Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients.

BACKGROUND: Epidural fentanyl/bupivacaine infusions often are limited to high dependency units or intensive care units. One thousand fourteen patients receiving epidural fentanyl/bupivacaine infusions for analgesia after major surgery who were managed in the general surgical ward were prospectively surveyed. METHODS: Patients leaving the recovery room with an epidural catheter in situ were assessed three times a day by acute pain service personnel for quality of pain relief, using a rating scale that accounted for pain on movement. The presence of side effects and complications was assessed. RESULTS: Data were collected from February 1990 to May 1993. The average duration of infusion was 3 days. A patient's pain relief was rated as good to excellent on 82.6% of visits. Side effects possibly attributable to fentanyl included sedation (7.4%), pruritus (10.2%), nausea and vomiting (3.1%), and respiratory depression (1.2%). Respiratory depression commonly was associated with sedation and was detected easily on the postsurgical ward, with only four patients requiring naloxone (0.4%). Side effects possibly related to bupivacaine included unpleasant sensory block (2.6%), significant lower limb motor block (3.0%), and hypotension (6.6%). There were two cases of epidural hematoma. Inflammation at the epidural catheter insertion site occurred in 3.8% (38), of which 42% (16) had some cutaneous purulence detected. There were no epidural space infections. Mechanical problems, including dislodgment of the catheter, accounted for 18.7% of infusion discontinuations within the first 72 h. CONCLUSIONS: Postoperative epidural fentanyl/bupivacaine infusions are effective and can be managed readily in general postsurgical wards with minimal complications provided that appropriate patient observations are performed.

A comparison of the effect of propofol or thiopentone on the incidence and severity of suxamethonium-induced myalgia.

We conducted a prospective, randomised single-blind study in 48 adult women undergoing laparoscopic gynaecological surgery to assess the incidence of suxamethonium-induced myalgia. Anaesthesia was induced with either thiopentone or propofol. All other aspects of clinical care were standardised between the groups. The propofol group had a significantly lower incidence of suxamethonium myalgia (19%) compared with the thiopentone group (63%) (P < 0.05). The mechanism of this effect is not understood.

Plasma concentrations of bupivacaine following combined sciatic and femoral 3 in 1 nerve blocks in open knee surgery.

We administered combined femoral 3 in 1 and sciatic nerve blocks to provide postoperative pain relief in 22 consecutive patients undergoing elective knee replacement surgery under spinal anaesthesia. The patients were allocated randomly to two groups. In group A (n = 11) the blocks were performed with 0.5% bupivacaine (with adrenaline) 3 mg/kg body weight and in group B (n = 11) 0.5% plain bupivacaine in the same dose was used. Serial plasma concentrations of bupivacaine were measured for up to 2 h and the duration of postoperative analgesia was measured in both groups. No significant differences were found between the two groups. There were no clinical signs or symptoms of bupivacaine toxicity in each group. This study demonstrated that, after combined sciatic and 3 in 1 femoral block, concentrations of bupivacaine associated with toxicity were not reached, even though the dose of bupivacaine administered exceeded the manufacturer's recommended dose by 50%.