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.

[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.

[Cerebral arterial air embolism associated with pneumothorax in a patient with pressure support ventilation]. / Embolie gazeuse cérébrale consécutive à un pneumothorax chez une patiente en aide inspiratoire.

A 20-year-old woman was admitted to the ICU following a road traffic accident. She had a periorbital haematoma with a normal cerebral state on CT-scan, intrahepatic and intrasplenic haematomas and several fractures of the limb that were fixed on day 3. Twenty-four hours later, she developed a cough with symptoms of decerebration The head CT-scan showed diffuse pneumocephalus suitable with cerebral air embolism and the chest X ray a right tension pneumothorax. A chest tube was inserted. Despite the lack of hyperbaric oxygen therapy the patient recovered fully. The pneumocephalus disappeared totally after 48 hours. Seven days later, CT-scan of the head with coronal slides showed an orbital floor fracture associated with an intra-orbital aerocele.

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.