The effect of transdermal scopolamine plus intravenous dexamethasone for the prevention of postoperative nausea and vomiting in patients with epidural PCA after major orthopedic surgery / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) is common complication of Patient-Controlled Analgesia (PCA) after surgery. The authors sought to determine whether a transdermal scopolamine (TDS) patch in combination with IV dexamethasone is more effective than IV dexamethasone alone or IV dexamethasone plus IV ramosetron for reducing PONV in patients receiving epidural PCA after major orthopedic surgery. METHODS: 120 patients that received epidural PCA with hydromorphone and ropivacaine after major orthopedic surgery under spinal anesthesia were allocated to 3 groups: Group D (n = 40) received IV dexamethasone 8 mg, Group DR (n = 40) received IV dexamethasone 8 mg plus IV ramosetron 0.3 mg, Group DS (n = 40) received IV dexamethasone 8 mg plus a TDS patch (Group DS, n = 40). Nausea and vomiting incidences, VAS for nausea, the use of additional antiemetics, and adverse effects (a dry mouth, blurred vision, drowsiness) during the first 24 hours postoperatively were subjected to analysis. RESULTS: The DS Group had a significantly higher rate of complete remission of PONV than the D and DR groups (82.5% vs 47.5%, and 50.0%, respectively), and had lower rates of nausea (17.5% vs 55.0%, and 50.0%), and vomiting (10.0% vs 50.0%, and 25.0%), and required less antiemetics (5.0% vs 35.0%, 22.5%) than group D and Group DR during the first 24 hours after surgery. Furthermore, no inter-group differences were observed with respect to adverse effects in the three groups. CONCLUSIONS: The prophylactic use of a TDS patch plus dexamethasone was found to be a more effective means of preventing PONV in patients that received epidural PCA after major orthopedic surgery than dexamethasone alone or dexamethasone plus ramosetron without adversely affecting side effects.

Influence of Ketamine and Midazolam on the Analgesic Effect of Epidural Bupivacaine and Fentanyl after Low Abdominal Surgery / 대한통증학회지

BACKGROUND: There are many ways to provide superior analgesia for postoperative pain after abdominal surgery of which epidural analgesics with opioids and local analgesics are the most useful. In an effort to maximize the level of analgesia and to minimize the side effects, ketamine, midazolam, clonidine, and adrenalin can be co-administrated as an adjuvant. This study examined the analgesic effect and side effects of midazolam compared with those given an epidural injection of bupivacaine, fentanyl and ketamine. METHODS: In a double blind randomized controlled trial, 50 patients received either fentanyl 0.3 microgram/kg/h and ketamine 0.1 mg/kg/h (Group FK) or fentanyl 0.3 microgram/kg/h, ketamine 0.1 mg/kg/h and midazolam 0.4 mg/h (Group FKM), added to 0.125% of bupivacaine at a rate of as much as 2 ml/h, for patient controlled epidural analgesia (PCEA) after low abdominal surgery. Ten minutes before surgery, the patients received either 10 ml of 0.125% bupivacaine with 0.5 mg/kg of ketamine or 10 ml of 0.125% bupivacaine with the same amount of normal saline, added to fentanyl 50microgram. The pain score and the side effects were recorded at 1, 3, 6, and 24 hours after surgery. RESULTS: There was no difference in the pain score except for the VAS on coughing 1 hour after surgery. FKM group had fewer side effects. CONCLUSIONS: There was a better analgesic effect and fewer side effects with the addition of epidural midazolam to bupivacaine and fentanyl with ketamine formula. However, more study on the dose and route of administration will be needed.

Comparison of Prophylactic Antiemetic Therapy with Patient-controlled Epidural Analgesia after Thoracotomy / 대한마취과학회지

BACKGROUND: Patient controlled analgesia (PCA) has become an important means for treating postoperative pain. However, postoperative nausea and vomiting (PONV) are a major problem for patient using PCA system. This study was designed to evaluate the efficacy of two prophylactic antiemetic regimens on PONV during PCA after lobectomy. METHODS: Sixty five patients, who underwent lobectomy and received a mixture of 0.18% ropivacaine at 0.5 microgram/kg/hr of fentanyl (2,000 microgram) via thoracic epidural catheter. The study design was a prospective, randomized, double-blinded, placebo-controlled study. Group C was saline control group. In Group A or B, Nasea(R) (ramosetron) or Zofran(R) (ondansetron) was administered as an intravenous bolus at completion of operation. We assessed the frequency and severity of PONV at 6, 24, 48 hours after anesthesia. Postoperative pain was assessed 6 hr after the operation and everyday for 6 days on visual analog scale (VAS). Postoperative side effects and patient satisfaction for epidural analgesia were assessed by 4 grades. RESULTS: PONV occurred in 20%, 20%, and 35% of patients in Group A, B, and C at 6 hr after anesthesia, and 12%, 30%, and 30% at 24 hr after anesthesia. There were no significantly statistical differences among three groups. The VAS scores during coughing were higher than those of resting state without intergroup difference. There were no serious clinical adverse events caused by the study drug and epidurally administered drugs in any study groups. CONCLUSIONS: This study found that ramosetron and ondansetron for preventing PONV during epidural PCA after lobectomy was not different from placebo control.

Influence of Ketamine on the Analgesic Effect of Epidural Bupivacaine and Fentanyl after a Transabdominal Hysterectomy / 대한통증학회지

BACKGROUND: There have been many attempts to alleviate pain after surgery, but there is no common approach to the control of postoperative pain. The use of epidural opioids, with local anesthetics, has been a widely employed formula to date. Ketamine, an N-methyl-d-aspartate receptor antagonist, has an excellent analgesic effect. Although there have been many reports on the dose and route of administrating analgesics, there have been few concerning the continuous epidural infusion of ketamine with fentanyl. We designed this study to find the effects of ketamine compared to those of epidurally injected bupivacaine and fentanyl, and used this trial to study any potential side effects. METHODS: In a double blind trial, 55 patients received either fentanyl, 0.3microgram/kg/h (Group F), or fentanyl, 0.3microgram/kg/h, and ketamine, 0.1 mg/kg/h (Group FK), added to 0.125% bupivacaine, at rates as high as 2 ml/h, for patient controlled epidural analgesia (PCEA) following a transabdominal hysterectomy. Ten minutes before the operation, patients received 10 ml of 0.125% bupivacaine, with either 0.5 mg/kg ketamine or the same amount of normal saline with 50microgram fentanyl added. The pain scores and the side effects were recorded at 1, 3, 6 and 24 hour post operation. RESULTS: There were no differences in the pain scores or side effects between the two groups. CONCLUSIONS: We failed to find any effect of the addition of epidural ketamine compared to the that of the bupivacaine and fentanyl formula. However, it is suggested that further investigations will be required on the dose and route of administration.