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Abstract Introduction: COVID-19 is mild in 80% of cases; however, it progresses to severe disease in 5% of patients, thus requiring intensive care unit (ICU) admission. Objective: To identify demographic, clinical, and treatment-related factors associated with mortality in patients with COVID-19 treated at the ICU of a quaternary care hospital in Medellín, Colombia. Materials and methods: Retrospective cohort study. The medical records of 182 patients admitted to the ICU between March and December 2020 due to COVID-19 were analyzed. Bivariate analyses (chi-square, Fisher's exact, unpaired Student's t test, or Mann-Whitney U test) were performed to evaluate the association between demographic characteristics, presence of coexisting diseases, laboratory results, therapeutic interventions, ventilatory and hemodynamic support requirement, and mortality. In addition, a multivariate analysis was performed, in which simple and multiple binary logistic regressions were used, calculating crude and adjusted relative risks (RR). A significance level of p<0.05 was considered. Results: Mortality was reported in 47.80% of patients. In the multivariate analysis model, the following factors were protective factors: age <60 years (aRR: 0.154, 95%CI: 0.059-0.401; p=0.000), use of vasopressors (aRR: 0.082, 95%CI: 0.021-0.319; p<0.001), and use of renal replacement therapy (aRR: 0.205 95%CI 0.059 - 0.716; p=0.013). On the other hand, not performing tracheostomy was an independent protective factor for mortality (aRR: 14.959, 95%CI: 4.865-45.998; p<0.001). A lower platelet count during the ICU stay had a neutral effect, although it was a significantly associated quantitative variable (aRR: 0.999, 95%CI: 0.990-0.999; p=0.003). Conclusions: In the present study, age <60 years, the use of vasopressors, and renal replacement therapy were protective factors, while not performing tracheostomy was a risk factor for mortality. Furthermore, a lower platelet count during ICU stay was a significantly associated quantitative variable.
Resumen Introducción. La COVID-19 se manifiesta en el 80% de los casos de forma leve; sin embargo, en el 5% progresa a enfermedad severa con necesidad de manejo en unidad de cuidados intensivos (UCI). Objetivo. Identificar los factores demográficos, clínicos y de tratamiento asociados a la mortalidad en pacientes con COVID-19 atendidos en la UCI de un hospital de cuarto nivel de atención de Medellín, Colombia. Materiales y métodos. Estudio de cohorte retrospectivo. Se analizaron las historias clínicas de 182 pacientes admitidos a UCI por COVID-19 entre marzo y diciembre de 2020. Se realizaron análisis bivariados (pruebas de chi-cuadrado, exacta de Fisher, t-Student no pareada o U de Mann-Whitney) para evaluar la asociación entre, por un lado, características demográficas, presencia de enfermedades coexistentes, resultados de laboratorio, intervenciones terapéuticas, requerimiento de soporte ventilatorio y hemodinámico, y, por otro, mortalidad. Además, se realizó un análisis multivariado en el que se construyeron regresiones logísticas binarias simples y múltiples, calculando riesgos relativos (RR) crudos y ajustados. Se consideró un nivel de significancia de p<0.05. Resultados. La mortalidad fue de 47.80%. En el análisis multivariado, los siguientes factores se comportaron como protectores para mortalidad: edad <60 años (RRa: 0.154, IC95%: 0.059-0.401; p=0.000), uso de vasopresores (RRa 0.082, IC95%: 0.021-0.319; p<0.001) y uso de terapia de remplazo renal (RRa: 0.205, IC95%: 0.059-0.716; p=0.013). La realización de traqueostomía se comportó como un factor protector independiente para mortalidad (RRa: 0.073, IC95%: 0.012-0.827; p<0.001). El conteo más bajo de plaquetas registrado durante la estancia en UCI tuvo un efecto neutro, aunque fue una variable cuantitativa significativamente asociada (RRa: 0.999, IC95%: 0.990-0.999; p=0.003). Conclusiones. En el presente estudio, la edad <60 años y el uso de vasopresores y de terapia de remplazo renal se comportaron como factores protectores, mientras que la no realización de traqueostomía se comportó como factor de riesgo para mortalidad. Además, el conteo más bajo de plaquetas registrado durante la estancia en UCI fue una variable cuantitativa significativamente asociada.
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Objective To systematically evaluate the incidences of complications of high frequency oscillatory ventilation ( HFOV) and conventional mechanical ventilation ( CMV ) in premature infants. Method Randomized controlled trials of HFOV and CMV in premature infants published in databases including PubMed, Embase, Cochrane Library, CNKI Database, Wanfang Database, Weipu Chinese Sci－Tech Periodical Database were searched.The retrieval time was from the establishment of the databases to January 2018.The quality of the literature were evaluated , and Stata 15.0 statistical software was used for meta－analysis.Result A total of 18 articles and 3 888 premature infants were included in the study , including 1 910 in the HFOV group and 1 978 in the CMV group.No significant differences were found in the incidences of in－hospital mortality, air leakage syndromes , retinopathy of prematurity (ROP),≥grade 3 intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC) and patent ductus arteriosus ( PDA) requiring medication or surgery ( P ＞0.05 ).The incidences of bronchopulmonary dysplasia (BPD) (RR ＝0.90,95%CI 0.83 ～0.98),≥grade 2 ROP (RR ＝0.78, 95%CI 0.63～0.96) and pulmonary hemorrhage (RR＝0.63, 95%CI 0.47～0.85) in HFOV group was significantly lower than the CMV group (P＜0.05).In the subgroup analysis, the results of the researches in 1980s, 1990s, 2000s, and 2010s showed that no significant differences existed in in－hospital mortality between the HFOV group and the CMV group on ventilator pressure control mode and volume control mode (P＞0.05).Conclusion Current evidences suggested that comparing with CMV , the application of HFOV in preterm infants might reduce the incidences of BPD ,≥grade 2 ROP and pulmonary hemorrhage.
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Objective To investigate the application and nursing of fiberoptic bronchoscopy in mechanical ventilation of patients with acute respiratory distress syndrome .Methods 63 patients with acute respiratory distress syndrome who were treated with mechanical ventilation were randomly divided into control group (n=32) and obser-vation group (n=31).The patients in each group were treated with mechanical ventilation and western medicine .The control group was given routine nursing and suctioning .The observation group was treated with fiberoptic bronchoscopy and high quality nursing.The treatment period was 7 days.The changes of blood oxygen saturation (SpO2),arterial blood carbon dioxide partial pressure (PaCO2 ) and oxygenation index (PaO2/FiO2 ),the time of mechanical ventilation,the number of cases of ventilator -associated pneumonia ( VAP) ,the number of successful cases of weaning ,and the 28-day mortality were observed .The curative effect of the two groups was observed .Results Before treatment , the SpO2,PaCO2,PaO2/FiO2 between the two groups had no statistically significant differences (all P >0.05).After treatment,the SpO2 of the two groups increased [(94.7 ±3.4)％ in the observation group,(90.5 ±3.0)％ in the control group],and the PaCO2 reduced[the observation group (46.1 ±3.9)mmHg,the control group (52.2 ±3.4)mmHg], PaO2/FiO2 increased[observation group (222.9 ±13.6)mmHg,control group (182.2 ±16.7)mmHg],which of the observation group were better than the control group (t=5.203,6.624,10.587,all P<0.01).The time of mechanical ventilation ,the number of VAP cases ,the number of successful cases of weaning ,28-day mortality in the observation group were (10.2 ±2.9) d,2 cases,24 cases and 22.58％,which were better than those in the control group ,the differences were statistically significant (t=6.325,χ2 =4.057,5.10,4.089,all P<0.05).The total effective rate in the observation group was 77.42％,which was significantly higher than 53.13％ in the control group (χ2 =4.089, P<0.05).Conclusion Application of fiber bronchoscopy and quality care in the mechanical ventilation of patients with acute respiratory distress syndrome has good effect ,it is worthy of clinical promotion .
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Objective To study the clinical effects of pulmonary recruitment maneuvers combined with pressure regulation volume control (PRVC) in the treatment of severe respiratory distress syndrome (RDS) in premature infants.Method From July 2015 to September 2016,preterm infants of grade Ⅲ-Ⅳ RDS who received PRVC treatment in neonatal department of Huai'an Maternal and Child Health Hospital were assigned into recruitment maneuver group and control group (without recruitment maneuver) using randon number table.The ventilator parameters were observed at 1,2,6,12,18 h and 24 h after ventilation.Recovery rate,duration of oxygen therapy and ventilation,duration of hospital stay,incidence of second dose of pulmonary surfactant and complications were compared between two groups.Result A total of 18 cases were included in recruitment maneuver group and 19 cases in control group.The recovery rate of recruitment maneuver group was higher than control group (16/18 vs.10/19).The duration of oxygen therapy [(6.6 ± 2.3) d vs.(11.8 ± 3.0) d],duration of ventilation [(4.1 ± 2.3) d vs.(6.4 ± 2.8) d],duration of hospital stay [(26.7 ± 7.0) d vs.(33.0 ± 8.4) d] in recruitment maneuver group were significantly shorter than control group (P ＜ 0.05).The proportion of bronchopulmonary dysplasia (1/18 vs.8/19),retinopathy of premature (1/18 vs.7/19),patent ductus arteriosus that require medication closure (1/18 vs.7/19)and incidence of second dose of pulmonary surfactant (2/18 vs.9/19) in recruitment maneuver group were significantly lower than control group (P ＜ 0.05).While the complication of air leak,necrotizing enteritis,Ⅲ-V grade intracranial hemorrhage showed no significant differences between the two groups (P ＞ 0.05).Conclusion Recruitment maneuvers combined with PRVC in treatment of severe RDS premature infants can improve recovery rate and oxygenation.It can also shorten the duration of oxygen therapy,ventilation and hospital stay.It can reduce the incidence of bronchopulmonary dysplasia and retinopathy of premature.It is worth spreading in clinical practice.reduce the incidence of bronchopuhmonary dysplasia and retinopathy.It is worthy of promotion.
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Objective To evaluate the therapeutic effects and complications of modified facial mask for non-invasive ventilation (NIV) in elderly patients with respiratory failure.Methods A total of 132 elderly patients(107 males and 25 female,aged 78.5±8.6 years) treated with NIV from February 2008 to May 2011 were randomized into two groups:modified facial mask(group A,n=68,56 males and 12 females,aged 78.8±22.2 years) and control facial mask(group B,n=64,64 males and 13 females,aged 76.6±20.4 years).Duration of NIV,time in RICU(respiratory intensive care unit),length of hospital stay,risk for hospital acquired pneumonia (HAP),risk for invasive ventilation,cure rates,in-hospital mortality,NIV failure rate and cost were compared between the two groups.The complications of NIV,such as oropharyngeal dryness,skin damage of face and nose,abdominal bloating,gas leakage from mask were also compared between the two groups.Results Compared with group B,duration of NIV(12.2±2.3 d vs.18.4±3.6d),time in RICU(7.3±3.2d vs.14.6t5.4d),length of in hospital stay(16.6±4.2d vs.28.2±6.2)d,and cost(2.23±0.12 ten thousand yuan vs.4.23± 0.24 ten thousand yua) in group A were significantly decreased(t=9.72,14.91,13.08,10.81 respectively,all P＜0.05).The risk for invasive ventilation [2.9％ (2 cases) vs.43.8％(28 cases)],NIV failure rate [5.9％ (4 cases) vs.12.5％ (28 cases)] were also decreased in group A compared with group B(x2 =31.26,25.74,both P＜0.05).Compared with group B,The complications of NIV such as skin damage of face and nose[4.4％ (3 cases) vs.37.5％ (24 cases)],abdominal bloating [2.9％ (2 cases) vs.28.1％ (18 cases)],gas leakage from mask [8.8 ％ (6 cases)vs.50％(32 cases)] in group A were significantly decreased(x2 =31.26,25.74,all P＜0.05).Conclusions Modified facial mask for NIV is effective in the treatment of elderly patients with respiratory failure.The complications and in-hospital mortality are reduced with the application of modified facial mask for NIV and it is highly tolerated by patients.Modified facial mask for NIV is the first choice in the treatment in elderly patients with respiratory failure.
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Aims: The purpose of the present study was to investigate the viability of the use of piglets as experimental model of newborn chest physiotherapy.Methods: Five piglets (1-2 days old) were studied. The animals received anesthesia and analgesia and were ventilated with positive pressure, on 100% oxygen. All piglets received chest physiotherapy protocol of manual vibration.Results: All five animals presented stable physiological parameters during the preparation phase and the physiotherapy protocol application.Conclusions: We conclude that piglets are a viable model for studies of chest physiotherapy in mechanically ventilated newborns.
Objetivos: o objetivo do presente estudo foi investigar a viabilidade do uso de suínos como modelo experimental de fisioterapia respiratória em recém-nascidos.Métodos: foram estudados cinco suínos recém-nascidos (1-2 dias de idade). Os animais receberam anestesia e analgesia e foram ventilados com pressão positiva, com oxigênio a 100%. Todos os animais receberam o protocolo de fisioterapia respiratória de vibração manual.Resultados: todos os cinco animais apresentaram estabilidade dos parâmetros fisiológicos durante a fase de preparação e aplicação do protocolo de fisioterapia.Conclusões: concluímos que os suínos representam um modelo viável para estudos de fisioterapia respiratória em recém-nascidos em ventilação mecânica.
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Animals , Infant, Newborn , Models, Animal , Respiration, Artificial , Respiratory TherapyABSTRACT
Objective To explore sedation effects of fentanyl and midazolam during mechanical ventilation.Methods 40 neonates admitted for purposes of mechanical ventilation were divided into two groups randomly ,20 cases of fentanyl, midazolam group of 20 patients. Group of fentany 2 ～5 μg · kg-1 · h-1 , continuously intravenous injection. Load of midazolam was 0. 1mg/kg by injection,continue to maintain by 0.05mg · kg-1 · h-1. Sedative effects were observed duration of mechanical ventilation and heart rate monitoring during the treatment the in two groups(HR),respiration(R) ,non-invasive mean arterial blood pressure(MBP). Results HR、R and MBP of Fentanyl group had no significant difference between after treatment 30min ,6h, 12h and 24h and before treatment (all P ＞ 0.05). HR、 R and MBP of midazolam group had significant difference between after treatment 30min, 6h, 12h and 24h and before treatment(all P ＜ 0. 05). Fentanyl group took shorter time and lower pressure duration of mechanical ventilation(all P ＜ 0.05). Two of the ideal number of cases sedation was no significant difference(P ＞ 0.05). Conclusion The sedation effect of fentanyl in the neonatal mechanical ventilation was better than midazolam, and impact on circulation and respiration was small, and the time from the ventilator was shorter.
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Objective To explore morphine usage in emergency department (ED) and its effect on outcome in elderly patients with acute decompensated heart failure (ADHF) in a single Chinese center. Methods A prospective observational analysis was performed in elderly patients aged 65-99years with newly diagnosed ADHF, who were treated and admitted from ED of our hospital. The data including patients' demographic characters, past medical history, initial presentations and medication taking were collected and analyzed. According to using morphine or not, the patients were divided into two groups. The effects of morphine on mechanical ventilation, hospitalization stay and in-hospital mortality were also evaluated. Results The 82 patients were enrolled in this study, 52 males and 30females. In the 41 (50. 0%) patients using morphine (morphine usage group), the foregone incidence rates of coronary heart disease, type 2 diabetes mellitus and stroke were less, the levels of troponin T and random blood sugar were increased in morphine usage group than in non-morphine usage group.No other differences were found in initial presentations between the two groups. The patients often theophylline before morphine administration. And they had a higher prevalence of mechanical ventilation (95%CI: 1.22-7.41), but no differences were found in hospitalization stay and in-hospital mortality between the two groups. Conclusions Morphine is still as a common medicine in treatment of ADHF in ED. Morphine usage can increase prevalence of mechanical ventilation without influencing hospitalization stay and in-hospital mortality even in elderly ADHF patients. Morphine may be a safe medication in the rational treatment of early-stage ADHF in elderly patients with mechanical ventilation support.
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Objective To discuss the flail chest in the rib the fixed surgery opportunity,in fixed spot. Meth-ads Clinical data of 26 flail cheat patients in my courtyard were retrospectively analyzed. Results 26 patients were cured completely,nobody died,no obvious cheat abnormity was observed. Condusion Regarding the flail cheat pa-tient, at the right moment to adopt the fixed surgery in the rib, restore the integrity of the thoracic wall, may reduce the mortality rate, the chest shape normal, the quality of life obtains the enhancement.
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Objective To investigate the effect of matrix metalloproteinases(MMPs) in ventilator-induced lung injury inflammatory reaction of newborn rabbits.Methods Seventy-five newborn rabbits aged 1-5 days were randomly arranged to 3 groups:control group(n=3),other 72 rabbits designed by 2?2?3 factorial were divided into high concentration oxygen(100%)and low concentration oxygen(45%) groups,and each group was subdivided into 2 groups:High peak inspiratory pressure(PIP)group and low PIP group.All rabbits were done by mechanical ventilation and killed to obtain lung tissue at 1,3,6 hours after trailing respectively.The concentration of MMP-9 and MMP-2 in lung tissue bomogenate were detected by ELISA,at the same time the ratio of wet to dry was detected and pathological section was analyzed.Results 1.The concentration of MMP-2 in high concentration oxygen group,high PIP group and low PIP group increased compared with that in normal group,and there were significant differences.2.The mean concentration of MMP-9 was lower in high concentration oxygen group than that in normal control group,and there was significant difference between 2 groups.The mean concentration of MMP-9 in low concentration oxygen group was higher than that in normal group,and there was no significant difference between 2 groups.There was no significant difference in effect to mean concentration of MMP-9 by different PIP.3.There were positive correlation between MMP-2 and MMP-9,MMP-2 and the ratio of wet to dry in lung.Conclusions Within 6 hours in newborn rabbits by mechanical ventilation,ventilation with high concentration oxygen up-regulate MMP-2,but down-regulated MMP-9.The lungs stretch by mechanical ventilation increase MMP-9,but decrease MMP-2.Mechanical ventilation can affect the synthesis of MMPs,and MMPs plays an important role in ventilator-induced lung injury of newborn rabbits.
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Objective: To investigate the changes of haemodynamics, pulmonary mechanics and blood gas in volume controlled and pressure controlled ventilatory patterns during one-lung ventilation (OLV). Methods: 20 patients with patent ductus arteriosus (PDA) underwent left thoracotomy PDA ligation with right OLV. The patients were divided into three groups: two-lung ventilation with volume controlled (TLV-VCV), one-lung ventilation with volume controlled (OLV-VCV), and one-lung ventilation with pressure controlled (OLV-PCV). After two-lung ventilation with VCV, one-lung ventilation was started by VCV and the ventilation mode was then switched to PCV. All measurements were made 25 min after initiation of the ventilation mode. The respiratory mechanics index was measured by side stream spirometry (SSS), including peak airway pressure (Ppeak), plateau pressure (Pplat), airway resistance (Raw), lung compliance (Cdyn) and inspiratory and expiratory minute ventilation (Mvi, Mve). Cardiac output (CO), stroke volume (SV), systemic vascular resistance (SVR), left ventricular ejectiontime (LVETi), and aortic blood flow acceleration (ACC) were also measured, by using the transesophageal Doppler (TED) monitor. Arterial blood gases was determined in every ventilation mode. Results: Ppeak、Pplat and Raw were significantly higher during OLV-VCV than that during TLV-VCV (P
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The effects of the prone position on the improvement of oxygenation in patients with ARDS were reported already twenty years ago. Recent studies have shown that the prone position would improve the ventilation and perfusion relationship as it improves the ventilation in the local area without altering the pulmonary blood flow during the support of ventilation in the patients with ARDS. We have applied the prone position repeatly on the patient with ARDS which developed after the removal of a bilateral pulmonary empyema and decortication. The initial effect of the prone position on oxygenation improved the PaO2/FiO2 (arterial oxygen tension divided by inspired oxygen concentration) ratio, 104.3 to 132.9, at FiO2 0.7. Improvement of oxygenation was maintained with repeat position change, three times over 24 hours, from supine to prone position.
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Humans , Empyema , Oxygen , Perfusion , Prone Position , Respiratory Distress Syndrome , VentilationABSTRACT
BACKGROUND: Mechanical ventilation is frequently used in the intensive care unit. Sedation is usually required to tolerate the presence of a tracheal tube and other unpleasant stimulus during mechanical ventilation. The ideal regimen for sedation has not yet been determined. This study was designed to compare the characteristics of safety and effectiveness of propofol to those of midazolam for sedation in patients undergoing mechanical ventilation in surgical intensive care unit. METHODS: 44 mechanically ventilated patients were randomized to receive either propofol (loading dose 20~40 mg, followed by 10~50 microgram/kg/min) or midazolam (loading dose 1~2 mg, followed by 0.2~0.8 microgram/kg/min). Infusion rates were titrated to 3~5 points of Ramsay scale. All patients also received morphine 0.5 microgram/kg/24 h without any muscle relaxants. Hemo-dynamic changes (SBP, DBP, HR), ventilatory parameters and recovery time were evaluated. Hepatic and renal functions were measured before start of infusion and after discontinuation of both drugs. RESULTS: The mean initial loading and maintenance dose were 0.35 mg/kg and 1.5 mg/kg/hr for the propofol, 29.2 microgram/kg and 29.1 microgram/kg/h for midazolam group, respectively. There was no difference between the two groups regarding the sedation score evaluated by Ramsay scale. Patients receiving propofol recovered more rapidly than those receiving midazolam (40.5+/-20.1 min vs. 88.2+/-29.5 min respectively; P30% of pre-injection value) or hepatic or renal function changes. CONCLUSIONS: Propofol is a sedative agent with shorter awakening time than midazolam but with the same safety and clinical effectiveness for the continuous sedation of mechanically ventilated patients.
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Humans , Critical Care , Intensive Care Units , Midazolam , Morphine , Propofol , Respiration, ArtificialABSTRACT
BACKGROUND: Mechanical ventilation is frequently used in the intensive care unit. Sedation is usually required to tolerate the presence of a tracheal tube and other unpleasant stimulus during mechanical ventilation. The ideal regimen for sedation has not yet been determined. This study was designed to compare the characteristics of safety and effectiveness of propofol to those of midazolam for sedation in patients undergoing mechanical ventilation in surgical intensive care unit. METHODS: 44 mechanically ventilated patients were randomized to receive either propofol (loading dose 20~40 mg, followed by 10~50 microgram/kg/min) or midazolam (loading dose 1~2 mg, followed by 0.2~0.8 microgram/kg/min). Infusion rates were titrated to 3~5 points of Ramsay scale. All patients also received morphine 0.5 microgram/kg/24 h without any muscle relaxants. Hemo-dynamic changes (SBP, DBP, HR), ventilatory parameters and recovery time were evaluated. Hepatic and renal functions were measured before start of infusion and after discontinuation of both drugs. RESULTS: The mean initial loading and maintenance dose were 0.35 mg/kg and 1.5 mg/kg/hr for the propofol, 29.2 microgram/kg and 29.1 microgram/kg/h for midazolam group, respectively. There was no difference between the two groups regarding the sedation score evaluated by Ramsay scale. Patients receiving propofol recovered more rapidly than those receiving midazolam (40.5+/-20.1 min vs. 88.2+/-29.5 min respectively; P30% of pre-injection value) or hepatic or renal function changes. CONCLUSIONS: Propofol is a sedative agent with shorter awakening time than midazolam but with the same safety and clinical effectiveness for the continuous sedation of mechanically ventilated patients.
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Humans , Critical Care , Intensive Care Units , Midazolam , Morphine , Propofol , Respiration, ArtificialABSTRACT
BACKGROUND: Epidural buprenorphine has been shown to reduce the anesthetic and analgesic requirements during the perioperative period. The goal of this study is to see whether epidural buprenorprhine reduce the dose of fentanyl infusion for anesthetic management and postoperative pain control and shorten the duration of postoperative ventilatory support and endotracheal intubation in open heart surgery patients. Method: Total 50 patients who underwent the open heart surgery were included for the study. General anesthesia was maintained with a nitrous oxide (2 L/min)-oxygen (2 L/min)-isoflurane (0.5~1.5 %). In control group additional anesthetic requirement is supplemented with intermittent intravenous injection of fentanyl. In buprenorphine group initial loading dose of 0.3 mg of epidural buprenorphine followed by continuous epidural infusion (20 microgram/hr) and additional anesthetic requirement was supplemented with intravenous fentanyl. RESULTS: The total dose of fentanyl requirement was significantly lower in buprenorphine group than in control group. The duration of ventilatory support and endotracheal intubation were significantly shorter in buprenorphine group than in control group. The duration of ICU stay was not different between two groups. CONCLUSIONS: Epidural buprenorphine reduced the anesthetic requirement and postoperative pain and shortened the duration of postoperative ventilatory support and endotracheal intubation. Therefore epidural buprenorphine can be an reasonable alternative for an adjunctive with general anesthesia and postoperative pain control.