Service dAnesthésie et de Réanimation Chirurgicale, Hôpital G et R Laënnec, Boulevard J Monod, CHU Nantes, F-44093 Nantes Cedex 01, France*Corresponding author
Accepted for publication: April 10, 2001
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Br J Anaesth 2001; 87: 6358
Keywords: analgesia, postoperative; analgesic techniques, epidural; analgesics anti-inflammatory, steroid; surgery, thoracic
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Methods and results |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The primary end-point was the total i.v. morphine requirements by patient-controlled analgesia (PCA) pump during the first postoperative 48 h. Secondary end-points were the 4-hourly interval morphine requirements during 48 h, visual analogue scale (VAS) pain assessment at rest and mobilization, quality of pain relief appreciated by the patient himself and the incidence of adverse events.
During the preoperative visit, the patient was instructed in the use of the VAS and PCA use. After premedication with hydroxyzine 1.5 mg kg1, an epidural catheter was inserted at T4T5 or T5T6. A mixture of 100 mg bupivacaine with 0.1 mg epinephrine, 20 µg sufentanil and saline solution (total volume of 30 ml), was injected at a rate of 5 ml every 5 min until a block was obtained extending from T1 to T10. General anaesthesia was induced with thiopental 6 mg kg1 and pancuronium bromide 0.1 mg kg1, orotracheal intubation was performed after local anaesthesia of the glottis, using a double lumen 3941 tube. Anaesthesia was maintained by inhalation of nitrous oxide and isoflurane. Patients were assigned randomly to two groups the day before surgery. At the end of the operation, patients in the MP group received epidural administration of 1 mg kg1 of MP diluted in 10 ml of saline solution followed by a continuous epidural infusion of 1.5 mg kg1 of MP diluted in 24 ml of saline solution. Patients in the placebo (P) group received identical volumes of saline solution epidurally, followed by a continuous epidural injection at the same rate. The various solutions were administered in double blind manner and maintained for 48 h postoperatively.
An initial morphine-loading dose was given when the patient complained of pain (VAS >3 cm). Titration of 1 mg boluses followed until pain was relieved (VAS <3). Subsequently, the PCA pump was set on PCA mode alone (10-min lockout, 1 mg bolus and no maximal dose).
Haemodynamic data, ventilatory frequency, SpO2 and level consciousness were evaluated every hour for 48 h. Consciousness was scored on a scale of 15 (1= asleep and not wakeable; 2=asleep but wakeable with altered vigilance; 3=asleep but wakeable and vigilant; 4=spontaneously awake; and 5=restless). The patient evaluated his pain (at rest and on coughing) every 4 h using a VAS (0=absence of pain; 10=unbearable pain). The patient evaluated the quality of relief of pain using a questionnaire insufficient, good, excellent at 72 h postoperatively. Adverse effects were recorded during the entire period.
Data are presented as mean (SD) or median with interquartile range. Statistical analysis was performed using the MannWhitney rank sum test for comparison of quantitative variables. Multivariate analysis of variance (MANOVA) for repeated measurements was used to compare VAS pain scores and morphine use over time between the groups or within each group throughout the study (Systat IM 7.0 software). The significance threshold for the tests was set at P<0.05.
Three patients were excluded because of misunderstandings with respect to the use PCA or technical failure. Therefore, 24 patients were included in the statistical analysis, 12 in each group. There were no significant differences between the two groups with respect to patient, surgical and anaesthetic characteristics.
Total morphine requirements during the study were not significantly different between the two groups (median 59 (4078) for MP group and median 65 (5993) for P group) (Fig. 1).
|
![]() |
Comment |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
The conclusions of studies concerning the analgesic efficacy of glucocorticoids are controversial. Some data support a central effect of glucocorticoids.5 Other studies have shown a lack of efficacy.6 Epidural glucocorticoids have been tested for postoperative pain after spinal surgery. Dexamethasone reduced postoperative lumbar pain after laminoarthrectomy.3 Epidural administration of methylprednisolone alone or in association with morphine decreased postoperative pain significantly after surgery on spinal stenosis, but not after disk surgery.4 However, it should be noted that methylprednisolone in spinal surgery acts at the surgical site essentially by a local anti-inflammatory effect. In postoperative pain as a result of PLT, this effect is probably less important.
It is concluded that our data do not support the use of epidural steroids for postoperative analgesia after PLT.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Carette S, Marcoux S. Epidural corticosteroid injection for sciatica due to herniated nucleus pulposus. N Engl J Med 1997; 336: 163440
3 Ang ET, Goldfarb G, Kobn S, et al. Analgésie postopératoire: injection péridurale de phosphate sodique de dexaméthasone. Ann Fr Anesth Réanim 1988; 7: 28993[Medline]
4 Mc Neil TW, Anderson GB, Schell B, Sinkora G, Nelson J, Lavender SA. Epidural administration of methylprednisolone and morphine for pain after a spinal operation. A randomized, prospective comparative study. J Bone Joint Surg (Am) 1995; 77: 18148[Abstract]
5 Hall ED. Glucocorticoids effects on central nervous excitation and synaptic transmission. Int Rev Neurobiol 1982; 23: 16595[ISI][Medline]
6 Abram SE, Marsala M, Yaksh TL. Analgesic and neurotoxic effects of intrathecal corticosteroids in rats. Anesthesiology 1994; 81: 11981205[ISI][Medline]