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Background: It remains unclear whether analgesia from intraperitoneal local anesthetics is via local or central mechanisms. This double-blind clinical trial tests the hypothesis that intraperitoneal local anesthetic is superior to continuous IV infusion for pain management. Primary outcome was morphine consumption during 0 to 24 h.

Methods: Informed consent was obtained from 60 patients, age 30 to 75 yr, American Society of Anesthesiologists physical status I to II, undergoing abdominal hysterectomy. A computer-generated program randomized patients in parallel arms to group IV: continuous infusion of lidocaine 50 mg/h (10 ml) IV and saline 10 ml/h intermittently intraperitoneal; group IP: injection of lidocaine 50 mg/h (10 ml) once every hour intraperitoneally and continuous infusion of saline 10 ml/h intravenously; and group P (placebo): saline 10 ml/h both intravenously and intermittent intraperitoneal injection. Postoperative morphine consumption, pain intensity, recovery, home discharge, and lidocaine concentrations were measured.

Results: Morphine consumption during 0 to 24 h was lower in group IP versus group IV, mean difference -22.6 mg (95% CI, 11.4 to 33.8; P < 0.01). No difference was seen between group IV and group P. The total mean plasma concentration of lidocaine in group IP was significantly lower than group IV, 0 to 4.5 h postoperatively (P = 0.03) with no evidence of systemic toxicity. Pain intensity and other recovery parameters were similar between the groups.

Conclusion: The lower supplemental morphine consumption and plasma lidocaine concentration in group IP would confirm that the effects of local anesthetics are likely to be predominant via local intraperitoneal receptors or anti-inflammatory effects and not via central mechanisms alone.

Background. Local anaesthetics (LA) injected intraperitoneally (i.p.) have been found to decrease postoperative pain. This double-blind randomized study was performed comparing continuous infusion or patient-controlled bolus injection of LA i.p. The primary endpoint was supplemental opioid consumption during the first 24 postoperative hours.

Methods. Two multi-hole catheters were placed i.p. at the end of the surgery in 40 patients undergoing elective abdominal hysterectomy. The patients were randomized into two groups: Group P: patients self-injected 10 ml of levobupivacaine 1.25 mg ml21 via the i.p. catheter as needed, maximum once/hour, and had continuous saline infusion 10 ml h21 into the second catheter. Group C: Patients received a continuous infusion of 10 ml h21 of levobupivacaine 1.25 mg ml21 i.p. through one catheter and 10 ml saline as bolus as needed via the other. Ketobemidone i.v. was administered as rescue medication.

Results. Total ketobemidone consumption during 0–24 hwas lower in Group P compared with Group C, (mean 23.1 vs 35.7 mg, P¼0.04). No differences in the median pain scores were found between the groups. Earlier return of gastrointestinal (GI) function was found in Group P vs Group C (mean 1.5 vs 2.2 days, P,0.01), which also resulted in earlier home-readiness (mean 1.9 vs 2.7 days, P¼0.04).

Conclusions. A statistically significant opioid-sparing effect was found when patientcontrolled levobupivacaine was administered i.p. as needed compared with continuous infusion. This was associated with a faster return of GI function and home-readiness. There was, however, a wide confidence interval in the primary endpoint, opioid consumption.

Background: Epidural anaesthesia and analgesia has been shown to suppress the neurohormonal stress response, but its role in the inflammatory response is unclear. The primary aim was to assess whether the choice of analgesic technique influences these processes in patients undergoing radical retropubic prostatectomy.

Methods: Twenty-six patients were randomized to Group P (systemic opioid-based analgesia) or Group E (thoracic epidural-based analgesia) perioperatively. Induction and maintenance of anaesthesia followed a standardized protocol. The following measurements were made perioperatively: plasma cortisol, glucose, insulin, C-reactive proteins, leucocyte count, plasma cytokines [interleukin (IL)-6, tumour necrosis factor (TNF)-alpha], and pokeweed mitogen-stimulated cytokines [interferon (IFN)-gamma, IL-2, IL-12p70, IL-10, IL-4, and IL-17]. Other parameters recorded were pain, morphine consumption, and perioperative complications.

Results: Plasma concentration of cortisol and glucose were significantly higher in Group P compared with Group E at the end of surgery, the mean difference was 232 nmol litre(-1) [95% confidence interval (CI) 84-381] (P=0.004) and 1.6 mmol litre(-1) (95% CI 0.6-2.5) (P=0.003), respectively. No significant differences were seen in IL-6 and TNF-alpha at 24 h (P=0.953 and 0.368, respectively) and at 72 h (P=0.931 and 0.691, respectively). IL-17 was higher in Group P compared with Group E, both at 24 h (P=0.001) and 72 h (P=0.018) after operation. Pain intensity was significantly greater in Group P compared with Group E (P<0.05) up to 24 h.

Conclusions: In this small prospective randomized study, thoracic epidural analgesia reduced the early postoperative stress response but not the acute inflammatory response after radical retrobupic prostatectomy, suggesting that other pathways are involved during the acute phase reaction.

BACKGROUND: Local infiltration analgesia (LIA) using a combination of local anesthetics, non-steroidal anti-inflammatory drugs and epinephrine, injected periarticularly during surgery has become popular in postoperative pain management following total knee arthroplasty (TKA). This study compared intrathecal morphine with LIA following TKA.

METHODS:  In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into two groups: Group M: 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and Group L: LIA using ropivacaine, ketorolac and epinephrine was infiltrated in the knee during the operation and two bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during three months follow-up. Primary endpoint was IV morphine consumption the first 48 postoperative hours.

RESULTS: Mean morphine consumption was significantly lower in group L compared to group M during the first 48 postoperative hours: 27 ± 18 vs. 54 ± 30 mg, i.e. a mean difference for each 24-hour-period of 14,2 (CI 95 % 7.6-20.9) mg. Pain scores at rest and on movement were lower during the first 48 h in group L compared to group M (P < 0.001). Pain score was also lower on walking in group L compared to group M at 24 h and 48 h postoperatively (P < 0.01). In group L more patients were able to climb stairs at 24 h: 50 % (11/22) vs. 4 % (1/23), i.e. a difference of 46 % (CI 95 % 23.5-68.5) and at 48 h: 70 % (16/23) vs. 22 % (5/23), i.e. a difference of 48 % (CI 95 % 23-73). Median (range) time to fulfillment of discharge criteria was shorter in group L compared to group M, 51 (24-166) h vs. 72 (51-170) h. The difference was 23 (CI 95 % 18-42) h (P = 0.001). Length of hospital stay also shorter in group L compared to group M: median (range) 3 (2-17) vs. 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L compared to group M (P = 0.001), but no differences were found in knee function, side effects or in patient-related outcomes, Oxford Knee score or EQ-5D.

CONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, compared to intrathecal morphine following TKA.

Background.Postoperative pain after radical retropubic prostatectomy is moderate to severe. The primary aim of this study was to assess whether intra-abdominal local anaesthetics provide similar analgesia compared with thoracic epidural analgesia (TEA).

Methods.Fifty patients, ASA I–II, participated in this prospective, doubleblinded study. All patients had TEA. After operation, they were randomized into two groups of 25 patients: Group PCLA (patient- ontrolled local analgesia): self-administration of 10 ml of ropivacaine 2 mg ml21 via the intra-abdominal catheter for 48 h. Group TEA: infusion of 10 ml h–1 of ropivacaine 1 mg ml–1, fentanyl 2mg ml21, and epinephrine 2mg ml21 epidurally for 48 h. The primary endpoint was pain on coughing at 4 h after operation. Rescue medication was morphine i.v. as required.

Results.Pain on coughing at 4, 24, and 48 h was significantly lower in Group TEA [0 (0–10)] compared with Group PCLA [4 (0–10)] (P,0.05). Significantly lower pain intensity was also found in Group TEA compared with Group PCLA at the incision site, deep pain, and pain on coughing at 4 and 24 h (P,0.05). Morphine consumption was significantly greater in Group PCLA [12 (0–46)] compared with Group TEA [0 (0–20)] at 0–48 h after operation [median (range)] (P¼0.015). Maximum expiratory pressure was higher in Group TEA compared with Group PCLA at 24 h (P,0.01).Conclusions.TEA provides superior postoperative pain relief with better preservation of expiratory muscle strength compared with PCLA.

Background and objective Local anaesthetics administered intraabdominally have been found to reduce analgesic requirements postoperatively after hysterectomy. This study was designed to assess the optimal dose of local anaesthetics for best pain relief.

Methods Sixty patients undergoing abdominal hysterectomy were randomly divided into three groups to receive 10 ml hS1 infusion of levobupivacaine intraabdominally postoperatively for 48 h in a double-blind manner: group L, 7.5mghS1; group M, 12.5mghS1 and group H, 17.5mghS1. Pain intensity was measured using the numeric rating scale, ketobemidone consumption over 48 h was measured with a patient controlled analgesia pump, recovery parameters, expiratory muscle strength, time to home readiness, plasma concentration of levobupivacaine and health-related quality of life were all measured at defined time points postoperatively.

Results No differences were found between the active groups in pain intensity, recovery parameters or healthrelated quality of life. Pain intensity was maximal during 0– 4 h and during coughing. Expiratory muscle strength decreased significantly during 0–4 h in all active groups, with no differences between the groups. Plasma concentration of levobupivacaine was below known toxic concentrations in humans, and no patient had symptoms of local anaesthetic toxicity. Health-related quality of life showed improved scores at 3 months after the operation compared with preoperative values, but no differences between the groups were found in any of the parameters. Conclusion Satisfactory analgesia can be achieved with low doses of levobupivacaine administered intraabdominally, except during the early postoperative period. No advantages were seen in this study when higher doses of levobupivacaine were administered as a continuous infusion for postoperative pain relief. Eur J Anaesthesiol 26:421–429 Q 2009 European Society of Anaesthesiology

Background: The aim of the present study was to examine the level of unconsciousness measured with bispectral index (BIS) at different minimal alveolar concentration (MAC) levels of sevoflurane, and to study the hemodynamic and BIS reactions during noxious stimulation with transcutaneous electrical nerve stimulation (TENS) and an ice water pain test (IWP).

Methods: This study was approved by the Ethics Committee and was performed on 10 healthy, young volunteers (six males and four females), ASA physical status I. Anesthesia was induced and maintained with sevoflurane in an oxygen/air mixture. The volunteers were spontaneously breathing, but if necessary, ventilation was mechanically supported. TENS and IWP were performed at 1.0, 1.5 and 2.0 MAC of sevoflurane.

Results: At 1.0 MAC, there was a significant increase in BIS during pain stimulation both with IWP (P<0.03) and with TENS (P<0.005), but at 1.5 MAC there were no changes. A marked variation in BIS was seen at 2.0 MAC, with periods of burst suppression and periods of high BIS values despite clinical signs of deep anesthesia. These marked variations in BIS were seen before, during and after pain stimulation. One volunteer (# 8) had a short episode of convulsions at 2.0 MAC.

Conclusion: BIS, heart rate and blood pressure increased during pain stimulation at 1.0 MAC but not at 1.5 MAC of sevoflurane. There was a remarkable variation in BIS at 2.0 MAC of sevoflurane, with BIS values indicating wakefulness despite clinical signs of deep anesthesia. This BIS variation is probably caused by epileptogenic activity due to sevoflurane.

BACKGROUND: In this study we assessed the efficacy of intraarticular regional analgesia on postoperative pain and analgesic requirements. METHODS: Fifty-one patients undergoing shoulder surgery (Bankart) were recruited into this double-blind study. At the end of the operation, patients were randomized to three groups to receive intraarticularly via a catheter: Group 1: ropivacaine 90 mg (9 mL), morphine 4 mg (10 mL), and ketorolac 30 mg (1 mL) (total volume 20 mL); Groups 2 and 3: saline (20 mL). In addition, Groups 1 and 3 received 1 mL saline IV while Group 2 received ketorolac 30 mg (1 mL) IV. Postoperatively, Group 1 received pain relief using 10 mL 0.5% ropivacaine on demand via the intraarticular catheter while Groups 2 and 3 received 10 mL of saline intraarticularly. Group 3 was the Control group. RESULTS: Postoperative pain at rest and on movement were lower in Group 1 than in Groups 2 and 3 during the first 30 and 120 min, respectively. The time to first request for local anesthetic infusion was longer in Group 1 than in Groups 2 and 3 (P < 0.001). The median morphine consumption during the first 24 postoperative hours was less in Groups 1 and 2 than in Group 3 (P < 0.001). There was no significant difference in analgesic consumption between Group 1 and Group 2. The median satisfaction score was higher in Group 1 compared with Groups 2 (P < 0.05) and 3 (P < 0.001). CONCLUSIONS: A combination of intraarticular ropivacaine, morphine, and ketorolac followed by intermittent injections of ropivacaine as needed provided better pain relief, less morphine consumption, and improved patient satisfaction compared with the control group. The group that received IV ketorolac consumed less morphine and was more satisfied with treatment than patients in the control group.

BACKGROUND: Effective pain relief is important after diagnostic and therapeutic arthroscopic knee surgery to permit early discharge and improve comfort and mobility at home. The aim of this study was to assess the efficacy of bupivacaine, ropivacaine, or a combination of ropivacaine, morphine, and ketorolac injected intra-articularly for postoperative pain relief after arthroscopic knee surgery. METHODS: Sixty-three healthy patients undergoing knee arthroscopy under local anesthesia (LA) were randomized to receive 1 of the following substances intra-articularly postoperatively: group B: 30 mL of bupivacaine (150 mg); group R: 30 mL of ropivacaine (150 mg); and group RMK: ropivacaine 150 mg, morphine 4 mg, and ketorolac 30 mg in normal saline (total volume 30 mL). Oral paracetamol 1g and tramadol 50 mg were used as rescue drugs. Postoperatively, pain was assessed at rest and movement, and side effects were recorded. The patients were asked to self-assess pain for 7 days and record analgesic consumption as well as activities of daily living (ADLs). Plasma concentration of LA was measured in another 8 patients. RESULTS: All groups had excellent analgesia at 0 and 4 hours postoperatively. Group RMK had significantly lower visual analog pain score at rest at 8 hours and during movement at 8 and 24 hours compared with the other groups (P<.05). Group RMK required less paracetamol and tramadol on day 1 (P<.05), had less sleep disturbances because of pain, more patients were ready to work on days 1 and 2 (P<.05), and were more satisfied on days 1 and 4 to 7. Postoperatively, plasma concentrations of ropivacaine and lidocaine were far below known systemic toxic concentrations in all patients. CONCLUSION: Addition of morphine and ketolorac to ropivacaine intra-articularly enhances analgesic efficacy of LA, reduces postdischarge analgesic consumption, and improves ADLs without increasing side effects after ambulatory arthroscopic knee surgery.

BACKGROUND: Postoperative pain after radical retropubic prostatectomy can be severe unless adequately treated. Low thoracic epidural analgesia and patient-controlled intravenous analgesia were compared in this double-blind, randomized study.

METHODS: Sixty patients were randomly assigned to receive either low thoracic epidural analgesia (group E) or patient-controlled intravenous analgesia (group P) for postoperative pain relief. All patients had general anesthesia combined with thoracic epidural analgesia during the operation. Postoperatively, patients in group E received an infusion of 1 mg/ml ropivacaine, 2 microg/ml fentanyl, and 2 microg/ml adrenaline, 10 ml/h during 48 h epidurally, and a placebo patient-controlled intravenous analgesia pump intravenously. Patients in group P received a patient-controlled intravenous analgesia pump with morphine intravenously and 10 ml/h placebo epidurally. Pain, the primary outcome variable, was measured using the numeric rating scale at rest (incision pain and "deep" visceral pain) and on coughing. Secondary outcome variables included gastrointestinal function, respiratory function, mobilization, and full recovery. Health-related quality of life was measured using the Short Form-36 questionnaire, and plasma concentration of fentanyl was measured in five patients to exclude a systemic effect of fentanyl.

RESULTS: Incisional pain and pain on coughing were lower in group E compared with group P at 2-24 h, as was deep pain between 3 and 24 h postoperatively (P < 0.05). Maximum expiratory pressure was greater in group E at 4 and 24 h (P < 0.05) compared with group P. No difference in time to home discharge was found between the groups. The mean plasma fentanyl concentration varied from 0.2 to 0.3 ng/ml during 0-48 h postoperatively. At 1 month, the scores on emotional role, physical functioning, and general health of the Short Form-36 were higher in group E compared with group P. However, no group x time interaction was found in the Short Form-36.

CONCLUSIONS: The authors found evidence for better pain relief and improved expiratory muscle function in patients receiving low thoracic epidural analgesia compared with patient-controlled analgesia for radical retropubic prostatectomy. Low thoracic epidural analgesia can be recommended as a good method for postoperative analgesia after abdominal surgery.