Acta Anaesthesiol &and 1992: 36: 70-74
Epidural bupivacaine, sufentanil or the combination for post-thoracotomy pain J. MOURISSE, M. A. W. M. HASENBOS, M. J. M. GIELEN, J. E. MOLLand G. J. E. CROMHEECKE Institute for Anaesthesiology, University of Nijmegen, Nijmegen, The Netherlands
Analgesia with epidural bupivacaine, sufentanil or the combination was studied in 50 patients who had undergone thoracotomy. During operation all patirnts received an initial dose of bupivacaine 0.5% with adrenaline 5 pg.mlP' (5-10 ml) by thoracic epidural catheter. One hour later the patients were divided into three groups: the bupivacaine group (bupivacaine 0.125%), the sufentanil group (50 pg sufentanil in 60 ml normal saline) and the combination group (50 pg sufentanil in 60 ml bupivacaine 0.125%). Analgesia i n the three groups was provided by a continuous epidural infusion (5-10 m1.h-l) for 3 days. The mean dose of bupivacaine was significantly higher (P 6 ) , the patient received systemic nicomorphine and was excluded from the study at that moment. The adequacy of analgesia was assessed every hour by means of the inverse visual analogue scale (IVAS), where 10 represents excellent pain relief and 0 represents no analgesia at all. Blood-gas estimations were made on the day before surgery, on the day of surgery (day I ) , and on the first and second days after surgery (day 2 and 3), using an indwelling arterial cannula, except for the preoperative value. During the study, arterial pressure, electrocardiogram and respiratory rate were monitored continuously. Pruritus, nausea or vomiting were noted by observation and questioning. Urinary retention was defined as residual urine of > 500 ml after bladder catheterisation, which was performed when the patient was not able to produce urine after 4 h or when he had an urge to do so. Statistical analysis of the data was undertaken by use of the nonparametric Wilcoxon Rank test, the chi-square test and the MannWhitney U-test; P-values below 0.05 were considered significant. Values expressed as means are given with the standard error of the mean.
RESULTS The patients in the three groups were comparable in age, body weight, body height and sex. There was no significant difference in the preoperative pulse, systolic and diastolic pressure, and the preoperative Paco,. However, a significantly greater number of patients in the combination group had chronic obstructive pulmonary disease (Table l ) . Intra-operative cardiovascular data were comparable in the three groups, except for a significant difference in the maximum systolic pressure between the sufentanil group (149.2 (s.e.mean 6.4) mmHg (13.8 (0.8) kPa)) and the combination group (122.5 (s.e. mean 3.8) mmHg (16.3 (0.5) kPa)) and a difference in the diastolic pressure between the bupivacaine group (87 (s.e.mean 4.7) mmHg ( 1 1.6 (0.6) kPa)) and the combination group (72.8 (s.e.mean 2.9) mmHg (7.7 (0.4) kPa)). The inverse visual analogue score (IVAS) is given in Fig. 1. During the first day, five patients from the bupivacaine group were excluded from the study be-
ss
cause of inadequate analgesia. The next day another two patients from the same group were excluded for the same reason. The IVAS scores in the bupivacaine group were consistently the lowest. The IVAS scores in the combination group were consistently the highest, except at some points where the scores were the same as in the sufentanil group. O n the first day, the mean IVAS score for the bupivacaine group was 7.0, for the sufentanil group 8.0 and for the combination group 8.3. I n Table 2 the number of patients experiencing pain on exercise is presented for each of the 3 observation days. We divided pain at exercise into three items, as shown in the table. The sufentanil group had a greater incidence of pain on exercise at all times, compared with the combination group. The need for additional boluses and subsequent increase of infusion rate on the first day was high for the bupivacaine group and the sufentanil group (Table 3). The amount of sufentanil used in the sufentanil group averaged
ivaa pain rcom 10
8-
6-
2 0 0 0 0
x x x x x x x x x
72
J. MOURISSE E T AL.
Tdbk 2 Pain on exercise postoperatively; For explanation of column ( I ) , (2) and (3), see legend to Table 1. Sufentanil Bupivacaine n = 10 n=20 day I day 2 day 3 During forced expiration During coughing During physiotherapy Total number of patients who had pain on exercise
7 7
7
(I)
' '
.
ns
6.37 (s.e.mean 0.23) pg.g-l and in the combination group 6.52 (s.e.mean 0.28) pg h-'. These values were not significantly different. Postoperative respiratory data are shown in Table 4. The respiratory rate was always highest in the bupivacaine group. In the course of 3 days, there was an increase in respiratory rate in the bupivacaine group. Patients in the sufentanil group had the lowest respiratory rates at all times. The combination group had the smallest difference between minimum and maximum rates and the difference becomes even smaller after 3 days. Paco, on the first day was higher than the preoperative Paco, in all groups. I n the bupivacaine group the Paco, decreased below the preoperative Paco, on the second and third day. I n the sufentanil group the Paco, remained above the preoperative value (significant on all days). I n the combination group it returned to the preoperative value (only significantly different on the first day). There were no significant differences in cardiovascular effects post-operatively between the three groups. The incidence of cardiovascular side-effects was very low. Only one patient in the bupivacaine group and one in the sufentanil group suffered orthostatic hypotension, which was easily corrected by intravenous fluid administration. Side-effects in the three groups are shown in Table 5. There were no differences in side-effects.
day I day 2 day 3 12 13 11
9 12 7
4
16
13
9
(2)
Combination n=20 day I day 2 day 3
8 3 ss, s, ns
I 1 2
I 2 1
0 0
3
3
1
(3)
1
s
DISCUSSION Epidural local anaesthetics Epidural local anaesthetics by both bolus injection and continuous infusion have been used extensively and found to be effective for postoperative pain relief. Benefits include increased blood flow, modification of the stress response and improved gastro-intestinal function. However, the side-effects of sympathetic and motor blockade have restricted the use of local anaesthetics to selected groups of patients. With a continuous infusion technique, stability of arterial pressure is more easily achieved. The local anaesthetic of choice for thoracic surgery is bupivacaine because of the low degree of motor blockade, low acute toxicity relative to potency and long duration of action, resulting in a low risk oftoxicity during continuous infusion (10-12). High concentrations of local anaesthetics are effective at providing analgesia, but are likely to be accompanied by an unacceptable degree of motor blockade and the risk of systemic toxicity. If bupivacaine 0.25% plain is used as a continuous infusion, the incidence of drowsiness is unacceptably high (4).Low concentrations of bupivacaine often fail to produce a demonstrable nerve block and may even fail to relieve pain. If started peroperatively with bupivacaine 0.5%, prolonged pain reliefwith bupivacaine 0.125% infused at a rate of 6 to 10 m1.h-I has been demonstrated
Table 3 Requirement for additional boluses and amount of drugs administered. The amount of drug is expressed as mean and standard error of the mean. For explanation of column ( I ) , (2) and (3), see legend to Table 1. The values with the sign * are purely illustrative because there was drop-out of patients due to inadequate analgesia. Bupivacaine n = 10 Number Number Number Amount Amount
of patients who needed boli of boluses on the first day of boluses for 3 days of bupivacaine delivered ( m e . h - ' ) of sufentanil delivered (pg . kg- . h - ' )
'
9 *I6 $18
(I) ns
Sufentanil n=20 12 20 24
(2)
Com bination n=20
ns
10
ns
12 16 9.82 (0.43) 6.52 (0.28)
$12.07 (0.97) 6.37 (0.23)
(3) S
S
73
POST-THORACOTOMY EPIDURAL ANALGESIA
Table 4 Postoperative respiratory data. Values are expressed as means and standard error of the mean. For explanation of column ( I ) , (2) and (3), see legend to Table 1. In the row with sign (4), statistical significance between preoperative Paco, and Paco, on the first day is given. The values with the sign * are purely illustrative because there was drop-out of patients due to inadequate analgesia. Bupivacaine Pre.op
Day I
Day2
Day3
n Paco,
10 5.01 (0.24)
(kPa) (4)
n min rate max rate Paco, n min rate max rate Paco, n min rate max rate Paco,
Sufentanil
(1)
20 4.86
ns
(2)
(0.12)
ns
ns
(kPa)
5 *19.7 (0.7) *28.6 (0.4) *5.94 (0.25)
(@a)
3 *19.7 (1.7) *29.3 (2.7) *4.70 (0.45)
@Pa)
3 *20.0 (4.0) *30.7 (4.8) *4.67 (0.32)
20 15.6 26.5 6.24
ns
20 15.4 23.8 5.61
ns ns ns
20 15.7 24.4 5.55
ss
ns
Epidural opioids Various beneficial effects of postoperative epidural opioids have been suggested, such as effective analgesia measured subjectively, and improved pulmonary function with fewer pulmonary complications than with systemic administration of the opioid (1, 7, 14). Morphine has been the most extensively used epidural opioid, but late respiratory depression is a major concern for this opiate (1 5-1 7). Sufentanil has the advantage of rapid onset and potent analgesic effect due to a high lipid solubility, an intermediate degree of ionisation, a low molecular weight, a very high mureceptor affinity, and a high therapeutic range (14). In this study we found good analgesia at rest (significantly
20 5.12
Nausea Vomiting Itching Urinary retention
(I)
I
ns ns ns ns
1
0 7 (n=9)
(3) ns S
18
(0.5) (1.1) (0.28)
ns
(0.3) (0.7)
ss
ns
(0.14)
ss
(0.5)
ss
(0.9) (0.12)
ns
S
ss
S
17.4 23.3 5.58
(0.8) (0.9) (0.20)
ns
18 18.1 23.0 5.12
(0.7) (0.7) (0.12)
ns
18 19.5 22.1 5.15
(0.6) (0.9) (0.16)
ns
ss
ns
S
ss
S
ns
better than in the bupivacaine group at some points), but if the patient carried out a forced expiration, coughed or had physiotherapy, analgesia was poor, especially on the first day. The respiratory rate was lower (minimum rate on the second day significantly lower) and the Pacol value was insignificantly higher than in the bupivacaine group. This could be explained as a tendency towards respiratory depression, although true respiratory depression was never seen. We found a high incidence of nausea. Urinary retention was also commonly found. Pruritus occurred in one patient. These side-effects were not significantly different. There was good cardiovascular stability. Combination of epidural local anaesthetics and opioids Some investigators have found that the combination of a local anaesthetic with an opioid gives a longer duration of action and results in better pain relief than an opioid alone (18-20). Others have not found any difference (21). There is agreement that the combination of a local anaesthetic with an opioid gives better pain relief than the local anaesthetic alone. In our investigation we found that the IVAS pain score was significantly higher at some points for the combination
Table 5 Side-effects. For explanation of column ( I ) , (2) and (3), see legend to Table 1. Bupivacaine n = 10
(0.11)
ss
ns ns ns
following lower abdominal surgery ( 13). However, for thoracic surgery the pain relief is insufficient. We found a low WAS score in most patients, a high incidence of pain on exercise and a high number of drop-outs due to inadequate analgesia. Respiratory data revealed a rapid shallow breathing pattern and a high Paco, on the first day. There was a low incidence of cardiovascular complications, nausea, vomiting and itching, but a high incidence of urinary retention.
Combination
Sufentanil n=20 4
2 I 11
(2)
Combination n=20
ns ns ns ns
7
2 1 7
13)
ns ns ns ns
74
J. MOURISSE E T AL.
group as compared with the individual agents given alone. This was particularly so during the first 24 h. The number of patients who experienced pain on cxcrcise was also significantly lower for the combination group. Respiratory rate and Paco, were less affected than in the other groups. In the sufentanil group 12 patients received 24 boluses and a subsequent rise in infusion rate. In the combination group 10 patients received 16 boli. Adjustment of the infusion rate was easier in the combination group. Cardiovascular stability in the combination group was as good as in the other groups. This is in accordance with previous reports (22). Nausea occurred frequently. Itching occurred in one patient. There were no differences in side-effects. We are aware that statistical analysis of the bupivacaine group, with a significant difference in size and a high incidence ofdrop-outs, is not ideal. These values are purely illustrative. I n conclusion, continuous epidural administration of0.125% bupivacaine in the dose used (5-10 ml. h - ' ) in our study was insufficient for post-thoracotomy pain. A continuous infusion of sufentanil alone (0.83 pg . ml-') resulted in good analgesia at rest. The combination of these agents provided superior pain relief at rest and was effective in pain on exercise, unlike the agents used alone. Adjustment of the infusion rate was easier with the combination of bupivacaine and sufentanil, and there were better respiratory results.
ACKNOWLEDGEMENTS 'The assistance given by H. Noorduin with statistical analysis is greatly appreciated.
J F. High thoracic epidural with sufentanil for post-thoracotomy pain. Reg Anesth 1988: 13: 62-68. 6. Hasenbos M A, Gielen M J, Bos J, Tielbeek E, Stanton Hicks M, Van Egmond J. High thoracic epidural sufentanil for postthoracotomy pain: influence of epinefrine as an adjuvant, a double-blind study. Aneslhesiology 1988: 69: 1017-1022. 7. Hasenbos M A, Simon M, Van Egmond J. Postoperative analgesia by nicomorphine intramuscularly versus high thoracic epidural administration. Acta Anaeslhesiol Scand 1988: 30: 426. 8. Hasenbos M. High thoracic cpidural analgesia during and after thoracic surgery. Thesis, Nijmegen, 1986. 9. Maas P P M, Hasenbos M A, Van Egmond J, Dirksen R, Gielen M. High thoracic epidural administration of nicomorphine for analgesia after thoracic surgery. B7 M e d J (Special Issue), 1987: 55-60. 10. Covino B G , Vassallo H G. Local anaesthetics: mechanisms of actions and clinical use. New York Grune and Stratton, 1976. 11. Wildsmith J A, Armitage E N. Principles and practice ofregional anaesthesia. Edinburgh: Churchill Livingstone, 1987. 12. Reynolds F. A comparison of the potential toxicity ofbupivacaine, lignocaine and mepivacaine during epidural blockade for surgery. B r . 7 Anaesth 1971: 43: 567-571. 13. Mitchell R W D, Scott D B, Holmquist E, Lamont M. Continuous extradural infusion of 0.125% bupivacaine for pain rclief after lower abdominal surgery. Br .j' Anaesth 1988: 60: 851-853. 14. Cousins M .I, Mather L E.--Intrathecal and epidural administration of opioids. Anesthesiology 1984: 61: 276-jlO. 15 Bromage P R, Camposesi E M, Durant P A C, Nielscn C H. Rostra1 spread of epidural morphine. Anesthesiology 1982: 56: 43 1-436. 16 Sandler A N, Chovaz P, Whiting W. Respiratory depression following morphine: a clinical study. Can Anaetlh Soc J 1986: 33: 542. 17. Vestegaard Madsen J, Rybro L, Schurizek B A. Rcspiratory depression following postoperative analgesia with epidural morphine. Acta Anaesthesiol Scand 1986: 30: 41 7. 18. Lee A, Simpson D, Whitfield A, Scott D B. Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. B r J Anaesth 1988: 60: 845. 19. Hortso N C, Lund C, Mogensen T. Epidural morphine improves pain relief and maintains sensory analgesia during continuous epidural bupivacaine after abdominal surgery. Anesth Analg 1986: 65: 1033.
REFERENCES 1. Hascnbos M A, Van Egmond J, Gielen M J. Postoperative analgesia by high thoracic epidural versus intramuscular nicomorphine after thoracotomy. A d a Anaestheriol Scand 1987: 31: 608. 2. Rosseel P M, Van Den Broek \.V G M, Boer E C, Prakasch 0. Epidural sufentanil for intra- and post-operative analgesia in thoracic surgery: a comparative study with intravenous sufcntanil. Arta Anaesthesiol Scand 1988: 32: 193-198. 3. Logas \V G, El-Baz N, El-Ganzouri A et al. Continuous thoracic epidural analgesia for postoperative pain relief following thoracotomy: a randomised prospective study. Anesthesiology 1987: 67: 787-79 I . 4. Griiliths D P G, Diamond A W, Cameron J D. Postoperative extradural analgesia following thoracic surgery: a feasability study. Br J Anaesth 1975: 47: 48-55. 5. Stanton Hicks M, Gielen M, Hasenbos M, Matthyssen C, Crul
20. Scott N B, Mogensen T, Bigler D, Lund C, Kehlet H. Continuous thoracic extradural 0.5% bupivacaine with and without morphine: effect on quality of blockade, lung function and the surgical stress response. B r J Anaesth 1989: 62: 253. 21. Douglas M J, McMorland G H, Janzen J A. Influence orbupivacaine as an adjuvant to epidural morphine for analgesia after cesarian section. Anesfh Analg 1988: 67: 1 138. 22. Hasenbos M A, Eckhaus M, Slappendel R, Gielen M. Continuous high thoracic epidural administration of bupivacaine with sufentanil or nicomorfine for postoperative pain relief aftcr thoracic surgery. Reg Anesth 1989: 14: 212. Address:
J . Mourisse University of Nijmegen Institute for Anaesthesiology Postbox 9101 6500 HB Nijmegen The Netherlands
Epidural bupivacaine, sufentanil or the combination for post-thoracotomy pain J. MOURISSE, M. A. W. M. HASENBOS, M. J. M. GIELEN, J. E. MOLLand G. J. E. CROMHEECKE Institute for Anaesthesiology, University of Nijmegen, Nijmegen, The Netherlands
Analgesia with epidural bupivacaine, sufentanil or the combination was studied in 50 patients who had undergone thoracotomy. During operation all patirnts received an initial dose of bupivacaine 0.5% with adrenaline 5 pg.mlP' (5-10 ml) by thoracic epidural catheter. One hour later the patients were divided into three groups: the bupivacaine group (bupivacaine 0.125%), the sufentanil group (50 pg sufentanil in 60 ml normal saline) and the combination group (50 pg sufentanil in 60 ml bupivacaine 0.125%). Analgesia i n the three groups was provided by a continuous epidural infusion (5-10 m1.h-l) for 3 days. The mean dose of bupivacaine was significantly higher (P 6 ) , the patient received systemic nicomorphine and was excluded from the study at that moment. The adequacy of analgesia was assessed every hour by means of the inverse visual analogue scale (IVAS), where 10 represents excellent pain relief and 0 represents no analgesia at all. Blood-gas estimations were made on the day before surgery, on the day of surgery (day I ) , and on the first and second days after surgery (day 2 and 3), using an indwelling arterial cannula, except for the preoperative value. During the study, arterial pressure, electrocardiogram and respiratory rate were monitored continuously. Pruritus, nausea or vomiting were noted by observation and questioning. Urinary retention was defined as residual urine of > 500 ml after bladder catheterisation, which was performed when the patient was not able to produce urine after 4 h or when he had an urge to do so. Statistical analysis of the data was undertaken by use of the nonparametric Wilcoxon Rank test, the chi-square test and the MannWhitney U-test; P-values below 0.05 were considered significant. Values expressed as means are given with the standard error of the mean.
RESULTS The patients in the three groups were comparable in age, body weight, body height and sex. There was no significant difference in the preoperative pulse, systolic and diastolic pressure, and the preoperative Paco,. However, a significantly greater number of patients in the combination group had chronic obstructive pulmonary disease (Table l ) . Intra-operative cardiovascular data were comparable in the three groups, except for a significant difference in the maximum systolic pressure between the sufentanil group (149.2 (s.e.mean 6.4) mmHg (13.8 (0.8) kPa)) and the combination group (122.5 (s.e. mean 3.8) mmHg (16.3 (0.5) kPa)) and a difference in the diastolic pressure between the bupivacaine group (87 (s.e.mean 4.7) mmHg ( 1 1.6 (0.6) kPa)) and the combination group (72.8 (s.e.mean 2.9) mmHg (7.7 (0.4) kPa)). The inverse visual analogue score (IVAS) is given in Fig. 1. During the first day, five patients from the bupivacaine group were excluded from the study be-
ss
cause of inadequate analgesia. The next day another two patients from the same group were excluded for the same reason. The IVAS scores in the bupivacaine group were consistently the lowest. The IVAS scores in the combination group were consistently the highest, except at some points where the scores were the same as in the sufentanil group. O n the first day, the mean IVAS score for the bupivacaine group was 7.0, for the sufentanil group 8.0 and for the combination group 8.3. I n Table 2 the number of patients experiencing pain on exercise is presented for each of the 3 observation days. We divided pain at exercise into three items, as shown in the table. The sufentanil group had a greater incidence of pain on exercise at all times, compared with the combination group. The need for additional boluses and subsequent increase of infusion rate on the first day was high for the bupivacaine group and the sufentanil group (Table 3). The amount of sufentanil used in the sufentanil group averaged
ivaa pain rcom 10
8-
6-
2 0 0 0 0
x x x x x x x x x
72
J. MOURISSE E T AL.
Tdbk 2 Pain on exercise postoperatively; For explanation of column ( I ) , (2) and (3), see legend to Table 1. Sufentanil Bupivacaine n = 10 n=20 day I day 2 day 3 During forced expiration During coughing During physiotherapy Total number of patients who had pain on exercise
7 7
7
(I)
' '
.
ns
6.37 (s.e.mean 0.23) pg.g-l and in the combination group 6.52 (s.e.mean 0.28) pg h-'. These values were not significantly different. Postoperative respiratory data are shown in Table 4. The respiratory rate was always highest in the bupivacaine group. In the course of 3 days, there was an increase in respiratory rate in the bupivacaine group. Patients in the sufentanil group had the lowest respiratory rates at all times. The combination group had the smallest difference between minimum and maximum rates and the difference becomes even smaller after 3 days. Paco, on the first day was higher than the preoperative Paco, in all groups. I n the bupivacaine group the Paco, decreased below the preoperative Paco, on the second and third day. I n the sufentanil group the Paco, remained above the preoperative value (significant on all days). I n the combination group it returned to the preoperative value (only significantly different on the first day). There were no significant differences in cardiovascular effects post-operatively between the three groups. The incidence of cardiovascular side-effects was very low. Only one patient in the bupivacaine group and one in the sufentanil group suffered orthostatic hypotension, which was easily corrected by intravenous fluid administration. Side-effects in the three groups are shown in Table 5. There were no differences in side-effects.
day I day 2 day 3 12 13 11
9 12 7
4
16
13
9
(2)
Combination n=20 day I day 2 day 3
8 3 ss, s, ns
I 1 2
I 2 1
0 0
3
3
1
(3)
1
s
DISCUSSION Epidural local anaesthetics Epidural local anaesthetics by both bolus injection and continuous infusion have been used extensively and found to be effective for postoperative pain relief. Benefits include increased blood flow, modification of the stress response and improved gastro-intestinal function. However, the side-effects of sympathetic and motor blockade have restricted the use of local anaesthetics to selected groups of patients. With a continuous infusion technique, stability of arterial pressure is more easily achieved. The local anaesthetic of choice for thoracic surgery is bupivacaine because of the low degree of motor blockade, low acute toxicity relative to potency and long duration of action, resulting in a low risk oftoxicity during continuous infusion (10-12). High concentrations of local anaesthetics are effective at providing analgesia, but are likely to be accompanied by an unacceptable degree of motor blockade and the risk of systemic toxicity. If bupivacaine 0.25% plain is used as a continuous infusion, the incidence of drowsiness is unacceptably high (4).Low concentrations of bupivacaine often fail to produce a demonstrable nerve block and may even fail to relieve pain. If started peroperatively with bupivacaine 0.5%, prolonged pain reliefwith bupivacaine 0.125% infused at a rate of 6 to 10 m1.h-I has been demonstrated
Table 3 Requirement for additional boluses and amount of drugs administered. The amount of drug is expressed as mean and standard error of the mean. For explanation of column ( I ) , (2) and (3), see legend to Table 1. The values with the sign * are purely illustrative because there was drop-out of patients due to inadequate analgesia. Bupivacaine n = 10 Number Number Number Amount Amount
of patients who needed boli of boluses on the first day of boluses for 3 days of bupivacaine delivered ( m e . h - ' ) of sufentanil delivered (pg . kg- . h - ' )
'
9 *I6 $18
(I) ns
Sufentanil n=20 12 20 24
(2)
Com bination n=20
ns
10
ns
12 16 9.82 (0.43) 6.52 (0.28)
$12.07 (0.97) 6.37 (0.23)
(3) S
S
73
POST-THORACOTOMY EPIDURAL ANALGESIA
Table 4 Postoperative respiratory data. Values are expressed as means and standard error of the mean. For explanation of column ( I ) , (2) and (3), see legend to Table 1. In the row with sign (4), statistical significance between preoperative Paco, and Paco, on the first day is given. The values with the sign * are purely illustrative because there was drop-out of patients due to inadequate analgesia. Bupivacaine Pre.op
Day I
Day2
Day3
n Paco,
10 5.01 (0.24)
(kPa) (4)
n min rate max rate Paco, n min rate max rate Paco, n min rate max rate Paco,
Sufentanil
(1)
20 4.86
ns
(2)
(0.12)
ns
ns
(kPa)
5 *19.7 (0.7) *28.6 (0.4) *5.94 (0.25)
(@a)
3 *19.7 (1.7) *29.3 (2.7) *4.70 (0.45)
@Pa)
3 *20.0 (4.0) *30.7 (4.8) *4.67 (0.32)
20 15.6 26.5 6.24
ns
20 15.4 23.8 5.61
ns ns ns
20 15.7 24.4 5.55
ss
ns
Epidural opioids Various beneficial effects of postoperative epidural opioids have been suggested, such as effective analgesia measured subjectively, and improved pulmonary function with fewer pulmonary complications than with systemic administration of the opioid (1, 7, 14). Morphine has been the most extensively used epidural opioid, but late respiratory depression is a major concern for this opiate (1 5-1 7). Sufentanil has the advantage of rapid onset and potent analgesic effect due to a high lipid solubility, an intermediate degree of ionisation, a low molecular weight, a very high mureceptor affinity, and a high therapeutic range (14). In this study we found good analgesia at rest (significantly
20 5.12
Nausea Vomiting Itching Urinary retention
(I)
I
ns ns ns ns
1
0 7 (n=9)
(3) ns S
18
(0.5) (1.1) (0.28)
ns
(0.3) (0.7)
ss
ns
(0.14)
ss
(0.5)
ss
(0.9) (0.12)
ns
S
ss
S
17.4 23.3 5.58
(0.8) (0.9) (0.20)
ns
18 18.1 23.0 5.12
(0.7) (0.7) (0.12)
ns
18 19.5 22.1 5.15
(0.6) (0.9) (0.16)
ns
ss
ns
S
ss
S
ns
better than in the bupivacaine group at some points), but if the patient carried out a forced expiration, coughed or had physiotherapy, analgesia was poor, especially on the first day. The respiratory rate was lower (minimum rate on the second day significantly lower) and the Pacol value was insignificantly higher than in the bupivacaine group. This could be explained as a tendency towards respiratory depression, although true respiratory depression was never seen. We found a high incidence of nausea. Urinary retention was also commonly found. Pruritus occurred in one patient. These side-effects were not significantly different. There was good cardiovascular stability. Combination of epidural local anaesthetics and opioids Some investigators have found that the combination of a local anaesthetic with an opioid gives a longer duration of action and results in better pain relief than an opioid alone (18-20). Others have not found any difference (21). There is agreement that the combination of a local anaesthetic with an opioid gives better pain relief than the local anaesthetic alone. In our investigation we found that the IVAS pain score was significantly higher at some points for the combination
Table 5 Side-effects. For explanation of column ( I ) , (2) and (3), see legend to Table 1. Bupivacaine n = 10
(0.11)
ss
ns ns ns
following lower abdominal surgery ( 13). However, for thoracic surgery the pain relief is insufficient. We found a low WAS score in most patients, a high incidence of pain on exercise and a high number of drop-outs due to inadequate analgesia. Respiratory data revealed a rapid shallow breathing pattern and a high Paco, on the first day. There was a low incidence of cardiovascular complications, nausea, vomiting and itching, but a high incidence of urinary retention.
Combination
Sufentanil n=20 4
2 I 11
(2)
Combination n=20
ns ns ns ns
7
2 1 7
13)
ns ns ns ns
74
J. MOURISSE E T AL.
group as compared with the individual agents given alone. This was particularly so during the first 24 h. The number of patients who experienced pain on cxcrcise was also significantly lower for the combination group. Respiratory rate and Paco, were less affected than in the other groups. In the sufentanil group 12 patients received 24 boluses and a subsequent rise in infusion rate. In the combination group 10 patients received 16 boli. Adjustment of the infusion rate was easier in the combination group. Cardiovascular stability in the combination group was as good as in the other groups. This is in accordance with previous reports (22). Nausea occurred frequently. Itching occurred in one patient. There were no differences in side-effects. We are aware that statistical analysis of the bupivacaine group, with a significant difference in size and a high incidence ofdrop-outs, is not ideal. These values are purely illustrative. I n conclusion, continuous epidural administration of0.125% bupivacaine in the dose used (5-10 ml. h - ' ) in our study was insufficient for post-thoracotomy pain. A continuous infusion of sufentanil alone (0.83 pg . ml-') resulted in good analgesia at rest. The combination of these agents provided superior pain relief at rest and was effective in pain on exercise, unlike the agents used alone. Adjustment of the infusion rate was easier with the combination of bupivacaine and sufentanil, and there were better respiratory results.
ACKNOWLEDGEMENTS 'The assistance given by H. Noorduin with statistical analysis is greatly appreciated.
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20. Scott N B, Mogensen T, Bigler D, Lund C, Kehlet H. Continuous thoracic extradural 0.5% bupivacaine with and without morphine: effect on quality of blockade, lung function and the surgical stress response. B r J Anaesth 1989: 62: 253. 21. Douglas M J, McMorland G H, Janzen J A. Influence orbupivacaine as an adjuvant to epidural morphine for analgesia after cesarian section. Anesfh Analg 1988: 67: 1 138. 22. Hasenbos M A, Eckhaus M, Slappendel R, Gielen M. Continuous high thoracic epidural administration of bupivacaine with sufentanil or nicomorfine for postoperative pain relief aftcr thoracic surgery. Reg Anesth 1989: 14: 212. Address:
J . Mourisse University of Nijmegen Institute for Anaesthesiology Postbox 9101 6500 HB Nijmegen The Netherlands
