Postoperative analgesia for Caesarean section using epidural methadone. Epidural analgesia with bupivacaine reduces postoperative paralytic ileus after hysterectomy. Gastric emptying following caesarean section and the effect of epidural fentanyl. Myoelectric activity in the stomach and duodenum after epidural administration of morphine or bupivacaine. Continuous epidural infusion of bupivacaine and morphine for postoperative analgesia after hysterectomy. Epidural tramadol for postoperative pain relief. Postoperative epidural morphine, but not epidural bupivacaine, delays gastric emptying on the first day after cholecystectomy. Continuous thoracic extradural 0.5% bupivacaine with or without morphine: effect on quality of blockade, lung function and the surgical stress response. Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. Postoperative pain and pulmonary complications: comparison of three analgesic regimens. Effect of continuous postoperative epidural analgesia on intestinal motility. What concentration of sufentanil should be combined with ropivacaine 0.2% wt/vol for postoperative patient-controlled epidural analgesia? Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery: bupivacaine, fentanyl or a mixture of both? [Effect of continuous postoperative analgesia with peridural bupivacaine on intestinal motility following colorectal resection]. Effects of the extradural administration of morphine, or bupivacaine, on the endocrine response to upper abdominal surgery. Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section. Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy. Epidural analgesia in colonic surgery: results of a randomized prospective study. Failure of epidural anesthesia to prevent postoperative paralytic ileus. Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery.
A prospective randomised double blind study was carried out to compare the use of epidural methadone, morphine and bupivacaine for pain relief after Caesarean section. The results indicate that methadone is the most effective agent with few side effects. Subsequently this method was used routinely for postoperative analgesia in all patients undergoing Caesarean section. A retrospective study of 178 patients having this method of analgesia was carried out and indicated that epidural methadone is an effective and safe method of postoperative pain relief. This study was undertaken to compare the effects of postoperative bupivacaine epidural analgesia with those of intermittent injections of ketobemidone (a synthetic opioid) on postoperative bowel motility in patients who had had hysterectomies. The epidural group (N = 20) received continuous epidural anesthesia with bupivacaine postoperatively for 26-30 hours and the control group (N = 20) received intermittent injections of ketobemidone for postoperative pain relief. Postoperative bowel movements and propulsive colonic motility were estimated from the first passage of flatus and feces and by following radiopaque markers by serial abdominal radiographs. In the epidural group, the times for first passing of flatus (31 +/- 22 hours; mean +/- SD) and feces (70 +/- 44 hours) were significantly shorter than in the control group (flatus 58 +/- 14 hours and feces 103 +/- 26 hours). The average position of the markers was significantly more distally in the epidural group immediately after operation and the markers continued to move forward during the first postoperative day. In the control group, the markers did not move during this period. The results demonstrate that postoperative bowel peristalsis returned earlier in the patients given epidural analgesia with bupivacaine for pain relief than in patients given a narcotic. The rate of absorption of paracetamol following oral administration was used as an indirect measure of the rate of gastric emptying. This was to determine the effect on gastric motility of the addition of fentanyl to a solution of local anaesthetic given into the epidural space to provide pain relief following Caesarean section. Thirty subjects were randomly allocated to receive either bupivacaine plus fentanyl or bupivacaine alone. The area under the curve of the graph of plasma paracetamol concentration versus time was calculated for each subject at 45 and 90 minutes after administration of the epidural injection, and this value was used as an index of the rate of gastric emptying. This study demonstrated that gastric emptying may be normal immediately following Caesarean section under epidural anaesthesia, but that if fentanyl is added to the epidural solution, gastric emptying is significantly slower in the first 45 minutes following surgery (p less than 0.05). Gastric emptying is delayed in patients receiving postoperative pain relief with epidural morphine compared to patients receiving epidural bupivacaine. The electrophysiological basis for this effect is unknown. The aim of this study was to compare the effects of epidural morphine with epidural bupivacaine on gastroduodenal myoelectric activity (EMG) in patients after surgery.
                Fourteen patients with epidural analgesia who underwent open cholecystectomy were randomly assigned to receive either epidural morphine (EM) or epidural bupivacaine (EB) for postoperative pain relief. During surgery EMG electrodes were placed in the subserosa in the antrum and duodenum and the EMG registration started 3.5 hours after the end of surgery. Gastric emptying measured with the acetaminophen test was studied in the morning the day after surgery.
                The spike activity in the antrum was significantly lower 160-340 minutes after the administration of morphine in the EM-group compared to the activity in the EB-group (P < 0.04). The incidence of regular slow wave rhythm in the antrum was significantly lower 160-520 minutes after the administration of morphine in the EM-group compared to the EB-group (P < 0.03). Duodenal Phase III activity measured with EMG was significantly more frequent during 160-520 minutes after the morphine administration in the EM-group compared to the EB-group (P < 0.02). The acetaminophen absorption was significantly delayed in the epidural morphine group compared to the epidural bupivacaine group.
                Gastroduodenal electromyographic activity was significantly changed during epidural morphine compared to epidural bupivacaine. The delayed gastric emptying during epidural morphine may be explained by decreased and uncoordinated contractile activity in the antrum, shown by decreased spike activity and irregular slow wave rhythm. The increased pressure activity in the duodenum, shown by increased Phase III activity, may also impair gastric emptying. The analgesic efficacy and side-effects of combined epidural infusion of bupivacaine and morphine, in comparison with these drugs alone, for postoperative analgesia after hysterectomy (60 patients) were evaluated. Before general anaesthesia, all patients had an epidural catheter placed (Th11-12) and 20 ml of 0.5%, bupivacaine was injected. In random order, epidural infusion was continued for 24 h with either 0.25% bupivacaine 4 ml.h-1 (BUPI-group), a bolus of 2 mg of morphine followed by morphine 0.2 mg.h-1 (MO-group), or a combination of the two drugs (COMB-group). A urinary bladder catheter was kept for 24 h. Supplementary postoperative pain medications were i.m. morphine 0.1 mg.kg-1 or rectal indomethacin 50 mg, on request. Immediately after awakening from general anaesthesia and transfer to the recovery room, 18/20 of the BUPI-group patients, 17/20 of the MO-group patients and 19/20 of the COMB-group patients were pain-free. In the postoperative evening and the first postoperative morning, the corresponding figures were 7/20 and 10/20 in the BUPI-group, 15/20 and 15/20 in the MO-group, and 18/20 and 15/20 in the COMB-group (postop, evening; P less than 0.01 BUPI vs. others). The number of patients requiring supplementary analgesics (morphine and indomethacin during the first 24 h was greatest in the BUPI-group P less than 0.01). The number of patients who vomited during the 24-h period was 3 in the BUPI-group, 9 in the MO-group and 5 in the COMB-group.(ABSTRACT TRUNCATED AT 250 WORDS) The efficacy of epidurally administered tramadol hydrochloride, a weak centrally acting analgesic, was studied for the relief of postoperative pain. Sixty patients undergoing abdominal surgery were randomly allocated to three treatment groups to be given the following agents by the epidural route: group 1 tramadol 50 mg; group 2 tramadol 100 mg; group 3 10 ml of bupivacaine 0.25%. The drugs were administered at the patients' request with each patient being allowed four doses in the first 24 h following surgery. Blood pressure, pulse rate, respiratory rate, arterial blood gas analyses, pain scores, the interval between doses and the occurrence of any side effects were recorded. Pain scores (assessed using a visual analogue scale) were significantly less (p < 0.05) at 3, 12, and 24 h in patients receiving tramadol 100 mg than in those receiving tramadol 50 mg or bupivacaine. The mean interval between doses for groups 1, 2 and 3 was 7.40 h, 9.36 h and 5.98 h respectively. The mean interval in group 2 was significantly longer than in group 3 (p < 0.05). The incidence of nausea and vomiting in group 2 was significantly higher than in group 3 (p < 0.05). Gastric emptying is delayed during the first days after abdominal surgery. Studies with volunteers have shown that epidural morphine delays gastric emptying but epidural analgesia with bupivacaine does not. The aim of this study was to evaluate whether these differences in healthy volunteers are also found after cholecystectomy when epidural morphine or epidural bupivacaine is used for postoperative pain relief.
                Eighteen healthy patients were randomly allocated into two groups. Nine patients received postoperative analgesia with epidural morphine and nine with thoracic epidural bupivacaine. Acetaminophen absorption was used as an indirect measure of the rate of gastric emptying, measured 22 hours after surgery and again 4 weeks later, so that each patient served as their own control. During epidural morphine, serum acetaminophen concentrations were lower, and the area under the concentration time curve from 0 to 60 minutes (AUC60) was smaller (p less than 0.02), the maximum serum acetaminophen concentration (Cmax) was lower (p less than 0.05), and the time taken to reach the maximum concentration (Tmax) was longer (p less than 0.01) compared to epidural bupivacaine. There were no statistically significant differences in AUC60, Cmax, and Tmax between the two groups during the control study.
                Postoperative gastric emptying was significantly delayed after epidural analgesia with morphine compared to thoracic epidural bupivacaine. Compared to the control situation, epidural bupivacaine did not influence gastric emptying. Twenty-two patients undergoing upper abdominal surgery were entered into a randomized, double-blind study to receive extradural (T7-T8) 0.5% bupivacaine 9 ml followed by 25 mg h-1 with or without additional extradural morphine (bolus 4 mg plus 0.5 mg h-1), for 16 h after operation. Addition of morphine was associated with total alleviation of pain, and a stable level of sensory analgesia, but not with changes in blood glucose and cortisol concentrations or postoperative impairment of lung function (PEFR, FEV1, FVC). Two patients were withdrawn because of hypotension or respiratory depression. Three solutions administered by continuous extradural infusion for postoperative analgesia were compared in a randomized, double-blind manner. All patients underwent major abdominal gynaecological surgery and received 0.125% bupivacaine in 0.9% saline, diamorphine in 0.9% saline (0.5 mg in 15 ml) or diamorphine mixed with 0.125% bupivacaine (0.5 mg in 15 ml), at a rate of 15 ml h-1. The bupivacaine-diamorphine mixture provided significantly superior analgesia compared with either bupivacaine or diamorphine alone. No major side effects were encountered. In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05). The effect of postoperative epidural bupivacaine on intestinal motility was studied by measuring the transit time of barium contrast through the intestines in 16 patients after resection of the left colon and/or rectum. Fourteen patients served as controls and received postoperative injections of pentazocine. Mean transit time through the intestinal tract was 35 h in the epidural group and 150 h in the control group, a difference that is significant at the 0.1 per cent level. The average time before passage of flatus and faeces was different between the two groups at the 0.1 per cent level. We conclude that postoperative epidural bupivacaine constitutes an effective means of analgesia after colorectal surgery and is associated with a short duration of intestinal paralysis. In this randomized double-blinded study, we sought to determine an optimal dose-combination of sufentanil with ropivacaine 0.2% wt/vol as postoperative epidural analgesics. One hundred twenty patients undergoing major abdominal surgery under general and thoracic epidural anesthesia (T9-11) were assigned to groups receiving patient-controlled epidural analgesia with ropivacaine 0.2% wt/vol (R), ropivacaine 0.2% wt/vol + sufentanil 0.5 microg/mL (R+S0.5), 0. 75 microg/mL (R+S0.75), 1.0 microg/mL (R+S1). A visual analog score of less than 40 was considered effective, and all side effects were recorded. In randomized subgroups (10 patients per group), plasma pharmacokinetic data were obtained for both epidural drugs. Four patients in Group R and two in Group R+S0.5 were excluded because of inadequate analgesia. The drug infusion rates (range of means: 5.4-5. 9 mL/h) were similar in all patients. Analgesia was superior for sufentanil 0.75 microg/mL with no further enhancement by the larger sufentanil concentration of 1 microg/mL. Sufentanil plasma levels were within the range of the minimal effective concentrations (highest in R+S1), and there was no covariation between plasma levels and pain relief. Free ropivacaine plasma concentrations remained stable for 96 h. No severe side effects were detected, although pruritus correlated with an increasing dose of sufentanil. We conclude that the combination of ropivacaine 0.2% wt/vol and 0.75 microg/mL sufentanil provided the best analgesia with the fewest side effects of the three combinations tested.
                Sufentanil is added to epidural infusions of ropivacaine 0.2% wt/vol to improve the effectiveness of postoperative pain management. Regarding the risk of side effects, however, it is still unclear what concentration of sufentanil should be added to the local anesthetic. For postoperative thoracic epidural analgesia after major abdominal surgery, the combination of ropivacaine 0.2% wt/vol and 0.75 microg/mL sufentanil resulted in an appropriate cost:benefit ratio between good analgesia and side effects. Thirty patients who had undergone elective abdominal aortic surgery were studied in a prospective, randomised double-blind comparison of thoracic epidural 0.2% bupivacaine alone, thoracic epidural fentanyl alone and thoracic epidural 0.2% bupivacaine combined with fentanyl. Pain relief, pulmonary function, cardiovascular stability and side effects were assessed. Pain relief was excellent in the combined bupivacaine-fentanyl series, being significantly better than the other groups (p less than 0.05) during the entire study period and was not accompanied by hypotension. Forced expiratory parameters were reduced in all groups throughout the study to 50-60% of the pre-operative values, but there were no significant differences between groups. The incidence of side effects attributable to either epidural bupivacaine or fentanyl was low. This study supports the increasing use of epidural infusion analgesia for postoperative pain management after abdominal surgery. In a prospective randomized trial the effects of continuous peridural analgesia on gastrointestinal motility and the postoperative course was studied in 48 consecutive patients with elective colorectal resections. 24 patients had peridural analgesia (PDA) with bupivacaine while 24 patients received intravenous analgesia (IVA) with pentazocine. With PDA the first passage of flatus and faeces was significantly accelerated. PDA was not associated with an increased rate of anastomotic breakdown and there were no respiratory complications in the PDA group. The endocrine response, and the relief of pain, following the extradural administration of morphine or a local anaesthetic agent bupivacaine (0.5%) were studied for 24h after abdominal surgery and compared with a control group given conventional i.v. morphine after operation. Samples were taken before and at 2, 4, 6, 12 and 24 h after skin incision. Pain relief in both extradural groups was significantly better when compared with the control group. In all three groups, the plasma concentration of cortisol was increased immediately after surgery. Thereafter, significantly lower values were seen in the extradural groups. Plasma adrenaline concentration was lower immediately after surgery only in the group given the extradural local anaesthetic. Plasma noradrenaline concentration remained unchanged after extradural local anaesthesia while an intermediate increase occurred after extradural morphine. Plasma noradrenaline concentration was significantly greater in the controls compared with both extradural groups. Our results indicate that extradural analgesia with a local anaesthetic drug can suppress the increases in the plasma concentrations of the catecholamines and cortisol after surgery. In contrast to extradural local anaesthetic extradural morphine cannot suppress the endocrine response immediately after surgery. However, later in the postoperative period, extradural morphine can suppress the endocrine response, thus indicating that postoperative pain is a factor involved in the stress response following surgery. In this randomized, double-blind study of 60 patients, we have assessed the analgesic efficacy of extradural bupivacaine and extradural fentanyl, either alone or in combination, after Caesarean section. Patients received 0.1% bupivacaine (group B), fentanyl 4 micrograms ml-1 (group F) or 0.05% bupivacaine combined with fentanyl 2 micrograms ml-1 (group BF) by patient-controlled extradural analgesia (PCEA). Adding fentanyl to bupivacaine reduced the dose of bupivacaine by up to 68%, improved analgesia at rest and decreased PCEA use. Motor and sensory block were decreased, but there was more pruritus. Overall patient satisfaction was increased. Adding bupivacaine to fentanyl reduced the dose of fentanyl by up to 57% without altering pain scores or PCEA use. Sensory block increased but pruritus did not decrease. Bupivacaine 0.05% produced clinically significant leg weakness in three patients. Overall patient satisfaction was not altered. There was a significant additive analgesic effect between 0.05% bupivacaine and fentanyl but no clinical benefit was demonstrated from using the combination compared with fentanyl alone for this group of postoperative patients. A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on bowel function after abdominal hysterectomy. The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces. Twenty-two patients were randomly allocated to two equal groups. An "epidural morphine" group received general anesthesia and epidural morphine for postoperative pain relief, and an "epidural bupivacaine" group was given combined general anesthesia and epidural anesthesia with 0.5% bupivacaine intraoperatively and epidural analgesia with 0.25% bupivacaine postoperatively. Epidural morphine or bupivacaine was given for 42 h postoperatively. Pain intensity (visual analog scale) was low in both groups, but lower (P less than 0.05) in the epidural bupivacaine group. The time to first passage of flatus was 22 +/- 16 h in the epidural bupivacaine group and 56 +/- 22 h in the epidural morphine group (P less than 0.001). The time to first postoperative passage of feces was shorter (P less than 0.05) in the former than in the latter 57 +/- 44 h vs 92 +/- 22 h). The patients of the epidural bupivacaine group started intake of oral fluids earlier (P less than 0.01) and to a greater extent (P less than 0.05) than those in the epidural morphine group. It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine. Colonic surgery patients were studied to measure: the influence of continuous thoracic epidural analgesia (TEA) on a postoperative pain score, the time till onset of defaecation, blood loss, postoperative temperature elevations, rate of bacterial contamination of wounds and urine, and general surgical complications. Group I patients (n = 57) received general anaesthesia and TEA for the operation, followed by continuous TEA (0.25 per cent bupivacaine) for 72 h. Group II patients (n = 59) received general anaesthesia for the operation, followed by systemic analgesia on request. Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation. However, there were fewer temperature elevations in group II. There was no significant difference between the groups in terms of positive bacteriological cultures, blood loss, need for postoperative mechanical ventilation and complications. However, there was a trend toward a higher rate of rectal anastomotic breakdown, increased blood replacement and intensive care therapy, and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen. In selected patients (i.e. those with severe pain or those prone to develop postoperative ileus) continuous TEA may be beneficial. This study used radiopaque markers and serial abdominal radiographs to assess the effect of epidural anesthesia on postoperative colonic ileus. Epidural anesthesia did not result in significantly faster return of propulsive motility in the colon after surgery as compared with control (P greater than 0.05). In addition, no significant difference was seen between the groups in colonic transit time and time for the first passage of gas and feces. The level of inhibition of sympathetic efferent nerves to the abdominal cavity was assessed by repeated measurements of blood glucose levels during the first postoperative day. Blood glucose levels were found to be significantly lower in the epidural group, demonstrating an inhibition of efferent sympathetic nerves below the level of T-5. Results show lack of effect of continuous epidural anesthesia in the prevention of postoperative paralytic ileus and suggest that mechanisms other than spinal reflexes play a major part in the development and maintenance of intestinal paralysis. We performed a prospective, randomized, double-blind study of continuous epidural analgesia for 72 hours after major abdominal procedures. Patients were randomly assigned to one of five treatment groups: epidural morphine, epidural bupivacaine, a combination of morphine and bupivacaine, epidural saline solution, and no epidural catheter. All patients received supplemental morphine sulfate or meperidine hydrochloride, intramuscularly or intravenously, as needed. Epidural infusion was begun at 2 to 4 ml/hr, depending on age and height, with two increments of 1 ml/hr allowed if pain relief was insufficient. All pain management decisions were made by nurses, who also monitored epidural function. Performance was measured four ways: pain as measured at regular intervals in the 72-hour period with a visual analog, pain as measured after 72 hours with the McGill Pain Questionnaire, amount of supplemental narcotics needed, and recovery of respiratory function and ambulation as percent of preoperative levels. The group that received the combination of morphine and bupivacaine did best on all measures; in most instances the difference between the results seen with the combination regimen and those seen with saline solution or no catheter were significant at the 0.05 level. With the exception of pruritus, complications were evenly distributed among all treatment groups, including noncatheterized controls. We conclude that epidural analgesia with the combination of morphine and bupivacaine is safe, is easily managed, and gives pain relief superior to that provided by traditional, systemic administration of narcotics. Sixty patients scheduled for colonic surgery were randomly allocated to four groups according to postoperative pain medication: I. Control group, the patients received oxycodone intramuscularly (0.15 mg kg-1) on request. II. Epidural bupivacaine (0.25%) continuously administered by infusion pump, 4-6 ml h-1, for 48 h. III. Epidural morphine, 2-6 mg, at the end of operation and repeated on the first and second postoperative mornings. IV. Epidural morphine, 2-6 mg per die, administered for 48 h continuously by infusion pump. All patients received a balanced anaesthesia with enflurane, fentanyl and vecuronium. Postoperatively, intramuscular oxycodone was given on request. There were no significant differences between the groups in changes in peak flow, spirometry and blood-gas analyses postoperatively. Pain intensity (visual analogue scale) was lower in Groups II and III at 3 h and in Group IV at 24 h compared to the control Group I. All the epidurally treated groups needed less additional analgesics than the control Group I. Postoperatively bowel movements occurred on the second day in Group II (bupivacaine) as compared to the fourth day in all other groups (P less than 0.05).
Administration of epidural local anaesthetics to patients undergoing laparotomy reduce gastrointestinal paralysis compared with systemic or epidural opioids, with comparable postoperative pain relief. Addition of opioid to epidural local anaesthetic may provide superior postoperative analgesia compared with epidural local anaesthetics alone. The effect of additional epidural opioid on gastrointestinal function is so far unsettled. Randomized, controlled trials comparing the effect of combinations of epidural local anaesthetic and opioid with epidural local anaesthetic alone on postoperative gastrointestinal function and pain are warranted.