To compare the effect of an adjunctive postoperative epidural local anesthetic with combined lumbar spinal epidural anesthesia versus systemic nonsteroidal analgesics with general anesthesia on disease recurrence following radical prostatectomy for prostate cancer.
This prospective randomized study describes an analysis of patients who underwent retropubic radical prostatectomy. We evaluated recurrence of prostate cancer after open radical prostatectomy in patients who received either combined lumber spinal epidural anesthesia with postoperative epidural analgesia (CSE group; n=30) or general anesthesia with postoperative nonsteroidal analgesia that consisted of ketorolac 30 mg intravenously every 8 h and paracetamol 1 g intravenously every 6 h over 48 h (GA group; n=30). The first dose of ketorolac was administered at the time of fascial closure. For patients in both groups, analgesic supplementation with tramadol 100 mg intramuscularly was used whenever the pain score exceeded 2/10 on the visual analogue scale. Specifically, we tested the hypothesis that recurrence of prostate cancer is less common with the CSE group than with the GA group. Follow-up chart review was performed to determine clinically evident or biochemical (prostate-specific antigen>0.4 ng/ml) recurrence of prostate cancer. Comparison by group was carried out using survival analysis.
The patients in the CSE group showed a significantly more stable hemodynamic profile. These patients also showed significantly less blood loss, need for blood transfusion, and also the surgical time was shorter in the patients of this group compared with those who received general anesthesia (the GA group), with the differences being statistically significant. In the postoperative period, the patients in the CSE group had a significantly shorter recovery time and less hospital stay; in addition, there was a highly significant difference in analgesic supplementation. Median disease-free survival could not be defined in either group, as less than 50% of patients in both groups developed recurrence by the end of the study. Biochemical recurrence of prostate cancer was observed in 5/30 patients in the CSE group and 8/30 patients in the GA group. There was one death because of prostate cancer in each group and a total of five deaths in the CSE group and six deaths in the GA group. The hazard ratio for recurrence in the CSE group compared with the GA group was 2.03 (95% confidence intervals 0.76–5.43; P=0.44 by the log-rank test).
No significant difference was observed between both groups in disease-free survival at a median follow-up time of 2 years. There is a need for large randomized-controlled trials to determine the ability of combined lumber spinal epidural anesthesia with postoperative epidural analgesia to alter disease recurrence rates following radical prostatectomy.
Epidural morphine is an effective analgesic technique for lower abdominal surgery, but pruritus is its most common side effect. Nalbuphine is an agonist–antagonist opioid and effective in treating opioid-induced pruritus. Dexamethasone is a corticosteroid with anti-inflammatory and antiallergic properties. We compared the effectiveness of intramuscular dexamethasone and nalbuphine in the prevention of epidural morphine-induced pruritus after lower abdominal surgery.
One hundred and fifty, American Society of Anesthesiologists physical status I or II, patients undergoing lower abdominal surgery with epidural anesthesia were assigned randomly to three groups. Group A, group B, and group C received intramuscular normal saline (2 ml; n=50), dexamethasone (8 mg/2 ml; n=50), and nalbuphine (10 mg/2 ml; n=50), respectively, after skin closure. The occurrence and severity of pruritus were assessed at 1, 4, 8, and 12 h after surgery.
Pruritus occurred less frequently in group C than group B (P<0.05). At 4, 8 and 12 h postoperatively, the severity of pruritus was significantly different (P<0.05) and was significantly less in group C than group B in the intergroup comparison (P<0.05).
Nalbuphine proved to be better than dexamethasone in the prevention of epidural morphine-induced pruritus in patients who underwent lower abdominal surgery. Prophylactic intramuscular nalbuphine (10 mg) is effective in decreasing the incidence and severity of pruritus and does not affect analgesia.
The aim of this study was to compare intrathecal dexmedetomidine (DXM) and intrathecal magnesium sulfate (MgSO4) as adjuvants to bupivacaine in lower abdominal operations.
This study was carried out at Al-Zahraa University Hospital and included 60 (ASA I or II) patients of both sexes. The patients were divided into three equal groups: group C (control group) received 15 mg of hyperbaric bupivacaine and 0.1 ml of normal saline; group D (DXM group) received 15 mg of hyperbaric bupivacaine and 0.1 ml (10 μg) of DXM; and group M (MgSO4 group) received 15 mg of bupivacaine and 0.1 ml (50 mg) of MgSO4. The following parameters were recorded: hemodynamic changes (heart rate and blood pressure), onset of sensory block and motor block, and regression time. The sedation level of the patients was assessed using the inverted observer assessment of alertness/sedation scale, in which 1=awake and 5=asleep/unarousable. Postoperative pain was assessed using the visual analogue score (VAS), and adverse effects, if any, were also recorded.
As regards hemodynamic stability, no significant difference was seen among the three groups. The onset of sensory block up to the T10 dermatome was rapid in the DXM group in comparison with the MgSO4 group and the control group (2.19±1.02 vs. 6.35±1.2 and 4.13±1.01, respectively; P<0.001). Moreover, the onset of motor block, according to a Bromage scale score of 3, was rapid in the DXM group in comparison with the MgSO4 group and the control group (3.85±0.81 vs. 7.05±1.28 and 4.51±0.04, respectively; P<0.001).
The regression time of the sensory, up to the T10 dermatome, and motor, according to a Bromage score of 0, block was prolonged in the DXM group (328±51 and 306±32) and in the MgSO4 group (240±56 and 223±48) in comparison with the control group (182±52 and 150±37); the difference between the three groups was statistically highly significant (P<0.001).
The VAS score was low in both groups D and M when compared with the group C. The difference in the intensity of postoperative pain among the three groups was statistically highly significant (P<0.001). The postoperative sedation (observer assessment of alertness/sedation) scale was higher in the groups D and M than in the group C.
Nausea and vomiting recordings showed no significant differences among the three groups. Shivering was recorded in eight patients of group C, in three patients of group M, and in two patients of group D.
DXM is safe as an adjuvant to spinal block with a rapid onset of sensory and motor blockade and prolongation of the duration of action. It also has a sedative effect and yields lower VAS scores. In group M, intrathecal magnesium delayed the onset of action when compared with the groups D and C. The prolongation of the duration of action was higher in the group M when compared with the group C but was lower when compared with the group D. Further, the group M had a lower VAS score than the group C.
Paravertebral block provides effective intraoperative and postoperative analgesia for many thoracic and abdominal surgeries both in children and in adults. This technique has a low failure rate, fewer complications, and can be unilaterally used in unilateral procedures and whenever epidural anesthesia is contraindicated. We aimed to compare the anesthetic effectiveness of a paravertebral block with epidural anesthesia in lower abdominal procedures.
This prospective study included 60 patients who underwent different lower abdominal surgeries, divided into two equal groups: group I [lumbar epidural (LE) group] received LE anesthesia and group II [thoracolumbar paravertebral (TLP) group] received a unilateral TLP block. In both groups, the anesthetic regimen was a single injection of bupivacaine 0.5% (10–14 ml) for intraoperative anesthesia, followed by bupivacaine 0.125% (10–14 ml) every 8 h or according to the patient’s needs for postoperative analgesia. Patients were assessed for hemodynamic parameters (heart rate and mean arterial pressure), motor blockade (Bromage scale), intensity of pain (visual analogue scale), the stress response (perioperative changes in serum glucose and adrenaline levels), and any perioperative complications. Assessment started from the onset of the block and continued for the first 24 h postoperatively.
Visual analogue scale (pain) scores were lower (better) in the TLP group at all times; the differences were statistically significant (P<0.05) at 1, 2, and 8 h after block, whereas they were comparable (P>0.05) at 4, 6, 10, 12, 18, and 24 h. Only one patient (3.33%) in the TLP group and two (6.67%) in the LE group required systemic analgesic supplementation postoperatively (P>0.05). Motor block was predominant in the LE group at 1, 2 (P<0.001), and 4 h (P<0.05) after block. Hemodynamic stability was better in the TLP group. Only one patient had intraoperative hypotension in the TLP group compared with three in the LE group (P>0.05). Serum glucose and adrenaline levels were lower in the TLP group at almost all times, with comparable results (P>0.05). Both techniques were uncomplicated.
Paravertebral blockade provided higher quality intraoperative and postoperative analgesia, and offered better modification of the stress response and a better side effect/complication profile than epidural anesthesia; however, the results were generally comparable.
Epiduralanalgesia is considered to be the preferred method of analgesia during labor. Systemic opioids are also a good, effective, and easy to administer alternative but may cause maternal and fetal respiratory depression. Remifentanil has rapid onset and offset effects, making it an ideal drug for the management of intermittent painful contractions during labor. Thus, this study aimed to confirm that remifentanil patient-controlled analgesia (PCA) is as effective as epidural analgesia as regards analgesic quality and patient satisfaction, with no or little side effects during labor.
A total of 90 pregnant women were randomly assigned to one of two groups with equal number of participants in each group. In the remifentanil group, PCA was set up to deliver a loading dose of 30 μg remifentanil and 30 μg bolus with a 3-min lockout time. The dose can be increased to 40 μg or decreased to 20 μg; the women were advised to start the PCA bolus when they felt the signs of an upcoming uterine contraction. The epidural group received epidural analgesia according to a standardized protocol using bupivacaine plus fentanyl.
All women showed a significant decrease in visual analog scale scores in the first hour after administration of analgesia (P<0.05). Analgesic quality in terms of the visual analog pain score, sedation score, and postdelivery patient satisfaction in both groups was comparable (P>0.05). PCA remifentanil infusion until the time of delivery produced no observable maternal, fetal, or neonatal side effects (P<0.05).
Intravenous PCA with remifentanil is an effective option for pain relief with minimal maternal and neonatal side effects, lower costs, and easier achievement of pain relief during labor.
The aim of this study is to investigate histopathologically the time course of the myotoxic effects of different concentrations of bupivacaine and levobupivacaine after a single intramuscular injection in adult albino rats.
Eighty male adult albino rats were allocated to five different groups of 16 rats each (n=16). The first two groups (B.100 and B.200) received intramuscular injections with 100 and 200 μl of 0.5% bupivacaine, respectively, into the right tibialis anterior muscle. The second two groups (L.100 and L.200) received intramuscular injections with 100 and 200 μl of 0.5% levobupivacaine in the same place. The fifth group (CS) received a 100 μl intramuscular injection of 0.9% isotonic saline. Four rats from each group were killed after 2, 4, 10 and 20 days. Samples were examined blindly under a light microscope for evidence of myotoxicity and analysed statistically.
Muscle damage in B.100, B.200, L.100 and L.200 groups was similar qualitatively. In samples taken 2 days after injection, the muscle damage and inflammatory cells’ infiltration had started. Muscle damage and inflammatory cells’ infiltration reached their maximum on day 4 in all the treated groups in comparison with the control saline group. However, muscle damage was more marked in the B.100 and B.200 groups than the L.100 and L.200 groups. Progressive replacement of the damaged muscle fibres with connective tissue was detected on days 2 and 4 after injection. Muscle samples taken 10 and 20 days after bupivacaine and levobupivacaine injection showed persistence of the muscle fibre damage, with their massive replacement with connective tissue fibres.
A single intramuscular injection of different concentrations of bupivacaine and levobupivacaine showed time-dependent and dose-dependent myotoxic effects on the skeletal muscle fibres. However, levobupivacaine was found to be qualitatively less myotoxic than bupivacaine. In all of the treated groups, the damaged muscle fibres failed to regenerate and had been replaced progressively with connective tissue fibres.
Inguinal hernia repair is one of the most frequently performed surgical procedures in the pediatric population worldwide and is a cause of significant pain in the postoperative period. Recently, a transversus abdominis plane (TAP) block has been reported to provide effective analgesia after inguinal hernia repair, but there are few data comparing ultrasound-guided TAP with an ilioinguinal/iliohypogastric nerve (IHN) block, which is the objective of this study.
Forty-two male patients ranging in age from 6 to 14 years scheduled for elective primary unilateral open inguinal hernia participated in this prospective randomized study. Surgery was performed under combined general anesthesia and ultrasound-guided TAP block (n=22) or IHN block (n=20). After 15 min of general anesthesia blocks were performed using an insulated 22-G needle and 0.2–0.3 mg/kg levobupivacaine as a local anesthetic. Postoperative analgesia comprised intravenous or patient-controlled analgesia morphine. Sonographic data such as the image acquisition time, the needle time under the skin, and image quality were recorded. Time to first analgesic request, faces pain rating score, total analgesic consumption, and adverse effects associated with morphine consumption were recorded for 24 h postoperatively.
In the IHN group, the ultrasound quality was rated as less than excellent in 75% of patients, and needle time under the skin was 77 (20–36) s in the IHN group versus 47 (50–62) s in the TAP group (P<0.001). The median (interquartile range) time to first analgesics request for morphine was 53 (29–229) min in the IHN group versus 19 (5–128) min in the TAP group.
In the IHN block group, there were reduced mean±SD of total morphine requirements in the first 48 postoperative hours (9.8±4.9 vs. 15.61±5.23 mg, P<0.01) compared with the TAP group. Also, postoperative faces pain rating score at rest and movement was reduced in the IHN block compared with the TAP block. Interval morphine consumption was reduced in 6, 12, and 24 h postoperatively in the IHN group. There were no differences between the groups in the incidence of sedation or nausea and vomiting. There were no complications attributable to the block or side effects with analgesics.
After pediatric inguinal repair, TAP block offers good visualization of nerves and the surrounding structure but IHN block offers good analgesia.
The aim of the current trial was to assess the value of adding tramadol to levobupivacaine in an ultrasound-guided transversus abdominis plane (TAP) block in women undergoing total abdominal hysterectomy.
The current study was a double-blind randomized-controlled trial on 66 patients scheduled for abdominal hysterectomy. Patients were divided into three equal groups, where general anesthesia was given, followed by an ultrasound-guided insertion of the needle to perform a bilateral TAP block. The women recruited were randomized as follows: group I, which included women who received a TAP block using 20 ml 0.5% levobupivacaine with 2 ml saline 0.9%, group II, which included women who received a TAP block using 2 ml (100 mg) tramadol in addition to using 20 ml 0.5% levobupivacaine; and group III, which included women who received a TAP block using 22 ml saline 0.9% (control). The mean 48-h morphine requirement, time to first rescue analgesic, total intraoperative fentanyl consumption, and number of patients who needed additional fentanyl were recorded. In addition, a visual analogue scale for assessment of pain in the postanesthesia care unit, as well as 2, 4, 6, 12, 24, and 48 h postoperatively, level of sedation, patient satisfaction, and adverse effect were recorded.
Morphine requirements in the postoperative 48 h were significantly less in group II (18.1±2.4 mg) than in group I (26.1±3.3 mg) and group III (55.8±3.1 mg) (P<0.001). Furthermore, time to first rescue analgesic was significantly longer in group II (250.8±23.3 min) than the other two groups. The total intraoperative fentanyl consumption and number of patients who needed additional intraoperative fentanyl were significantly less in groups I and II compared with group III. The median postoperative pain score was significantly lower in the women in groups II and I compared with women of group III at 2, 4, and 6 h postoperatively. The differences in these outcomes between groups I and II were significant in favor of group II. The incidence of nausea, vomiting, and sedation was significantly reduced in patients of groups I and II in comparison with group III. All TAP patients reported high levels of satisfaction with their postoperative analgesic regimen than the control group. No complications attributed to the block were recorded.
Addition of tramadol to the local anesthetic in a TAP block significantly reduced the immediate postoperative pain, prolonged the time to first rescue analgesia, reduced the mean 48-h morphine consumption, and prolonged the duration of postoperative analgesia.
Advances in cataract surgery including the use of phacoemulsification have shortened the duration of surgery, resulting in the use of shorter acting anesthetic agents with less invasive methods of administration. Thus, a small volume (1 ml) of short and rapidly acting local anesthetics (lidocaine) have been used in sub-Tenon’s block for anesthesia of such operations.
The aim of the present study was to reduce the complications of sub-Tenon’s anesthesia by using low-volume lidocaine and to study its benefits with regard to pain during surgery and ocular akinesia.
Sixty patients of American Society of Anaesthesiologists (ASA) grade I–III, aged between 18 and 70 years, scheduled for phacoemulsification cataract surgery were randomly assigned to two groups. Group I received 1 ml of 10% lidocaine and group II received 3–5 ml of a mixture of 2% lidocaine and 0.5% bupivacaine. Pain during administration of anesthesia and during surgery was graded using the verbal analogue scale and compared for both groups. Subconjunctival hemorrhage, chemosis, akinesia, and major complications such as brainstem anesthesia, optic neuropathy, globe perforation, hemorrhage, and squint were also compared.
Pain during administration of anesthesia was significantly lower in group I compared with group II, and more patients in group I compared with group II were pain free, without a significant difference between the two groups. Akinesia, subconjunctival hemorrhage, and chemosis occurred less often and patient and surgeon satisfaction was significantly better in group I compared with group II. No major complications were detected in both groups.
Lidocaine (10%) at a dose of 1 ml is safe and effective for sub-Tenon’s anesthesia and is a suitable alternative to the mixture of 2% lidocaine and 0.5% bupivacaine used traditionally.
Peribulbar eye block is a safe and inexpensive technique with the advantage of providing efficient anesthesia with good lid and globe akinesia. It is also an effective treatment for operative pain. It has become common practice to use the polypharmacy approach to enhance the onset and increase the duration of the block, because no drug has yet been identified that specifically inhibits nociception without associated side effects.
This prospective double-blind randomized controlled study included 75 patients of either sex who were candidates for cataract surgery, between 40 and 80 years of age, with an American Society of Anesthesiologists physical status of I–III. Peribulbar block was performed in the operating room by a senior anesthesiologist who was unaware of the nature of the solution injected. The patients were divided randomly into three groups according to the medications they received: group O (control group): local anesthetic+0.9% saline (1 ml); group M: local anesthetic+magnesium sulfate 50 mg in 1 ml of 0.9% saline; group R: local anesthetic+0.06 mg/kg rocuronium (maximum 5 mg) in 1 ml saline. The success of the block was evaluated by scoring the mobility of the globe and the eyelid, as well as by assessing corneal anesthesia.
Time to start surgery was significantly lower in the rocuronium (R) group; however, complete corneal anesthesia was achieved in all groups at 10 min. No pain was present in any case, but a supplemental dose was required in groups O and M to achieve complete akinesia.
The addition of rocuronium to the local anesthetic mixture results in a better akinesia score and faster establishment of suitable conditions to start cataract surgery compared with those in the magnesium and placebo groups.
Postherpetic neuralgia (PHN) is an extreme form of neuropathic pain. Although a number of treatment options are available, drug interactions and side effects frequently limit their use. This study aimed to compare the efficacy of repeated paravertebral block with that of topical sequential lidocaine/capsaicin therapy, considering the degree of patient comfort, in the management of pain of PHN after resolution of the acute phase.
We compared the efficacy of repeated paravertebral block with that of topical sequential lidocaine/capsaicin therapy, considering the degree of patient comfort, in the management of pain of PHN after resolution of the acute phase in 80 patients divided into two equal groups. The patients in group I received topical lidocaine 2% cream, followed after 20 min by capsaicin 7% ointment. The patients in group II received twice-weekly paravertebral injections of the affected dermatomes with a mixture of bupivacaine 0.25%+dexamethasone. Patients were followed up for pain (using visual analogue score), allodynia (using numeric rating scale), Q+-uality of life [using The European quality-of-life questionnaire (EQ-5D) and sleep questionnaire (sleep Q)], and finally their satisfaction (on a three-category score).
It was found that after 1 week of therapy, reduction in the severity of pain and allodynia was significantly more remarkable in group 1 compared with group 2. After 2 weeks of therapy, there was a significantly greater improvement in pain and allodynia, associated with a greater improvement in quality of life in group I compared with group II. By the end of the study period, the topical regimen was shown to be significantly more pleasant for most of the patients.
The use of topical lidocaine/capsaicin sequentially leads to better improvement of pain and allodynia, with more improvement in sleep pattern and hence of quality of life than repetitive paravertebral block with bupivacaine/dexamethasone when either of them is combined with gabapentin/amitriptyline oral therapy.
Phenytoin is a widely used anticonvulsant drug in the ICU that requires therapeutic drug monitoring. It carries a major risk of dose-related toxicity because of its saturation (zero-order) pharmacokinetic. Hepatic injury with phenytoin is common and varies from almost trivial to massive necrosis and is usually hepatocellular. Here, we report on a 45-year-old woman who was admitted to the ICU with subarachnoid hemorrhage and developed an acute liver injury 16 days after phenytoin injection. Phenytoin was stopped and replaced by oxcarbazepine. Possible drug interactions and risk factors are also discussed.