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0.2% ropivacaine with or without fentanyl for patient-controlled epidural analgesia after major abdominal surgery: a
Study Objective:
To evaluate the effects of adding low concentration of fentanyl to 0.2% ropivacaine when providing patient-controlled epidural analgesia (PCEA) outside the Post-Anesthesia Care Unit.
Design:
Prospective, randomized, double-blind study.
Setting:
Inpatients at a University Department of Anesthesia.
Patients:
32 ASA physical status I, II, and III patients, who were scheduled for elective major abdominal surgery, including bowel resection, hepatic resection, and pancreaticoduodenectomy.
Interventions:
Patients received standard general/epidural anesthesia. After surgery patients were randomly allocated in a double-blind fashion to receive PCEA with either 0.2% ropivacaine (n = 16) or 0.2% ropivacaine/2 microg/mL fentanyl (n = 16) [background infusion ranging between 4 and 6 mL/hr, with 1.5-mL incremental doses and a 20-min lock-out time]. Dynamic pain during coughing, sedation, pulse oxymetry, hemodynamic variables, and motor block were evaluated at 1, 6, 12, 24, and 48 hours after the end of surgery by a blinded observer. Occurrence of untoward events, including nausea, vomiting, pruritus, need for supplemental oxygen (for SpO(2) < 90%), and respiratory complications, as well as total consumption of PCEA solution and incremental doses given to the patient were also recorded.
Measurements And Main Results:
No differences in pain relief, motor block, degree of sedation, recovery of gastrointestinal motility, and other side effects were observed between the two groups. Patients receiving 0.2% ropivacaine alone requested far more incremental doses (23 doses [0-60] vs. 5 doses [0-25]) (p = 0.006) and needed far more analgesic solution (230 mL [140-282] vs. 204 [130-228]) (p = 0.003) than patients receiving the ropivacaine/fentanyl mixture. Peripheral oxygen saturation was lower at 12, 24, and 48 hours during ropivacaine/fentanyl infusion than in patients receiving ropivacaine alone (12 h: 91% +/- 2% vs. 95% +/- 2%, p < 0.006; 24 h: 93% +/- 1% vs. 96% +/- 2%, p = 0.003; 48 h: 92% +/- 1.8% vs. 96% +/- 1%, p = 0.004).
Conclusions:
A thoracic epidural infusion of 0.2% ropivacaine, with or without fentanyl, provided effective pain relief in most patients with a very low degree of motor blockade. Adding 2 microg/ml fentanyl to 0.2% ropivacaine reduced total consumption of local anesthetic solution and need for incremental doses, but did not provide clinically relevant advantages in quality of pain relief and incidence of motor block, leading to a significant decrease in peripheral SpO(2), lasting up to 48 hours after surgery.