidural analgesia (PCEA) in terms of overall patient satisfaction with postoperative pain management after lumbar spine fusion. In numerous surgical disciplines, PCEA and PCA have proved to be effective methods of postoperative pain control. The literature states that with PCEA, less opioid use is required during the immediate postoperative period to maintain equivalent pain control compared to PCA. Continuous epidural infusion has been assessed in spine fusion patients, but PCEA has not been evaluated. Furthermore, this is the first prospective randomized clinical trial to assess overall patient satisfaction while stratifying patients for both anxiety level and preoperative opioid use. For this study, 74 patients were assigned randomly to one of two treatment groups, with PCA and PCEA administered in a double-blind manner for a 3-day postoperative course. All the patients received both PCA and PCEA delivery systems. Assessment was by a blinded, independent observer. Overall patient satisfaction with pain management was assessed by a visual analog scale at the end of postoperative day 3. Secondary measures included: three scales from the Functional Independence Measure instrument; opioid quantity; side effects; and length of hospital stay. Thirty-eight patients were randomized to PCA, and 36 were randomized to PCEA. No baseline variable differences between the groups were observed. The results showed no difference between the groups on the following measures: overall patient satisfaction with pain management, ambulation, and length of stay. The PCA patients used significantly more opioid than the PCEA patients. Both postoperative analgesic regimens provided good overall patient satisfaction. The only clinical advantage of PCEA over PCA for spine fusion patients was the lower amount of opioid consumed, although the PCEA group experienced significantly more side effects than the PCA group. There were no other significant differences. Therefore, patient or physician preference could select either postoperative pain management delivery system.

Patient-controlled femoral nerve analgesia versus patient-controlled intravenous analgesia for postoperative analgesia after trochanteric fracture repair

Abstract We assessed the efficacy of intravenous patient-controlled analgesia (PCA) and femoral nerve PCA after trochanteric fracture repair. A total of 40 patients were randomised to receive either femoral nerve PCA (Group I) or intravenous (IV) PCA (Group II) in the postoperative period. Group I received a continuous infusion of 0.125 bupivacaine at rate of 4 ml h −1 plus PCA boluses of 3 ml with lockout time of 20 min. Morphine by IV PCA was applied as 1 mg bolus dose and 7 min lockout time in Group II. Pain scores (active–passive movement and during the resting), side effects, and patient satisfaction were recorded. Pain scores at rest were similar in both groups. Significantly better pain control at movement was observed in the Group I. Side effects were observed significantly more frequently in the Group II. Patient satisfaction was greater in Group I. Of the two PCA techniques tested, femoral nerve PCA with continuous infusion provides greater patient comfort both at rest and with ambulation than does IV PCA.

A Comparison of Multimodal Perioperative Analgesia to Epidural Pain Management After Gastric Bypass Surgery

We compared pain intensity, analgesic consumption, patient satisfaction, and length of stay in 114 patients undergoing gastric bypass surgery under general anesthesia. Patients were randomized to incisional local anesthetic infiltration plus postoperative patient-controlled analgesia (Group A), epidural anesthesia and analgesia (Group B), or postoperative patient-controlled analgesia (Group C). All received perioperative nonsteroidal antiinflammatory drugs. Age, sex, body mass index, length of stay, and patient satisfaction were equivalent in all groups. Pain at time 0 and 36 h was the smallest in Group B, greater in Group A, and greatest in Group C. Pain scores in a subset of Group A were lower at all times than in Groups B and C, but this difference was significant only at 0, 12, and 36 h. In responders, infiltration analgesia as part of a multimodal regimen offers a simple, safe, and inexpensive alternative to epidural pain control.

Comparison between patient-controlled analgesia and subcutaneous morphine in elderly patients after total hip replacement

The goal of this study was to evaluate the effectiveness on postoperative pain, and cognitive impact, of patient-controlled analgesia (PCA) compared with subcutaneous (s.c.) injections of morphine in elderly patients undergoing total hip replacement (THR). Forty patients older than 70 yr were randomly assigned to two different postoperative analgesic techniques for 48 h: i.v. PCA morphine (dose, 1 mg; lockout interval, 8 min; PCA group) or regular s.c. morphine injections (SC group). Postoperative pain was assessed at rest and when moving, using a visual analogue scale (VAS) every 4 h. A Mini Mental Status (MMS) examination was used to assess cognitive functions before surgery, at 2 h, 24 h and 48 h after surgery, and at hospital discharge. Side-effects were also recorded systematically during the first 48 h after surgery. The PCA group showed significantly lower pain scores than the SC group both at rest and during mobilization. However, the clinical significance of pain scores was weak. There was no intergroup difference in postoperative MMS scores. The incidence of side-effects was similar in both groups. We conclude that in healthy elderly subjects undergoing THR, the flexibility of the analgesic regimen is more important than the route of administration with regard to efficacy, adverse effects and recovery of cognitive function.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Subjective and Objective Comparison of Critical Care Pathways for Open Donor Nephrectomy

In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy. Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed. The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02). Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.

Analgesia For Shock Wave Lithotripsy

We evaluated the effectiveness of and patient preference for analgesia used during shock wave lithotripsy by comparing diclofenac alone with a combination of diclofenac and patient controlled analgesia, that is alfentanil. A total of 64 patients were treated using a Lithotriptor S (Dornier Medical Systems, Marietta, Georgia) and randomized to receive diclofenac alone or combined with an alfentanil patient controlled analgesia pump. If treated twice, they crossed over to the alternative form of analgesia. A record was maintained of the site and size of the stone, maximum power achieved, number of shocks, amount of alfentanil used and need for additional analgesia. After treatment patients scored on a visual analog scale the maximum level of pain and satisfaction with analgesia. There was no difference in the mean size of the stone treated (8.6 and 7.5 mm.), energy level (71% and 71% or approximately 17 kV.) or number of shocks (3,000 and 2,900, respectively) in the groups. Only 2 patients in the diclofenac group required additional analgesia and there were no significant side effects from either treatment. The mean pain scores were not significantly different in the diclofenac and patient controlled analgesia groups (3.54 and 2.93, respectively, (p = 0.34), although those on patient controlled analgesia were more satisfied (7.72 versus 9.14, p = 0.04). Of the 38 patients who presented twice 58% preferred diclofenac alone. This study suggests that there is no significant difference in the level of pain experienced with diclofenac alone or when combined with an alfentanil patient controlled analgesia pump during shock wave lithotripsy. However, patients are more satisfied with treatment when a patient controlled analgesia pump is available.

A Randomized Trial of Intrapartum Analgesia in Women With Severe Preeclampsia

OBJECTIVE: To estimate whether the cesarean delivery rate differs between women with severe preeclampsia who receive intrapartum epidural analgesia versus patient-controlled intravenous opioid analgesia. METHODS: Women with severe preeclampsia at at least 24 weeks' gestation were randomly assigned to receive either intrapartum epidural (n = 56) versus patient-controlled intravenous opioid analgesia (n = 60), and each was administered by a standardized protocol. The sample size was selected to have 80% power to detect at least a 50% difference in the predicted intergroup cesarean delivery rates. Data were analyzed by intent to treat. RESULTS: Selected maternal characteristics and neonatal outcomes were similar in the two groups. The cesarean delivery rates in the epidural group (18%) and the patient-controlled analgesia group (12%) were similar (P = .35). Women who received epidural analgesia were more likely to require ephedrine for the treatment of hypotension (9% versus 0%, P = .02), but their infants were less likely to require naloxone at delivery (9% versus 54%, P <.001). Epidural analgesia provided significantly better pain relief as determined by a visual analogue intrapartum pain score (P <.001) and a postpartum pain management survey (P =.002). CONCLUSION: Compared with patient-controlled intravenous opioid analgesia, intrapartum epidural analgesia did not significantly increase the cesarean delivery rate in women with severe preeclampsia at our level III center, and it provided superior pain relief.

Continuous subgluteus sciatic nerve block after orthopedic foot and ankle surgery: Comparison of two infusion techniques

Background and Objective: To compare continuous infusion or a patient-controlled technique for postoperative analgesia after foot surgery, using a new subgluteus approach for continuous sciatic nerve block. Methods: Fifty healthy patients, undergoing orthopedic foot surgery, received a continuous sciatic nerve block using a new subgluteus approach. All blocks were placed with the aid of a nerve stimulator using a 10-cm, 18-gauge insulated Tuohy needle. After either plantar flexion or dorsiflexion of the operated foot was elicited at [le ] 0.5 mA, 20 mL of 0.75% ropivacaine was injected incrementally using repeated aspiration tests, then followed by the introduction of a 20-gauge epidural catheter. Postoperatively, 0.2% ropivacaine was infused with either a 10 mL/h continuous infusion (group Continuous, n = 25) or with a 5 mL/h basal rate with 5 mL bolus every 60 minutes (group patient-controlled analgesia [PCA], n = 25). Intraoperative analgesic supplementation, as well as postoperative pain relief, morphine consumption, incidence of complication, and patient satisfaction were recorded by an observer unaware of group assignment. Results: The sciatic catheter was successfully placed in all patients. Intravenous fentanyl supplementation (dose range, 50 to 150 [mu ]g) was required in 4 patients in each group, but no patient required general anesthesia. Catheter dislocation was reported in 2 patients (4%). The quality of pain relief was good in both groups, and none experienced complications. Nine patients of the Continuous group (37%) and 7 patients of the PCA group (29%) required rescue morphine analgesia because of pain in the femoral dermatomes (P = .76). Ropivacaine consumption was 240 mL in the Continuous group (range, 200 to 240 mL) and 140 mL in the PCA group (range, 120 to 290 mL) (P = .0005). Patient acceptance was good in both groups. Conclusions: The continuous subgluteus sciatic nerve block represents an easy and reliable option for postoperative analgesia after foot surgery; using a patient controlled rather than a continuous infusion technique reduces the consumption of local anesthetic solution without affecting the quality of pain relief. Reg Anesth Pain Med 2002;27:168-172.

Epidural analgesia compared with intravenous morphine patient-controlled analgesia: Postoperative outcome measures after mastectomy with immediate TRAM flap breast reconstruction

Background and Objectives: Epidural analgesia has been shown to provide superior pain control compared with intravenous (IV) opioids after major surgical procedures. In this study, we compared the effect of epidural analgesia and IV morphine patient-controlled analgesia (PCA) on pain relief, duration of hospitalization, oral nutrition, ambulation, and side effects in patients undergoing a major surgical procedure (i.e., unilateral mastectomy with immediate transverse rectus abdominis musculocutaneous flap reconstruction). Methods: Eighteen patients were prospectively randomized to receive either epidural analgesia or PCA during the postoperative period. The intensity of pain was assessed daily by a 100-mm visual analog scale. The total length of hospital stay, time to ambulation, and time to oral nutrition were recorded. Results: The epidural group had significantly lower pain scores at 3 evaluation times through postoperative day number 4 ( P < .05). The total length of hospitalization for the epidural group (median, 101 hours) was significantly less than the PCA group (median, 126 hours; P = .0498). The time to first ambulation, time to first bowel sounds, time to tolerating oral nutrition, incidence of nausea/vomiting or pruritus, and time to first flatus were not statistically different between the groups. Conclusions: These results show that epidural analgesia compared with PCA offered improved pain control after breast reconstruction with immediate transverse rectus abdominis musculocutaneous flap reconstruction. It also resulted in a 25-hour reduction in time of hospitalization. Reg Anesth Pain Med 2001;26:444-449.