Choice of opioid supplementation for day-case rigid bronchoscopy:a randomized placebo-controlled comparison of a bolus of remifentanil and alfentanil.

OBJECTIVE: To compare the efficacy of different bolus doses of remifentanil, alfentanil, and saline at controlling the hemodynamic responses to day-case rigid bronchoscopy under general anesthesia. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Tertiary referral cardiothoracic hospital, single center. PARTICIPANTS: Eighty consenting adults scheduled for elective day-case rigid bronchoscopy under general anesthesia. INTERVENTIONS: Patients were randomized to receive a bolus of 10 micro g/kg of alfentanil, 1 micro g/kg of remifentanil, 2 micro g/kg of remifentanil or saline. After this, anesthesia was induced and maintained with a target-controlled propofol infusion (TCI) and succinylcholine was used for muscle relaxation. Heart rate and noninvasive arterial pressure were measured at 1-minute intervals throughout. MEASUREMENTS AND MAIN RESULTS: Patients' characteristics were similar in all 4 groups. There were no differences in time to return of spontaneous ventilation, wake-up times, or use of rescue vasopressors, and no patients complained of postoperative nausea. Remifentanil provided greater hemodynamic stability than alfentanil and a bolus of remifentanil of 2 micro g/kg significantly attenuated the rise in heart rate and was the most effective in preventing a rise in blood pressure. CONCLUSIONS: A bolus of 2 micro g/kg of remifentanil successfully attenuated the hemodynamic response to rigid bronchoscopy without delaying recovery.

Suprascapular nerve block for ipsilateral shoulder pain after thoracotomy with thoracic epidural analgesia: a double-blind comparison of 0.5% bupivacaine and 0.9% saline.

UNLABELLED: Despite receiving thoracic epidural analgesia, severe ipsilateral shoulder pain is common in patients after thoracotomy. We recruited 44 patients into a double-blinded randomized placebo-controlled study to investigate whether suprascapular nerve block would treat postthoracotomy shoulder pain effectively. All patients received a standard anesthetic with a midthoracic epidural. Thirty patients who experienced shoulder pain within 2 h of surgery were randomly assigned to receive a suprascapular nerve block with either 10 mL of 0.5% bupivacaine or 10 mL of 0.9% saline. Shoulder pain was assessed before nerve blockade, at 30 min, and then hourly for 6 h after the block using a visual analog scale (VAS) and a 5-point verbal ranking score (VRS). The incidence of shoulder pain before nerve block was 78%. There was no significant decrease in either VAS or VRS in the Bupivacaine group. These results suggest that this pain is unlikely to originate in the shoulder and lead us to question the role of a somatic afferent in referred visceral pain. We conclude that suprascapular nerve block does not treat ipsilateral shoulder pain after thoracotomy in patients with an effective thoracic epidural. IMPLICATIONS: This randomized, double-blinded, placebo-controlled trial showed that suprascapular nerve block does not treat the severe ipsilateral shoulder pain that patients experience after thoracotomy. This has implications for established theories of referred pain and indicates that this pain is unlikely to originate in the shoulder.