Narinder Rawal

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia

BACKGROUND:Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the “gold standard” in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research. METHODS:In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed. RESULTS:Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate. CONCLUSIONS:Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.

Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function

In a randomized double-blind study of thirty grossly obese patients undergoing gastroplasty for weight reduction, the effects of intramuscular and epidural morphine were compared as regards analgesia, ambulation, gastrointestinal motility, early and late pulmonary function, duration of hospitalization, and occurrence of deep vein thrombosis in the postoperative period. The patients were operated on under thoracic epidural block combined with light endotracheal anesthesia. A six-grade scale was devised to quantify postoperative mobilization. A radioactive isotope method using 99mTc-plasmin was employed to detect postoperative deep vein thrombosis. For 14 hr after the first analgesic injection, respiratory frequency was noted every 15 min and arterial blood gases were measured hourly. Peak expiratory flow was recorded daily until the patient was discharged from hospital. Spirometry was performed the day before and the day after surgery. Plasma concentrations of morphine were measured after both intramuscular and epidural administration. Both intramuscular and epidural morphine gave effective analgesia, but the average dose of intramuscular morphine was up to seven times greater than that required by the epidural route. A larger number of patients receiving epidural morphine postoperatively were able to sit, stand, or walk unassisted within 6, 12, and 24 hr, respectively. Being alert and more mobile as a result of superior postoperative analgesia from epidural morphine, patients in this group benefited more from vigorous physiotherapy routine, which resulted in fewer pulmonary complications. Furthermore, earlier postoperative recovery of peak expiratory flow and bowel function presumably contributed to a significantly shorter hospitalization in patients receiving epidural morphine. There was no evidence of prolonged respiratory depression in this high-risk category of patients. The 99mTc-plasmin tests revealed no significant difference between the two groups.

Organization of acute pain services: a low-cost model

&NA; It is being increasingly recognized that the solution to the problem of inadequate postoperative pain relief lies not so much in development of new techniques but in development of a formal organization for better use of existing techniques. Acute Pain Services (APS) are being increasingly established to provide good quality postoperative analgesia. In the United States such 24‐h services usually consist of anesthesiologists, residents, specially trained nurses and pharmacists. However, less than 30% of US surgical population has access to APS. Furthermore, only patients selected by surgeons receive the benefits of these services. Additionally, the economic costs of such services are high (≥

A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty

200/ patient). Less expensive alternatives have to be developed if the aim is to improve the quality of postoperative analgesia for every patient after any type of surgery. Sophisticated analgesia techniques such as epidural and patient‐controlled analgesia (PCA) are neither necessary nor realistic for the majority of patients. Our nurse‐based anesthesiologist‐supervised model is based on the concept that postoperative pain relief can be greatly improved by provision of in‐service training for surgical nursing staff, optimal use of systemic opioids and use of regional analgesia techniques and PCA in selected patients, Regular recording of each patients pain intensity by VAS every 3 h and recording of treatment efficacy on a bedside vital‐sign chart are the cornerstones of this model. A VAS greater than 3 is promptly treated. Surgeon and ward nurse participation are crucial in this organization. An Acute Pain Nurse (APN) makes daily rounds of all surgery departments. Her duties include referral of problem patients to the anesthesiologist. At our hospital about 18,000–20,000 surgical procedures are performed each year; our low‐cost (

Postoperative patient-controlled local anesthetic administration at home

3–4/patient) organization is designed to benefit all of these patients. This organization has been functioning satisfactorily for 3 years, and it can be easily modified for non‐surgical wards.

An Experimental Study of Urodynamic Effects of Epidural Morphine and of Naloxone Reversal

The PROSPECT Working Group, a collaboration of anaesthetists and surgeons, conducts systematic reviews of postoperative pain management for different surgical procedures (http://www.postoppain.org). Evidence‐based consensus recommendations for the effective management of postoperative pain are then developed from these systematic reviews, incorporating clinical practice observations, and transferable evidence from other relevant procedures. We present the results of a systematic review of pain and other outcomes following analgesic, anaesthetic and surgical interventions for total knee arthroplasty (TKA). The evidence from this review supports the use of general anaesthesia combined with a femoral nerve block for surgery and postoperative analgesia, or alternatively spinal anaesthesia with local anaesthetic plus spinal morphine. The primary technique, together with cooling and compression techniques, should be supplemented with paracetamol and conventional non‐steroidal anti‐inflammatory drugs or COX‐2‐selective inhibitors, plus intravenous strong opioids (high‐intensity pain) or weak opioids (moderate‐ to low‐intensity pain).

The Analgesic Efficacy of Patient-controlled Ropivacaine Instillation After Cesarean Delivery

F or most day-surgery patients, postoperative pain can be managed adequately at home with conventional oral analgesics, such as paracetamol, nonsteroidal antiinflammatory drugs (NSAIDs), and weak opioids (codeine, dextropropoxyphene). However, for moderate to severe pain, this treatment may be inadequate (l-4). Our recent study of 1035 patients undergoing a variety of day-surgical procedures (5) showed that approximately 30% of patients experienced moderate to severe pain at home. Severe pain was experienced by many patients who underwent the following surgeries: orthopedic (knee, shoulder, iliac bone graft, maxillofacial, halux valgus), breast augmentation, inguinal hernia, and varicose veins. We describe a technique using an elastometric balloon pump, which allows the patient to self-administer local anesthetic analgesia at home. This study was undertaken to evaluate the safety and applicability of the technique in a wide range of surgical procedures.

Epidural technique for postoperative pain: gold standard no more?

Urinary retention after epidural morphine is a distressing and troublesome complication. This study was undertaken to determine the effects of morphine (epidural, intramuscular, and intravenous) on urinary bladder function and possible reversal by naloxone. Thirty male volunteers (aged 20–28 years) were studied; the doses studied were 2, 4, and 10 mg of epidural morphine, 10 mg intramuscular morphine, and 10 mg intravenous morphine. The urodynamic study consisted of measurements of urine flow rate, strength of detrusor contraction, bladder capacity, and urethral pressure. Irrespective of dose, all subjects receiving epidural morphine showed marked relaxation of the detrusor shortly after injection. There was a corresponding increase in the maximal bladder capacity leading to urinary retention. These effects lasted an average of 14–16 h. Urethral pressures remained unchanged. Urodynamic changes after intramuscular and intravenous morphine were minimal. Treatment using a single intravenous injection of 0.8 mg naloxone promptly reversed the effects of epidural morphine on the bladder. Prevention of urinary retention was achieved with an intravenous infusion of naloxone started before administration of epidural morphine. The possible mechanisms of urinary retention following epidural opiates are discussed.

A comparison of intra-operative or postoperative exposure to music : a controlled trial of the effects on postoperative pain

To assess the efficacy and safety of wound instillation of ropivacaine, when administered via a patient-controlled elastometric pump, 50 term parturients undergoing cesarean delivery were enrolled into this prospective, placebo-controlled, double-blinded study. In all cases, a standard spinal anesthetic was administered. After the surgery, a multihole 20-gauge epidural catheter (B. Braun, Melsungen, Germany) was placed above the fascia such that the tip was sited at the point that demarcated 50% of the length of the surgical wound. Thereafter, the catheter was connected to the elastometric pump. According to a computer-generated randomization schedule, the pump was filled with either ropivacaine 0.2% (Ropivacaine Group) or an equal volume of sterile water (Control Group). Postoperatively, patient-controlled analgesia was administered via the elastometric pump. During the first 6 postoperative hours, a coinvestigator administered “rescue” morphine (2 mg, IV). Thereafter, “rescue” dipyrone (1 g) was administered on patient request. In a subset of 10 patients, blood ropivacaine levels were assessed. Compared with the Control Group, significantly fewer patients in the Ropivacaine Group received “rescue” morphine (92% vs 48%, respectively) (P < 0.01). The total “rescue” morphine administered during the first 6 postoperative hours was 2 ± 3 mg vs 10 ± 5 mg (P < 0.01) for the Ropivacaine and Control Groups, respectively. Patient-generated resting pain scores were similar between the groups. However, pain scores generated after coughing and leg raise were significantly (P < 0.04) less in the Ropivacaine Group. More patients in the Ropivacaine Group than in the Control Group described their analgesia as good or excellent. In the subset of patients (n = 10) studied, unbound ropivacaine blood levels were below the toxic threshold (600 ng/mL). However, blood ropivacaine accumulation was noted. All patients stated that the elastometric pump was easy to use. Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery. Implications Ropivacaine wound instillation via an elastometric pump is a simple technique that provides safe and effective analgesia after cesarean delivery.

Patient-controlled regional analgesia (PCRA) at home: controlled comparison between bupivacaine and ropivacaine brachial plexus analgesia.

Abstract Epidural analgesia is a well-established technique that has commonly been regarded as the gold standard in postoperative pain management. However, newer, evidence-based outcome data show that the benefits of epidural analgesia are not as significant as previously believed. There are some benefits in a decrease in the incidence of cardiovascular and pulmonary complications, but these benefits are probably limited to high-risk patients undergoing major abdominal or thoracic surgery who receive thoracic epidural analgesia with local anaesthetic drugs only. There is increasing evidence that less invasive regional analgesic techniques are as effective as epidural analgesia. These include paravertebral block for thoracotomy, femoral block for total hip and knee arthroplasty, wound catheter infusions for cesarean delivery, and local infiltration analgesia techniques for lower limb joint arthroplasty. Wound infiltration techniques and their modifications are simple and safe alternatives for a variety of other surgical procedures. Although pain relief associated with epidural analgesia can be outstanding, clinicians expect more from this invasive, high-cost, labour-intensive technique. The number of indications for the use of epidural analgesia seems to be decreasing for a variety of reasons. The decision about whether to continue using epidural techniques should be guided by regular institutional audits and careful risk-benefit assessment rather than by tradition. For routine postoperative analgesia, epidural analgesia may no longer be considered the gold standard.