Summary

Background: The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain. Methods: Forty-two ASA physical status II–III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5–10 mL h−1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h. Results: The area under the curve of the visual analogue pain score during coughing over time was 192 (60–444) cm h−1 in group EPI and 228 (72–456) cm h−1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was −9 (0 to −9)% in group PVB and −17 (0 to −38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8–9.8) cm in group EPI and 9 (7.5–10) cm in group PVB (P = 0.65). Conclusions: Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.

Summary

Cardiac complications are the major cause of perioperative morbidity and mortality of patients undergoing non-cardiac surgery. This is related to the frequent presence of underlying coronary artery disease. In the last few decades, attention has focused on preoperative cardiac risk assessment that may help to identify patients at increased cardiac risk for whom cardioprotective medication and, when indicated, coronary revascularization may improve perioperative outcome. On the other hand, less attention was given to the role of anaesthesia and monitoring techniques in the cardiac risk management of high-risk patients undergoing non-cardiac surgery. The aim of this review was to summarize the current evidence from published studies on the effect of the type of anaesthesia and monitoring techniques on perioperative cardiac outcome in non-cardiac surgery.

Summary

Background and objective: Epidural anaesthesia is the preferred technique of anaesthesia for Caesarean section in pre-eclampsia. Spinal anaesthesia is considered by some as a safe and effective alternative, which is especially useful in emergency situations. Combined spinal–epidural anaesthesia, using low doses of local anaesthetics with opioids, is effective and reduces the incidence of hypotension in normal pregnancy. We performed a retrospective chart analysis to evaluate the effects of combined spinal–epidural anaesthesia on maternal haemodynamics and fetal outcome compared to conventional epidural anaesthesia.

Methods: A retrospective anaesthesia chart analysis of all pre-eclamptic patients who underwent Caesarean section over a 4 yr period was performed. Patient characteristic, obstetric, haemodynamic, fetal and neonatal data were gathered and analysed according to the anaesthetic technique used.

Results: Seventy-seven pre-eclamptic parturients undergoing Caesarean section were identified (26 women were severely pre-eclamptic and 51 demonstrated mild pre-eclampsia). Epidural anaesthesia was performed in 62 patients and combined spinal–epidural anaesthesia was performed in 15. No differences in patient characteristic and obstetric data were noted. Highest mean arterial pressure prior to anaesthesia was comparable between the groups (epidural: 106 ± 12 vs. combined spinal–epidural anaesthesia: 109 ± 18 mmHg) as well as the lowest recorded mean arterial pressure following anaesthesia (epidural: 93 ± 13 vs. combined spinal–epidural anaesthesia: 98 ± 17 mmHg). In the combined spinal–epidural anaesthesia group more ephedrine was used compared to the epidural group (14.6 ± 4.4 vs. 3.6 ± 4.6 mg, P<0.05). However, more lactated Ringer's was used in the epidural group. Umbilical artery pH was lower in the epidural group (7.26 ± 0.01 vs. 7.29 ± 0.02, P<0.05). Similar results were noted in 26 severely pre-eclamptic patients. Seven women underwent combined spinal– epidural anaesthesia and 19 underwent epidural anaesthesia in the severely pre-eclamptic group. Also more ephedrine was used in the combined spinal–epidural anaesthesia group. A tendency towards a lower umbilical artery pH was observed in the epidural group but this difference did not reach statistical significance.

Conclusions: Combined spinal–epidural anaesthesia appears to be safe as anaesthetic technique for pre-eclampsia and severe pre-eclampsia. However, it is important to consider the retrospective design of the study and the large number of epidural anaesthetics performed.

Summary

Background and objective: Epidural blocks should provide good analgesia for the treatment of chronic low back pain without any motor block to allow active physiotherapy. Epidural ropivacaine is known to produce less motor block compared to bupivacaine at anaesthetic concentrations. This prospective, randomized double blind study compares the analgesic, motor block, and haemodynamic effects of single shot epidural injections of ropivacaine 0.2% 10 mL with bupivacaine 0.125% in outpatients suffering from chronic low back pain.

Methods: Forty patients were assigned to receive either ropivacaine 0.2% (n = 20) or bupivacaine 0.125% (n = 20) within a series of eight single shot epidural blocks.

Results: Thirty-six patients received either ropivacaine 0.2% (n = 18) or bupivacaine 0.125% (n = 18) within a series of eight single shot epidural blocks. Both groups showed no significant differences either in analgesia, or in motor blockade or haemodynamic changes. Thus ropivacaine 0.2% did not reduce the incidence of motor block (9.0% of patients with motor block Bromage scores 1, 2 or 3 in ropivacaine or bupivacaine). The combination of repeated epidural analgesia and physiotherapy reduced the median pain-scores (visual analogue scale, 0–10) from 7 (SD ± 1.6) at the beginning of the study to 4.1 (SD ± 1.7) at the end of the series.

Conclusions: Both bupivacaine 0.125% and ropivacaine 0.2% appear suitable for epidural administration to outpatients with chronic low back pain attending for epidural analgesia associated with physiotherapy (physical therapy).