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PubMedDate not supplied

The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital.

BACKGROUND AND OBJECTIVES: This study examined the safety and efficacy of combined spinal and epidural (CSE) analgesia/anesthesia performed in a community hospital. METHODS: Labor and Surgical Anesthesia Quality Assessment Worksheets were completed by the responsible anesthesiologist for 7,893 general anesthetics and 7,931 regional anesthetics from January 1, 1994 to December 31, 1997. A retrospective computerized analysis of these data tabulated the number of regional anesthesia techniques and identified anesthesia effectiveness and complications associated with these procedures. The safety and efficacy of CSE analgesia/anesthesia (6,002 blocks) was assessed by comparing these results with reported complications and failure rates for spinal and epidural anesthesia. RESULTS: The CSE technique did not increase the risk of anesthesia complications, as compared with the reported prevalence associated with major regional anesthesia. It provided decreased failure rates for labor analgesia and comparable or decreased failure rates for surgical anesthesia, when compared with reported failure rates for epidural anesthesia. Apnea did not occur in parturients who received 4,164 CSE blocks with intrathecal sufentanil (ITS; 10, 15, or 20 microg) for labor pain relief. However, the prevalence of laboring patients requiring intravenous medication for side effects was related to the dose of ITS: 10 microg (1.1%), 15 microg (4.6%), and 20 microg (5.5%) (P < .001). Patients who received prior systemic narcotics less than 6 hours before ITS were twice as likely to require intravenous treatment for low oxygen saturation/drowsiness (21%) than were those who experienced dysphagia or pruritus (10%) (P < .001). CONCLUSIONS: This review of 6,002 CSE blocks performed in a community hospital has demonstrated that CSE labor analgesia, surgical anesthesia are safe and efficacious. We believe that patient observation and continuous pulse oximetry for 1-2 hours after administration of ITS and prompt treatment with intravenous naloxone for severe drowsiness, low oxygen saturation (PaO2 < 90% unresponsive to mask oxygen), or dysphagia should be used to minimize the risk of apnea.

Analgesia, Epidural↗
PubMed2003

Which administration route of fentanyl better enhances the spread of spinal anaesthesia: intravenous, intrathecal or both?

BACKGROUND: To enhance the spread of spinal anaesthesia, fentanyl may be administered intrathecally (i.t.) or intravenously (i.v.). The purpose of this prospective study was to investigate the effects of fentanyl administered i.v., i.t. or concurrently by both i.v. and spinal routes on the spread of spinal anaesthesia. METHODS: Sixty patients were randomly assigned to one of three groups. In Groups I and II, spinal anaesthesia was performed with plain bupivacaine 10 mg plus 20 micro g fentanyl and in Group III with 10 mg of plain bupivacaine. The level of first peak sensory block was marked. In addition, fentanyl 50 micro g was administered i.v. in Groups II and III or by saline in Group I after the sensory blockade reached the highest dermatomal level. Ten minutes after i.v. administration, the level of the second peak sensory block was marked. The distance between the first- and second-highest levels of sensory block was measured. RESULTS: The distance between the first- and second-highest level of sensory block was significantly different for the three groups: Group II (5.8 +/- 2.6 cm) > Group III (2.9 +/- 2.1 cm) > Group I (-0.15 +/- 1.7 cm). The peak dermatomal level of spinal block was significantly higher in Group II [T4 (T3-T7)] than in Group I [T6 (T4-T9)] and Group III [T6 (T4-T8)]. In Groups I and II the sensory block regressed to S2 for a longer period of time than it did in Group III. CONCLUSION: Both the spinal and systemic administration of fentanyl enhanced the spread of spinal anaesthesia. The co-administration of spinal and i.v. fentanyl produced a greater increase in the cephalad spread of spinal block.

Adult↗
PubMed2000

Continuous spinal anaesthesia/analgesia for the perioperative management of high-risk patients.

The intraoperative effects of continuous spinal anaesthesia, and the efficacy of postoperative continuous spinal analgesia in 48 elderly high risk patients undergoing major abdominal, vascular or orthopaedic surgery is reported. Intraoperative anaesthetic technique proved to be safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesic regimen which involved intrathecal fentanyl and bupivacaine, and intravenous tenoxicam, provided effective analgesia for all patients. The intrathecal analgesic regimen was administered continuously through a PCA pump which had the facility to provide bolus doses when requested in predetermined lockout intervals. The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 h postoperatively were 14.5 +/- 1.5 microg h(-1) (mean +/- SD) and 0.72 +/- 0.08 mg h(-1) (mean +/- SD), respectively, while the requirements for analgesia decreased progressively overtime but lasted for 118 h. The technique provided effective analgesia with low pain scores that was reflected by the ease in performing physical exercises and the pleasant co-operation with the physiotherapist. Only minor complications related to anaesthesia/analgesia were encountered.

Aged↗
PubMed1982

Maternal and fetal concentration of morphine after intrathecal administration during labour.

Twenty-five healthy women in labour received morphine 1-1.75 mg in normal saline intrathecally. The residual pain was evaluated on a scale from 0 to 5 at 10 min (score 2.5) and at 25 min (score 1.5). After delivery the maternal and fetal plasma morphine concentrations were measured by radioimmunoassay in 14 parturients. Twenty-three women of 25 had vaginal deliveries, 20 of them without forceps. The maternal and fetal plasma concentrations of morphine were 6 ng ml-1 or less. The intrathecal (but not extradural) administration of morphine is effective and could provide an interesting alternative for pain relief in labour.

Anesthesia, Obstetrical↗
PubMed1993

Comparison of the analgesic effects of intrathecal clonidine and intrathecal morphine after spinal anaesthesia in patients undergoing total hip replacement.

We have studied the anaesthetic and analgesic properties of intrathecal clonidine and intrathecal morphine in patients undergoing total hip replacement under spinal anaesthesia. After routine spinal anaesthesia with 0.5% plain bupivacaine 2.75 ml, patients were allocated randomly to receive intrathecal clonidine, morphine or saline (control) as adjuvant to the bupivacaine. Postoperative analgesic effects were measured by consumption of morphine via patient-controlled analgesia and visual analogue pain scores. Both intrathecal clonidine and intrathecal morphine prolonged the time to first analgesia compared with saline (mean 278 (SD 93.2) min, 498 (282.4) min and 54 (61.9) min, respectively) (P < 0.001). Total morphine consumption on the first night after operation was significantly less in the intrathecal morphine group. There were no differences between the clonidine and the control group. Intrathecal clonidine prolonged the duration of spinal analgesia, but was markedly inferior to the intrathecal morphine in providing subsequent postoperative analgesia.

Adult↗
PubMed1998

The dose-response relation of intrathecal fentanyl for labor analgesia.

BACKGROUND: This study determined the dose-response relation of intrathecal fentanyl for labor analgesia and described the onset, duration, and quality of analgesia when used as the sole analgesic. METHODS: Eighty-four parturients in active labor who requested analgesia were randomized to one of seven treatment groups. They received 5-45 microg intrathecal fentanyl as part of a combined spinal-epidural technique. Visual analog pain scores were recorded before and at intervals after injection patients requested additional analgesia. The occurrence and severity of pruritus, nausea, and vomiting were also recorded. Maternal blood pressure was recorded before injection and at intervals after injection. Fetal heart rate was recorded before and 30 min after injection. RESULTS: By 5 min after injection, pain scores were significantly different among groups (P < 0.001). Mean duration of analgesia increased to 89 min as the dose increased to 25 microg. Maternal diastolic blood pressure was significantly lower 10 and 30 min after injection. There was no difference among groups in the incidence of pruritus; nausea and vomiting were uncommon. Fetal heart rates did not change after injection. A dose-response curve indicates that the median effective dose of intrathecal fentanyl for labor analgesia is 14 microg (95% confidence interval, 13-15 microg). CONCLUSIONS: Intrathecal fentanyl produces rapid, profound labor analgesia with minimal side effects. These data indicate that there is little benefit to increasing the dose beyond 25 microg when it is used as the sole agent for intrathecal labor analgesia.

Adult↗
PubMed2005

Intrathecal morphine for analgesia after postpartum bilateral tubal ligation.

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 microg intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 microg of fentanyl, and either 50 microg of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P=0.003) and pain was less intense at rest (P=0.008) and on movement (P <0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P=0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P=0.006), pain on movement was significantly less at 4 h (P=0.002) and 12 h (P=0.0004), and pruritus was significantly more frequent at 12 h (P=0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P=0.006) and the time to first request of analgesia was significantly longer (P=0.006) in the morphine group. We conclude that the addition of 50 microg of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

Adult↗
PubMed2006

Use of neostigmine in the management of acute postoperative pain and labour pain: a review.

Neostigmine is a parasympathomimetic agent that has been recently investigated for use as an adjunct analgesic agent in the perioperative and peripartum period. A number of studies have investigated the intrathecal, epidural, caudal and intra-articular routes of administration of this agent, as well as the addition of neostigmine to local anaesthetics used for brachial plexus block and intravenous regional anaesthesia. While the intrathecal administration of neostigmine produced useful analgesic effects in the postoperative period in some studies, the high incidence of adverse events, mainly nausea and vomiting, limit the clinical usefulness of this route of administration. Several studies investigated the postoperative analgesic effects of epidural neostigmine using a number of different regimens. Overall, this route of administration appeared to improve postoperative analgesia in most studies without increasing the incidence of adverse events, and merits further research. Neuraxial administration of neostigmine appears to be safe in the obstetric population, with no reported adverse effects in the mother or fetus. While intrathecal administration is limited by a high incidence of nausea and vomiting in this patient population, the epidural route appears more promising and requires further investigation. The addition of neostigmine to caudal local anaesthetics was associated with improved postoperative analgesia in a number of studies. A dose of 2 microg/kg proved to be effective in several studies but was associated with an increased incidence of vomiting in some studies. Intra-articular administration of neostigmine 500microg produced a useful analgesic effect in the postoperative period in several studies and was not associated with an increase in the incidence of adverse effects. Studies investigating the efficacy of adding neostigmine to the local anaesthetics used for brachial plexus block and intravenous regional anaesthesia reported conflicting results. Further studies are required to determine the place of the administration of neostigmine by these routes.

Anesthesia, Conduction↗
PubMed1994

[The influence of small dose intrathecal fentanyl on shivering during transurethral resection of prostate under spinal anesthesia].

Shivering during spinal anesthesia is a common complication in patients undergoing transurethral resection of prostate. The high incidence of shivering may be due to decreased core temperature secondary to peripheral vasodilation from sympathetic blockade and/or cold irrigation fluid. Shivering is known to increase O2 consumption, ventilation and cardiac output, which can result in morbidity to patients with limited cardiopulmonary reserves. The aim of this randomized double-blind study was to investigate whether 1.25 micrograms of intrathecal fentanyl administered would influence the incidence and severity of shivering in patients who underwent TURP under spinal anesthesia. In the present study, 79 patients with (n = 41) or without (n = 38) low dose fentanyl were study. The incidence of shivering was 65.8% in control group and 12.2% in the study group. The difference was statistical significance. The shivering grade (1.0 +/- 0 vs 1.76 +/- 0.7) and accumulative shivering scores (2.4 +/- 0.8 vs 12.5 +/- 5.6) were also significantly decreased in the study group (P < 0.05). Obviously, there was no difference in the incidence of pharmacologic side effect. We concluded that low dose intrathecal fentanyl is a god method for decreasing both incidence and severity of shivering during spinal anesthesia.

Aged↗
PubMed1993

[Intrathecal meperidine attenuates shivering induced by spinal anesthesia].

Shivering is a common and complex phenomenon that occurs in many patients during spinal anesthesia. Shivering can increase oxygen consumption up to 500 per cent which may be detrimental to patients with decreased myocardial reserve. The metabolic costs and cardiorespiratory consequences of shivering are important particularly for patients with anemia, coronary arterial disease, cardiopulmonary insufficient, debilitated status or are elderly. We studied whether intrathecal meperidine could prevent shivering after spinal anesthesia. 60 patients with ASA class I-II were divided into intrathecal meperidine group (Group I) (n = 30) and control group (Group II) (n = 30). Group I received spinal tetracaine 12-16 mg with meperidine 0.2 mg/kg and Group II received spinal tetracaine 12-16 mg without meperidine. During operation the highest level of spinal anesthesia, ambient and rectal temperatures, blood pressure (BP) and heart rate (HR), presence or absence of shivering, intensity of shivering in both groups were recorded. Close observation for side effects was given post-operatively. There was a significant reduction (p < .005) in incidence of shivering in group I patients (16.7%) when compared with group II (56.7%). There was no or less side effects observed with other neuraxial opioids except nausea. We concluded that intrathecal meperidine could suppress shivering induced by spinal anesthesia.

Adult↗
PubMed1996

Lymphomatous infiltrates within leptomeninges and spinal roots in adult patients with non-Hodgkin's lymphomas after intrathecal methotrexate administration.

Based on post-mortem neuropathological evaluation the authors analyzed the incidence and distribution of the lymphomatous infiltrates within the leptomeninges and spinal roots in 21 patients with high grade non-Hodgkin's lymphomas (HGNHL) treated with intrathecal methotrexate (ITMTX) prophylaxis. The investigations revealed that lymphomatous infiltrates were most frequent within cerebellar leptomeninges and around spinal roots. In spinal leptomeninges and roots the infiltrates occurred significantly rare after more than 3 ITMTX injections, but further ITMTX applications did not diminish infiltrates incidence in the mentioned regions. In the remaining regions infiltrates incidence was similar, irrespective of the number of ITMTX injections. From the neuropathological point of view ITMTX prophylaxis isn't able to prevent the development of the infiltrates in the mentioned regions. In an attempt to determine the clinical usefulness of the ITMTX prophylaxis in adult patients with HGNHL and to elaborate optimal prophylactic management, the more detailed clinical and pathological evaluations are required.

Adolescent↗
PubMed1998

[Spread of spinal anesthesia with 3 different hyperbaric solutions used in Japan].

We studied the spread of spinal anesthesia with 3 different hyperbaric solutions commercially available in Japan. Percamin-S [0.3% dibucaine in 5% hyperbaric saline] (P), Neo-Percamin.S [0.24% dibucaine with 0.12% T-caine in 9.5% glucose] (N) and 0.5% Tetcaine [tetracaine] in 10% glucose (T) were studied. Two ml of each solution was administered intrathecally using a 25 gauge Quincke needle. Patients (n = 90) were allocated to one of 9 groups receiving 2 ml of P, N or T at L 2-3, L 3-4 or L 4-5 interspace. Both N and T produced significantly higher spread of analgesia than P at any of L 3-4 and L 4-5 interspaces. P and N have the same specific gravity, even though significant differences were found in spread of segmental analgesia. Local anesthesic agents and solvent solutions themselves are considered to influence the spread of spinal anesthesia as the specific gravity of hyperbaric solution does.

Adult↗