Anaesthesia, 1992, Volume 47, pages 352-364

Correspondence Personal experience of three commonly used methods of postoperative pain relief A . M . H . Lynch, FFARCS Pre-operative paravertebral block for peri-operative analgesia J . MacKenzie, M R C P . FFARCS Pattern of use of the laryngeal mask airway J.A. Hughes, FFARCS and P.S. Gataure, FCAnaes The laryngeal mask airway in recovery R.J. Erskine. FCAnaes and P.G. Rabey, FCAnaes Defective feed mount N . Koehli. FCAnaes Propofol for sedation in intensive care in a patient with an acute porphyric attack J . C . Harrison, FCAnaes and F.T. McAuley, M B , ChB Propofol and mono-amine oxidase inhibitors C.A. Hodgson. FCAnaes Failed tracheal intubation S . Q . M . Tighe, FCAnaes Basic life support performance M . A . Y . Elias, FCAnaes A malformed guidewire W . R . Harvey, FCAnaes A.J. Perrival ‘Slipped’ trachea during laryngo-uesophagectomy M . A . Y . Elias. FCAnaes Exaggerated epidural blockade? A.D. Magides, FCAnaes and R.J.S. Birks. FCAnaes M . T . Popat, FCAnaes. A . R. Jadad. M D and C.J. GIynn, FCAnaes

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Missing O-ring causes unrecognised large gas leak P . D . Berry, M B , ChB and D . G . Ross, FFARCS Measurement of VAS pain scores with a ‘magic screen’ H . Spens, FCAnaes and G . C . Pugh, FCAnaes The potential hazards of using iodine as an antiseptic solution D . Watson, FCAnaes Anaphylactoid reaction to ranitidine in an obstetric patient J.E.S. Barry, FFARCS, R. Madan, FFARCS and P.B. Hewitr. FFARCS The upside down facemask again W.C. Edmondson, FFARCSI and A . Rushron. B M . BCh Another use for paediatric masks R. Williamson, FFARCS ‘On/off’ switches on anaesthetic machines S . R . Haynes, FCAnaes and C.J. Best, FCAnaes T. Longman Splitting tubes M.U. Smith, FCAnaes and J.D. Watts, M B , BS J . Lloyd Davies Local anaesthesia for reduction of neonatal inguinal hernia O . A . Williams, FCAnaes Doxapram after general anaesthesia I.J. Uroome, FCAnaes and C . H . Mills, M B , ChB V . Sarma, FFARCS Insertion of interpleural catheters E . M . Lee, FFARCSI and U. Ben, David, M B

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Personal experience of three commonly used methods of postoperative pain relief There have been some excellent articles recently on postoperative pain relief and pain relief services [I-31. I have recently experienced three currently used methods a t first hand during the first 24 h after a total hip replacement and venture to suggest that my subjective experiences might be of interest to other anaesthetists. The operation was performed at a well run teaching hospital, whose Anaesthetic Department is renowned for its high standards. I awoke on arrival in the recovery room, clear-headed and pain free after an anaesthetic which consisted of epidural block, with propofol sedation. The epidural catheter was still in place, and attached to a Graseby-2000 pump. A dull pain in the gluteal region was rapidly corrected by adjustment of the pump by my anaesthetist.

I remained comfortable, happy and clear-headed during my 4 h stay in the recovery room and was able to report any side effects to the nursing staff. On two occasions I felt light-headed, and each time my systolic blood pressure was found to have decreased to below 80 mmHg. On one occasion I realised that deep breathing and coughing were becoming difficult and the level of the block has risen to T4. These side effects were rapidly detected and corrected. I was impressed that it was so easy to report these problems at an early stage. After 4 h the recovery ward closed for the weekend (it was Saturday afternoon) and I was transferred to my ward. Since the ward nursing staff are not allowed to care for patients with continuous epidurals, the catheter was removed, and a PCA pump attached to an intravenous

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Correspondence cannula. This was a Graseby 2000, containing morphine 1 m g m - ' ; 1 mg was allowed to be delivered every 10 min at most. To my surprise the use of this PCA was not nearly as pleasant or effective as I had always supposed it to be. Pain relief was slow in onset and not nearly as adequate as the epidural had been. I became drowsy, dizzy and dysphoric. The worst side effect was the onset of persistent and eruptive vomiting, which was not controlled by prochlorperazine. It was not easy to clear my airway as I could neither sit nor turn sideways; also I was drowsy. I have received opioids postoperatively in the past but never experienced nausea or vomiting with them. Some hours later, both the infusion and the auxillary cannula for the PCA pump leaked into the tissues (subcutaneous morphine stings!). My veins were not pronounced that evening and the resident orthopaedic surgeon was unable to resite a cannula. My consultant anaesthetist kindly came in from home and managed to resite the infusion after several attempts and with much skill. Only then could the PCA be restarted. By this time an hour or two without the pump must have elapsed and analgesia had worn off completely, but so had the vomiting. The vomiting increased as the analgesia again took effect. At around 0200 the infusion drip tissued once more and some time elapsed while medical staff were contacted and made the decision to discontinue the infusion that night. This also meant discontinuation of PCA. After further discussion I received simultaneous intramuscular

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injections of morphine and prochlorperazine. The pain relief was soon superior to that with the PCA; vomiting ceased and I slept. Intramuscular analgesia was administered when needed (about 4-hourly, I believe) and at no time wore off to the extent that the PCA had done; it was far more pleasant. It is fairly common for cannulae to become misplaced during the first night postoperatively and for time to elapse before resiting. This must be a great disadvantage to the patient if a PCA pump is dependent on the cannula. I am due to have my second hip replacement in a few months time. My choice of analgesia will in future be: ( I ) continuous epidural; (2) intramuscular opioids. Before the above experience my first choice was definitely PCA, which I now consider less safe than continuous epidural analgesia in my own case. Ormskirk and District General Hospital, Ormskirk L39 2AZ

A.M.H. LYNCH

References [ I ] The Royal College of Surgeons of England and The College of Anaesthetists. Commission on provision of surgical services. Report of the working party on pain after surgery, 1990. [2] HARMER M .Postoperative pain relief-time to take our heads out of the sand. Anuesthesiu 1991; 46: 167-8. [3] WHEATLEY RG, MADEJTH, JACKSON IJB, HUNTER D. The first year's experience of an acute pain service. Erirish Journal of Anaesthesia, 1991; 67: 353-9.

Pre-operative paravertebral block for peri-operative analgesia A dominant theme in current clinical practice is to improve quality of pain relief after operation, and one of the things that we can all d o is to make better use of existing techniques. I would like to report my experiences with paravertebral block in 110 patients. In the presence of unilateral wounds, this technique makes a valuable contribution to patient comfort in the immediate postoperative period, typically reducing pain scores to nil or slight. Paravertebral block has been dismissed as of historical interest only, but it is regularly employed by our veterinary colleagues. Indeed, a recent photograph in Anaesthesia News showed a cow undergoing Caesarean section with a paravertebral block. The technique I use is that described by Eason and Wyatt [I] and the block is performed after induction of anaesthesia with the patient in the lateral position with the side to be operated on uppermost. For a single-shot technique an 18 gauge Venflon paravertebral block needle is used (Viggo AB, Helsingborg, Sweden). Bupivacaine 0.5% with 1 : 200000 adrenaline in a volume of 25 ml is used. The injectate spreads laterally into the adjacent space and craniocaudally over the anterior surfaces of the ribs to adjacent paravertebral spaces [2]. In adults, 3-4 segmental nerves can be blocked by this volume. Catheterisation of the paravertebral space using a Tuohy needle and epidural catheter is equally simple, with easy passage of the catheter indicating successful entry into the paravertebral space. Infusion of 0.25% bupivacaine with adrenaline 1 :200000 at 5-10 m1.h-' then maintains a moderate sensory block of a somatic wound. Requirement for opioid is often reduced to single or twice daily dosage; greater need suggests failure of the technique. Over the last 18 months I have made increasing use of uniateral paravertebral block to supplement general anaesthesia in cases where surgery involves a unilateral

incision. A single-shot technique is used for procedures such as mastectomy, enterostomy, appendicectomy or inguinal hernia repair. Analgesia usually lasts 4-6 h into the immediate postoperative period. When more prolonged analgesia is required, a catheter technique has been used successfully (in 25 patients to date) for up to 48 h following cholecystectomy, renal surgery and prosthetic hip or knee replacement. Out of the total of 110 cases receiving paravertebral block, there have been only five technical failures and one occasion when a catheter could not be passed. Inadvertent intravenous injection occurred on one occasion when a single-shot was performed at the end of surgery during emergence from anaesthesia; a brief convulsion resulted, but subsequent recovery was full. On this occasion plain bupivacaine was used; intravascular injection could possibly have been recognised earlier if an adrenaline containing solution had been used as a test dose. Medial spread into the epidural space is also a possible complication. Clinically evident epidural spread of local anaesthetic, as judged by the presence of bilateral numbness and leg weakness, was seen in four patients. The versatility and simplicity of paravertebral block suggests that in the presence of a unilateral wound, this technique may offer advantages over epidural block. Following paravertebral block, haemodynamic stability is evident, as pressor responses to surgical stimuli are obtunded yet sympathetic block is limited. Bladder sensation is not lost, and leg weakness does not occur, unless the block is sited at L2-.,. In addition, the other potential risks associated with epidural block are minimised. The good quality of analgesia that results from effective somatic paravertebral block reduces requirement for opioid analgesics and thereby reduces the likelihood of their undesirable side effects, but at the same time promotes

Personal experience of three commonly used methods of postoperative pain relief.

Anaesthesia, 1992, Volume 47, pages 352-364 Correspondence Personal experience of three commonly used methods of postoperative pain relief A . M . H...
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