Nesimi Uckunkaya

Low-dose clonidine and neostigmine prolong the duration of intrathecal bupivacaine-fentanyl for labor analgesia.

BACKGROUND Intrathecal (IT) opioid and local anesthetic combinations are popular for labor analgesia because of rapid, effective pain relief, but the duration of analgesia is limited. This study was undertaken to determine whether the addition of clonidine and neostigmine to IT bupivacaine-fentanyl would increase the duration of analgesia without increasing side effects for patients in labor. METHODS Forty-five healthy parturients in active labor were randomized to receive a 2-ml IT dose of one of the following dextrose-containing solutions using the combined spinal-epidural technique: (1) bupivacaine 2.5 mg and fentanyl 25 microg (BF); (2) BF plus clonidine 30 microg (BFC); or (3) BFC plus neostigmine 10 microg (BFCN). Pain, sensory levels, motor block, side effects, maternal vital signs, and fetal heart rate were systematically assessed. RESULTS Patients administered BFCN had significantly longer analgesia (165+/-32 min) than those who received BF (90+/-21 min; P<0.001) or BFC (123+/-21 min; P<0.001). Pain scores, block characteristics, maternal vital signs, Apgar scores, maternal satisfaction, and side effects were similar among groups except for nausea, which was significantly greater in the BFCN group (P<0.05 as compared with BFC). CONCLUSIONS The addition of clonidine and neostigmine significantly increased the duration of analgesia from IT bupivacaine-fentanyl during labor, but neostigmine caused more nausea. Although serious side effects were not observed in this study, safety must be further addressed before the routine use of multiple IT drugs is advocated.

Effects of perioperatively administered bupivacaine and bupivacaine-methylprednisolone on pain after lumbar discectomy.

Study Design. A prospective, randomized, controlled trial that compared the efficacy of different protocols of local tissue infiltration with bupivacaine or bupivacaine-methylprednisolone at the surgical site for pain relief after lumbar discectomy. Objective. To determine the efficacy of preemptive wound infiltration with bupivacaine and bupivacaine-methylprednisolone after lumbar discectomy. Summary of Background Data. Patients usually have significant pain after lumbar discectomy. Wound infiltration with bupivacaine or bupivacaine-methylprednisolone is one method to address this. Methods. Seventy-five patients were randomly allocated to 5 equal groups as follows: Group I (n = 15) had the musculus multifidi near the operated level infiltrated with 30 mL 0.25% bupivacaine and 40 mg methylprednisolone just before wound closure; Group II (n = 15) had the same region infiltrated with 30 mL 0.25% bupivacaine alone before closure; Group III (n = 15) had this region infiltrated with 30 mL 0.25% bupivacaine and 40 mg methylprednisolone before the incision was made; in Group IV (n = 15), this region infiltrated with 30 mL 0.25% bupivacaine alone before incision; and Group C (controls, n = 15) had this region infiltrated with 30 mL 0.9% NaCl just before wound closure. Demographics, vital signs, postoperative pain scores, and morphine usage were recorded. Results. All 4 groups treated with bupivacaine or bupivacaine-methylprednisolone (by preemptive or preclosure wound infiltration) showed significantly better results than the control group for most parameters. The treated groups had lower parenteral opioid requirements after surgery, lower incidences of nausea, and shorter hospital stays. Further, the data indicate that, compared with infiltration of these drugs at wound closure, preemptive injection of bupivacaine or bupivacaine-methylprednisolone into muscle near the operative site provides more effective analgesia after lumbar discectomy. Conclusion. In addition, our data suggest that preemptive infiltration of the wound site with bupivacaine alone provides similar pain control to preemptive infiltration of the wound site with bupivacaine and methylprednisolone combined.

Combined use of axillary block and lateral femoral cutaneous nerve block in upper-extremity injuries requiring large skin grafts

An axillary block and lateral femoral cutaneous nerve block combination was used in 11 patients with upper-extremity injuries requiring large skin grafts. In our experience, this block combination was highly successful. All but one of the patients obtained excellent pain relief (mean visual analog pain scores, 0.2) that required no narcotic analgesics or sedatives. There were no systemic or neurologic side effects attributed to the local anesthetic drugs. We believe that combining an axillary block and a lateral femoral cutaneous nerve block is a clinically useful and effective technique and an excellent anesthetic alternative for procedures requiring large grafts for the upper extremity.

Accidental epidural catheterization during continuous interscalene block via the posterior approach

Abstract In recent years, interscalene catheterization via the posterior approach and continuous local anesthetic infusion has been suggested for pain relief related to brachial plexus tumor infiltration. Improper catheterization could lead to complications such as epidural or spinal anesthesia or phrenic nerve paralysis.A 54 year old man was referred to our pain clinic with severe right upper extremity and shoulder pain, dysesthesia and allodynia involving the right C7-T1 dermatomes, and 3/5 strength loss of the right forearm due to inoperable apical lung tumor with brachial plexus infiltration. For pain relief, a continuous interscalene block via the posterior approach was performed in the sitting position. Four millilitres 1% lidocaine without epinephrine were administered through the catheter. Approximately 5 minutes after the injection, the patient developed respiratory distress and dizziness. Fifteen minutes after the injection, side effects regressed and the vital signs stabilized. To confirm cathe...

Lumbar epidural lysis: a cranio-caudal lateral intralaminar approach

AbstractThe standard approach for epidural lysis is reaching to the problematic area through the caudal canal. If the symptoms do not cease and no improvement is seen, a cranio-caudal approach can be tried. In a patient with back pain due to failed back surgery syndrome for six months, epidurography was performed using caudal approach under fluoroscopy in the first intervention. A catheter was progressed to fibrotic tissue for epidural lysis. But the pain regression was not satisfactory at the L4 dermatome. After 3 weeks, a second intervention was planned with the lateral cranio-caudal approach at the L3-4 level and a catheter was placed around the fibrotic tissue and lysis was applied. The patients back pain totally disappeared and neurological symptoms started to decrease at the end of the first week. We suggest that, for patients with low back pain due to failed back surgery syndrome, a cranio-caudal approach may be applied after caudal epidural lysis.

Acute respiratory distress after cervical plexus block caused by acute brainstem anaesthesia

Abstract A 50-year-old man was scheduled for left carotid endarterectomy under deep and superficial cervical plexus blockade. At the end of the third injection into the deep cervical plexus, he suffered from respiratory distress and hypotension. Surgery was interrupted and he was admitted to the Intensive Care Unit with acute brainstem anesthesia from unintentional injection of local anesthetic solution into the subarachnoid space.

Low-dose Clonidine and Neostigmine Prolong the Duration of Intrathecal Bupivacaine-Fentanyl for Labor Analgesia

Background Intrathecal (IT) opioid and local anesthetic combinations are popular for labor analgesia because of rapid, effective pain relief, but the duration of analgesia is limited. This study was undertaken to determine whether the addition of clonidine and neostigmine to IT bupivacaine–fentanyl would increase the duration of analgesia without increasing side effects for patients in labor. Methods Forty-five healthy parturients in active labor were randomized to receive a 2-ml IT dose of one of the following dextrose-containing solutions using the combined spinal–epidural technique: (1) bupivacaine 2.5 mg and fentanyl 25 &mgr;g (BF); (2) BF plus clonidine 30 &mgr;g (BFC); or (3) BFC plus neostigmine 10 &mgr;g (BFCN). Pain, sensory levels, motor block, side effects, maternal vital signs, and fetal heart rate were systematically assessed. Results Patients administered BFCN had significantly longer analgesia (165 ± 32 min) than those who received BF (90 ± 21 min;P < 0.001) or BFC (123 ± 21 min;P < 0.001). Pain scores, block characteristics, maternal vital signs, Apgar scores, maternal satisfaction, and side effects were similar among groups except for nausea, which was significantly greater in the BFCN group (P < 0.05 as compared with BFC). Conclusions The addition of clonidine and neostigmine significantly increased the duration of analgesia from IT bupivacaine–fentanyl during labor, but neostigmine caused more nausea. Although serious side effects were not observed in this study, safety must be further addressed before the routine use of multiple IT drugs is advocated.