We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (general anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded-eight in Group TEA and four in Group GA-because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.

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Bupivacaine has a chiral centre and is currently available as a racemic mixture of its two enantiomers: R(+)-bupivacaine and S(-)-bupivacaine. Preclinical studies have demonstrated that there is enantiomer selectivity of action with the bulk of central nervous system and cardiovascular toxicity residing with the R(+) isomer. The aim of this study was to compare the clinical efficacy and safety of S(-)-bupivacaine with racemic RS-bupivacaine for extradural anaesthesia. We studied 88 patients undergoing elective lower limb surgery under lumbar extradural anaesthesia who received 15 ml of 0.5% or 0.75% S(-)-bupivacaine, or 0.5% RS-bupivacaine in a randomized, double-blind study. There was no difference in onset time, maximum spread of sensory block or intensity of motor block between the three groups. Duration of sensory block was significantly longer for 0.75% S(-)-bupivacaine. We conclude that S(-)-bupivacaine has similar local anaesthetic characteristics to RS-bupivacaine when used for extradural anaesthesia.

No abstract

SummaryWound infiltration with local anaesthetics is a simple, effective and inexpensive means of providing good analgesia for a variety of surgical procedures without any major side-effects. In particular, local anaesthetic toxicity, wound infection and healing do not appear to be major considerations. The purpose of this review is to outline the existing literature on a procedure-specific basis and to encourage a more widespread acceptance of the technique, ensuring that all layers are infiltrated in a controlled and meticulous manner. A thorough understanding of the pathophysiology of the surgical wound is necessary to improve both analgesia and postoperative recovery for any given operation. Crile's concept of anoci-association almost a century ago has been largely ignored by our specialty. Crile proposed that true peripheral afferent blockade prevents propagation of abnormal reflexes that cause major organ dysfunction and death [1]. Thus, postoperative complications can be minimised and recovery enhanced. Since Crile's original hypothesis, we have learnt that the major reasons for surgical morbidity and mortality are the operation itself, the surgeon's personal expertise, the stress response to that trauma and patient comorbidities.Postoperative analgesia is a major component of perioperative care and local anaesthetic (LA) techniques are more effective than systemic analgesia regardless of the operation and mode of delivery [2]. Until recently, research and clinical practice has focused on central neuraxial blockade and peripheral nerve blockade. These, although highly effective, are reserved for major thoracic and abdominal surgery, mainly because of high failure rates [3] and the risks of infection and spinal haematoma. When choosing a 'procedure-specific' technique, the simplest, safest and most effective block should be employed whenever possible [4]. Thus, the meticulous direct application of LA to each identifiable layer during a surgical procedure has considerable appeal for both surgeon and anaesthetist. Local anaesthetic infiltration for surgery itself has largely been confined to small superficial outpatient procedures. However, performed well, this is a logical means of preventing pain and other noxious stimuli from reaching the spinal cord. When combined with specific nerve blockade, e.g. ilio-inguinal nerve block or transversus abdominis plane (TAP) block during hernia repair, this allows a 'multimodal local anaesthetic' means of combating pain and anoci-association.By allowing patients to mobilise more quickly, wound infiltration may be as effective as central and proximal peripheral blocks in ensuring a safe postoperative recovery. Although untreated postsurgical pain may cause chronic pain [5], our knowledge of its pathogenesis, prevention and treatment is still basic. An individual patient's personality and pain response are important and may correlate to early postoperative pain appreciation and outcome. During surgery, multimodal analgesia combats peripheral and central 'wind-up' and sho...

Bupivacaine is used widely as a local anaesthetic but has potential for severe cardiovascular and central nervous system (CNS) toxicity. It has an asymmetric carbon atom giving it a chiral centre, and the commercial preparation is a racemic mixture of its two enantiomers: dextro or R(+)-bupivacaine and levo or S(-)-bupivacaine. Preclinical studies have demonstrated reduced cardiotoxicity and CNS toxicity for S(-)-bupivacaine. In this study we have compared the clinical efficacy of S(-)-bupivacaine with racemic RS-bupivacaine for supraclavicular brachial plexus block in 75 patients undergoing elective hand surgery. Patients received 0.4 ml kg-1 of either 0.25% or 0.5% S(-)-bupivacaine or 0.5% RS-bupivacaine in a randomized, double-blind study. Clinical assessments of sensory and motor block were performed at regular intervals. There were no significant differences in onset time, dermatomal spread or duration of both sensory and motor block between the three groups (the power of the study was 81% to detect a 4-h difference in duration). Duration of sensory block was prolonged with wide interpatient variation: 892 (SD 250) min, 1039 (317) min and 896 (284) min for 0.25% S(-)-bupivacaine, 0.5% S(-)-bupivacaine and 0.5% RS-bupivacaine, respectively. There were no differences in the overall success rate of the technique. We conclude that S(-)-bupivacaine was suitable for local anaesthetic use in brachial plexus block anaesthesia.

A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.

SummaryIn order to evaluate the general public's knowledge of postoperative pain and its management, a simple questionnaire was devised and sent out to five general practices in Scotland and Yorkshire. Questionnaires were completed voluntarily by 529 people attending their general practitioner for reasons not related to surgery. Five hundred and fifteen completed questionnaires were analysed. Two hundred and thirty-nine (46.4%) responders had undergone previous major surgery whereas 267 (51.8%) had not. Attitudes to pain varied greatly and confirm the findings of other surveys that amongst the general public there is little or no understanding of the nature of postoperative pain or of the methods available to treat it. Despite the published literature, the public have a high degree of confidence in the ability of doctors and nurses to treat such pain. Widespread public and professional education is required before further improvements can be made to such a universal and basic clinical problem. Pain following surgery is a universal and potentially dangerous problem which until the last decade received little attention from the medical profession. The publication in 1990 of the report of the working party of the Royal Colleges of Surgeons and Anaesthetists has led to some organisational improvements in the provision of pain relief after surgery [1] and, to meet the report recommendations, many hospitals have established pain teams which can achieve significant reductions in pain scores [2]. However, other surveys have highlighted the lack of improvement in some hospitals in staff attitudes to pain and the poor knowledge amongst patients in hospital awaiting surgery [3][4][5][6]. No data are available regarding the perceptions and knowledge that the general public have of postoperative pain or on the importance it places in the topic. This was the purpose of the study. MethodsA simple questionnaire was designed to assess the knowledge and attitudes of the general public towards postoperative pain and the methods currently available for its treatment. An initial 30 questionnaires were sent out to nonclinical staff and to hotel staff within the HCI hospital complex to determine the ease with which the questions were understood and completed. Following this, questionnaires were sent to four general practices in Scotland (two in Aberdeen, one in Edinburgh, one in Dumfries) and one practice in Keighley, Yorkshire. Over a 6-month period, patients attending the general practices for reasons unrelated to surgery were invited to complete the questionnaires voluntarily. It was not necessary for patients to have undergone previous surgery. If blanks were left, the answers were counted as a 'don't know' or in the case of questions on sex or age 'not answered'. The differences in responses between males and females, different age groups and previous surgery and no surgery groups were examined using the Chi-squared test. A probability of less than 0.05 was taken to be significant. ResultsFive hundred and twenty-nine questionnair...