• The Korean Journal of Pain
• /
• 제10권1호
• /
• pp.34-41
• /
• 1997

Background : Patient-controlled analgesia(PCA) is a safe and effective technique for providing postoperative pain relief. Studies that compare epidural vs intravenous routes of opiate administration show conflicting results. We designed a prospective, randomized, controlled study to evaluate the safety and efficacy of epidural(EPI-PCA) morphine-bupivacaine versus intravenous (IV-PCA) nalbuphine when administered with a PCA system. Methods : Forty healthy women were randomly assigned to receive an epidural bolus of morphine 3 mg and 0.5% bupivacaine 10 ml, followed by a EPI-PCA with 0.01% morphine and 0.143% bupivacane (basal infusion 1 ml/hr, bolus 1 ml, lock-out interval 30 min) or intravenous bolus of nalbuphine 0.1 mg/kg followed by a IV-PCA with nalbuphine(basal infusion 1 mg/hr, bolus 1 ml, lock-out interval 20 min) for pain relief after cesarean delivery. This study was conducted for 2 days after cesarean section to compare the analgesic efficacy, side effects, patient satisfaction either as EPI-PCA or as IV-PCA. Results : EPI-PCA group had significant lower visual analog pain scale(VAS) at immediate postoperative period, whereas no significant difference was observed when pain was assessed at other time sequence. Urinary retention and pruritus were more frequent with EPI-PCA group, although the incidence of other side effects were the same. Conclusions : Although EPI-PCA with morphine-bupivacaine was of significantly lower VAS at immediate postoperative period, IV-PCA with nalbuphine is a safe and effective alternative to EPI-PCA with morphine-bupivacaine for providing pain relief after cesarean delivery. Further studies about IV-PCA with nalbuphine are needed to control the immediate postoperative pain and to further improve effective pain management.

• The Korean Journal of Pain
• /
• 제11권1호
• /
• pp.54-59
• /
• 1998

Background: Tramadol administered epidurally is known to have one-thirtieth the potency of morphine for treatment of pain following abdominal surgery. We designed a prospective, randomized, controlled study to evaluate the analgesic efficacy and safety of combined epidural infusion of bupivacaine and tramadol with 2-day infusor as ompared to bupivacaine and morphine combined epidural infusion. Methods: Sixty healthy women scheduled for Cesarean delivery were assigned randomly in double- blind fashion: Group 1 (n=20) were given a mixture of morphine 10 mg(1 ml), 0.5% bupivacaine 40 ml and normal saline(NS) 40 ml; Group 2(n=20) a mixture of tramadol 300 mg(6 ml), 0.5% bupivacaine 40 ml and NS 54 ml; Group 3(n=20) or a mixture of tramadol 500 mg(10 ml), 0.5% bupivacaine 50 ml and NS 50 ml, of continuous dose via epidural route following 1% lidocaine 6 ml as bolus dose for 48 hours postoperatively. We evaluated the analgesic efficacy and side effects of these three groups using visual analogue pain scale (VAPS) and verbal rating scale (VRS). Results: VAPS of group 1 and 3 were lower than group 2, and VAPS of group 1 was lower than group 3(12, 24, 36, 48 hours). VRS of group 1 and 3 were lower than group 2 (12, 24, 36 hours). There were incidences of pruritus was 16 patients in group 1. Conclusions: Tramadol does possess the analgesia effect of morphine, but has the added analgesia following increment. Further research to determine the most effective administration method and reguired dosage of tramadol is further needed.

• The Korean Journal of Pain
• /
• 제10권2호
• /
• pp.196-202
• /
• 1997

Background: Various pain treatments have been administered to relieve patients suffering from postoperative pain. Among these, epidural or intravenous opiate administration is by far the most widly applied treatment in recent times. However it was our objective to device a more effective and safe means of postoperative analgesia. Methods: We studied 110 healthy pregnant women scheduled for delivery by elective cesarean section. EPI(epidural)-group is administered morphine 1.5 mg and 0.25% bupivacaine 8 ml as bolus dose, then, a mixture of morphine 6 mg and 0.125% bupivacaine 95 ml as continuous dose via epidural route. IV(intravenous)-group is administered nalbuphine 6~7 mg as bolus dose and nalbuphine 60~70 mg with 0.9% normal saline 90 ml as continuous dose via intravenous route, at the rate of 2 ml/hr for 2 days. We compared the analgesic efficacy and side effects of these two groups using VAS pain score and time duration of constant pain level. Results: VAS pain score was similar between the two groups, but pain duration was significantly shorter in EPI-group. Incidence of pruritus was significantly lower with the IV-group, of nausea and vomiting were similar for both groups, no respiratory depression for either groups. Conclusions: Although the EPI-group had better analgesic efficacy, the IV-group had lower incidence of side effects, and simplicity and safety methods of operation. Therefore, We propose further research and consideration of administering the kinds and doses of those medications prescribe to the IV group in conjunction with other drugs for safer and better efficacy of postoperative analgesia.

• The Korean Journal of Pain
• /
• 제2권1호
• /
• pp.21-25
• /
• 1989

For the simple operations of the perineal region, caudal, epidural and saddle blocks of analgesia are preferable anesthesia techniques in men. But, if the operations shoud be delayed or the physicians are willing to observe and manipulate the patients for a couple of days, as in the ureteral stone manipulation, continuous epidural analgesia will be a reliable method. The authors have observed 36 male patients of ureteral calculi with continuous lumbar epidural analgesia for the purpose of elimination of an undesirable pain sensation which was associated with the transurethral cystoscopic manipulation. The results were as follows: 1) In most cases, the anesthetics used were 1% lidocaine 20 ml through the $L_{3-4}$ and $L_{4-5}$ interspace with 4~6cm of catheter tip advancement mainly to cephalad. 2) There was no motor weakness or paralysis in the lower extremities except some numbness and paresthesia on the perineal area. 3) Besides the various minor complications, there were no problems in respiration with small doses of morphine extradurally. 4) Among them, four cases of ureteral calculi dropped into the bladder spontaneously due to the epidural technique during transportation of the patients from the pain clinic to the urology out-clinic. One case of calculi was dropped by the aid of instrumentation at the ward, and twelve cases of calculi were removed directly by Dormia stone basket in the scopic room. For the remaining patients, we deduced that their calculi was be evacuated out because there were no complaints were notified after discharge.

• The Korean Journal of Pain
• /
• 제10권1호
• /
• pp.48-53
• /
• 1997

Background : Epidural morphine provides excellent postoperative analgesia but is often associated with side effects such as nausea, vomiting and pruritus. It has been reported that mixed agonist-antagonist, nalbuphine can reverse side effects of epidural morphine without compromising analgesia. This study was designed to compare the efficacy of each intravenous dose of nalbuphine for treatment of side effects following epidural morphine. Methods : All patients received continuous infusion(2 ml/hr) of epidural morphine-local anesthetics mixture(morphine 4 mg, 1% mepivacaine 50 ml and 0.25% bupivacaine 50 ml) following a loading dose (morphine 2 mg with 1% mepivacaine 7 ml). Patients requesting treatment for nausea, vomiting and pruritus randomly received intravenous nalbuphine 0.05 mg/kg(Group 1; n=20), 0.1 mg/kg(Group 2; n=20) or 0.15 mg/kg(Group 3; n=20). The severity of nausea, vomiting, pruritus, degree of pain, sedation and vital sign were assessed prior to and 30 min after each dose. Results : The severity of nausea, vomiting and pruritus decreased significantly in all groups(p<0.01). Pain and sedation scores were unchanged in all groups. One patient received nalbuphine 0.15 mg/kg, complained of dizziness, agitation and palpitation. His blood pressure who had increased to 170/100 after first dose. Conclusions : This study suggests that intravenous nalbuphine is good for treatment of side effects following epidural morphine, and the dose of Group 1, 0.05 mg/kg, may be recommended as an optimal dose.

• The Korean Journal of Pain
• /
• 제8권2호
• /
• pp.235-243
• /
• 1995

A retrospective study was performed to evaluate the effects, and side effects, of epidural analgesia for postoperative pain relief of 2,381 surgical patients who received general-epidural, or epidural anesthesia only. Anesthesia records, patients charts, and pain control records were reviewed and classified according to: age, sex, body weight, department, operation site, epidural puncture site, degree of pain relief by injection mode & epidural injectate, and side effects(including nausea, vomiting, pruritus, urinary retention and respiratory depression). The results were as follows: 1) From the total of 2,381 patients, there were 1,563(66%) female patients; 1.032(43%) patients were from Obstetrics and Gynecology. 2) Lower abdomen, thorax, lower extremity and upper abdomen in the operation site; and lumbar, upper, lower thoracic in puncture site were order of decreasing frequency. Length of epidural injection for pain relief averaged $1.72{\pm}1.02$ days. 3) Ninety three percent of the patients experienced mild or no pain in the postoperative course. Analgesic quality was not affected by the kind of epidural injectate. 4) Nausea occurred in 3.2% of all patients, vomiting in 1.1%, pruritus 0.9%, urinary retention 0.6%, respiratory depression 0.08%. 5) Frequency of nausea was higher with female patients compared to male patients(p<0.05). 6) Pruritus frequency was higher with male patients than female patients(p<0.05); and more frequent with patients who received epidural injection with morphine than patients who received epidural injection without morphine(p<0.01). 7) Urinary retention was higher in female patients, and more frequent with patients who had received epidural injection with morphine than epidural injection without morphine(p<0.05). 8) There were two cases of respiratory depression. The course of treatment consisted of: cessation of epidural infusion, then administration of oxygen and intravenous naloxone. We conclude that postoperative epidural analgesia with a combination of local anesthetics and opiate is and effective method for postoperative pain relief with low incidence of side effects. However, patients should be carefully evaluated as rare but severe complications of respiratory depression may ensue.

• The Korean Journal of Pain
• /
• 제26권1호
• /
• pp.39-45
• /
• 2013

Background: Good postoperative pain control is an important part of adequate postoperative care. Patient-controlled epidural analgesia (PCEA) provided better postoperative analgesia compared to other conventional analgesic methods, but several risks have been observed as well. We therefore surveyed the efficacy and safety of PCEA in this retrospective observational study. Methods: We analyzed collected data on 2,276 elective surgical patients who received PCEA with ropivacaine and fentanyl. Patients were assessed by a PCA service team in the post-anesthesia care unit (PACU), at 1-6 h, 6-24 h, and 24-48 h postoperatively for adequate pain control. The presence of PCEA-related adverse events was also assessed. Results: Numerical pain score (median [interquartile range]) were 3 [1-4], 5 [4-7], 4 [3-5], and 3 [3-5] in the PACU, at 1-6 h, 6-24 h, and 24-48 h postoperatively. Median pain scores in patients underwent major abdominal or thoracic surgery were higher than other surgical procedure in the PACU, at 1-6 h after surgery. Nausea and vomiting (20%) and numbness and motor weakness (15%) were revealed as major PCEA-related adverse events during the postoperative 48 h period. There were 329 patients (14%) for whom PCEA was ceased within 48 h following surgery. Conclusions: Our data suggest that the use of PCEA provides proper analgesia in the postoperative 48 h period after a wide variety of surgical procedures and that is associated with few serious complications. However, more careful pain management and sustainable PCEA monitoring considering the type of surgical procedure undergone is needed in patients with PCEA.

• The Korean Journal of Pain
• /
• 제26권3호
• /
• pp.265-269
• /
• 2013

Background: Transforaminal epidural steroid injections are known to reduce inflammation by inhibiting synthesis of various proinflammatory mediators and have been used increasingly. The anti-inflammatory properties of opioids are not as fully understood but apparently involve antagonism sensory neuron excitability and pro-inflammatory neuropeptide release. To date, no studies have addressed the efficacy of transforaminal epidural morphine in patients with radicular pain, and none have directly compared morphine with a tramadol for this indication. The aim of this study was to compare morphine and tramadol analgesia when administered via epidural injection to patients with lumbar radicular pain. Methods: A total of 59 patients were randomly allocated to 1 of 2 treatment groups and followed for 3 months after procedure. Each patient was subjected to C-arm guided transforaminal epidural injection (TFEI) of an affected nerve root. As assigned, patients received either morphine sulfate (2.5 mg/2.5 ml) or tramadol (25 mg/0.5 ml) in combination with 0.2% ropivacaine (1 ml). Using numeric rating scale was subsequently rates at 2 weeks and 3 months following injection for comparison with baseline. Results: Both groups had significantly lower mean pain scores at 2 weeks and at 3 months after treatment, but outcomes did not differ significantly between groups. Conclusions: TFEI of an opioid plus local anesthetic proved effective in treating radicular pain. Although morphine surpassed tramadol in pain relief scores, the difference was not statistically significant.

• The Korean Journal of Pain
• /
• 제19권1호
• /
• pp.87-90
• /
• 2006

Background: There are many ways to provide superior analgesia for postoperative pain after abdominal surgery of which epidural analgesics with opioids and local analgesics are the most useful. In an effort to maximize the level of analgesia and to minimize the side effects, ketamine, midazolam, clonidine, and adrenalin can be co-administrated as an adjuvant. This study examined the analgesic effect and side effects of midazolam compared with those given an epidural injection of bupivacaine, fentanyl and ketamine. Methods: In a double blind randomized controlled trial, 50 patients received either fentanyl $0.3{\mu}g/kg/h$ and ketamine 0.1 mg/kg/h (Group FK) or fentanyl $0.3{\mu}g/kg/h$, ketamine 0.1 mg/kg/h and midazolam 0.4 mg/h (Group FKM), added to 0.125% of bupivacaine at a rate of as much as 2 ml/h, for patient controlled epidural analgesia (PCEA) after low abdominal surgery. Ten minutes before surgery, the patients received either 10 ml of 0.125% bupivacaine with 0.5 mg/kg of ketamine or 10 ml of 0.125% bupivacaine with the same amount of normal saline, added to fentanyl $50{\mu}g$. The pain score and the side effects were recorded at 1, 3, 6, and 24 hours after surgery. Results: There was no difference in the pain score except for the VAS on coughing 1 hour after surgery. FKM group had fewer side effects. Conclusions: There was a better analgesic effect and fewer side effects with the addition of epidural midazolam to bupivacaine and fentanyl with ketamine formula. However, more study on the dose and route of administration will be needed.

• The Korean Journal of Pain
• /
• 제20권1호
• /
• pp.50-53
• /
• 2007

Background: Continuous epidural catheterization is a popular and effective procedure for postoperative analgesia. However, continuous epidural catheterization has associated complications such as venous puncture, dural puncture, subarachnoid cannulation, suboptimal catheter placement, and paresthesia because the tip of the epidural catheter touches thenerves of the dura in the epidural space. In this study, we compared the incidence of paresthesia in two different lengths of epidural catheter insertion. Methods: One hundred women undergoing gynecologic or orthopedic surgery were enrolled in this prospective, double-blinded, randomized study. All patients were randomly divided into two groups based on the insertion length of the epidural catheter 2 cm (group A) or 4 cm (group B). A Tuohy needle was inserted in the lumbarspinal region with a bevel directed cephalad by use of the median approach, and then the epidural space was confirmed by the loss of resistance technique with air. While the practitioner inserted an epidural catheter into the epidural space, a blind observer checked for paresthesia or withdrawal movement. Results: In 97 included patients, 30.6% of the patients in group A (n = 49) had paresthesia, versus 31.3% in group B (n = 48). Withdrawal movements were represented in 2% and 6% of the patients in group A and group B, respectively. There was no difference in the incidence of paresthesia and withdrawal movement between the two groups. Conclusions: There is no clear relationship for the incidence of catheter-related paresthesia according to the catheter length inserted into the epidural space for epidural analgesia.