Summary The present study tested the hypothesis that patients receiving epidural bupivacaine before surgery would require less morphine postoperatively and/ or report less intense pain than patients receiving epidural bupivacaine after incision but before the end of surgery. Forty-nro patients (ASA class I-III) scheduled for lower abdominal surgery were randomly assigned to I of 2 groups of equal size and prospectively studied using a double-blind, placebo-controlled crossover design. Epidural catheters were placed in the Tlz-Ll or L1-L2 interspaces pre-operatively, the position of the catheter was confirmed with 3Vo chloroprocaine with epinephrine L :200,000, and sensory testing was carried out until levels had receded to below T12. Group I received 15 ml of 0.5Vo epidural bupivacaine injected 35 min before incision followed by 15 ml of epidural normal saline 30 min after incision. Group 2 received 15 ml of epidural normal saline injected 37 min before incision followed by 15 The results suggest that single-shot pre-emptive epidural local anaesthesia is associated with a short-term morphine-sparing effect which is most pronounced between 12 and 24 h after surgery. Extending the pre-operative blockade into the postoperative period may prolong the initial advantage conferred by pre-emptive epidural local anaesthesia.

Summary This study tested the hypothesis that high dose systemic alfentanil administered before and during aMominal hysterectomy would pre-empt post'operative pain to a greater extent than administration of either low dose alfentanil or no alfentanil perioperatively. Patients (ASA I or 2) were randomly assigned to group 1 (r = 15), no opioid; group 2 (n = 15), low dose alfentanil; or group 3 (n = l5). high dose alfentanil. Anaesthesia was induced in group I with midazolam and thiopentone and was maintained with isoflurane andTO% N2O in 02, Anaesthesia was induced in group 2 with midazolam, thiopentone and i.v. alfentanil (30pg kg-l), and was maintained with isoflurane. 70VoN2O in 02, and bolus doses of i.v. alfentanil (10-20pg kg-l) every hour. Anaesthesia was induced in group 3 withmidazolamandi.v. alfentanl (l0opgkg-t),and wasmaintained wtlt70% N2Oin Oz,andanintusionof i.v. alfentanil(l-2pgkg-l min-l). Blood samples were drawn at 30 and 120 min after surgery and assayed for plasma alfentanil. Morphine consumption and VAS pain scores were consistently lowest in group 3 over the 48 h study period, A composite measure of pain and morphine consumption was significantly lower in group 3 than group 2 up to 6 h after surgery and significantly lower than group I up to 12 h. No adverse effects were observed. A 6-month follow-up did not reveal any significant differences among the three groups. It is concluded that intra-operative high dose alfentanil anaesthetic pre-empts post-oporative pain after abdominal hysterectomy, but the effects are small and of short duration.Surgical procedures carried out under general anaesthesia using standard (and even high) doses of opioids intraoperatively provide suboptimal protection from the injury banage brought about by incision and subsequent noxious surgical events.

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. 608 pages. ISBN 2 7606 1951 6 J'ai eu un grand plaisir à lire ce livre. Comme anesthésiologiste ayant une pratique médicale diversifiée, j'ai aimé l'aspect pragmatique ainsi que d'érudition. Le contenu est tout à fait pertinent pour les anesthésiologistes. Le livre est divisé en deux: les aspects fondamentaux et l'approche clinique. Je dois dire que même dans les chapitres fondamentaux se retrouvaient plusieurs éléments pragmatiques utiles en clinique.Travaillant en milieu universitaire, je sais que même actuellement, l'enseignement de la douleur, et en particulier de sa pharmacologie, est souvent superficiel. Les mythes sur le soulagement de la douleur sont toujours présents. J'ose espérer que ce livre connaîtra une large diffusion, car la douleur aiguë ou chronique est une entité clinique largement répandue. Le livre touche aux particularités pédiatriques, gériatriques et même obstétricales.C'est un livre d'une grande qualité qui peut s'adresser aussi aux étudiants en médecine, aux rési-dents, aux infirmières et à tous ceux qui veulent acquérir un savoir-faire basé sur des connaissances en profondeur. Ce livre devrait se retrouver dans toutes les bibliothèques de nos centres hospitaliers ou de nos départements.Ce livre constitue une revue exceptionnelle des dernières avancées et ce dans un excellent français, ce qui rend sa lecture agréable.

SummaryA number of reports have been published describing (recurrent) respiratory depression after the use of alfentanil intraoperatively. To evaluate the severity of respiratory depression after the administration of alfemanil, 49 patients undergoing general anaesthesia for abdominal hysterectomy were randomly allocated to one of three groups and studied in a double-blind manner. During surgery patients received no opioic:h (group 1), low dose (group 2) or high dose of alfentanil (group 3) . Postoperatively patients were monitored with pulse oximetry and respiratory inductive plethysmography. Postoperative pain was managed with PCA morphine.T hirty-nine patients completed the study. Respiratory depressar1t effects were found in all three groups. A hiRher number of apnoeas (at 60 minutes in group 1: 3.3 ± 1.6; group 2: 3.5 ± 1.8; group 3: 12.2 ± 2.8) and a higher morphine consumption was found in group 2 when compared with group l and 3. o differences were found among the groups in the other respiratory parameters or in terms of the number of patients with respiratory depression at any one time. No cases of dear-t.-ut recurrent respiratory depression were identified.