Effects of Intravenous and Epidural Patient-Controlled Analgesia on Postoperative Pain and Knee Rehabilitation after a Unilateral Total Knee Replacement / 대한마취과학회지

BACKGROUND: Postoperative pain is a major concern after a total knee replacement (TKR). It hinders early intense physical therapy, the most influential factor for good postoperative knee rehabilitation. The purpose of this study was to compare intravenous patient-controlled analgesia (IV-PCA) using morphine and continuous ketorolac IV infusion with patient-controlled epidural analgesia (PCEA) using morphine and continuous bupivacaine infusion in terms of analgesic efficacy and postoperative knee rehabilitation after a unilateral TKR. METHODS: Eighteen patients undergoing a unilateral total knee replacement were randomly allocated to one of the two groups. In group IV-PCA (n = 9), 30 min before the end of surgery, patients received ketorolac 30 mg IV bolus followed by continuous infusion with ketorolac (5 mg/h) and IV-PCA with morphine (20microgram/kg, lockout 10 min). In group PCEA (n = 9), 30 min before the end of surgery, patients received 2 mg morphine bolus followed by continuous infusion with 0.1% bupivacaine (2 ml/h) and PCEA with morphine (1 mg, lockout 15 min). RESULTS: There were significant differences in visual analogue scale scores at the first 2-hours after the unilateral TKR, cumulative morphine consumption and number of postoperative days required to obtain 90o knee flexion. CONCLUSIONS: PCEA using a morphine-bupivacaine combination provided better pain relief and faci litated the continuous passive motion more than IV-PCA using a morphine-ketorolac combination. This results in possible faster postoperative knee rehabilitation.

Comparing the Effects between a Continuous Epidural Infusion of an Opioid or an Opioid-Local Anesthetic Mixture and a Continuous IV Infusion of an Opioid after a Spinal Laminectomy / 대한마취과학회지

BACKGROUND: Postoperative pain after a spinal laminectomy has very harmful effects on human physiology, and many people are trying to control it more easily and safely. There are controversies in methods used for controlling postoperative pain after a spinal laminectomy. The purpose of this study was to examine an effective way to control postoperative pain after a spinal laminectomy. METHODS: Ninety patients (ASA I-II, aged 40 to 70) scheduled for a spinal laminectomy were divided into three groups. In group A, we administered fentanyl 1,000 microgram and morphine 5 mg (mixed in 0.9% normal saline) using the continuous epidural infuser; in group B, we administered fentanyl 500 microgram and morphine 5 mg and 0.25% bupivacaine (mixed in 0.9% normal saline) using the continuous epidural infuser; in group C, we administered fentanyl 1,500 microgram and morphine 10 mg (mixed in 0.9% normal saline) using the continuous IV infuser. We compared effects between the continuous epidural infusion and the continuous intravenous infusion by using the visual analogue scale and side effects. RESULTS: There was no significant difference between continuous epidural infusion groups. When the continuous epidural infusion groups and the continuous IV infusion group were compared, there were significant differences in 3 hr, 6 hr, and 12 hr VAS scores (P < 0.01). The incidence of side effects was very low, and there was no significant difference in side effects between the continuous epidural infusion and the continuous IV infusion groups. CONCLUSIONS: It was found that continuous epidural infusion methods were more effective than the continuous IV infusion method, but none of them showed satisfactory postoperative pain control in the early periods.

Comparison of the Plasma Concentrations of Nalbuphine after Epidural and Intravenous Administration / 대한마취과학회지

BACKGROUND: Nalbuphine is one of the opioid agonist-antagonists and is used frequently in the anesthetic field. Usage is focused on potent analgesic action and the adjuvant of narcotics because of less complications with preserved analgesia. The most common routes of administration for postoperative pain control are epidural and intravenous, so we compared both pharmacokinetic profiles. METHODS: Twelve patients were randomly divided into two groups. All patients were given a spinal anesthesia with tetracaine hydrochloride. One group (n = 6) received nalbuphine 10 mg via epidural route and another group (n = 6) received the same dose via intravenous route. Venous blood was drawn at 0, 0.25, 0.5, 1, 2, 4, 6 and 8 hours to measure plasma nalbuphine concentrations. Analysis was performed by high performance liquid chromatography with an electrochemical detector. RESULTS: At 0.25 hour, the plasma concentration of nalbuphine was significantly higher in the epidural administration group (49.48 +/- 4.98 ng/ml) than in the intravenous administration group (40.44 +/- 1.64 ng/ml). At 6 and 8 hours, the plasma concentration of nalbuphine was significantly higher in the epidural administration group (5.98 +/- 1.86 ng/ml, 3.85 +/- 0.94 ng/ml) than in the intravenous administration group (3.80 +/- 0.33 ng/ml, 2.43 +/- 0.32 ng/ml). Clearance, elimination half life, volume of distribution and AUC were not significantly different between the two groups. CONCLUSIONS: The plasma concentrations of nalbuphine via epidural route and intravenous route were similar in both groups after 0.25 hour to 6 hours. At 0.25 hour and after 6 hours, the epidural administration group had a higher plasma concentration of nalbuphine than the intravenous administration group.

A Comparison of the Antiemetic Effect of Ondansetron and Metoclopramide on Nausea and Vomiting Associated with Epidural Buprenorphine / 대한마취과학회지

BACKGROUND: Epidural buprenorphine provides good pain relief after Cesarean section, but is often associated with nausea and vomiting. Ondansetron, a selective 5-hydroxytryptamine 3 (5-HT3) receptor antagonist, is known to prevent and treat emesis after chemotherapy in cancer patients and after general anesthesia. The purpose of this study was to compare the prophylactic antiemetic effect of ondansetron and metoclopramide on nausea and vomiting after epidural buprenorphine. METHODS: Sixty women undergoing Cesarean section were studied. The patients were given subarachnoid injections of 0.5% tetracaine 9 mg and were inserted with epidural catheters for postoperative pain control. Prior to closure of the peritoneum, we injected a mixture of buprenorphine and bupivacaine through the epidural catheters and gave intravenous boluses of saline 6 ml, metoclopramide 10 mg and ondansetron 4 mg randomly. The incidence of nausea and vomiting and the degree of satisfaction were evaluated until 24 hr after the injection of epidural buprenorphine. RESULTS: The number of patients who became nauseated or vomited did not differ significantly between the ondansetron group and the metoclopramide group. Also, subjective ratings of satisfaction and incidence of other side effects did not differ significantly between the groups. CONCLUSIONS: Ondansetron, administered intravenously, prevented postoperative nausea and vomiting associated with epidural buprenorphine equally as well as metoclopramide.

Clinical Consideration of Headache Following Accidental Dural Puncture / 대한마취과학회지

BACKGROUND: Puncture of the dura can lead to a severe and often incapacitating headache. There is a report that the frequency of headache following accidental dural puncture with a 17 or 18 gauge needle is 86.7%. We reviewed the records to evaluate the efficacy of management for all patients whose epidural for postoperative pain control was complicated by dural puncture during a 3-year period. METHODS: The subject of patients in whom dural puncture occurred (35 cases in 1574 epidurals) was divided into two group. Group W5 consisted of 16 patients who received epidural saline and drugs in a rate of 5 ml/hr. Group W10 consisted of 19 patients who received epidural saline and drugs in a rate of 10 ml/hr. All patients were monitored daily by the pain control resident for occurrence of headache. RESULTS: The frequency of accidental dural puncture was 2.2% (35 cases of 1574 epidurals). In group W5, 6 of 16 patients (38%) experienced headache. In group W10, 6 of 19 patients (32%) experienced headache. There were no significant differences between both groups. CONCLUSIONS: The results of this study suggest that the epidural infusion with high volume of 0.9% saline and drugs should be considered as an alternative effective method of managing postdural puncture headache.

Effects of Concentration of Preoperatively Administered Epidural Bupivacaine on Postoperative Pain Control / 대한마취과학회지

BACKGROUNDS: Epidural anesthesia before surgical stimulus may reduce or prevent subsequent pain by preemptive analgesia. We studied the effect of varied concentration of a local anesthetic agent administered through epidural catheter before operation on preemptive analgesia after an abdominal hysterectomy. METHODS: Fourty-five patients scheduled for abdominal hysterectomy were blindly randomized to receive 10 ml of 0.5% bupivacaine (group I), 0.25% bupivacaine (group II) or saline (group III) respectively before induction of anesthesia. For postoperative pain control all patients received the same analgesic regimen which was 10 ml of 0.125% bupivacaine and buprenorphine 0.15 mg after resection of the uterus. Then the epidural catheter was connected with infusion pump containing 100 ml of 0.125% bupivacaine and buprenorphine 0.45 mg. Its infusion rate was 2 ml/hour. Pain was assessed using the Visual Analogue Scale (0 = no pain to 10 = intolerable pain) on rest, motion, cough and verbal rating scale at 1, 3, 6, 24 and 48 hour after operation. Side effects were recorded at the same time intervals. RESULTS: Using the ANOVA on ranksum test, pain scores 1 hour after operation differed between groups I and III (P<0.05). In VAS in motion, the pain scores 24 hours after operation differed between groups I and III (P<0.05). In VRS, the pain scores 3 hours after operation differed between groups II and III (P<0.05), and those 24 hours after operation differed between groups I and III (P< 0.05). The incidence of motor weakness using Chi-square test in group I differed from groups II, III (P< 0.05). CONCLUSIONS: Among the 45 patients who had a postoperative pain control after abdominal hysterectomy with initial bolus injection and then continuous infusion of epidural bupivacaine and buprenorphine, postoperative pain scores of patients who had preoperative epidural injection of 10 ml of 0.5% bupivacaine (n = 15) were lower than those of saline injected patients (n = 15), but those of patients with a preoperative epidural injection of 10 ml of 0.25% bupivacaine (n = 15) were not lower than those of saline injected patients.

Effects of Epidural Ketamine for Postoperative Pain Management / 대한마취과학회지

BACKGROUND: Ketamine hydrochloride, NMDA receptor antagonist is a potent analgesic and anesthetic. Other analgesics, like opioid, have been shown to effectively relieve postoperative pain when infused into epidural space, but effects of ketamine hydrochloride infused into epidrual space for postoperative pain control is still controversial, and therefore the present study was undertaken. METHODS: Ninety adult patients (ASA I or II) scheduled for upper abdominal and chest surgery were randomized into ketamine and fentanyl groups. For all patients, informed consent was obtained preoperatively. Anesthesia was induced with thiopental sodium/succinylcholine and maintained with nitrous oxide/oxygen/enflurane. Skeletal muscle relaxation was maintained with vecuronium. Epidural catheterization was done after operation. Ketamine group received epidural bolus of 0.1% bupivacaine 10 ml followed by continuous epidural infusion of 0.1% bupivacaine 100 ml containing ketamine 200 mg. Fentanyl group received epidural bolus of 0.1% bupivacaine 10 ml containing fentanyl 100 microgram followed by continuous epidural infusion of 0.1% bupivacaine 100 ml containing fentanyl 600 microgram. Continuous infusion rate was 2 ml/hr in both groups. Analgesic effects were assessed using VAS (visual analogue score), PHS (Prince Henry score) and PRS (pain relief score). Side effects and number of patients using additional analgesics were evaluated. RESULTS: Analgesic effects were significant in both group after drug administration. But fentanyl group had greater analgesic effects than ketamine group. Fentanyl group experienced side effects such as pruritus (27 cases), nausea and vomiting (9 cases). Ketamine group had side effects such as nausea and vomiting (13 cases). Number of patients using additional analgesics were seven and twenty-four in the fentanyl and ketamine groups, respectively. CONCLUSIONS: We conclued continuous epidural infusion of ketamine had fewer analgesics effect at early state of postoperative pain than fentanyl.

The Effect of Analgesic Technique on Recovery of Patients after Colon Surgery / 대한마취과학회지

BACKGROUND: Different types of analgesia may affect the rate of recovery of gastrointestinal function after colon surgery. METHODS: Sixty-six patients undergoing colon surgery which including right and left hemicolectomy, anterior resection and Miles` operation were categorized into four groups. All groups received a general anesthesia. Control group, in surgical ward the patients received adjuvant analgesics on request postoperatively. Group M received a intraoperative bolus epidural morphine followed by an infusion of morphine. Group MB received a intraoperative bolus of epidural morphine followed by an infusion of bupivacaine and morphine. Group PCA received a intraoperative bolus of intravenous morphine followed by patient- controlled morphine postoperatively. RESULTS: Ambulation, oral feeding and duration of hospitalization were not differed among groups. Group MB, recovered gastrointestinal function approximately 30 hours earlier than Group PCA (p<0.05). CONCLUSION: Epidural analgesia with bupivacaine and morphine accelerated postoperative recovery of gastrointestinal function.

The Postoperative Analgesic Effects of Epidural Clonidine during General Anesthesia / 대한마취과학회지

BACKGROUND: Epidurally administered clonidine produces analgesia by an alpha 2-adrenergic mechanism and may provide postoperative analgesia without nausea, pruritus and respiratory depression associated with opioid administration. Many studies have shown the beneficial effects of epidural clonidine in postoperative pain management. Pre-administered epidural analgesic agent before the skin incision may prevent the nociceptive input. We provided the pre-emptive analgesia and compared the postoperative analgesic effects of epidural clonidine when used as the sole analgesic agent with epidural fentanyl and epidural bupivacaine. METHODS: Thirty-nine gynecologic patients, ASA physical status 1, 2, undergoing elective lower abdominal surgery under general anesthesia, were studied. They were not taking any premedications. Before anesthesia, an epidural catheter was inserted at the L2~3 interspace. Patients were divided into 3 groups randomly. Group 1 received 0.125% bupivacaine 20 ml through the epidural catheter, group 2 received 100 microgram fentanyl in normal saline 20 ml, and group 3 received 150 microgram clonidine in normal saline 20 ml. During the operation, we recorded the vital signs and side effects. Just before suturing peritoneum, we injected the corresponding drugs on individual groups through the epidural catheter. In the recovery room, the postoperative analgesia was assessed by VAS (visual analogue scale). Vital signs, sedation score and side effects were also checked. RESULTS: VAS and systolic blood pressure were significantly lower in group 3 than group 1 or group 2 at the recovery room. The diastolic blood pressure, heart rate and sedation score were not significantly different between three groups at the recovery room. Also the vital signs during the operation were notsignificantly different between three groups. The incidence of hypotension was 3 out of 13 in group 3 and 1 out of 13 in group 1. CONCLUSION: Epidural bolus clonidine 150 microgram produces more profound and longer postoperative analgesic effects than fentanyl 100 microgram or 0.125% bupivacaine at the lower abdominal surgery. But hypotension may occur more frequently. So, if we select the patient cautiously, epidural clonidine is a good alternative analgesic agent for the postoperative analgesia.

Clinical Experience of Postoperative Pain Control / 대한마취과학회지

BACKGROUND: We prospectively studied 615 patients who received postoperative pain control (epidural analgesia or intravenous patient controlled analgesia) to evaluate pain relief, side effects and complications. METHODS: All study patients receiving postoperative pain control were assessed three times a day by the pain control resident for pain relief, using a visual analogue scale. The presence of side effects and complications was assessed. RESULTS: Over 1year, 615 patients (65.9% women, aged 46.9+/-16.4yr) were studied. General surgery, gynecology and obstetrics in the department; and lower abdomen, upper abdomen and perineum in the operation site were order of decreasing frequency. The most common site of epidural puncture level was T12-L1 in the epidural analgesia. The average pain score using VAS in all groups was less than 3.0 and the degree of satisfaction in postoperative pain control was rated as good on 88% of the patients. Nausea occurred in 9.1% of all patients, vomiting in 6.3%, pruritis in 0.9%, urinary retention in 2.6%, hypotension in 3.2%, but there was no case of respiratory depression. Dislodgement of the epidural catheter occurred in 0.5% of all patients. CONCLUSIONS: Postoperative epidural fentanyl/bupivacaine infusions and IV PCA are an effective method of postoperative pain control with a low incidence of side effects. We believe that, with appropriate patient observations and careful drug selection and with the use of epidural catheters placed appropriately for the proposed surgery, that high quality postoperative pain control can be offered.

A Comparative Study on Epidural Fentanyl, Bupivacaine, Lidocaine, and Intravenous Fentanyl in Patients Undergoing Gastrectomy under General Anesthesia / 대한마취과학회지

Backgronud : Postoperative pain control became anesthesiologist's familiar yield, so many anesthesiologists are very interested in opioid and local anesthetic's characterestics and there cardiovascular effects. It's important which anesthetic has the best pain killing and the least cardiovascular effect. We used epidural opioid and local anesthetics and intravenous opioid to investigate their pain killing and cardiovascular effects. METHODS: We studied 50 patients undergoing gastrectomy. An epidural catheter was placed via the T8-9 or L1-2 interspace. Epidural fentanyl group (Ep-F) received fentanyl 2 microgram/kg in 10ml saline, epidural bupivacaine group (Ep-B), 10 ml 0.25% bupivacaine, and epidural lidocaine group (Ep-L), 10 ml 1.5% lidocaine, epidurally; intravenous fentanyl group (IV-F) received fentanyl, 2 microgram/kg. 50% of the original dose was repeated every hour until the operation ended. Control group was given nothing before general anesthesia. Cardiovascular data was compared between those before and those at 1hour after skin incision. The time interval between end of the operation and the time of first analgesic requirement and the total number of intramuscular analgesic requirements during the first 48hours postoperatively were compared. RESULTS: Urinary output during surgery was significantly larger in group Ep-F. Group Ep-L developed more frequent episodes of hypotension. Group Ep-F, group IV-F and control group required higher enflurane concentrations. CONCLUSIONS: Group Ep-F was accompanied less hypotension and postoperative analgesic requirements were reduced.

The Effects of Single Epidural Triamcinolone Injection on the Blood ACTH and Cortisol Level / 대한마취과학회지

BACKGROUND: Epidural steroids injections are often used for the treatment of low back pain but their effects on the endocrine system have not been determined. Few studies have quantified the degree or duration of the suppression of the hypothalamic-pituitary-adrenal (HPA) axis in humans given epidural triamcinolone injection (ETI) for low back pain. The evaluation of the blood adrenocorticotropic hormone (ACTH) and cortisol was undertaken to determine the extent of suppression of the HPA axis in patients given ETI. METHODS: Lumbar epidural triamcinolone injections were performed on the painful lumbar intervertebral space with patients in the lateral decubitus position. The injection consisted of 40 mg of triamcinolone acetonide diluted in 10 mL of 1% lidocaine. Patients remained in the lateral position for 10 min after the procedure. Basal blood sampling was performed at 30 min before ETI and tested blood sampling was obtained at 7 days, 10 days, and 14 days after ETI. RESULTS: The blood cortisol level was significantly decreased at 7 days and 10 days but at 14 days was not significantly decreased and the blood ACTH level was not significantly decreased at 7 days, 10 days, and 14 days. CONCLUSIONS: Above results demonstrate that blood ACTH and cortisol level normalize 7 days and 14 days, respectively, after epidural triamcinolone 40 mg injection.