Evaluation of lidocaine and tetracaine mixture in axillary brachial plexus block.

The mixture of 1% lidocaine and 0.2% tetracaine with 1:200,000 epinephrine, so-called "supercaine," has been used extensively for axillary brachial plexus blockade for several decades. Since the advent of bupivacaine, the supercaine mixture has fallen into relative disuse despite its record of effectiveness and safety. No studies have been done recently to evaluate quality of anesthesia, duration of postoperative analgesia, and degree of patient satisfaction with this mixture when used for axillary brachial plexus blockade. The assumptions were as follows: surgical anesthesia will be adequate, length of postoperative analgesia will be approximately 4 to 9 hours, and patients will be highly satisfied. The specific aim of the present study was to describe the anesthetic characteristics of supercaine. Patients between 18 and 65 years of age received a standard mixture of supercaine, totaling 450-500 mg of lidocaine and 90 to 100 mg of tetracaine. Epinephrine in a solution of 1:200,000 and an 8.4% solution of sodium bicarbonate were added, and the transarterial technique was used. Patients were contacted on postoperative day 1 to determine the duration of sensory and motor block; overall satisfaction with the block was rated. Data were analyzed with the Statistical Program for the Social Sciences (SPSS, Chicago, Ill) and Stata (Stata Corp., College Station, Tex) computer programs. The mean +/- SD findings were as follows: duration of sensory block, 465 +/- 204 minutes; duration of motor block, 473 +/- 214 minutes; patient satisfaction score, 9 +/- 1 on a 1 to 10 scale. Data are reported within a 95% confidence interval. Variables examined and compared were not statistically significant. We concluded that the duration of block supports findings reported in the literature, patients equate duration of sensory block with duration of motor block, differences in duration were probably due to levels of provider experience, and patients were extremely satisfied with the anesthetic.

Effects of intrathecal fentanyl on duration of bupivacaine spinal blockade for outpatient knee arthroscopy.

The purpose of this study was to determine if intrathecal fentanyl speeds the onset and prolongs the duration of sensory and motor block, prolongs the duration of postoperative analgesia, or increases the incidence of adverse effects in patients undergoing spinal anesthesia for outpatient knee arthroscopy. Fifty patients were randomized to receive 12 mg of hyperbaric bupivacaine 0.75% with 25 micrograms (0.5 mL) of fentanyl (group 1) or 12 mg of hyperbaric bupivacaine 0.75% with 0.5 mL of preservative-free normal saline (group 2). One-tailed t tests were used to determine differences in onset and duration of sensorimotor block and postoperative analgesia. No differences were found in onset and duration of sensory or motor block. Group 1 experienced significantly better postoperative analgesia lasting more than 3 hours longer than analgesia for group 2. Group 1 demonstrated significantly more pruritus, but there were otherwise no differences. We conclude that fentanyl does not enhance the onset and duration of sensory or motor block produced by 12 mg of intrathecal bupivacaine. Fentanyl, however, prolongs postoperative analgesia and increases the risk of pruritus.

Effect of intrathecal fentanyl dose on the duration of labor analgesia.

The short duration of effective analgesia produced by intrathecal fentanyl (ITF) at doses ranging from 5 to 25 micrograms limits the drug's use for the management of labor pain. The understanding of the potential of ITF related to duration of analgesia in the labor patient is derived from studies of and clinical experience with ITF at doses not exceeding 25 micrograms and less. We hypothesized that by increasing the dose beyond 25 micrograms, a prolonged duration of analgesia could be achieved. The purpose of the present study was to compare the difference in duration of effective analgesia and adverse effects produced by 25, 37.5, and 50 micrograms of ITF. A sample population of 60 term parturient women with uncomplicated singleton pregnancies who were in active labor and requesting pain control were randomly assigned to 1 of 3 groups: group 1, 25 micrograms (n = 20); group 2, 37.5 micrograms (n = 20); and group 3, 50 micrograms (n = 20). The ITF was then administered by an anesthesia provider blinded to the dose via a combined spinal epidural technique. The time from injection to the time of request for subsequent pain control (considered the duration of effective analgesia), maternal and fetal vital signs, and adverse effects were recorded at specific intervals until the patient requested activation of the epidural catheter or delivery occurred, ending participation in the study. Statistical analysis using a 1-way analysis of variance and considering a P value of < .05 to be significant revealed no difference in duration of effective analgesia between the groups. Statistical differences in the incidence of adverse effects, particularly uterine hyperstimulation, hypotension, pruritus, nausea, and fetal heart rate decelerations were not evident using the Fisher Irwin test and a significance of P < .05. The findings of the present study demonstrate that there is no real advantage of using doses of ITF greater than 25 micrograms in quality and duration of effective labor analgesia.

The knowledge and attitudes of nonanesthesia nurses regarding postoperative epidural analgesia.

The provision of epidural analgesia for postoperative pain control offers many patient benefits and has become commonplace on many nursing units. Since nurses are responsible for the day-to-day management of patients receiving epidural analgesia, their knowledge, attitudes, and practices regarding this technique are pivotal to its success. Therefore, the purpose of the present descriptive study was to examine the knowledge base, attitudes, and clinical practice of registered nurses (N = 85) regarding postoperative epidural analgesia as managed by an acute pain service (APS). Information was obtained from a survey distributed via a convenience sample to all nurses working on 6 units in a large military teaching facility. We developed the "Epidural Knowledge and Attitude Survey" using the nursing literature on epidural analgesia. The survey consisted of a demographics section, true/false (T/F) questions, multiple choice (M/C) questions, an attitude section, and a comment section. These sections addressed the nurses' knowledge, attitudes, and practices in regard to epidural pharmacology, management, and adverse effects, as well as their general satisfaction with the APS of their facility. Data were analyzed statistically using means, standard deviations, percentages, forward step-wise linear regression, the Fisher-Irwin (exact) test, the chi 2 test, and analysis of variance with Bonferroni multiple comparisons. A P value of < .05 was considered statistically significant. Results of the study demonstrated that the respondents attained a 78% overall correct score on T/F questions and 38% on M/C questions. The attitude section illustrated that 73% of nurses had "positive" attitudes toward epidural analgesia. Correct management of patients receiving epidural analgesia was being practiced by 77% of nurses. The satisfaction with the APS at this facility was 32% "very satisfied" and 62% "somewhat satisfied." The demographic characteristics that best predicted a higher score on the knowledge portion of the survey were greater years of practice as a nurse and receipt of pain education in nursing training. Nurses who had received inservice education about epidural analgesia rated a "good" self-knowledge of epidurals more often (40%) than those who did not (10%) and scored significantly higher on the knowledge portion of the survey.

Acute pain management clinical practice guideline: implications for nurse anesthetists.

Millions of operative procedures are performed in the United States each year. One of the greatest concerns for the surgical patient is postoperative pain. Despite traditional efforts to alleviate this pain, clinical studies indicate that postoperative pain is not relieved in most patients. The federal Agency for Health Care Policy and Research (AHCPR) developed a clinical practice guideline, Acute Pain Management: Operative or Medical Procedures and Trauma to help clinicians, patients, and patient's families understand the assessment and treatment of postoperative acute pain in both adults and children. Certified registered nurse anesthetists (CRNAs) can use the guideline to improve acute pain management within their institutions. Effective pain management can be accomplished through a collaborative, interdisciplinary approach using an individualized proactive pain control plan. Frequent assessment and reassessment of pain, use of drug and nondrug therapies, and implementation of an institution-wide program using CQI/QA methods in necessary. Implications for CRNAs include providing patient and staff education, establishing standards of care for pain management, and adapting an aggressive "no pain, much gained" clinical practice.