Anesthesia and analgesia
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialIntraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery.
We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. ⋯ Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialContinuous wound infiltration with ropivacaine reduces pain and analgesic requirement after shoulder surgery.
After achieving a reduction of pain scores for 10 h with a single dose wound infiltration after shoulder surgery, we examined in a prospective, placebo-controlled and double-blinded study the analgesic effects of continuous wound infiltration with different concentrations of ropivacaine. Forty-five patients undergoing shoulder surgery were randomly assigned into three groups to receive single dose wound infiltration with 30 mL saline (group S) or ropivacaine 7.5 mg/mL (groups R2 and R3.75) after skin closure. Postoperatively, patients received a continuous wound infiltration with saline (group S), ropivacaine 2 mg/mL (group R2) or ropivacaine 3.75 mg/mL (group R3.75) for 48 h. Supplemental pain relief was provided by IV patient-controlled analgesia with the opioid piritramide. At 1, 2, 3, 4, 24, and 48 h postoperatively visual analogue scale (VAS) values (0-100 mm), piritramide requirements and side effects were registered. Plasma levels of ropivacaine were measured preoperatively and at 24 h and 48 h after surgery. Until 48 h VAS values were smaller in group R3.75 compared with group S (group R3.75, 8 +/- 9 mm; group S, 31 +/- 14 mm; P < 0.005), whereas 4 h and 48 h postoperatively VAS values were even smaller in group R3.75 compared with group R2 (P < 0.05). Cumulative piritramide consumption was always smaller in groups R2 and R3.75 compared with group S (1-24 h, P < 0.005; 48 h, P < 0.05). Plasma ropivacaine levels remained less than the toxic threshold. We conclude that continuous postoperative wound infiltration with ropivacaine, especially using 3.75 mg/mL, provides smaller VAS values and opioid requirement in comparison with saline after shoulder surgery. ⋯ The continuous postoperative wound infiltration after shoulder surgery with different concentrations of ropivacaine, 2 mg/mL and 3.75 mg/mL, results in lower pain scores and opioid requirement compared with infiltration with placebo. Plasma levels of ropivacaine remained less than the toxic threshold.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Comparative Study Clinical TrialA comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy.
The optimal anesthetic technique for outpatient knee arthroscopy remains controversial. In this study, we evaluated surgical operating conditions, patient satisfaction, recovery times, and postoperative analgesic requirements associated with psoas compartment block, general anesthetic, or spinal anesthetic techniques. Sixty patients were randomized to receive a propofol/nitrous oxide/fentanyl general anesthetic, spinal anesthesia with 6 mg of bupivacaine and 15 micro g of fentanyl, or psoas compartment block with 40 mL of 1.5% mepivacaine. All patients received IV ketorolac and intraarticular bupivacaine. The frequency of postanesthesia recovery room admission was 13 (65%) of 20 for patients receiving general anesthesia, compared with 0 of 21 for patients receiving spinal anesthesia and 1 (5%) of 19 for patients receiving psoas block (P < 0.001). The median time from the end of surgery to meeting hospital discharge criteria did not differ across groups (131, 129, and 110 min for general, spinal, and psoas groups, respectively). In the hospital, 45% of general anesthesia patients received opioid analgesics, compared with 14% of spinal anesthesia and 21% of psoas block patients (P = 0.087). There was no difference among groups with respect to the time of first analgesic use or the number of patients requiring opioid analgesia. Pain scores were highest in patients receiving general anesthesia at 30 min (P = 0.032) and at 60, 90, and 120 min (P < 0.001). Patient satisfaction with anesthetic technique (P = 0.025) and pain management (P = 0.009) differed significantly across groups; patients receiving general anesthesia reported lower satisfaction ratings. We conclude that spinal anesthesia or psoas block is superior to general anesthesia for knee arthroscopy when considering resource utilization, patient satisfaction, and postoperative analgesic management. ⋯ Outpatient knee arthroscopy may be performed using a variety of anesthetic techniques. We report that spinal anesthesia and psoas compartment block are superior to general anesthesia when considering resource utilization, patient satisfaction, and postoperative analgesic management.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialThe effects of preoperative inflammation on the analgesic efficacy of intraarticular piroxicam for outpatient knee arthroscopy.
We conducted a double-blinded study in 90 patients undergoing elective arthroscopic knee surgery to determine whether there is a role of inflammation in the analgesic efficacy of intraarticular piroxicam. Standardized general anesthetic techniques were used for all patients. At the end of the operation, after harvesting synovial biopsies, patients were randomized into three intraarticular groups equally. Group 1 received 25 mL saline, Group 2 received 25 mL 0.25% bupivacaine, and Group 3 received 25 mL 0.25% bupivacaine and piroxicam 20 mg. After microscopic examination of the synovial materials, the patients were divided into two subgroups, inflammation positive (I+) and inflammation negative (I-). Preoperatively and postoperatively at 1, 2, 4, and 6 h, pain levels, analgesic duration, and postoperative analgesic consumption were recorded. Analgesic duration was significantly longer in the I+ subgroup than the I- subgroup of Group 3 (P < 0.05). Pain scores at 1, 2, and 4 h postoperatively were significantly lower in the I+ subgroup than the I- subgroup of Group 3 (P < 0.05), whereas there were no significant differences among the subgroups of Group 1 and 2. We concluded that preoperative inflammation is one of the most important determinants of analgesic efficacy of intraarticular piroxicam. ⋯ Intraarticular administration of piroxicam along with bupivacaine improves postoperative analgesia in synovial inflammation before surgery.
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Anesthesia and analgesia · Oct 2003
Randomized Controlled Trial Clinical TrialSevoflurane requirements to suppress responses to transcutaneous electrical stimulation during epidural anesthesia with 0.5% and 1% lidocaine.
We sought to determine general anesthetic requirements to suppress skin vasomotor reflex (SVmR) and pupillary dilation (PD) in response to transcutaneous electrical stimulation (TES) during combined epidural-general anesthesia. Thirty-five patients undergoing lower abdominal surgery were randomly divided into 2 groups to epidurally receive 0.5% (Group 1) or 1% lidocaine (Group 2) with sevoflurane anesthesia. A bolus injection of either lidocaine was followed by the infusion of the same solution, and the central dermatomal level of loss of cold sensation (C) was determined. After the induction of general anesthesia with 5% sevoflurane and 67% nitrous oxide, nitrous oxide was discontinued, and sevoflurane concentration was decreased. TES was given at both site C and site three dermatomal segments (U) cephalad to C to determine the end-tidal sevoflurane concentration required to suppress SVmR and PD. End-tidal sevoflurane concentration that suppressed both responses was larger in Group 1 than in Group 2 at both sites and was larger at site U than at site C in both groups. We conclude that sevoflurane requirements to suppress SVmR and PD in response to TES during combined epidural-general anesthesia are different depending on the concentration of lidocaine and the site where surgical stimulation is applied. ⋯ We evaluated sevoflurane requirements to suppress skin vasomotor reflex and pupillary dilation in response to a transcutaneous electrical stimulation at the surgical site during combined epidural-general anesthesia. Our results indicate that when epidural anesthesia is combined, general anesthetic requirements decrease depending on the lidocaine concentration for epidural anesthesia and the site where surgical stimulation is applied.