Scalp nerve blocks decrease the severity of pain after craniotomy.

UNLABELLED: Up to 80% of patients report moderate to severe pain after craniotomy. In this study, we assessed the efficacy of scalp block for decreasing postoperative pain in brain surgery. Thirty patients scheduled for supratentorial craniotomy were enrolled. They were randomly divided into two groups: Ropivacaine (scalp block with 20 mL of ropivacaine 0.75%) and Saline (scalp block with 20 mL of saline 0.9%). Anesthesia was standardized. The scalp block was performed after skin closure and before awakening. Postoperative pain was assessed at 4, 8, 12, 16, 20, 24, and 48 h by using a 10-cm visual analog scale. Analgesia was provided with sub- cutaneous codeine as requested by the patient. Average visual analog scale scores were higher in the Saline group as compared with Ropivacaine (3.7 +/- 2.4 vs 2.0 +/- 1.6; P = 0.036). The total dose of codeine did not differ, nor did the duration of time before the first dose of codeine was required in the Ropivacaine (571 +/- 765 min) versus Saline (319 +/- 409 min; P = 0.17) group. In conclusion, we found that postoperative scalp block decreases the severity of pain after craniotomy and that this effect is long lasting, possibly through a preemptive mechanism. IMPLICATIONS: Up to 80% of patients report moderate to severe pain after craniotomy. This randomized double-blinded study demonstrated that ropivacaine scalp block decreases the severity of pain after supratentorial craniotomy.

The safe use of epidural anesthesia after subcutaneous injection of low-dose heparin in general abdominal surgery.

OBJECTIVE: To determine if epidural anesthesia after the subcutaneous injection of low-dose unfractionated heparin (LDUH) in patients who undergo elective bowel surgery is safe with respect to hemorrhagic complications. DESIGN: A prospective cohort study. SETTING: Two hospitals affiliated with the Université de Montréal. PATIENTS: Fifty patients scheduled for elective bowel surgery. INTERVENTION: Subcutaneous injection of 5000 units of LDUH and elective surgery for colonic carcinoma, chronic diverticulosis or inflammatory bowel disease. MAIN OUTCOME MEASURES: Activated partial thromboplastin time (APTT), anti-IIa and anti-Xa heparin levels measured before and 2 and 4 hours after injection of LDUH. RESULTS: In no case was the heparin anti-IIa or anti-Xa level higher than 0.20 U/mL, which is considered a significant detectable level of heparin. CONCLUSION: LDUH given subcutaneously is not associated with significant detectable heparin levels, so epidural anesthesia should be safe when performed 2 hours after LDUH injection in patients who undergo general abdominal surgery in the absence of any other impairment of hemostasis.

Percutaneous biliary drainage: clinical trial of analgesia with interpleural block.

PURPOSE: To determine the analgesic efficacy and safety of interpleural block for percutaneous biliary drainage. MATERIALS AND METHODS: In this double-blind study, 34 age- and sex-matched patients who were to undergo percutaneous biliary drainage because of malignant biliary obstruction were randomly assigned to the true-block group (30 mL 0.5% bupivacaine block) or placebo-block group; all had access to a patient-controlled analgesia (fentanyl) pump. Self medication, pain reports, blood pressure, heart rate, and oxygen saturation were monitored during and until 8 hours after drainage. The McGill Pain Questionnaire was administered 1 hour after biliary drainage. RESULTS: Patients in the placebo group self administered statistically significantly more fentanyl than did patients in the true-block group (P = .008). Peak pain scores (10-point scale) and McGill Pain Questionnaire scores were statistically significantly higher for the placebo group patients (P = .017 and P = .001, respectively). There were no differences between groups in terms of blood pressure, heart rate, and oxygen saturation. Two patients had pneumothorax caused by the interpleural block. CONCLUSION: Interpleural block was effective in decreasing pain and opioid requirements during and after percutaneous biliary drainage and did not compromise the cardiopulmonary status of the patient. However, the rate of pneumothorax was higher than previously reported.

Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery.

UNLABELLED: To assess the role of postoperative analgesia on myocardial ischemia after aortic surgery, we compared intravenous patient-controlled analgesia (PCA) with thoracic epidural analgesia (TEA). One hundred twenty-four patients were prospectively randomized to the PCA or TEA group. In the TEA group, a T6-7 or T7-8 epidural catheter was inserted before the induction of general anesthesia. Within 1 h of the end of surgery, analgesia and 24-h two-channel Holter monitoring were begun. Myocardial ischemia was defined as ST segment depression > or = 1 mm, 0.06 s after the J point, and lasting for more than 1 min. In the PCA group, a bolus of morphine, 0.05 mg/kg, was given, followed by 0.02 mg/kg of morphine on demand every 10 min. Bupivacaine 0.125% and fentanyl 10 microg/mL was used in the TEA group. Analgesics were titrated to maintain a visual analog scale score < or = 3. The overall incidence of myocardial ischemia was 18.4%-18.2% for TEA and 18.6% for PCA (P = not significant). There were no differences between the groups in the total duration of ischemia per patient (22.2 +/- 119.8 min for TEA and 20.5 +/- 99 min for PCA) and the number of episodes per patient (0.69 +/- 2.1 for TEA and 1.2 +/- 4.9 for PCA). Twenty-three patients had an adverse cardiac outcome, although there were no differences between the groups. The postoperative pain control was superior with TEA. In these patients undergoing elective aortic surgery, the use of postoperative TEA did not result in a lower incidence of early myocardial ischemia compared with intravenous PCA with morphine, despite better analgesia with TEA. IMPLICATIONS: Postoperative myocardial ischemia is associated with adverse cardiac outcome. Using Holter monitoring after aortic surgery, this study shows that the use of thoracic epidural analgesia with bupivacaine and fentanyl did not result in a lower incidence of myocardial ischemia compared with intravenous patient-controlled analgesia with morphine.

Bupivacaine decreases epidural meperidine requirements after abdominal surgery.

PURPOSE: The purpose of this study was to determine the optimal of three concentrations of bupivacaine (0.0%, 0.05%, 0.10%) to add to an epidural infusion of meperidine (1 mg.ml-1) for postoperative pain relief. METHODS: In this prospective, double blind study, 60 patients undergoing abdominal surgery with general anaesthesia were randomized into three groups to receive for postoperative epidural analgesia: 1) 1 mg.ml-1 meperidine (0% group), 2) bupivacaine 0.05% and 1 mg.ml-1 meperidine (0.05% group), 3) bupivacaine 0.10% and 1 mg.ml-1 meperidine (0.10% group). Postoperatively, the epidural infusion rate was titrated to produce adequate analgesia and pain was assessed at rest and on movement. RESULTS: There were no differences in demographic data, average pain scores or side effects among the three groups. However, there was improvement of pain relief at rest over time in the three groups (P < 0.05). Postoperative epidural analgesic infusion rates increased over time for the three groups (P < 0.05) and were lower in the 0.10% group (mean of 10.0 ml.hr-1) than in the 0% group (mean of 12.6 ml.hr-1) (P < 0.05). More than half of the 0% group had serum meperidine concentrations > 400 g.L-1 to control moderate postoperative pain. CONCLUSION: Although analgesia was identical among groups, the lower serum concentrations of meperidine support the addition of bupivacaine 0.10% to meperidine when administered as a continuous infusion following abdominal surgery.

[Evaluation of the activity of a postoperative analgesia department in a Canadian hospital]. / Bilan d'activité d'un service d'analgésie postopératoire dans un hôpital canadien.

OBJECTIVE: To describe the setting up and the activity of an acute pain service (APS). STUDY DESIGN: Retrospective descriptive study including two surveys among the nursing staff, the first one eight months after the setting up of the APS and the second one ten months later. RESULTS: In the first 19 months, 3,404 patients were treated in the APS: 1,456 with patient-controlled analgesia (PCA), 1,299 with epidural analgesia, 589 with spinal opioids and 60 with continuous nerve blocks. The resulting overall incidence of respiratory depression was 0.7%. It ranged from 0% with continuous nerve block to 1.2% with PCA. It was at 0.3% with epidural analgesia and 0.5% with spinal opioids. Both surveys confirmed that nurses had a positive attitude toward the APS, mainly because they believed it offered patients significant advantages. Many of them thought that epidural analgesia and PCA were likely to impede patient's ambulation and most of them agreed that these techniques increased their work load. CONCLUSION: Although the incidence of respiratory depression was low among the APS patients, it can probably still be decreased by a more refined patient selection. Setting up an APS is viewed positively by the nursing staff in spite of some perceived disadvantages.

Changes in oxygen saturation in the 72 hours after hip surgery: the effect of oxygen therapy.

The aim of this study was to investigate changes in oxygen saturation (SpO2) occurring during the three days following hip surgery in patients in this hospital and to determine to what extent SpO2 might be improved by oxygen therapy for 24 or 72 hours. Eighty-three patients (aged 43-96 years) scheduled for elective total hip replacement or emergency surgery for hip fractures were studied. Forty-four patients had 24 hour postoperative oxygen prescribed by their anaesthetist or surgeon; we randomized these to either continue oxygen for a total of three days (Group 1) or to discontinue oxygen after Day 1 (Group 2). Patients not prescribed oxygen by the surgeon or anaesthetist (n = 39) were randomly assigned either to receive oxygen for three days (Group 3) or not to receive oxygen (Group 4). Oxygen was administered through nasal cannulae at a flow of 2 l.min-1. SpO2 was measured every 10 seconds for three days and stored on computer disc. Percentage of time spent with SpO2 below 90% was used as an index of desaturation. Patients receiving oxygen had significantly improved SpO2. In patients not receiving oxygen, desaturation was most severe on Days 1 and 2, improving somewhat on Day 3. On Day 2 desaturation was similar in Groups 2 and 4. When oxygen was not being administered males were significantly more desaturated than females. Our investigations indicate that following hip surgery poor saturation continues for at least two days and can be improved by oxygen therapy.

Coeliac plexus block for chronic pain syndromes.

The purpose of this article is to familiarize the anaesthetist with the basic anatomy of the coeliac plexus; the techniques used to perform the procedure, its indications, complications and results in the management of chronic abdominal pain syndromes. Radiological, surgical and anaesthetic literature from the beginning of the century were reviewed. The main indication for neurolytic coeliac plexus block is intractable pain secondary to carcinoma of the pancreas or stomach. There appear to be theoretical advantages to techniques that result in spread of solution anterior to the aorta, such as the trans-aortic approach. These have not yet been demonstrated in any studies with large numbers of patients.