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Query: UMLS:C0344307 (analgesia)
 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

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.
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PMID:Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section. 868 56

At the Glasgow Royal Infirmary in Scotland, a 26-year-old woman requested termination of her 18-week pregnancy. She had no history of cervical or uterine surgery. She was administered under supervision 200 mg oral mifepristone followed 48 hours later by 600 mcg vaginal misoprostol, which was repeated 6 hours later. Four hours later painful uterine contractions developed. She was administered slow intravenous (IV) diamorphine (total 10 mg) for analgesia. She had vaginal bleeding (about 100 ml). 30 minutes later, the fetus was delivered but not the placenta. Severe abdominal pain ensued, requiring 10 mg more IV diamorphine. She then blanched and peripherally shut down. Physicians had to perform emergency manual removal of the placenta under general anesthesia. They then checked the uterine cavity digitally and discovered a large defect in the uterine wall and a palpable ovary (right) within the uterine cavity. A laparotomy revealed an 8 cm right uterine side wall rupture with considerable hemorrhage into the broad ligament and abdominal cavity. The surgeons performed a hysterectomy and right salpingo-oophorectomy to control the bleeding. The patient lost about 4000 ml of blood. She required 7 units of packed red cells, 1500 ml gelofusine, and 2 l crystalloid and 2 units of fresh frozen plasma. She received 1.2 g augmentin and 120 mg gentamicin perioperatively. She recovered uneventfully. Pathological analysis confirmed the 8 cm rupture. It also revealed normal endometrial decidualization and myometrial hypertrophy and no underlying weakness. This case is the first recorded of uterine rupture after administration of oral mifepristone and vaginal misoprostol. Uterine rupture occurs rarely in second trimester medical terminations of pregnancy. Many cases had risk factors associated with uterine rupture. As a result of this 26-year-old case, the physicians have amended their regimen for drug-induced abortion in cases of second trimester termination of pregnancy.
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PMID:Uterine rupture during second trimester termination of pregnancy using mifepristone and a prostaglandin. 873 Jun 20

Conventional extradural analgesia during labour with 0.25-0.375% bupivacaine may induce motor weakness and subjective sensory deficit, reducing maternal satisfaction. Even in a regimen for ambulatory extradural analgesia (0.1% bupivacaine-fentanyl 2 micrograms ml-1), a potential for proprioreception impairment exists, which may impair safe ambulation. We have combined fentanyl with clonidine for extradural analgesia in labour, and compared its effects with 0.25% bupivacaine, in a randomized, double-blind study. We studied 28 women requesting extradural analgesia for labour; they were allocated randomly to either group 1, who received clonidine 120 micrograms with fentanyl 50 micrograms, or group 2, who received bupivacaine 25 mg. Detailed clinical neurological examination was undertaken 30 min later. Pain was assessed subjectively using a 10-cm visual analogue scale (VAS). There were no significant differences in VAS between the groups at any time. Median onset of analgesia was longer in group 1 (24.3 (interquartile range 20-35) compared with 17.5 (15-25) min) (P < 0.05) and 79% of group 1 vs 86% of group 2 patients reported a high degree of satisfaction with extradural analgesia. Patients in group 2 had a much higher incidence of motor weakness (P < 0.01), impaired perception of pinprick (P < 0.01) and impaired distal joint proprioception (P < 0.05) than group 1. We conclude that clonidine 120 micrograms-fentanyl 50 micrograms provided comparable extradural analgesic efficacy as 0.25% bupivacaine for the first stage of labour. Furthermore, unwanted neurological effects were significantly less.
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PMID:Extradural analgesia with clonidine and fentanyl compared with 0.25% bupivacaine in the first stage of labour. 867 78

A combination of epidural opioids with local anaesthetics has been used to improve pain relief during labor and to reduce side effects, such as muscle weakness, usually seen when local anaesthetics are used alone. The addition of epidural fentanyl (F) produces highly effective analgesia, the only side effect being mild itching. Initial trials investigated the improvement in analgesia after a single administration of F during first- but not during second-stage labor. Even though pain perception during second-stage labor under epidural analgesia with local anaesthetics can be severe, the addition of opioids was avoided for fear of neonatal or maternal depression. A recent report found maternal and umbilical plasma concentrations following injection of 100 micrograms F to be safe and the investigators speculated that repeated addition of epidural/F to injection of local anaesthetic may prove beneficial for the parturient without exposing the mother or fetus to risk. We therefore studied maternal analgesia, maternal and umbilical plasma levels and associated side effects following repeated addition of 100 micrograms F to bupivacaine epidural analgesia during labor. METHODS. Following institutional and governmental approval 53 parturients were randomly assigned to receive either 8 ml bupivacaine 0.25% + 0.1 mg fentanyl (B + F group; n = 28) or 8 ml bupivacaine 0.25% + 2 ml saline (BUP group; n = 25) in an epidural catheter at L2/3. The same dose was reinjected upon the patients' request regardless of the degree of cervical dilatation. Blood pressure, heart rate, respiratory rate and the incidence of side effects were recorded before and following each epidural injection. Pain relief was determined at each injection and following cord clamping using the visual analogue pain scale (VAS; 0-100 mm). Maternal venous blood samples were collected to measure plasma F concentrations before and 20 and 40 min after each injection and at birth when umbilical venous and arterial blood was obtained. After centrifugation the samples were maintained at -20 degrees C and then analyzed by radioimmunoassay. At delivery, Apgar scores and umbilical venous and arterial blood gas values were determined. RESULTS. Both groups were comparable for age, weight, height, gestational age and parity. A total of 48 epidural injections were evaluated in the B + F group, 43 in the BUP group. No statistically significant group difference was found between the frequency of injections per delivery (B + F: 2.2; BUP: 1.8); regarding the time between the initial and the first top-up dose (B + F: 144 min; BUP: 140 min) or regarding the interval between the last injection and birth (B + F: 94 min; BUP; 90 min). However, the quality of pain relief during labor and particularly at birth was significantly improved by F (mean VAS in B + F group: 6 mm; mean VAS in BUP group: 42 mm). Mild itching was observed in 43% of patients receiving F, moderate shivering in 13% versus 40% in patients not receiving F. At control mean maternal F plasma levels were not zero but 0.25 ng/ml. After the initial injection and following the first and second top-up dose mean maximum maternal F plasma concentrations were 0.54 ng/ml (+/-0.32; +/-SD), 0.88 ng/ml (+/-0.62) and 1.06 ng/ml (+/-0.4) (range 0.18-2.76 ng/ml), respectively. The increase in maternal F concentrations with increasing injection frequency was statistically significant (P < 0.02). Mean umbilical venous and arterial F concentrations at birth were 0.72 ng/ml (+/-1.16) and 0.62 ng/ml (+/-0.52). No significant group differences were found regarding Apgar scores or umbilical blood gas analyses. In one newborn, radioimmunoassay resulted in unexplainably high umbilical F concentrations without any clinical signs of sedation, depressed vigilance and without any sequellae. DISCUSSION. Repeated addition of 100 micrograms F to epidural anaesthesia with bupivacaine significantly improves analgesia and provides pain relief not only during the fir
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PMID:[Repeated addition of fentanyl to bupivacaine peridural analgesia in labor. Clinical action and fentanyl plasma level]. 877 2

Two patients with neuralgic amyotrophy (Parsonage-Turner syndrome) are described. Problems arising from the shoulder girdle commonly present to accident and emergency (A&E) departments. Neuralgic amyotrophy is an infrequent neuromuscular disorder which predominantly affects the shoulder girdle. Characterised by severe pain followed by muscle weakness, atrophy, and variable sensory deficits, the diagnosis is based on history and physical findings and is confirmed by electromyography. The prognosis is excellent and treatment is supportive using analgesia and physiotherapy.
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PMID:Neuralgic amyotrophy presenting to an accident and emergency department. 902 24

Intravenous opioids cause analgesia and increase release of ACh in spinal cord dorsal horn in animals, and these effects are enhanced by intrathecal neostigmine injection. The purpose of the current study was to test whether intrathecal neostigmine enhanced analgesia and increased cerebrospinal fluid concentrations of ACh over those induced by i.v. alfentanil in volunteers, and also to test whether neostigmine enhanced alfentanil-induced side effects. After human studies committee approval, 40 healthy volunteers received an intrathecal injection of saline or neostigmine (50, 100 or 200 microg) followed in 60 min by a computer-controlled, stepped i.v. infusion of alfentanil to escalating targeted plasma concentrations. Pain report to hand and foot immersion in ice water, sedation, nausea, weakness, vital signs, end-tidal CO2 and oxyhemoglobin saturation were measured 60 min after spinal injection and at the end of each 20-min alfentanil infusion. Cerebrospinal fluid was sampled once after drug administration. Intrathecal neostigmine alone caused analgesia in the foot but not in the hand, and was accompanied by leg weakness, whereas IV alfentanil alone caused equivalent analgesia in both the hand and the foot and was accompanied by nausea, sedation, increased end-tidal CO2 and decreased oxyhemoglobin saturation. Neostigmine enhanced analgesia but not respiratory effects induced by i.v. alfentanil; it also enhanced nausea and sedation. Intravenous alfentanil increased cerebrospinal fluid ACh concentration, and neostigmine enhanced this change. These data in humans are consistent with a spinal cholinergic mechanism of i.v. opioid analgesia. Because neostigmine enhances both analgesia and side effects induced by i.v. alfentanil, the clinical utility of their use in combination will depend on the relative strength of these interactions.
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PMID:Enhancement of analgesia from systemic opioid in humans by spinal cholinesterase inhibition. 922 43

We audited and analysed the adverse effects and safety of postoperative pain management on 2509 consecutive patients under care of the Acute Pain Service at a tertiary referral teaching hospital over a 32-month period. Our standard respiratory monitoring consisted of continuous pulse oximetry, hourly respiratory rate counting, sedation scoring and intermittent arterial blood gas sampling. This protocol was reliable and detected six episodes of bradypnoea, 13 of hypercapnia and 23 of oxygen desaturation occurring in 39 patients (1.8% of all spontaneously breathing patients). Two patients required naloxone injection and none had long-term sequelae. Hypotension due to epidural bupivacaine 0.0625% and fentanyl 3.3 micrograms.ml-1 infusion occurred in four patients (1.2%), all with a sensory block higher than T5. They readily responded to fluid infusion and ephedrine (two patients). Postoperative nausea or vomiting occurred in 723 (28.8%) and 380 (15.1%) patients, respectively. Odds ratio analysis showed that the risk factors for postoperative nausea and vomiting were: female gender, gynaecological operations, nongeriatric patients and systemic analgesia. Postoperative nausea and vomiting decreased analgesic efficacy by discouraging the use of patient-controlled analgesia and was regarded as equally distressing as pain. Other side-effects included: pruritus in 182 patients; dizziness in 333 and lower limb weakness in 73 (21.2% of patients receiving epidural local anaesthetics). It is concluded that a standard monitoring and management protocol, an experienced nursing team and reliable Acute Pain Service coverage is mandatory for the safe use of modern analgesic techniques.
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PMID:An audit of the safety of an acute pain service. 940 64

The aim of this prospective study was to assess the feasibility and postoperative outcome of the "plug" technique in inguinal hernia. One hundred and forty-six consecutive patients were operated for 151 hernias. A plug was applied in 131 cases (86.8%). The Lichtenstein technique was used in 20 cases (13.2%) because of a wide weakness of the posterior wall. Eleven (7.3%) postoperative benign complications occurred. No severe complications were observed and no patient was reoperated. The mean duration of oral analgesia was 2.7 (0-10) days. Mean durations of postoperative hospital stay, time off work and cessation of normal activities were 1.2 (0-4) days, 18.1 (1-37) days and 5.8 (1-18) days, respectively. In conclusion, the "plug" technique is feasible in a wide range of hernias and allows a short hospital stay and an early return to normal activity.
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PMID:[Feasibility and short-term results of the "plug" technique in inguinal hernia. A prospective evaluation]. 940 60

Walking after regional blockade for labour using low-dose combinations of bupivacaine and fentanyl is possible due to the maintenance of lower limb motor power. In order to investigate concerns that dorsal column function, important in maintaining balance, is impaired after such techniques, clinical assessment of lower limb proprioception and vibration sense was evaluated in parturients after either low-dose epidural (n = 30) or spinal blockade (n = 30) for labour analgesia and compared with spinal anaesthesia (n = 30) for elective Caesarean section using a larger total dose of local anaesthetic. Of the patients receiving low-dose regional labour analgesia 7% (n = 4) had abnormal dorsal column function compared with 97% (n = 29) receiving spinal anaesthesia for Caesarean section (p < 0.001). All patients in the Caesarean section group developed lower limb motor weakness, compared with only 10% (n = 6) in the low-dose groups (p < 0.001). There were no significant differences between the low-dose groups with respect to sensory block, motor block or dorsal column function. Overall, 90% of patients receiving low-dose bupivacaine/fentanyl regional labour analgesia had both normal lower limb motor power and dorsal column function. Assessment of these parameters is recommended before allowing patients to walk after low-dose regional techniques for labour.
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PMID:Dorsal column function after epidural and spinal blockade: implications for the safety of walking following low-dose regional analgesia for labour. 984 92

We have compared 0.5% bupivacaine 75 mg (group A; n = 15) with three 0.5% bupivacaine 75 mg-ketamine mixtures for extradural block in 59 ASA I-III patients undergoing total knee replacement in a randomized, double-blind study. The following doses of preservative-free 1% ketamine were used: 0.3 mg kg-1 (group B: n = 14); 0.5 mg kg-1 (group C: n = 5); and 0.67 mg kg-1 (group D: n = 15). Level of sensory block, degree of motor weakness and sedation scores were recorded before and after operation. Duration of postoperative analgesia was also noted. There was no difference between groups in median maximum level of sensory block (group A: T4 (range T10-T2); group B: T4 (T10-T2); group C: T4 (T8-T2); and group D: T3 (T8-C3)) or in the degree of motor block. Thirty-three of the 44 patients who received ketamine showed signs of systemic absorption (blurred vision, sedation) within 10 min of injection. There was no significant difference between groups in median duration of analgesia (group A: 240 (range 115-340) min; group B: 198 (97-460) min; group C: 150 (122-448) min; and group D: 210 (130-390) min). No patient suffered any adverse psychomimetic effects. We conclude that at the doses used, addition of ketamine to extradural bupivacaine did not improve extradural block in adult patients undergoing total knee replacement.
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PMID:Double-blind comparison of extradural block with three bupivacaine-ketamine mixtures in knee arthroplasty. 962 27


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