Torsten Mueller Joem Meuser, Michael Knoch
Dept of Anaesthesiology and Intensive Care Klimkum Neubrandenburg, D 17022 Neubrandenburg Germany

Background: A new adaptive system has been designed to improve patient controlled analgesia with variable bolus doses of opioids without lockout time on base of a pharmacokmetic model The drug dosage is dependent on the frequency of demands So every patient can individually titrate his own bolus dose In a randomized study we compared this system with a conventional PCA System recovering from major abdominal surgery.

Patients and methods: The APCA pump and a commercial PCA pump were used after agreement of the ethics commission in 66 patients (PCA 32 APCA 31, drop out 3 patients) The maximum dose of analgesic fentanyl per hour amounted in both procedures was 200ug/h Dunng the 24 hours observation in the first 6 hours once per hour after 12 and after 24 hours the pain was seized on the VAS (0-100) in rest and after deep breathing efforts After the observation phase a retrospective pain and satisfaction score as well as the side effects (nausea vomiting, sedation) dunng the treatment were documented.

Results: We found no differences in demographic data, operations type and onset pain score Both systems proved as safe All patients were hemodynamic stable the measured oxygen saturation were even greater 90% In the APCA-group was a significant difference in the rest pain score after 2, 3,4, 5 and 12 hours compared to the PCA group (p<0 05) The side effect rates were identical with both systems.

Conclusions: The APCA system proved by the variable bolus sizes and missing lock out time as an effective way for treatment the acute pain in major abdominal surgery Time-consuming individual dose titration at the beginning of the therapy and pain peaks (care, physiotherapy etc ) is taken over by the APCA system.

INTRAVENOUS PATIENT CONTROLLED ANALGESIA WITH FENTANYL OR TRAMADOL IN POSTOPERATIVE PAIN THERAPY

Osman N AYDIN. Feray GURSOY Varlik EREL
Adnan Menderes University, Faculty of Medicine, Dept of Anaesthesiology, 09100, Aydin/Turkey

Aim of investigation: The purpose of this study was to evaluate the effects complications and cost of fentanyl and tramadol in postoperative pain therapy.

Methods: The double-blind, randomized and prospective study was performed in 60 patients (ASA I-II ages with 18 80) after elective mtra abdominal surgery The effects of intravenous (IV) fentanyl (Group F) were compared tramadol (Group T), (Loading dose was Img/kg and 1 5mg/kg, bolus dose was 15ug and 20 mg, lock out time was 10 and 15 minutes respectively) with PCA Visual analogy scale (VAS) scores sedation scores and complications were recorded Patients , doctors and nurses satisfactions rates were inquired at 2, 6 and 24 hours Total cost of the both drugs were calculated.

Results: VAS scores and sedation scores decreased continuously in 24 hours (p<0,05) VAS was significantly higher in the group T than the group F at 2 hours postoperatively (p<0,05) Sedation scores, satisfaction rates of patients, doctors and nurses, and complications were similar in the both groups The total cost of fentanyl was three times lower than tramadol (p<0 05).

Conclusions: Postoperative pain therapy with fentanyl has similar efficiency when compared with tramadol Major advantage of using fentanyl is lower cost of therapy.

CONTINUOUS INFUSION OF TRAMADOL / DIPYRONE OR TRAMADOL ALONE AS AN ALTERNATIVE TO PCA IN POSTOPERATIVE ANALGESIA

 W Jaksch. R Reichhalter, S Fitzal
Dept of Anesthesiology and Intensive Care, Wilhelminenspital, Montleartstr 37 ,1160 Vienna, Austria

Aim of Investigation: Due to limited personnel and financial resources patient controlled analgesia (PCA) can often be provided only for a minority of all postoperative patients Therefore we studied continuous infusion of tramadol / dipyrone (T/D) and tramadol (T) alone in comparison to PCA retrospectivly dunng a period of 4 years.

Methods: In 801 patients pain at rest (VAS-R) and on movement (VAS-M) was evaluated 24 h after gynecological, urological or abdominal surgery using a 10-score visual analog scale After pro-vidmg pain relief down to VAS < 3 for all patients with pintramide, the PCA group received pintramide (1 5mg boluses 8mm lock out time, no basal rate, 4h max 30mg) whereas the other patients received tramadol infusion (500mg) with or without 2 5g dipyrone (T/D or T) over 24 hours Differences were calculated by using the Mann Whitney test.

Results: PCA n=346 T/D n = 368 T n = 87
	efficacy (* p<0 001)
VASR	1,87	0,57*	0,84*
VAS-M	4,32	1,57*	2,46*
drop outs	0	1 6%	35%
side effects (%)
none	89,88	85,87	83,91
nausea	8,38	8,42	8,05
sedation	0,87	2,17	2,3
others	0,87	3,54	5,74

Conclusions: All pain control regimens proved to be effective with a small but significant difference in favour of the infusion groups However, PCA seems to work better in patients undergoing extensive surgical interventions But when providing sufficient analgesia in the immediate postoperative period infusion regimens with tramadol are low cost and effective alternatives to PCA for the great majority of patients

TRAMADOL AND KETOROLAC IN ELASTOMERIC PUMP FOR POSTOPERATIVE ANALGESIA: COMPARISON OF TREE THERAPEUTIC REGIMES

 Aniello De Nicola & Maria Jose Sucre
Pain Control Unit, S Leonardo Hospital, Castellammare di Stabia (Italy) & Dept. of Anaesthesiology, West General Hospital, Caracas (Venezuela)

Aim of investigation: Quality of continuous infusion for postoperative analgesia provided by tree therapeutic regimes: tramadol (T), ketorolac (K) and tramadol + ketorolac (TK) through an elastomeric infuser (Infusor" Baxter 1071).

Methods: Randomly was studied a group of 150 patients (70 men and 80 women; mean age 31.0 ± 10.6 years; mean body weight 69.2 ± 13.3 kg) undergoing major surgery, urology and gynaecology.

Was given I.V. analgesics at the time of extubation, followed by a maintenance infusion in each group of 50 patients.

	T	K	TK
Loading dose	100 mg	30 mg	50 mg + 10 mg
Continuous infusion in 24h	300 mg	90 mg	40 mg + 200 mg

During the first 24 hours at 3 hours intervals the following data were recorded: means of Visual Analogue Scale (VAS), degree of consciousness, systolic and diastolic blood pressure, heart rate and adverse side effects.

Results: The 3 schemes determined the control of postoperative pain, as simplified in the table.

Median VAS	T	K	TK
6 hour	1.5±2.1	4.0 ± 2.1 (p<0.01)	1.2±1.3
12 hour	2.0±0.8	3.7±2 (p< 0.05)	1.6±0.9

Five patients in the T, nine in the K and none in TK needed supplementary analgesia. Sedation was the most frequent side effects in T (8%) and gastralgia in K (5%).

Conclusions: On the basis of this experience the combination of tramadol and ketorolac has been demonstrated to be an effective and reliable procedure to provide better postoperative analgesia than ketorolac alone.

INTRAPLEURAL ANALGESIA, INTERCOSTAL BLOCK AND PREEMPTIVE ANALGESIA WITH SYSTEMIC PATIENT CONTROLLED ANALGESIA(PCA) AFTER THORACIC SURGERY.

Arslan A.KarsI B,Trakya A,Erman M.
Akdeniz University, Faculty of Medicine, Dept.of Anesth and Rean,Antalya/rurkey

Introduction: The one of the most important factors to reduce postoperative pulmonary complication in patients undergoing thoracotomy The aim of this study was compare the results of mtrapleural analgesia.intercostal nerve block and preemptive analgesia for postoperative pain relief after thoracotomy.

Methods: With Institutional Review Board approval and after obtaining patients consent,36 patients of ASA I-III,undergoing elective thoracotomy were included to the study. Patients in Group I(intrapleural) received 10 ml 0.5% bupivacaine+50 mg(l ml)+9 ml saline intrapleurally Intrapleural analgesia with bupivacaine applied every 4 hours using a catheter. The intercostal nerve blocks of two segments performed with 9 ml 0.5% bupivacaine+50 mg(l ml) tramadol to the patients in Group II(intercostal). In control group(preemptive) patients received iv.bolus 50 mg tramadol 15 min before onset of surgery. At the end of the surgery.iv.tramadol infusion adjusted patient controlled analgesia(PCA).The haemodynamic measurements, functional vital capacity(FVC),rorced expiration volume of 1" min(FEV 1)were recorded preoperative and 2,4,6,12,24 and 48th hours of postoperative periods.

Results: The breathing function tests has better in intrapleural group than the other two group.Intercostal blocks and mterpleural analgesia reduced postoperative tramadol demand. In our study, the intrapleural catheter application+iv.tramadol infusion were found to be superior when evaluating postoperative pain and vital signs.

Conclusion: With the those findings it was concluded that intrapleural analgesia could be good choise for pain relief after thoracotomy.

References: l.Anaesthesiol 1997;22(6): 159-63. 2.Anesth Analg 1998;87(1): 107-11.

PATIENT-CONTROLLED INTRAVENOUS ANALGESIA (PCIA) WITH REMIFENTANIL FOR OOCYTE RETRIEVAL

 Fabienne Roelants MD, Mona Momeni MD, PanagioU Xenitos MD, Patricia Lavand'homme MD, PhD
Anaesthesiology Dept, Universite Catholique de Louvain 1200 Bmssels, Belgium

Aim of investigation: Oocyte retrieval by transvagina puncture is a painful but short lasting procedure for whici various techniques of anesthesia / analgesia have beei reported^]. The ultrashort action of remifentanil (R) makes i an ideal agent for ambulatory patients. This study compare' R PCIA combined with either midazolam (M) or ketaminf (K).

Methods: 42 patients were included. All received an F PCIA pump which was set to deliver boluses of 25 ug ever} 3 minutes. Group M (n=17) received an initial intravenous bolus of M 1.5 mg and group K (n=25) K 0.2 mg/kg. Al patients had 6 L/min oxygen with a facial mask. Total F doses, vital parameters, oxygen saturation (Sp02), adverse drug effects, perioperative sedation score (0-4: alert, sleepy asleep, not arousable), pain scores (VAS 0-100) after th< procedure, satisfaction (score: 0-5) and postoperativf analgesics requirements (post A R) were recorded Statistical analysis used ANOVA; p?0.05 significant.

Results: There was no significant difference betweel patients'parameters. Results are detailed in the Table.

	Group M	Group K	P
n	17	25
Opioids* (ug/kg/min)	0.06±0.03	0.07±0.04	ns
Sedation* ( 0-4)	0.3±0.6	0.34±0.6	ns
Satisfaction* (0-5)	3.1±1.2	3.5±1	ns
VAS* (0-100)	36±22	7.5±12	0.03
Post A R (n patients)	13/17	13/25	<0.05
* mean ± SD

Three patients given K presented hallucinations.

Conclusions: Patients expressed great satisfaction with the PCIA system. Combination of K small bolus increased postoperative comfort and analgesia but induced episodes of hallucination in some patients.

Reference: 1 Anaesthetist 1999 48(10):698-704

CONTINUOUS AND PCEA EPIDURAL INFUSION FOR POST-OPERATIVE PAIN RELIEF IN THORACIC SURGERY

 Sidiropoulou T.. Servetti S., Silvi B., Dauri M., Siglioccolo A., Frisardi R, Pedicelli E., Federici C.
Dept. of Anesthesiology, University of Rome "Tor Vergata", Italy.

Aim of Investigation: To assess the efficacy of continuous and PCEA analgesia on post-operative pain using two different thoracic epidural infusion rates, of ropivacaine and sufentanil, given at doses with minimal adverse effects liability in thoracic surgery patients.

Methods: Eighteen patients (ASA 2-3, mean age 62.7 yrs) were included in the study after written informed consent was obtained. Patients were divided in two groups. In group 1 seven patients received ropivacaine 0.2% plus sufentanil 0.015 ug/kg/h in continuous epidural infusion (CEI) (5 ml/h). In group 2 eleven patients received ropivacaine 0.2% plus sufentanil 0.015 ug/kg/h in CEI (7 ml/h). The duration of infusion was 36 hrs. The two groups were granted PCEA boluses of 5 and 7 ml respectively The lock-out period amounted to 3 hrs. The adequacy of analgesia was assessed by means of the visual analogue scale (VAS) at rest and after coughing at the following postoperative times: Tl:30mm; T2:lhr; T3:2hrs; T4:4hrs: T5:8hrs; T6:18hrs; T7:24hrs.

Results: Mean VAS scores at rest (VAS-R) and after coughing (VAS-C) are reported (see table). The number of boluses administered were similar in both groups. No significant adverse effects (pruritus, PONV, urinary retention, respiratory depression and sedation) were observed in any group.

VAS-R	T1	T2	T3	T4	T5	T6	T7
Group 1	2,16	1,83	2.16	1	2,5	2,16	1
Group 2	2	2,2	2	1,3	1,2	1,66	1,44
VAS-C	T1	T2	T3	T4	T5	T6	T7
Group 1	2,83	3,16	3,5	2,33	3,83	3,5	2,33
Group 2	2,3	3,88	2,7	2	2,1	2,8	2,33

Conclusions: Although adequate analgesia was obtained in all groups, the second group showed a trend for lower VAS scores.

Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 279, 283, 285, 314, 316, 320, 323.