Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units.

BACKGROUND: Intubation procedure in obese patients is a challenging issue both in the intensive care unit (ICU) and in the operating theatre (OT). The objectives of the study were (i) to compare the incidence of difficult intubation and (ii) its related complications in obese patients admitted to ICU and OT. METHODS: We conducted a multicentre prospective observational cohort study in ICU and OT in obese (BMI≥30 kg m(-2)) patients. The primary endpoint was the incidence of difficult intubation. Secondary endpoints were the risk factors for difficult intubation, the use of difficult airway management techniques, and severe life-threatening complications related to intubation (death, cardiac arrest, severe hypoxaemia, severe cardiovascular collapse). RESULTS: In cohorts of 1400 and 11 035 consecutive patients intubated in ICU and in the OT, 282 (20%) and 2103 (19%) were obese. In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT (16.3% vs 8.2%, P<0.01). In both cohorts, risk factors for difficult intubation were Mallampati score III/IV, obstructive sleep apnoea syndrome, and reduced mobility of cervical spine, while limited mouth opening, severe hypoxaemia, and coma appeared only in ICU. Specific difficult airway management techniques were used in 66 (36%) cases of difficult intubation in obese patients in the OT and in 10 (22%) cases in ICU (P=0.04). Severe life-threatening complications were significantly more frequent in ICU than in the OT (41.1% vs 1.9%, relative risk 21.6, 95% confidence interval 15.4-30.3, P<0.01). CONCLUSIONS: In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT and severe life-threatening complications related to intubation occurred 20-fold more often in ICU. CLINICAL TRIAL REGISTRATION: Current controlled trials. Identifier: NCT01532063.

A prospective study on the user-friendliness of four anaesthesia workstations.

BACKGROUND AND OBJECTIVES: Unlike for intensive care unit and home mechanical ventilators, no study has evaluated the user-friendliness of the recently introduced new anaesthesia workstations. METHODS: We performed a prospective study to evaluate the user-friendliness of four anaesthesia workstations, which were categorized into two groups: first-generation (Kion) and second-generation (Avance, Felix and Primus). Twenty users (12 nurse-anaesthetists and 8 anaesthesiologists) from three different anaesthesia departments at the same univeristy hospital participated in the study. The user-friendliness scale evaluated 10 criteria, including two design and monitoring criteria, four maintenance criteria and four ventilation use criteria. Each criterion was evaluated from 0 (poor) to 10 (excellent). RESULTS: The mean score obtained for the first-generation workstation was lower than those obtained for the three second-generation workstations (P < 0.05). No significant differences in the overall user-friendliness score was observed for the three second-generation workstations. The first-generation workstation obtained a significantly lower score than the three second-generation workstations for the design criteria (P < 0.01). For the screen criteria, the highest score was obtained by Felix, which has the largest screen and associated characters. For the main maintenance criteria, Kion and Felix obtained the lowest scores. No significant differences between the four anaesthesia workstations were found for only three of the user-friendliness criteria (self-test, alarms and settings). CONCLUSIONS: Anaesthesia machines have benefited from considerable advances in design and technology. This novel user-friendliness scale revealed that the most recent workstations were more appreciated by users than the first-generation of anaesthesia workstations. This user-friendliness scale may help the anaesthetic staff to 'consensually' choose the future workstation for their anaesthesia department.

[Quality assurance program for postoperative pain management: impact of the Consensus Conference of the French Society of Anesthesiology and Intensive Care]. / Programme d'assurance qualité de prise en charge de la douleur postopératoire: impact de la Conférence de consensus de la Sfar.

OBJECTIVE: To assess the impact of a pain management quality assurance program (PQAP) after abdominal surgery. The means used were mainly based on the French Society of anaesthesiology's pain management guidelines. STUDY DESIGN: Prospective evaluation using a before after study design: two audits among surgical patients: a first one in 1997 before implementation of PQAP, and a second one year later. PATIENTS AND METHODS: First, standards were defined including objectives about pain relief and patient satisfaction. After analysis of discrepancy observed between these objectives and the data of the first audit, a pain management program was introduced that included education of physicians, nurses and patients, systematic assessment of pain, organized pain relief protocols and implementation of modern analgesic technologies. RESULTS: 201 consecutive inpatients were evaluated in the first audit, and 117 in the second one. Comparing the second audit with baseline, the visual analog pain scores decreased during the five postoperative days, and the rate of very satisfied patients increased (36% versus 26%). 43% of the patients were given a regular analgesic medication in 1998 versus 15% in 1997. 65% of medications were administered with an effective interval between doses versus 47% in 1997. Patient-controlled techniques were used in 28% of the cases in 1998 versus 9% in 1997. CONCLUSION: The PQAP provided an improvement in efficacy of postoperative pain management in our unit, with the help of the overall ward staff, but without requiring personnel specially qualified.

How to choose an anesthesia ventilator?

During the past few years, many manufacturers have developed a new generation anesthesia ventilators or anesthesia workstations with innovative technology and introduced so-called new ventilatory modes in the operating room. The aim of this article is to briefly explain how an anesthesia ventilator works, to describe the main differences between the technologies used, to describe the main criteria for evaluating technical and pneumatic performances and to list key elements not to be forgotten during the process of acquiring an anesthesia ventilator.

[Esophageal cancer surgery: evolution of pain management, hemodynamics and ventilation practices during 16 years]. / Œsophagectomie carcinologique : 16ans d'évolution des pratiques anesthésiques ventilatoires, hémodynamiques et analgésiques.

OBJECTIVE: To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery. PATIENTS AND METHODS: We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994-2009). Statistical analysis was done on 4 chronologic quartiles of same sample size. RESULTS: Two hundred and seven consecutive patients were included during the 4 periods 1994-1997 (n=52), 1997-1999 (n=52), 1999-2003 (n=52) and 2004-2009 (n=51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6-10.6] vs 7.6[7.0-8.3] mL/kg of ideal body weight (IBW), p<0.01), increased use of Positive End Expiratory Pressure (0 vs 83%, p<0.001) and increased use of post-operative non-invasive ventilation (0 vs 51%, p<0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0-24.6] vs 12.6 [9.7-16.2] mL/h/kg of IBW, p<0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57%, p<0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn't change. CONCLUSIONS: During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.

The preoperative administration of ketoprofen improves analgesia after laparoscopic cholecystectomy in comparison with propacetamol or postoperative ketoprofen.

BACKGROUND: Non-opioid analgesics, paracetamol and non-steroid anti-inflammatory drugs (NSAIDs) are proposed for pain relief after laparoscopy. We compared perioperative propacetamol (P) and ketoprofen (K) to provide analgesia after laparoscopic cholecystectomy. METHODS: After ethical committee approval, we included 104 ASA I-II patients, without preoperative analgesic drugs, who were scheduled to undergo laparoscopic cholecystectomy. Anaesthesia was standardized using propofol, fentanyl, atracurium, isoflurane and N(2)O 50%. Ketoprofen 100 mg or propacetamol 2 g or a saline drip (a 100-ml unit of saline in 10 min) was infused blindly and randomly. Patients received either ketoprofen (group K1) or propacetamol (group P1) before induction of anaesthesia and saline after surgery, or saline before surgery and ketoprofen (group K2) or propacetamol (group P2) after surgery. Postoperative visual analogue pain scores (VAS 0-100 mm) were recorded during 24 h. If VAS was >30, a second dose (placebo, ketoprofen or propacetamol) was infused. Nalbuphine 0.2 mg kg(-1) i.v. was given as rescue analgesic if VAS was > or =50. RESULTS: Ninety-eight patients were studied The number of patients not requiring the second analgesic was greater in K1 (33.5%) than the others (K2 0%, P1 0%, P2 7.5%). VAS scores were significantly lower in K1 (P=0.001), with less nalbuphine consumption compared with P1. VAS and opioid request were similar in K2 and P2. CONCLUSION: Preoperative administration of ketoprofen improves postoperative analgesia after laparoscopic cholecystectomy compared with its postoperative administration and pre- and postoperative propacetamol.

Pre-emptive lidocaine inhibits arterial vasoconstriction but not vasopressin release induced by a carbon dioxide pneumoperitoneum in pigs.

BACKGROUND: We assessed the preventive effects of i.v. or i.p. lidocaine administration on increases in vascular resistance produced by carbon dioxide pneumoperitoneum and related this to vasopressin release. METHODS: Carbon dioxide pneumoperitoneum (14 mm Hg intra-abdominal pressure) was performed in 32 anaesthetized young pigs and monitored using a pulmonary artery catheter. Animals received lidocaine 0.5% (0.5 mg kg(-1)) i.v. (n=9) or 2 ml kg(-1) i.p. (n=9) or saline (n=5) 15 min before the pneumoperitoneum and were compared with a control group (n=9). RESULTS: I.V. and i.p. lidocaine inhibited increases in mean systemic vascular resistance induced by the pneumoperitoneum [2109 (SD 935) and 2282 (895), respectively, vs 3013 (1067) dyne s(-1) cm(-5) in the control group]. Cardiac output was increased. Plasma lidocaine concentrations were threefold higher after i.p. administration than after i.v. administration. After pneumoperitoneum insufflation, plasma lysine-vasopressin concentrations increased in all groups (control 74%, saline 65%, i.p. lidocaine 57%, i.v. lidocaine 74%). CONCLUSIONS: I.V. and i.p. lidocaine blunted systemic vascular responses to carbon dioxide pneumoperitoneum in pigs, but without influencing vasopressin release.

Improved postoperative analgesia with isoflurane than with propofol anaesthesia.

PURPOSE: The impact of hypnotic drugs on postoperative analgesia has not been evaluated. We compared the influence of the maintenance of anaesthesia with either propofol or isoflurane on postoperative pain. METHODS: Forty ASA 1-2 women, undergoing cosmetic abdominoplasty were randomized to receive either 6-12 mg.kg-1.hr-1 propofol i.v. (P, n = 20) or MAC 1-1.5 isoflurane inhalation (Iso, n = 20). The lungs were ventilated with N2O 60% and O2 40%, and 1 microgram.kg-1 fentanyl i.v. provided intraoperative analgesia. Before surgical closure, 2 g propacetamol i.v. were administered. Postoperative analgesia was provided after hourly assessment of pain (VAS 0-100 mm), with 10 mg nalbuphine i.v. if VAS > or = 50 mm, during the eight hours after surgery. Sedation score (awake 0 to unrousable 4) was also recorded. Analgesia satisfaction score (nil 0 to excellent 4) obtained from the patient on discharge. RESULTS: Sedation scores were similar in both groups except in the first postoperative hour, when it was higher in the Iso group. The VAS at rest (15.4 +/- 18.6 vs 29.7 +/- 19.8 mm, P = 0.0001) and nalbuphine requirements (0.13 +/- 0.35 vs 0.70 +/- 0.80 doses, P = 0.004) were lower in the Iso group during the first six hours, although emesis was more frequent than in P (60 vs 25%; P = 0.03). The incidence of analgesia satisfaction score (> or = 3) was similar between the two groups (P: 95; Iso: 75%). CONCLUSION: These results suggested that isoflurane anaesthesia provides better analgesia than propofol anaesthesia in the first six hours after abdominoplasty.

Adrenal steroid-secreting cells express endothelin-1.

Endothelin-1 (ET-1) is involved in adrenal steroid secretion but its cell origin remains unclear. We showed, using RT-PCR the expression of the mRNAs for preproET-1 and ECE-1 in primary cultures of human adrenal cells enriched in glomerulosa cells. Since these expressions could be due to contamination of steroid secreting cells by other cells, we also used the human adrenocortical cell line H295R, which was shown to produce steroids. This cell line also expressed preproET-1-RNA and released mature ET. Functional ET receptors were shown on H295R and cultured human adrenocortical cells. These findings indicate that adrenal steroid-secreting cells synthesize and release ET-1, raising the possibility for an autocrine-paracrine effect of ET-1 on adrenocortical functions.

[Hemodynamic monitoring using esophageal Doppler ultrasonography during laparoscopic cholecystectomy]. / Monitorage hémodynamique par Doppler oesophagien lors de la cholécystectomie par coelioscopie.

PURPOSE: To evaluate the use of a 4-mHz continuous wave esophageal Doppler monitor in the hemodynamic management of 48 ASA I to III patients undergoing laparoscopic cholecystectomy. METHODS: General anesthesia was induced with fentanyl and propofol, maintained with N20 N20/02 and muscle relaxation was provided with atracurium. The lungs were mechanically ventilated. Non invasive arterial blood pressure, heart rate, capnography, arterial blood gas were monitored during CO2 pneumoperitoneum at 15-mmHg. Using the velocity waveform of descending aortic blood flow, the Doppler device estimated changes in cardiac output and systemic vascular resistances. RESULTS: Peritoneal insufflation resulted in a mean 19% decrease in cardiac output (range -49 to +5%; P < 0.05) and a mean 48% increased in systemic vascular resistances (range -7 to +101%; P < 0.01). There was no relationship between changes in cardiac output and mean arterial pressure or PETCO2. The esophageal Doppler provided, in two patients, details of hypertensive peaks (mean arterial pressure > 140 mmHg) which responded to administration of nicardipine. CONCLUSION: The Esophageal Doppler provided an easy-to-handle and non invasive tool to monitor changes in cardiac output during laparoscopic cholecystectomy. However, further comparison with a thermodilution cardiac output technique is required.

Postoperative treatment of myocardial ischaemia by thoracic extradural local anaesthetic.

This case report describes an episode of postoperative myocardial ischaemia after total oesophagectomy that was successfully treated by extradural administration of local anaesthetic. Extension of sympathetic blockade in this manner resolved the myocardial ischaemia and haemodynamic disturbances experienced by the patient.

Signaling mechanisms induced by endothelin agonists in human adrenal glomerulosa cells.

Endothelin-1 (ET-1) exhibits secretagogue and trophic actions on the adrenal zona glomerulosa (ZG). Little information is available on the intracellular signaling events that follow stimulation of ET receptors on ZG cells. This study examined the expression of ET receptor subtypes and their involvement in transduction mechanisms induced by ET agonists on human ZG cells in primary culture. RT-PCR allowed the detection of both ETA and ETB receptor mRNAs in these cells. ET-1 induced a concentration-dependent increase in inositol phosphate (IP) accumulation in the presence of LiCl, whereas ETB agonists were inactive. The ET-1-induced increase in IP accumulation was prevented by BQ-123. ET-1 evoked an increase in [Ca2+]i, which was partially prevented by BQ-788. IRL 1620 also delayed the rise in [Ca2+]i. These results show that in human adrenal ZG cells, ET-1 induces an increase in IP accumulation through ETA receptor activation and evokes a rise in [Ca2+]i via stimulation of both ETA and ETB receptors.

gamma-aminobutyric acid type B receptors are expressed and functional in mammalian cardiomyocytes.

gamma-Hydroxybutyrate (GHB), an anesthetic adjuvant analog of gamma-aminobutyrate (GABA), depresses cell excitability in hippocampal neurons by inducing hyperpolarization through the activation of a prominent inwardly rectifying K(+) (Kir3) conductance. These GABA type B (GABA(B))-like effects are clearly shown at high concentrations of GHB corresponding to blood levels usually reached during anesthesia and are mimicked by the GABA(B) agonist baclofen. Recent studies of native GABA(B) receptors (GABA(B)Rs) have favored the concept that GHB is also a selective agonist. Furthermore, cloning has demonstrated that GABA(B)Rs assemble heteromeric complexes from the GABA(B)R1 and GABA(B)R2 subtypes and that these assemblies are activated by GHB. The surprisingly high tissue content, together with anti-ischemic and protective effects of GHB in the heart, raises the question of a possible influence of GABA(B) agonists on excitable cardiac cells. In the present study, we provide electrophysiological evidence that GHB activates an inwardly rectifying K(+) current in rat ventricular myocytes. This effect is mimicked by baclofen, reversibly inhibited by GABA(B) antagonists, and prevented by pertussis toxin pretreatment. Both GABA(B)R1 and GABA(B)R2 are detected in cardiomyocytes by Western blotting and are shown to coimmunoprecipitate. Laser scanning confocal microscopy discloses an even distribution of the two receptors in the sarcolemma and along the transverse tubular system. Hence, we conclude that GABA(B)Rs are distributed not only in neuronal tissues but also in the heart, where they can be activated and induce electrophysiological alterations through G-protein-coupled inward rectifier potassium channels.

The risk of cardiac injury during laparoscopic fundoplication: cardiac troponin I and ECG study.

BACKGROUND: Myocardial trauma has been described during gastroesophageal reflux laparoscopic surgery, in association with the proximity of cardiac structures. In addition, specific haemodynamic changes induced by CO2 pneumoperitoneum could exacerbate perioperative cardiac complication even in patients without cardiac risk factors. The aim of this study was to evaluate the influence of gastroesophageal reflux laparoscopic surgery on the perioperative ECG, cardiac troponin I and myocardial enzyme changes. METHODS: Forty-two ASA I-II patients without ischaemic heart disease or combined double-risk factors were studied. Automated ST segment analysis was used intraoperatively. ECG, plasma myocardial enzyme and cardiac troponin I concentrations were reported on arrival in the recovery room (HO), 4 h (H4) and 24 h (H24) postoperatively. RESULTS: Intraoperative ST segment changes occurred in two patients: the first during a hypotensive episode (MAP<55 mmHg; 3/42 patients) and the second during a hypertensive episode (MAP >110 mmHg; 3/42 patients). One case of intraoperative subcutaneous emphysema occurred without ST disturbance. One case of pneumothorax was observed at H0-H4 in another patient without clinical symptoms. Cardiac troponin I and CK-MB were not increased postoperatively. Transaminase concentrations increased (2-fold normal values) in 26/42 patients. In these 26 patients, 7 experienced 5-fold isolated transaminase increase, associated with left hepatic artery section. CONCLUSION: According to perioperative ECG changes and/or specific cardiac troponin I measurements, we did not identify specific myocardial damage following gastroesophageal reflux laparoscopic surgery. Unexpectedly, the incidence of hepatic cytolysis was frequent (62%) and has not previously been reported in the literature.

Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery.

BACKGROUND: Patient-controlled analgesia (PCA) with intravenous morphine and patient-controlled epidural analgesia (PCEA), using an opioid either alone or in combination with a local anesthetic, are two major advances in the management of pain after major surgery. However, these techniques have been evaluated poorly in elderly people. This prospective, randomized study compared the effectiveness on postoperative pain and safety of PCEA and PCA after major abdominal surgery in the elderly patient. METHODS: Seventy patients older than 70 yr of age and undergoing major abdominal surgery were assigned randomly to receive either combined epidural analgesia and general anesthesia followed by postoperative PCEA, using a mixture of 0.125% bupivacaine and sufentanil (PCEA group), or general anesthesia followed by PCA with intravenous morphine (PCA group). Pain intensity was tested three times daily using a visual analog scale. Postoperative evaluation included mental status, cardiorespiratory and gastrointestinal functions, and patient satisfaction scores. RESULTS: Pain relief was better at rest (P = 0.001) and after coughing (P = 0.002) in the PCEA group during the 5 postoperative days. Satisfaction scores were better in the PCEA group. Although incidence of delirium was comparable in the PCA and PCEA groups (24% vs. 26%, respectively), mental status was improved on the fourth and fifth postoperative days in the PCEA group. The PCEA group recovered bowel function more quickly than did the PCA group. Cardiopulmonary complications were similar in the two groups. CONCLUSION: After major abdominal surgery in the elderly patient, patient-controlled analgesia, regardless of the route (epidural or parenteral), is effective. The epidural route using local anesthetics and an opioid provides better pain relief and improves mental status and bowel activity.

The relationship among carbon dioxide pneumoperitoneum, vasopressin release, and hemodynamic changes.

UNLABELLED: We assessed the role of vasopressin (VP) for the hemodynamic response to pneumoperitoneum in pigs. Four groups of anesthetized pigs were investigated. Nine pigs were intraabdominally insufflated with CO2 and eight were intraabdominally insufflated with argon; eight pigs received an i.v. injection of 1 mg/kg SR 49059, a VP antagonist, before CO2 insufflation; and six pigs received SR 49059 alone. Hemodynamics, plasma concentrations of VP and vasoactive hormones, and Paco2 were measured. Data were analyzed by using analysis of variance, Student's t-test, and Mann-Whitney U-test. Five minutes after insufflation, changes in systemic vascular resistance (SVR) were significantly correlated with changes in VP (r = 0.72; P = 0.005) but not with changes in epinephrine, norepinephrine, renin activity, or Paco2. SVR increased during CO2 insufflation but not during argon insufflation or CO2 insufflation with a preceding infusion of SR 49059. The SR 49059 injection itself resulted in increases in heart rate and cardiac output and decreases in blood pressure and SVR. We conclude that, during CO2 pneumoperitoneum in pigs, absorbed CO2 initiates a pathophysiological process that stimulates VP release. Hence, VP most likely plays a key role in the hemodynamic response to a CO2-induced pneumoperitoneum. IMPLICATIONS: Intraabdominal insufflation of CO2 is associated with hemodynamic and hormonal changes. Investigating CO2 and argon-insufflated pigs and using a vasopressin antagonist, we found that CO2 insufflation released vasopressin, which, in turn, induced hemodynamic perturbances.

Changes in occlusion pressure (P0.1) and breathing pattern during pressure support ventilation.

BACKGROUND: The purpose of this study was to investigate changes in breathing pattern, neuromuscular drive (P0.1), and activity of the sternocleidomastoid muscles (SCM) during a gradual reduction in pressure support ventilation (PSV) in patients being weaned off controlled mechanical ventilation. METHODS: Eight non-COPD patients recovering from acute respiratory failure were included in this prospective interventional study. All patients were unable to tolerate discontinuation from mechanical ventilation. Each patient was evaluated during a period of spontaneous breathing and during PSV. Four successive levels of PSV were assessed in the following order: 20 cm H2O (PS20), 15 cm H2O (PS15), 10 cm H2O (PS10), and 5 cm H2O (PS5). RESULTS: When pressure support was reduced from PS20 to PS10 the respiratory rate (f) and the rapid shallow breathing index (f/VT) significantly increased and tidal volume (VT) significantly decreased. These parameters did not vary when pressure support was reduced from PS10 to PS5. Conversely, P0.1 varied negligibly between PS20 and PS15 but increased significantly at low PSV levels. P0.1 values were always greater than 2.9 cm H2O (4.1 (1.1) cm H2O) when SCM activity was present. When contraction of the SCM muscles reappeared the P0.1 was the only parameter that changed significantly. CONCLUSIONS: In postoperative septic patients the value of P0.1 seems to be more useful than breathing pattern parameters for setting the optimal level of pressure assistance during PSV.

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

UNLABELLED: In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.