Absence of an early pre-emptive effect after thoracic extradural bupivacaine in thoracic surgery.

We have determined if thoracic extradural block before surgical incision for thoracotomy produces pre-emptive analgesia. Using a double-blind, placebo-controlled, crossover design, 45 patients (ASA II-III) undergoing posterolateral thoracotomy for lung resection were randomized to one of three groups: group 1 received 0.5% bupivacaine and adrenaline 1/200,000 (B+E) 8 ml through a thoracic extradural catheter (tip T3-T5) 30 min before skin incision and saline 8 ml 15 min after skin incision; group 2 received saline 8 ml extradurally before incision and B+E 8 ml after incision; group 3 received saline 8 ml extradurally before and after incision. General anaesthesia was induced and maintained with propofol, alfentanil and atracurium. The alfentanil infusion was stopped before chest closure and fentanyl 50 micrograms in saline 10 ml was given extradurally. Patient-controlled extradural analgesia (PCEA) was commenced with 0.125% bupivacaine, adrenaline 1/400,000 and fentanyl 6 micrograms ml-1 (continuous rate of 2 ml h-1 and supplementary doses of 0.5 ml per 6 min). Visual analogue scale (VAS) scores (recorded at rest, on mobilization and after cough), verbal rating scale (VRS) (recorded at rest), number of successful PCEA demands and complications were measured during the first 48 h after operation. There was no significant difference between groups, either in PCEA requirements (P > 0.21) or in VAS scores (either at rest, during mobilization of the ipsilateral arm of surgery or after cough). No significant differences between groups were found in the VRS. Thoracic extradural block with bupivacaine did not produce an early preemptive effect after thoracotomy.

Difficult management of pain following sacrococcygeal chordoma: 13 months of subarachnoid infusion.

We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ineffective in the early stages of treatment, we tried to achieve pain relief by using epidural morphine. This was also unsatisfactory. Intrathecal infusion of morphine and bupivacaine through a catheter inserted at the L2-L3 level was also found to be ineffective; only a segment block was observed. A structural anomaly of the spine was suspected and confirmed by myelography, showing metastasis at L3. Pain relief improved when an infusion of morphine+bupivacaine was employed through a catheter placed at the L4-L5 level below the blockage. A major problem which continued throughout the course of the disease was the daily occurrence of episodes of unbearable sharp pain that required addition of midazolam to the local anesthetic/opioid subarachnoid infusion. The patient received this mixture through an intrathecal port during the last 13 months of life, a gradually increasing dose being necessary. Periods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningitis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.

Acid aspiration prophylaxis in elective biliary surgery. A comparison of omeprazole and famotidine using manually aided gastric aspiration.

We have compared the effects of single oral doses of omeprazole 40 mg, famotidine 40 mg or placebo on gastric secretion in 45 non-obese patients the night before elective biliary surgery. After stable anaesthesia had been established, a Salem orogastric tube was introduced and gastric contents were aspirated by a blinded observer. The volume and pH were noted. After the abdomen was opened aspiration was repeated but on this occasion with the surgeon's manual assistance. We found that the initial aspirate volume underestimated total gastric volume by an average (SD) of 7.1 (6.6) ml. Famotidine, but not omeprazole, produced a significant decrease in gastric volume and acidity. Patients were considered to be at risk if pH < 2.5 and volume > 0.4 ml.kg-1. Three patients in the omeprazole group, three in the placebo group and none in the famotidine group came into this category. We conclude that a single oral dose of omeprazole 40 mg given the night before surgery does not afford adequate prophylaxis for acid aspiration syndrome.