[Shoulder-tip pain during cesarean section under combined spinal-epidural anesthesia].

BACKGROUND: Although shoulder-tip pain during cesarean section has been reported, little is known about this entity. We investigated the incidence of shoulder-tip pain in patients undergoing cesarean delivery under combined spinal-epidural anesthesia (CSEA). Next, we studied whether head-up position during surgery reduced the incidence of shoulder-tip pain due to prevention of the spread of blood and amniotic fluid from the subphrenic space. METHODS: Women with ASA physical status I or II undergoing elective or emergency cesarean delivery under CSEA at our hospital were enrolled in this study. In all women, it was investigated whether shoulder-tip pain occurred or not during and after cesarean delivery. In some of the parturient women in this study, 2 to 5 degree head-up position was employed during the operation (head-up group). We compared the frequency of shoulder-tip pain in the head-up group with that in women who were maintained in a horizontal position (horizontal group). RESULTS: One hundred and twelve of the 242 women recruited to this study experienced shoulder-tip pain. The pain was usually mild to moderate and was relieved in a few days, but 14 patients experienced severe pain as "can not breathe". One hundred and twenty-six of the 160 women lying on an operating table in a head-up position were classified as a head-up group. Shoulder-tip pain was less frequent in the head-up group than horizontal group (50/126 vs. 62/164, P < 0.05). CONCLUSIONS: This study showed that women undergoing cesarean section under CSEA experience shoulder-tip pain with great frequency. Head-up position during surgery decreases shoulder-tip pain during and after cesarean delivery. The results suggest that one of the causes of this pain is the presence of blood or amniotic fluid in the subdiaphragmatic region.

Effects of local infiltration analgesia for posterior knee pain after total knee arthroplasty: comparison with sciatic nerve block.

BACKGROUND: Although femoral nerve block provides good analgesia after total knee arthroplasty (TKA), residual posterior knee pain may decrease patient satisfaction. We compared the efficacy of periarticular infiltration analgesia (PIA) and sciatic nerve block (SNB) for posterior knee pain. METHODS: Forty-nine patients scheduled for TKA were prospectively randomized into the PIA group (n = 25) or SNB group (n = 24) and received general anesthesia with ultrasound-guided femoral nerve block (FNB). In the PIA group, 60 ml 0.5% ropivacaine and 0.3 mg epinephrine were injected intraoperatively into the periarticular soft tissue before inserting the components. In the SNB group, patients received ultrasound-guided SNB with 20 ml 0.375% ropivacaine and periarticular infiltration with 20 ml normal saline and 0.3 mg epinephrine. We evaluated postoperative pain scores, posterior knee pain, frequency of rescue analgesics for 36 h, and performance time of PIA and SNB. RESULTS: Visual analogue pain scores at 12-24 h were significantly lower in the PIA group than in the SNB group (p < 0.05). The majority of patients had no posterior knee pain. There were no significant differences between the groups in frequency and time of first administration of rescue analgesics and in side effects. Time for performance of periarticular infiltration was significantly shorter than that for SNB (p < 0.05). The dose of intraoperative remifentanil was significantly lower in the SNB group than in the PIA group (p < 0.001). CONCLUSIONS: The combination of FNB and PIA provides sufficient analgesia after TKA. The rapid and convenient periarticular infiltration technique could be a good alternative to SNB.

[Anesthetic management with remifentanil infusion during laparoscopic cholecystectomy].

BACKGROUND: In the anesthetic management of laparoscopic surgery, hemodynamic changes appear on the skin incision and pneumoperitoneum. Remifentanil may suppress the cardiovascular changes on the pneumoperitoneum in the laparoscopic cholecystectomy (LC). METHOD: One hundred-seven patients scheduled for LC were assigned into two groups; remifentanil (R), and epidural (E) groups. In R group, remifentanil was administered at 0.2 microg x kg(-1) x min(-1) from the induction of anesthesia. In E group, an epidural catheter was placed between T10-12 and 0.2% ropivacaine was infused continuously at 6 ml x hr(-1) via epidural catheter. Anesthesia was maintained by propofol at 5 mg x kg(-1) x hr(-1) following the induction by propofol and vecuronium in both groups. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) and bispectral index (BIS) were compared at the entrance of the operating room, skin incision, pneumoperitoneum and extubation of the endotracheal tube between two groups. RESULTS: At the pneumoperitoneum, statistical significance was found in HR, but there was no significant difference in blood pressure and BIS between the two groups. CONCLUSIONS: Compared with epidural anesthetic management, remifentanil suppresses significantly the elevation of heart rate, but not blood pressure at the pneumoperitoneum.