title: Epidemiology and morbidity of regional anesthesia in children: a follow-up one-year prospective survey of the French-Language Society of Paediatric Anaesthesiologists (ADARPEF). The effect of intraoperative thoracic epidural anesthesia and postoperative analgesia on bowel function after colorectal surgery Effects of general and regional anesthesia on the neonate (a prospective, randomized trial). Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Epidural analgesia in colonic surgery: Results of a randomized prospective study Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Anaesthetic technique for elective caesarean section and neurobehavioural status of newborns. Continuous thoracic extradural 0.5% bupivacaine with or without morphine: effect on quality of blockade, lung function and the surgical stress response. Effects of Thoracic Epidural Anesthesia on Systemic Hemodynamic Function and Systemic Oxygen Supply‐Demand Relationship Gastric emptying following Caesarean section and the effect of epidural fentanyl Thoracic epidural versus patient-controlled analgesia in elective bowel resections. Effects of the extradural administration of morphine, or bupivacaine, on the endocrine response to upper abdominal surgery. Spinal and epidural versus general anesthesia for elective Cesarean section at term: effect on the acid–base status of the mother and newborn Major Complications of Regional Anesthesia in France: The SOS Regional Anesthesia Hotline Service Anaesthetic techniques for surgical correction of fractured neck of femur Short-term outcome of newborn infants: spinal versus general anesthesia for elective cesarean section. A prospective randomized study. A Prospective Randomised Trial Comparing Spinal Anaesthesia using Hyperbaric Cinchocaine with General Anaesthesia for Lower Limb Vascular Surgery Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphine. Mental function and morbidity after acute hip surgery during spinal and general anaesthesia Postoperative Analgesia with Intramuscular Morphine at Fixed Rate Versus Epidural Morphine or Sufentanil and Bupivacaine in Patients Undergoing Major Abdominal Surgery Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Postoperative outcome in high‐risk infants undergoing herniorrhaphy: comparison between spinal and general anaesthesia Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study. The effects of epidural anesthesia on the neuroendocrine response to major surgical stress: a randomized prospective trial. [Patient-controlled postoperative analgesia in orthopedic surgery: epidural PCA versus intravenous PCA]. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Patient-controlled extradural analgesia with bupivacaine, fentanyl, or a mixture of both, after Caesarean section. General anaesthesia versus epidural anaesthesia for primary caesarean section--a comparative study. Prospective, Randomized Trial Comparing General with Spinal Anesthesia for Cesarean Delivery in Preeclamptic Patients with a Nonreassuring Fetal Heart Trace Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty? [Postoperative delirium after general anesthesia vs. spinal anesthesia in geriatric patients]. Postoperative Epidural Morphine, but not Epidural Bupivacaine, Delays Gastric Emptying on the First Day after Cholecystectomy [Patient-controlled analgesia versus epidural analgesia using bupivacaine or morphine following major abdominal surgery. No difference in postoperative morbidity]. Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery Postoperative Apnea, Bradycardia, and Oxygen Desaturation in Formerly Premature Infants: Prospective Comparison of Spinal and General Anesthesia Epidural infusions of bupivacaine and fentanyl do not improve rehabilitation following one-stage bilateral total knee arthroplasty. Post-operative recovery after inguinal herniotomy in ex-premature infants: comparison between sevoflurane and spinal anaesthesia. What Concentration of Sufentanil Should be Combined with Ropivacaine 0.2% wt/vol for Postoperative Patient-Controlled Epidural Analgesia? Epidural Anesthesia and Analgesia in High‐risk Surgical Patients Ropivacaine epidural anesthesia and analgesia versus general anesthesia and intravenous patient-controlled analgesia with morphine in the perioperative management of hip replacement. Ropivacaine Hip Replacement Multicenter Study Group. The effect of balanced analgesia on early convalescence after major orthopaedic surgery Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy Extradural and parenteral pethidine as analgesia after total hip replacement: Effects and kinetics. A controlled clinical study Thoracolumbar epidural anaesthesia and isoflurane to prevent hypertension and tachycardia in patients undergoing abdominal aortic surgery. Epidural tramadol for postoperative pain relief Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients. Effects of Perioperative Analgesic Technique on Rate of Recovery after Colon Surgery [The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs]. Postoperative apnea in former preterm infants: prospective comparison of spinal and general anesthesia. Caudal block for postoperative analgesia in children Randomized Comparison of General and Regional Anesthesia for Cesarean Delivery in Pregnancies Complicated by Severe Preeclampsia Perioperative ischaemia in aortic surgery: combined epidural/ general anaesthesia and epidural analgesia vs general anaesthesia andiv analgesia Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia Postoperative pain and pulmonary complications: Comparison of three analgesic regimens The effect of delivery on umbilical arterial cord blood gases and lipid peroxides: comparison of vaginal delivery and cesarean section. [Changes in dementia rating scale scores of elderly patients with femoral neck fracture during perioperative period]. Reducing Perioperative Blood Loss in Patients Undergoing Total Hip Arthroplasty Comparison of general and epidural anesthesia in elective cesarean section for placenta previa totalis: maternal hemodynamics, blood loss and neonatal outcome. The effect of bupivacaine and morphine on pain and bowel function after colonic surgery Preoperative and Postoperative Oxygen Saturation in the Elderly following Spinal or General Anaesthesia—An Audit of Current Practice Double-masked Randomized Trial Comparing Alternate Combinations of Intraoperative Anesthesia and Postoperative Analgesia in Abdominal Aortic Surgery Anaesthetic techniques for surgical correction of fractured neck of femur. A comparative study of ketamine and relaxant anaesthesia in elderly women. Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery Comparison of Neonatal Effects of Epidural and General Anesthesia for Cesarean Section The effect of anaesthesia on changes in blood pressure and plasma cortisol levels induced by cementation with methylmethacrylate A prospective randomized comparison of epidural infusion of fentanyl and intravenous administration of morphine by patient-controlled analgesia after radical retropubic prostatectomy. Comparison of general and regional anesthesia for cesarean section: success rate, blood loss and satisfaction from a randomized trial. Thoracic epidural infusion for postoperative pain relief following abdominal aortic surgery: bupivacaine, fentanyl or a mixture of both? Epidural Infusion of Bupivacaine 0.0625% plus Fentanyl 3.3 μg/ml Provides Better Postoperative Analgesia than Patient-Controlled Analgesia with Intravenous Morphine after Gynaecological Laparotomy Thoracic epidural analgesia compared with patient controlled intravenous morphine after upper abdominal surgery Myoelectric activity in the stomach and duodenum after epidural administration of morphine or bupivacaine [Postoperative course and endocrine stress reaction of geriatric patients with para-articular hip fractures. Prospective randomized study comparing spinal anesthesia and halothane intubation narcosis]. Anaesthesia for surgical correction of fractured femoral neck A comparison of three techniques Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Postoperative Confusion after Anesthesia in Elderly Patients with Femoral Neck Fractures Continuous epidural infusion of bupivacaine and morphine for postoperative analgesia after hysterectomy Effect of Epidural Anesthesia and Analgesia on Perioperative Outcome: A Randomized, Controlled Veterans Affairs Cooperative Study Is penile block better than caudal epidural block for postcircumcision analgesia? A comparison between local anaesthetic dorsal nerve block and caudal bupivacaine with ketamine for paediatric circumcision. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. Combined Epidural and General Anaesthesia versus General Anaesthesia for Abdominal Aortic Surgery: A Prospective Randomised Trial Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia Effects of Intravenous Patient-Controlled Analgesia with Morphine, Continuous Epidural Analgesia, and Continuous Three-in-One Block on Postoperative Pain and Knee Rehabilitation After Unilateral Total Knee Arthroplasty [Effect of continuous postoperative analgesia with peridural bupivacaine on intestinal motility following colorectal resection]. Epidural Bupivacaine-Morphine Analgesia versus Patient-controlled Analgesia following Abdominal Aortic Surgery: Analgesic, Respiratory, and Myocardial Effects Postoperative analgesia after circumcision in children. Ketoprofen for pain after hip and knee arthroplasty. Postoperative analgesia for Caesarean section using epidural methadone
abstract: BACKGROUND The French- Language Society of Paediatric Anaesthesiologists ( ADARPEF ) design ed a 1-year prospect i ve , multicenter and anonymous study to up date both epidemiology and morbidity of  regional anesthesia in children . METHODS From November 2005 to October 2006 , data from participating hospitals were recorded using an identification form , a data recording form , and a complication form . Information collected included the characteristics of the hospitals , the number and type of regional anesthetics ( RA ) , the age of the involved children as well as the incidence , and type of complications . RESULTS Data collected in 47 institutions included 104,612 pure general anesthesias ( GAs ) , 29,870 GAs associated with regional blocks , and 1262 pure regional blocks .  Central blocks accounted for 34 % of all RA . Peripheral blocks ( 66 % ) were upper or lower limb blocks ( 29 % of peripheral blocks ) , trunk blocks , and face blocks ( 71 % ) . In children aged ≤3 years , the percentage of central blocks was similar to the peripheral ones ( 45 % vs 55 ) , while in older children , peripheral blocks were more than four times used than central ones . Complications ( 41 involving 40 patients ) were rare and usually minor . They did not result in any sequelae . The study revealed an overall rate of complication of 0.12 % ; CI 95 % [ 0.09 - 0.17 ] , significantly six times higher for central than for peripheral blocks . CONCLUSIONS As a result of the low rate of complications , RA techniques have a good safety profile and can be used to provide postoperative analgesia . In addition , the results should encourage anesthesiologists to continue to use peripheral instead of central ( including caudal ) blocks as often as possible when appropriate PURPOSE : Colorectal surgery is associated with postoperative ileus , which contributes to delayed discharge . This study was design ed to investigate the effect of thoracic epidural anesthesia and analgesia on gastrointestinal function after colorectal surgery under st and ardized controlled postoperative care . METHODS : Forty-two patients diagnosed with either colonic cancer , diverticulitis , polyps , or adenoma , and scheduled for elective colorectal surgery , were r and omly assigned to either postoperative patient-controlled analgesia ( PCA ) with intravenous morphine ( n=21 ) or epidural analgesia with a mixture of bupivacaine and fentanyl ( n=21 ) . Postoperative early oral feeding and assistance to mobilization were offered to all patients . Pain visual analog scale ( 1–100 mm ) , passage of flatus and bowel movements , length of hospital stay , and readiness for discharge were recorded . RESULTS : Pain visual analog scale ( visual analog scale , 1–100 mm ) at rest , on coughing , and daily on mobilization was significantly lower in the epidural group compared with the patient-controlled analgesia group . Median values for the visual analog scale group were 7 ( 95 percent confidence interval , 2–18 ) mm , 19 ( 95 percent confidence interval , 4–38 ) mm , and 10 ( 95 percent confidence interval , 5–33 ) mm , respectively , and , for the patient-controlled analgesia group , were 24 ( 95 percent confidence interval , 18–51 ) mm , 59 ( 95 percent confidence interval , 33–74 ) mm , and 40 ( 95 percent confidence interval , 29–79 ) mm , respectively ( P<0.01 ) . Intake of protein and calories and time out of bed were similar in both groups . Mean time intervals ± st and ard deviation from surgery to first flatus and first bowel movement occurred earlier in the epidural group , 1.9±0.6 days and 3.1±1.7 days , respectively , compared with patient-controlled analgesia , 3.6±1.5 days and 4.6 ± 1.6 days , respectively ( P<0.01 ) . Postoperative complications occurred in 33 percent of the patient-controlled analgesia group and 28 percent of the epidural group . There was no significant difference in length of hospital stay between the two groups with a mean of 7.3±3.7 days in the patient-controlled analgesia group and 8.5±4.2 days in the epidural group . Readiness for discharge was similar in both groups . CONCLUSION : Thoracic epidural analgesia has distinct advantages over patient-controlled analgesia morphine in providing superior quality of analgesia and shortening the duration of postoperative ileus . However , discharge home was not faster , indicating that other perioperative factors influence the length of hospital stay UNLABELLED Anesthetic methods used during cesarean section have advantages and disadvantages to both mothers and infants and may result in short and long term neonatal effects . OBJECTIVE To determine the effects of general and regional anesthesia on the infants , a prospect i ve , r and omized trial was performed in Siriraj Hospital , Mahidol University . MATERIAL AND METHOD 341 uncomplicated pregnant women who were to be delivered at term by Cesarean section were recruited and r and omized to receive general anesthesia , GA ( 103 ) ; epidural anesthesia , EA ( 120 ) and spinal anesthesia , SA ( 118 ) . The immediate fetal and neonatal effects were assessed by cord blood gas analysis and the infant 's Apgar scores . The Neurologic and Adaptive Capacity Scores ( NACS ) was performed within 4 hours after birth by two pediatricians who were blind to the anesthetic method . RESULT Maternal age , weight , height , duration of the operation and infants ' birth weight were not different among the study groups . In the EA and SA group , maternal systolic blood pressure decreased more than 20 per cent from the baseline in more than half . The infants ' Apgar scores at 1 and 5 minutes were 8.3 + /- 1.9 ; 8.2 + /- 1.6 ; 6.7 + /- 2.8 , and 9.7 + /- 0.9 ; 9.8 + /- 0.7 ; 9.2 + /- 1.6 in EA , SA and GA group respectively . The adaptive capacity , active tone , passive tone , general assessment and primary reflexes of the NACS were not statistically different . CONCLUSION Apgar scores of the infants whose mothers received general anesthesia were lower than infants whose mothers received regional anesthesia but the NACS were not statistically different among the three study groups The actual incidence of neurologic dysfunction result ing from hemorrhagic complications associated with neuraxial blockade is unknown . Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics , recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient population s. Overall , the risk of clinical ly significant bleeding increase with age , associated abnormalities of the spinal cord or vertebral column , the presence of an underlying coagulopathy , difficulty during needle placement , and an indwelling neuraxial catheter during sustained anticoagulation ( particularly with st and ard heparin or low-molecular weight heparin ) . The need for prompt diagnosis and intervention to optimize is also consistently reported . In response to these patient safety issues , the American Society of Regional Anesthesia and Pain Medicine ( ASRA ) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation . Practice guidelines or recommendations summarize evidence -based review s. However , the rarity of spinal hematoma defies a prospect i ve r and omized study , and there is no current laboratory model . As a result , the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation . These are based on case reports , clinical series , pharmacology , hematology , and risk factors for surgical bleeding . An underst and ing of the complexity of this issue is essential to patient management Colonic surgery patients were studied to measure : the influence of continuous thoracic epidural analgesia ( TEA ) on a postoperative pain score , the time till onset of defaecation , blood loss , postoperative temperature elevations , rate of bacterial contamination of wounds and urine , and general surgical complications .  Group I patients ( n = 57 ) received general anaesthesia and TEA for the operation , followed by continuous TEA ( 0·25 per cent bupivacaine ) for 72 h.  Group II patients ( n = 59 ) received general anaesthesia for the operation , followed by systemic analgesia on request . Significant beneficial effects of TEA in group I were demonstrated by lower pain scores in the first 24 h after surgery and earlier defaecation . However , there were fewer temperature elevations in group II . There was no significant difference between the groups in terms of positive bacteriological cultures , blood loss , need for postoperative mechanical ventilation and complications . However , there was a trend toward a higher rate of rectal anastomotic breakdown , increased blood replacement and intensive care therapy , and longer hospitalization in group I. These results do not suggest any significant beneficial therapeutic effect of continuous TEA in colonic surgery compared with a conventional systemic analgesic regimen . In selected patients ( i.e. those with severe pain or those prone to develop postoperative ileus ) continuous TEA may be beneficial We have studied the effect of extradural analgesia on postoperative venous thrombosis in patients undergoing knee arthroplasty . Forty-eight patients were allocated r and omly to receive either general anaesthesia or extradural analgesia with local anaesthetics for 3 days . All patients wore compressive elastic stockings and no anticoagulant drugs were administered . Bilateral venography was performed 10 days after surgery . Continuous extradural analgesia did not impede mobilization of the patients . One case of nonfatal pulmonary embolism occurred in a patient who received general anaesthesia . The use of continuous extradural analgesia result ed in a significant difference in the total incidence of deep vein thrombosis ( 18 % compared with 59 % after general anaesthesia ( P = 0.02 ] . The incidence of calf vein thrombosis was 12 % compared with 45 % after general anaesthesia ( P = 0.05 ) Ninety healthy parturients undergoing elective caesarean section were r and omly allocated to receive either general ( n = 30 ) , epidural ( n = 30 ) or spinal ( n = 30 ) anaesthesia .  Acid-base status , Apgar score and neurobehavioural status , using the neurologic and adaptive capacity scoring ( NACS ) system , were studied in the newborn . Apgar scores and acid-base parameters were similar in all the three groups . NACS testing revealed significantly more vigorous babies in the spinal anaesthesia group than in the other two groups at 15 min and 2 h interval after delivery , despite a higher incidence of maternal hypotension . We conclude that newborns tend to have a better neurobehavioural status in the early post-delivery period if their mothers receive spinal anaesthesia rather than general or epidural anaesthesia for caesarean section Twenty-two patients undergoing upper abdominal surgery were entered into a r and omized , double-blind study to receive extradural ( T7-T8 ) 0.5 % bupivacaine 9 ml followed by 25 mg h-1 with or without additional extradural morphine ( bolus 4 mg plus 0.5 mg h-1 ) , for 16 h after operation . Addition of morphine was associated with total alleviation of pain , and a stable level of sensory analgesia , but not with changes in blood glucose and cortisol concentrations or postoperative impairment of lung function ( PEFR , FEV1 , FVC ) .  Two patients were withdrawn because of hypotension or respiratory depression The effects of thoracic epidural anesthesia ( TEA ) on total body oxygen supply-dem and ratio are complex due to potential influences on both O2 delivery ( & OV0422;O2 ) and consumption ( & OV0312;O2 ) . One hundred and five patients undergoing abdominal aortic surgery were r and omly assigned to one of three groups to compare the cardiovascular and metabolic responses associated with ( 1 ) thoracic epidural anesthesia plus light general anesthesia ( group TEA ) ; ( 2 ) general anesthesia with halothane ( group H ) ; and ( 3 ) neuroleptanalgesia ( group NLA ) . Values of cardiac index ( CI ) and & OV0422;O2 were less intra operatively in the TEA group than in the H or NLA groups , while & OV0312;O2 values were similar . & OV0312;O2 during recovery was greater in both the TEA and NLA groups than in the H group . Consequently the oxygen supply-dem and ratio ( & OV0422;O2/&OV0312;O2 ) was less in the TEA group throughout the perioperative period and about 30 % below baseline values during early recovery . At comparable & OV0312;O2 , CI and mixed venous O2 saturation were always less in the TEA group than in the NLA group . Heart rate was slowest intra operatively during TEA , and stroke work was less with TEA than with NLA . As cardiac filling pressure and systemic vascular resistance did not differ among the three groups , reduced adaptation of CI to tissue O2 needs during TEA was attributed to negative inotropic and chronotropic effects of the sympathetic blockade . We conclude that in patients undergoing abdominal aortic surgery , TEA has no apparent advantage over general anesthesia The rate of absorption of  paracetamol following oral administration was used as an indirect measure of the rate of gastric emptying . This was to determine the effect on gastric motility of the addition of fentanyl to a solution of local anaesthetic given into the epidural space to provide pain relief following Caesarean section . Thirty subjects were r and omly allocated to receive either  bupivacaine plus fentanyl or bupivacaine alone . The area under the curve of the graph of plasma paracetamol concentration versus time was calculated for each subject at 45 and 90 minutes after administration of the epidural injection , and this value was used as an index of the rate of gastric emptying . This study demonstrated that gastric emptying may be normal immediately following Caesarean section under epidural anaesthesia , but that if fentanyl is added to the epidural solution , gastric emptying is significantly slower in the first 45 minutes following surgery ( p < 0.05 ) BACKGROUND This study was undertaken to determine if thoracic epidural analgesia is of practical benefit after bowel resection . METHODS Patients were prospect ively r and omized to receive either a  thoracic epidural or patient-controlled analgesia for pain control after bowel resection . A st and ardized postoperative protocol was instituted after surgery . RESULTS Pain scores were significantly lower in the epidural group . Return of bowel function , and interval to discharge was not different between groups . Cost and complication rates were significantly higher in the epidural group . CONCLUSIONS Although pain scores were significantly lower in the epidural group , this did not translate into a quicker return of bowel function or earlier discharge of the patient . Furthermore , the epidural group had a significantly higher complication rate and cost . Therefore , while thoracic epidural analgesia provides superior pain control , it does not offer a significant advantage over patient-controlled analgesia in return of bowel function after bowel resection The endocrine response , and the relief of pain , following the extradural administration of morphine or a local anaesthetic agent bupivacaine ( 0.5 % ) were studied for 24h after abdominal surgery  and compared with a control group given conventional i.v . morphine after operation . Sample s were taken before and at 2 , 4 , 6 , 12 and 24 h after skin incision . Pain relief in both extradural groups was significantly better when compared with the control group . In all three groups , the plasma concentration of cortisol was increased immediately after surgery . Thereafter , significantly lower values were seen in the extradural groups . Plasma adrenaline concentration was lower immediately after surgery only in the group given the extradural local anaesthetic . Plasma noradrenaline concentration remained unchanged after extradural local anaesthesia while an intermediate increase occurred after extradural morphine .  Plasma noradrenaline concentration was significantly greater in the controls compared with both extradural groups . Our results indicate that extradural analgesia with a local anaesthetic drug can suppress the increases in the plasma concentrations of the catecholamines and cortisol after surgery . In contrast to extradural local anaesthetic extradural morphine can not suppress the endocrine response immediately after surgery . However , later in the postoperative period , extradural morphine can suppress the endocrine response , thus indicating that postoperative pain is a factor involved in the stress response following surgery Objective : To compare general , epidural and combined spinal-epidural anesthesia with respect to short-term outcome of newborns delivered by elective Cesarean section of healthy parturients with normal pregnancies . Study design : A total of 238 eight pregnant women admitted to our institution between January 1998 and July 2002 , for whom elective Cesarean section was planned after 38 weeks ' gestation , were grouped according to the kind of anesthesia used for the procedure . Maternal characteristics , birth weight , Apgar scores , and maternal and umbilical artery ( UA ) acid-base parameters were analyzed . Results : Maternal pH was significantly lower and pCO2 and pO2 were significantly higher in the general anesthetic group , compared to the other two groups ( 7.38 ± 0.03 vs. 7.43 ± 0.02 and 7.43 ± 0.05 , respectively ; 35.03 ± 3.88 mmHg vs. 29.25 ± 5.05 mmHg and 29.64 ± 4.16 mmHg , respectively ; and 224.56 ± 86.77 mmHg vs. 151.28 ± 38 mmHg and 157.36 ± 53.51 mmHg , respectively , p < 0.05 ) . The pH of the UA was higher in the general anesthetic group , compared to the spinal-epidural group ( 7.29 ± 0.02 vs. 7.26 ± 0.06 , p < 0.05 ) . The pO2 as well as O2 saturation of the UA were higher when general anesthetic was administered , compared to the two regional modalities ( 15.60 ± 5.48 mmHg vs. 9.29 ± 4.41 mmHg and 9.20 ± 4.06 mmHg , respectively ; and 17.37 ± 9.79 % vs. 7.87 ± 4.98 % and 6.90 ± 5.22 % , respectively , p < 0.05 ) . UA O2 saturation fell to zero in some cases in the combined spinal-epidural group , without an evident effect on fetal well-being . No fetal acidemia was noted in any group . Neonatal outcomes were similar in the three groups studied . Conclusions : Type of anesthesia does not influence short-term outcomes in infants born via elective Cesarean section , although differences in acid-base status of both the mother and especially the newborn recommend careful use of spinal anesthesia Background Several previous surveys have estimated the rate of major complications that occur after regional anesthesia . However , because of the increase in the use of regional anesthesia in recent years and because of the introduction of new techniques , re appraisal of the incidence and the characteristics of major complications is useful . Methods All French anesthesiologists were invited to participate in this 10-month prospect i ve survey based on ( 1 ) voluntary reporting of major complications related to regional anesthesia occurring during the study period using a telephone hotline service available 24 h a day and managed by three experts , and ( 2 ) voluntary reporting of the number and type of regional anesthesia procedures performed using pocket booklets . The service was free of charge for participants . Results The participants ( n = 487 ) reported 56 major complications in 158,083 regional anesthesia procedures performed ( 3.5/10,000 ) . Four deaths were reported . Cardiac arrest occurred after spinal anesthesia ( n = 10 ; 2.7/10,000 ) and posterior lumbar plexus block ( n = 1 ; 80/10,000 ) . Systemic local anesthetic toxicity consisted of seizures only , without cardiac toxicity .  Lidocaine spinal anesthesia was associated with more neurologic complications than bupivacaine spinal anesthesia ( 14.4/10,000 vs. 2.2/10,000 ) . Most neurologic complications were transient . Among 12 that occurred after peripheral nerve blocks , 9 occurred in patients in whom a nerve stimulator had been used . Conclusion This prospect i ve survey based on a free hotline permanent telephone service allowed us to estimate the incidence of major complications related to regional anesthesia and to provide a detailed analysis of these complications Fifty-five patients presenting with fractured neck of femur were r and omly allocated to either a st and ard general anaesthetic or spinal block in the lateral position combined with light sedation . The comparability of the two groups was established . There was little difference in the intra-operative course of postoperative morbidity in the two groups . There was a statistically significant difference in post-operative mortality between two groups , the general anaesthetic group showing a much higher mortality than the spinal group OBJECTIVE To compare general and spinal anesthesia with respect to the short-term outcome of newborns born by elective cesarean deliveries . METHODS Pregnant women admitted to our hospital from January 1999 to July 2000 , for whom elective repeat cesareans were planned after 37 weeks gestation , were allocated r and omly after their informed consent to spinal anesthesia or general anesthesia . Maternal age , gestational age , birth weight , Apgar 's score , hospital stay duration , and duration of cesarean section time were all noted . The rate of the neonatal respiratory depression , perinatal asphyxia , and admittance to the neonatal intensive care unit of the infants were documented . We also studied arterial sample s withdrawn from the cord for the pH , bicarbonate , PaO(2 ) ( oxygen pressure , arterial ) , and PaCO(2 ) ( carbon dioxide pressure , arterial ) . The serum levels of creatine kinase with myocardial-specific isoform , aspartate aminotransferase , alanine aminotransferase , and total cortisol levels of the newborns were measured and served in ruling out perinatal stress and in confirming the diagnosis of perinatal asphyxia ( and of myocardial damage ) . Statistical analyses was performed with the use of an unpaired Student 's t-test , Chi-square test , and a power calculation was done . RESULTS From the r and omly selected patients , we had 38 ( 45.2 % ) infants for general anesthesia and 46 ( 54.8 % ) for spinal anesthesia . None of our primary endpoints favored any of the study groups , and the clinical short-term outcome of the infants was similar in the neonates born both by spinal and general anesthesia ( P>0.05 ) . The biochemical assays did not rule out or confirm any differences in the occurrence of perinatal stress ( P>0.05 ) . CONCLUSION Anesthesia type does not seem to influence the short-term outcome of the newborn infants for the elective cesarean deliveries . We believe that both spinal and general anesthesia could be performed in elective term cesarean deliveries without any risk to the newborn infants One hundred and one patients were r and omly allocated to have their peripheral vascular surgery performed under general anaesthesia ( 51 patients ) or spinal anaesthesia ( 50 patients ) .  Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group ( 72 % vs 31 % ) and a higher incidence of hypertension in the general anaesthesia group ( 22 % vs 0 % ) . Blood loss was significantly less in the spinal group ( 560 , SD 340 , ml vs 792 , SD 440 , ml ) . Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia , and one had a myocardial infa rct . Two patients in the spinal group had myocardial infa rcts , both had been treated for bradycardia and hypotension intraoperatively , and one died . There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group ( 33 % vs 16 % ) . There was no significant difference between the groups in the incidence of postoperative confusion , or lower limb amputation rate or need for further surgery prior to hospital discharge Three solutions administered by continuous extradural infusion for postoperative analgesia were compared in a r and omized , double-blind manner . All patients underwent major abdominal gynaecological surgery  and received 0.125 % bupivacaine in 0.9 % saline , diamorphine in 0.9 % saline ( 0.5 mg in 15 ml ) or diamorphine mixed with 0.125 % bupivacaine ( 0.5 mg in 15 ml ) , at a rate of 15 ml h-1 . The bupivacaine-diamorphine mixture provided significantly superior analgesia compared with either bupivacaine or diamorphine alone . No major side effects were encountered Forty elderly patients ( mean age 78.9 years ) undergoing acute surgery for hip fracture were given at r and om either spinal analgesia with bupivacaine 0.75 % or general anaesthesia with diazepam , fentanly and N2O/O2 . Mental function was studied pre‐operatively with an abbreviated mental test and 1 week and 3 months postoperatively in both groups . Mortality and number of complications was similar in the two groups , but a shorter time of ambulation was seen in the spinal group compared to the general anaesthetic group . No persistent impairment in mental function was found after acute hip surgery under spinal or general anaesthesia and the only advantage of regional technique was a shorter time of ambulation We assessed the efficacy and side effects of postoperative analgesia with three different pain regimens in 90 patients undergoing major abdominal surgery . The patients were r and omly assigned to one of three groups : epidural morphine ( EM ) or sufentanil ( ES ) , both combined with bupivacaine , or IM morphine ( IM ) at fixed intervals . Before incision , patients in the epidural groups received sufentanil or morphine in bupivacaine via a thoracic catheter , followed by a continuous infusion 1 h later . General anesthesia consisted of N2 O/O2 and isoflurane for all groups . Patients in all groups received IV sufentanil as part of their anesthetic management . Patients in the IM group received IV sufentanil 1 [ micro sign]g/kg before incision , and patients in all groups received sufentanil 10 [ micro sign]g for inadequate analgesia . Postoperatively , the epidural or IM treatment was continued for > or = to5 days . Postoperative analgesia at rest and during coughing and movement was significantly better in the epidural groups than in the IM group during the 5 consecutive days . There were no significant differences between the epidural groups . The incidence of most side effects was similar in all groups . We conclude that epidural analgesia provided better pain relief than IM analgesia , even if the latter was optimized by fixed-dose administration at fixed intervals and included adjustments on dem and . Epidural sufentanil and morphine , both combined with bupivacaine , seemed to be equally effective with similar side effects . Implication s : Postoperative analgesia with epidural sufentanil or morphine and bupivacaine after major abdominal surgery seemed to be better than the conventional method of IM morphine treatment , despite optimal administration , i.e. , fixed doses at fixed intervals with regular adjustments . Analgesic efficacy and side effects of epidural sufentanil and morphine were similar . ( Anesth Analg 1998;87:1346 - 53 BACKGROUND AND OBJECTIVES This prospect i ve r and omized study was design ed to determine the hemodynamic effects and quality of combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia in the elderly for repair of proximal femoral fractures . METHODS Twenty-nine elderly patients ranging in age from 68 to 97 years were r and omly assigned to 2 groups : a spinal anesthesia group with single-shot 3 mL 0.5 % plain bupivacaine , and a combined block group with 30 mL lidocaine 1.33 % with epinephrine for the posterior lumbar plexus block and 10 mL same mixture for the parasacral block and an iliac crest block with 5 mL lidocaine 1 % . RESULTS No need for general anesthesia was encountered in either group . Anesthesia was judged unsatisfactory in 1 of 15 patients in the combined block group . The initial decrease of mean arterial pressure was 38 % in the spinal group and 27 % in the block group and was not significantly different . A more prolonged hemodynamic effect was found in the spinal group , indicated by the more frequent use of ephedrine to stabilize blood pressure ( P<.05 ) . Patients over 85 years had a significantly larger decrease in blood pressure than younger patients ( P<.01 ) . CONCLUSIONS Plain bupivacaine spinal anesthesia and combined lumbar/sacral plexus block provided adequate anesthesia for repair of hip fracture in the elderly . Hypotension was induced by both the combined peripheral nerve block and plain bupivacaine spinal anesthesia in aged patients ; hypotension was found to be longer lasting after spinal anesthesia and of a larger magnitude in patients over 85 years of age The incidence of inguinal hernia is higher in premature infants , particularly in low birth weight neonates . This latter group may also incur increased postoperative respiratory complications and inpatient admissions . The purpose of this study was to compare the effects of general and spinal anaesthesia on postoperative respiratory morbidity and on the length of hospital stay in high‐risk infants undergoing inguinal herniorrhaphy . Forty patients , all high‐risk infants who underwent unilateral or bilateral herniorrhaphies , were r and omly assigned to receive general anaesthesia ( n = 20 ) or spinal anaesthesia ( n = 20 ) . There was a significant difference in respiratory morbidity between the two groups , as well as a significant difference in the inpatient hospital stay . The present study suggests that spinal anaesthesia can be used safely for high‐risk infants , preterm or formerly preterm , undergoing inguinal hernia repair We performed a prospect i ve , r and omized , double-blind study of continuous epidural analgesia for 72 hours after major abdominal procedures . Patients were r and omly assigned to one of five treatment groups : epidural morphine , epidural bupivacaine , a combination of morphine and bupivacaine , epidural saline solution , and no epidural catheter .  All patients received supplemental morphine sulfate or meperidine hydrochloride , intramuscularly or intravenously , as needed . Epidural infusion was begun at 2 to 4 ml/hr , depending on age and height , with two increments of 1 ml/hr allowed if pain relief was insufficient . All pain management decisions were made by nurses , who also monitored epidural function . Performance was measured four ways : pain as measured at regular intervals in the 72-hour period with a visual analog , pain as measured after 72 hours with the McGill Pain Question naire , amount of supplemental narcotics needed , and recovery of respiratory function and ambulation as percent of preoperative levels . The group that received the combination of morphine and bupivacaine did best on all measures ; in most instances the difference between the results seen with the combination regimen and those seen with saline solution or no catheter were significant at the 0.05 level . With the exception of pruritus , complications were evenly distributed among all treatment groups , including noncatheterized controls . We conclude that epidural analgesia with the combination of morphine and bupivacaine is safe , is easily managed , and gives pain relief superior to that provided by traditional , systemic administration of narcotics It has long been held that the acute-phase and neuroendocrine response to stress requires afferent neural input for its propagation . To further clarify the role of afferent neural impulses in this process and to determine the ability of epidural anesthesia to attenuate the normal perioperative stress response , 39 patients undergoing uncomplicated abdominal aortic replacement were r and omized to receive either general anesthesia with postoperative patient-controlled intravenous morphine ( n = 19 ) or combined regional/general anesthesia with intraoperative epidural catheter anesthesia using Bupivacaine to the T4 dermatome level followed by postoperative epidural morphine ( n = 20 ) . The stress response was quantitated by blinded measurement of baseline and postoperative ( 0 , 12 , 24 , 48 , and 72 hours ) serum cortisol , epinephrine norepinephrine , total catecholamines , interleukin (IL)-1beta , IL-6 , tumor necrosis factor (TNF)-alpha , and C-reactive protein ( CRP ) . Total operative time ( 4.2 + /- 0.3 vs 4.3 + /- 0.4 hours ) , 72-hour fluid requirement ( 7.0 + /- 0.6 vs 6.8 + /- 0.71 mL ) , and length of hospitalization ( 7.8 + /- 1.4 vs 8.1 + /- 1.2 days ) were not different between groups . All patients showed a significant increase in cortisol , epinephrine , norepinephrine , total catecholamines , CRP , and IL-6 in the postoperative period ( P < 0.05 ) . IL-1beta and TNF-alpha were less predictable and undetectable in most patients . There was no difference in any of the stress response indices between those patients receiving patient-controlled or epidural catheter anesthesia . In fact , the only parameter that was predictive of increased activation of the stress response was the length of operation , irrespective of anesthetic method . Those patients with operative times greater than 5 hours ( n = 10 ) developed significantly higher CRP , IL-1beta , IL-6 , and TNF-alpha levels ( P < 0.05 ) at 12 and 24 hours postoperatively than those with total operative times less than 4 hours ( n = 16 ) . The neuroendocrine response to major surgical stress is propagated normally despite epidural blockade and is intensified with prolonged operative times . The inflammatory cytokines appear to play a major role in this process OBJECTIVE To evaluate both effectiveness and incidence of side effects of two techniques of postoperative pain treatment : intravenous and epidural PCA . DESIGN Prospect i ve analysis of data from two groups of r and omized patients . SETTING S Orthopedic and trauma center . PATIENTS Figty ASA class II-III patients undergoing total hip replacement under combined Spinal-Epidural Anesthesia . METHODS Patients were divided into 2 groups who received different postoperative pain treatment . One group ( group PCA ) received a patient-controlled intravenous analgesia with morphine 30 mg and ketorolac 90 mg in 100 ml of saline ( back-ground infusion 2 - 4 ml , according to body weith , bolus 1 ml , lockout 5 min , 4 h dose limit 40 ml ) . PCEA group received a patient-controlled epidural analgesia with morphine 4 mg and bupivacaine 0.125 % 100 ml , ( background infusion 3 - 4 ml , according to patient ' height , bolus 1 ml , lockout 10 min , 4 h dose limit 25 ml ) . Postoperative pain intensity was evaluated , through 24 postoperative hours , by a verbal analogue scale ( VPS = 0 to 3 ) and a total pain score ( TOTPAR ) was calculated for each patient at 6 and 24 postoperative hours . Side effects were recorded and their incidence was obtained for each group . Statistical data analysis was performed by one-way ANOVA and non-parametric tests for ordinal data . Nominal data were analyzed by chi 2 test . p < 0.05 was considered significant . RESULTS Patient receiving PCEA showed a significant ( p < 0.005 ) decrease of incident pain , while VPS at rest was similar in the two groups . TOTPAR VPS was lower ( p < 0.05 ) in PCEA group both at 6 and 24 postoperative hours . Somnolence was observed more often in PCA patients ( 8 % vs 2 % ; p 0.05 ) , while no significant differences were noted among other side effects incidence . CONCLUSIONS Our data show a better control of postoperative pain arising from total hip replacement during PCEA when compared to PCA . It should be emphasized that incident pain is far more decreased by PCEA , so that this technique is particularly indicated when an early postoperative mobilization is required BACKGROUND Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain . The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the duration of convalescence . METHODS Before st and ardized general anesthesia , 56 adult scheduled for major knee surgery were r and omly assigned to one of three groups , each to receive a different postoperative analgesic technique for 72 h : continuous epidural infusion , continuous femoral block , or intravenous patient-controlled morphine ( dose , 1 mg ; lockout interval , 7 min ; maximum dose , 30 mg/4 h ) . The first two techniques were performed using a solution of 1 % lidocaine , 0.03 mg/ml morphine , and 2 microg/ml clonidine administered at 0.1 ml x kg(-1 ) x h(-1 ) . Pain was assessed at rest and during continuous passive motion using a visual analog scale . The early postoperative maximal amplitude of knee flexion was measured during continuous passive motion at 24 h and 48 h and compared with the target levels prescribed by the surgeon . To evaluate functional outcome , the maximal amplitudes were measured again on postoperative day 5 , at hospital discharge ( day 7 ) , and at 1- and 3-month follow-up examinations . When the patients left the surgical ward , they were admitted to a rehabilitation center , where their length of stay depended on prospect ively determined discharge criteria RESULTS The continuous epidural infusion and continuous femoral block groups showed significantly lower visual analog scale scores at rest and during continuous passive motion compared with the patient-controlled morphine group . The early postoperative knee mobilization levels in both continuous epidural infusion and continuous femoral block groups were significantly closer to the target levels prescribed by the surgeon than in the patient-controlled morphine group . On postoperative day 7 , these values were 90 degrees ( 60 - 100 degrees)(median and 25th-75th percentiles ) in the continuous epidural infusion group , 90 degrees ( 60 - 100 degrees ) in the continuous femoral block group , and 80 degrees ( 60 - 100 degrees ) in the patient-controlled morphine group ( P < 0.05 ) . The duration s of stay in the rehabilitation center were significantly shorter : 37 days ( range , 30 - 45 days ) in the continuous epidural infusion group , 40 days ( range , 31 - 60 days ) in the continuous femoral block group , and 50 days ( range , 30 - 80 days ) in the patient-controlled morphine group ( P < 0.05 ) . Side effects were encountered more frequently in the continuous epidural infusion group . CONCLUSION Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion , thereby hastening convalescence In this r and omized , double-blind study of 60 patients , we have assessed the analgesic efficacy of extradural bupivacaine and extradural fentanyl , either alone or in combination , after Caesarean section . Patients received 0.1 % bupivacaine ( group B ) , fentanyl 4 micrograms ml-1 ( group F ) or 0.05 % bupivacaine combined with fentanyl 2 micrograms ml-1 ( group BF ) by patient-controlled extradural analgesia ( PCEA ) . Adding fentanyl to bupivacaine reduced the dose of bupivacaine by up to 68 % , improved analgesia at rest and decreased PCEA use . Motor and sensory block were decreased , but there was more pruritus . Overall patient satisfaction was increased . Adding bupivacaine to fentanyl reduced the dose of fentanyl by up to 57 % without altering pain scores or PCEA use . Sensory block increased but pruritus did not decrease . Bupivacaine 0.05 % produced clinical ly significant leg weakness in three patients . Overall patient satisfaction was not altered . There was a significant additive analgesic effect between 0.05 % bupivacaine and fentanyl but no clinical benefit was demonstrated from using the combination compared with fentanyl alone for this group of postoperative patients Forty-seven healthy parturients undergoing elective Caesarean section were r and omly allocated to either general anaesthesia  ( n = 24 ) or epidural anaesthesia  ( n = 23 ) under st and ardized anaesthetic and surgical conditions . Seven women of the epidural group required additional systemic analgesia or sedation following delivery of the neonate . Nine of 24 newborns obtained 1-min Apgar scores below 7 after general anaesthesia compared to only 3/23 after epidural anaesthesia . The time period to establish normal colour in the babies was 2.2 min after epidural and 4.9 min after general anaesthesia . Three of the 24 general-anaesthesia newborns demonstrated a tendency to hypotonia compared to only one in the epidural group . Twenty-four hours and 7 days after delivery all infants of both groups were completely normal . At the time of delivery maternal PO2 was higher in the general anaesthesia compared to the epidural group , due to higher inspired oxygen concentrations . Comparable results were obtained in umbilical PO2 venous values ; lower pH values , however , were observed in the umbilical artery after general anaesthesia . There were no significant differences in the glucose levels between the groups . A significant correlation was established between uterine incision-delivery interval and 1-min neonatal Apgar scores in the general-anaesthesia group , but not in the epidural group . Our investigation did not show either the incision-delivery interval or the start of operation-delivery interval to play a role in neonatal outcome . Epidural anaesthesia is superior to general anaesthesia in Caesarean section under normal conditions with regard to neonatal outcome . Whether this is also true for critical conditions can not be concluded from this study Background There are no r and omized studies on neonatal outcome after spinal versus general anesthesia for cesarean delivery in preeclamptic patients with a nonreassuring fetal heart trace . This study examined both markers of neonatal hypoxia and maternal hemodynamics . Methods Seventy patients were r and omized to general ( n = 35 ) or spinal anesthesia ( n = 35 ) . The general anesthesia group received thiopentone , magnesium sulfate , and suxamethonium intravenously before intubation , followed by 50 % nitrous oxide in oxygen , 0.75–1.5 % isoflurane , and morphine after delivery . The target end-tidal partial pressure of carbon dioxide ( Pco2 ) was 30–34 mmHg . The spinal anesthesia group received 1.8 ml hyperbaric bupivacaine plus 10 & mgr;g fentanyl at the L3–L4 interspace . Heart rate and blood pressure were measured at specific time points . Hypotension was treated with ephedrine .  Maternal arterial and neonatal umbilical arterial blood gas sample s were taken at delivery . Resuscitation requirements were recorded . Results In both groups , hemodynamic measures remained within acceptable limits . Spinal anesthesia patients required more ephedrine ( 13.7 vs. 2.7 mg ) . Maternal Paco2 was lower in the spinal group ( 28.9 vs. 32.4 mmHg ) . One-minute Apgar scores were lower after general anesthesia . Base deficit was greater ( 7.13 vs. 4.68 mEq/l ) and neonatal umbilical arterial pH was lower ( 7.20 vs. 7.23 ) after spinal anesthesia . Post hoc analysis showed that if maternal diastolic blood pressure on admission was greater than 110 mmHg , neonatal umbilical arterial base deficit was greater after spinal anesthesia . There was no difference in the number of patients with Apgar scores less than 7 at 1 or 5 min or umbilical arterial pH less than 7.2 or in the requirements for resuscitation . Conclusions In preeclamptic patients with a nonreassuring fetal heart trace , spinal anesthesia for cesarean delivery was associated with a greater mean neonatal umbilical arterial base deficit and a lower median umbilical arterial pH. The clinical significance remains to be established . Maternal hemodynamics were similar and acceptable with either anesthetic technique Evidence of pre‐emptive analgetic effect of opioid would offer great potential benefit to patients with postoperative pain , a better pain relief with less opioid . The aim of this double blind r and omised trial was to study the effect of intramuscular morphine premedication on postoperative pain BACKGROUND Influence of the type of anesthesia on postoperative delirium was examined in geriatric patients with femoral neck fracture . METHODS Forty patients aged 70 or more were r and omly allocated to receive either general anesthesia ( sevoflurane , nitrous oxide in oxygen , G group , n = 21 ) or spinal anesthesia ( 0.5 % bupivacaine , S group , n = 19 ) . G group received the oxygen therapy during the 12-hour postoperative period . Postoperative assessment s included the rate of postoperative delirium during the 4-day postoperative period , oxygen saturation during the 18-hour postoperative period , the value of hemoglobin at 1 postoperative day and the number of analgesics requirements during the 4-day postoperative period . RESULTS The rate of postoperative delirium was similar between the two groups during the 4-day postoperative period . However , that of S group tended to be higher during the 1-day postoperative period . Postoperative analgesic effect and the value of hemoglobin at 1 postoperative day were similar between the two groups . Oxygen saturation was similar between the two groups except 6 hours after the operation . CONCLUSIONS The type of anesthesia , general or spinal , does not affect the postoperative delirium in geriatric patients with femoral neck fracture Background and Objectives . Gastric emptying is delayed during the first days after abdominal surgery . Studies with volunteers have shown that epidural morphine delays gastric emptying but epidural analgesia with bupivacaine does not . The aim of this study was to evaluate whether these differences in healthy volunteers are also found after cholecystectomy when epidural morphine or epidural bupivacaine is used for postoperative pain relief . Methods . Eighteen healthy patients were r and omly allocated into two groups . Nine patients received postoperative analgesia with epidural morphine  and nine with  thoracic epidural bupivacaine .  Acetaminophen absorption was used as an indirect measure of the rate of gastric emptying , measured 22 hours after surgery and again 4 weeks later , so that each patient served as their own control . During epidural morphine , serum acetaminophen concentrations were lower , and the area under the concentration time curve from 0 to 60 minutes ( AUC60 ) was smaller ( p < 0.02 ) , the maximum serum acetaminophen concentration ( Cmax ) was lower ( p < 0.05 ) , and the time taken to reach the maximum concentration ( Tmax ) was longer ( p < 0.01 ) compared to epidural bupivacaine . There were no statistically significant differences in AUC60 , Cmax , and Tmax between the two groups during the control study . Conclusions . Postoperative gastric emptying was significantly delayed after epidural analgesia with morphine compared to thoracic epidural bupivacaine . Compared to the control situation , epidural bupivacaine did not influence gastric emptying In 1987 , Yeager et al. reported that intraoperative epidural anesthesia with local anesthetics and postoperative epidural analgesia with opiates diminished postoperative morbidity . In our first clinical trial on this topic , the better postoperative analgesia with epidural bupivacaine-fentanyl failed to improve the outcome after major abdominal operations over that obtained with parenteral piritramide . This r and omized controlled investigation was design ed to assess whether intraoperative epidural anesthesia with bupivacaine plus light general anesthesia and postoperative epidural analgesia with morphine would diminish the overall rate of postoperative complications after major abdominal operations compared with general anesthesia ( without epidural ) followed by patient controlled analgesia with morphine , and with intraoperative epidural anesthesia with bupivacaine and light general anesthesia followed by postoperative bupivacaine-morphine analgesia . METHODS . A total of 292 patients undergoing infrarenal aortic bypass operation , gastric resection , gastrectomy , duodenum-preserving pancreatic resection , Whipple 's operation or cystectomy and neobladder formation were r and omly divided into three groups : 1 . PCA group ( patient controlled analgesia , n = 107 ) : patients were operated on under general anesthesia ( midazolam , fentanyl , N2O/O2 , if necessary with addition of halothane , enflurane or isoflurane ; muscle relaxation with pancuronium bromide ) . Postoperative management consisted in patient-controlled analgesia with morphine ( Prominject ) , bolus 2 mg , lock-out 5 min ( recovery room , intensive care unit ) or 15 min ( surgical ward ) . 2 . EBM group ( epidural bupivacaine+morphine , n = 95 ) : operation under light general anesthesia ( midazolam , low-dose fentanyl , N2O/O2 , pancuronium bromide ) . In addition , a mixture of bupivacaine ( 0.25 % ) and morphine ( 60 micrograms/ml ) was infused ( approximately 0.1 ml/kg.h ) via an epidural catheter during and after the operation ( approximately 72 h ) . 3 . EM group ( epidural morphine , n = 90 ) : operation under the same kind of general-epidural anesthesia as in the EBM group . Postoperatively , epidural injection of morphine ( 0.05 mg/kg in 10 ml of saline ) on request up to the 3rd postoperative day . Quality of analgesia ( at rest and when patients coughed vigorously ) , strength of cough , and rate-pressure product were recorded at 8:00 h , 12:00 noon , 16:00 h and 20:00 h on the 1st , 2nd and 3rd postoperative days . Incidence and intensity of all postoperative complications ( cardiovascular , pulmonary , renal and other organ failure , reoperations , major infection , sepsis , thromboembolism , metabolic and mental disturbances ) were assessed from the day of operation until discharge or death ( n = 10 ) , respectively . RESULTS AND DISCUSSION . In the PCA and EM groups analgesia was equal but of slightly inferior quality compared with the EBM group . The ability to cough was best in the EBM group and significantly worse in the PCA and EM groups , with no difference between the last two . ( ABSTRACT TRUNCATED AT 400 WORDS Background and objective : This prospect i ve , r and omized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery . Methods : Thirty patients ( > 65 yr ) undergoing hip fracture repair were r and omly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5 % ( Group Spinal , n = 15 ) or volatile induction and maintenance anaesthesia with sevoflurane ( Group SEVO , n = 15 ) . General anaesthesia was induced by increasing the inspired concentration to 5 % . A laryngeal mask airway was placed without muscle relaxants , and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability . Hypotension ( decrease in systolic arterial pressure > 20 % from baseline ) , hypertension or bradycardia ( heart rate < 50 beats min−1 ) requiring treatment , and the length of stay in the postanaesthesia care unit was recorded . Cognitive functions were evaluated the previous day , and 1 and 7 days after surgery with the Mini Mental State Examination test . Results : Hypotension occurred in seven patients of Group Spinal ( 46 % ) and in 12 patients of Group SEVO ( 80 % ) ( P = 0.05 ) . Phenylephrine was required to control hypotension in three spinal patients ( 21 % ) and four SEVO patients ( 26 % ) ( n.s . ) . SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction ( P = 0.01 ) . Bradycardia was observed in three SEVO patients ( 22 % ) . Discharge from the postanaesthesia care unit required 15 ( range 5 - 30 ) min in Group Spinal and 55 ( 15 - 80 ) min in Group SEVO ( P = 0.0005 ) . Eight patients in Group Spinal ( 53 % ) and nine patients in Group SEVO ( 60 % ) showed cognitive decline ( Mini Mental State Examination test decreased ⩾ 2 points from baseline ) 24 h after surgery ( n.s . ) . Seven days after surgery , confusion was still present in one patient of Group Spinal ( 6 % ) and in three patients of Group SEVO ( 20 % ) ( n.s . ) . Conclusions : In elderly patients undergoing hemiarthroplasty of the hip , induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia . This technique represents an attractive option when patient refusal , lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia Eighteen formerly premature infants scheduled for inguinal herniorrhaphy and who were less than 51 wk postconceptional age were assigned to either the general anesthesia group ( GA : atropine , halothane , and nitrous oxide ) or the spinal anesthesia group ( SA : hyperbaric tetracaine ) . Twelve-hour , three-channel continuous recordings of respiratory rate ( chest wall impedance ) , electrocardiogram ( ECG ) , and  hemoglobin O2 saturation ( Spo2 ) were obtained preoperatively and after surgery . These were analyzed for short ( 11 - 15 s ) and long ( > 15 s ) apnea spells , periodic breathing , and episodes of hemoglobin oxygen desaturation and bradycardia . Infants in the GA group had lower postoperative minimum Spo2 ( 68.7 % + /- 11.4 % ) and minimum heart rate ( 79 bpm + /- 19 ) than infants in the SA group ( 80.7 % + /- 9.2 % , and 109 bpm + /- 30 , respectively ; P < 0.05 ) and had lower postoperative minimum Spo2 and minimum heart rate than they had preoperatively ( 79.0 % + /- 13.7 % , and 93 bpm + /- 31 , respectively ; P < 0.05 ) ; pre- and postoperative studies in the SA group did not differ . There were no differences in the incidence of postoperative central apnea . We conclude that spinal anesthesia reduces postoperative hemoglobin oxygen desaturation and bradycardia in formerly premature infants undergoing inguinal herniorrhaphy . ( Anesth Analg 1995;80:7 - 13 Epidural analgesia with local anaesthetic minimizes the catabolic response to surgery . To determine whether this could enhance the rate of recovery following orthopaedic surgery , 51 patients undergoing bilateral one-stage total knee arthroplasty were allocated to receive infusions of either continuous epidural bupivacaine/fentanyl or continuous intravenous fentanyl to compare the efficacy of these modes of pain relief on postoperative clinical outcomes and rates of rehabilitation . Infusions were maintained for 36 to 48 hours in a post-anaesthesia care unit ( PACU ) . Postoperatively , pain relief ( visual analogue scale ) , attainment of physical therapy goals and cardiopulmonary complications were measured daily for 7 days . Epidural analgesia with a combination of bupivacaine and fentanyl did not result in any measurable improvement in rehabilitation milestones or reduction in postoperative complications following bilateral total knee arthroplasty than with fentanyl infusions alone We prospect ively studied the post-operative recovery profile of 28 ex-premature infants undergoing inguinal herniotomy . All infants had a post-conceptual age of less than 46 weeks at the time of surgery and were r and omized to receive either sevoflurane ( group 1 , 14 patients ) or spinal anaesthesia ( group 2 , 14 patients ) . All patients received supplemental caudal analgesia before skin incision . Cardiorespiratory function was continuously recorded in all patients before and after surgery . A blinded observer analysed each paired recording for predefined episodes of apnoea , hypoxaemia or bradycardia and the reports were used to compare the two groups . Spinal anaesthesia was attempted unsuccessfully in four patients in group 2 . Five patients in group 1 demonstrated an ' excess ' number of episodes ( median 4 , range 3 - 12 ) of clinical ly silent post-operative cardiorespiratory complications . ( ' Excess ' in our study was defined as a 3-fold or greater increase in the number of post-operative episodes of bradycardia or apnoea relative to pre-operative occurrence ) . Three of these patients had pre-existing abnormal respiratory function and accounted for 80 % of the episodes ( 26/32 ) of post-operative bradycardia and all five episodes of post-operative apnoea identified . All episodes of bradycardia and apnoea were temporally unrelated . None of the remaining patients in group 2 demonstrated an unacceptable number of post-operative cardiorespiratory complications . Our limited study suggests that general anaesthesia with an inhalational agent such as sevoflurane may induce or unmask abnormalities of cardiopulmonary function in predisposed infants . Spinal anaesthesia may be preferable but it is potentially stressful for the infant and associated with a clinical ly significant failure rate In this r and omized double-blinded study , we sought to determine an optimal dose-combination of sufentanil with ropivacaine 0.2 % wt/vol as postoperative epidural analgesics . One hundred twenty patients undergoing major abdominal surgery under general and thoracic epidural anesthesia ( T9 - 11 ) were assigned to groups receiving  patient-controlled epidural analgesia with ropivacaine 0.2 % wt/vol ( R ) , ropivacaine 0.2 % wt/vol + sufentanil 0.5 & mgr;g/mL ( R+S0.5 ) , 0.75 & mgr;g/mL ( R+S0.75 ) , 1.0 & mgr;g/mL ( R+S1 ) . A visual analog score of less than 40 was considered effective , and all side effects were recorded . In r and omized subgroups ( 10 patients per group ) , plasma pharmacokinetic data were obtained for both epidural drugs . Four patients in Group R and two in Group R+S0.5 were excluded because of inadequate analgesia . The drug infusion rates ( range of means : 5.4–5.9 mL/h ) were similar in all patients . Analgesia was superior for sufentanil 0.75 & mgr;g/mL with no further enhancement by the larger sufentanil concentration of 1 & mgr;g/mL.  Sufentanil plasma levels were within the range of the minimal effective concentrations ( highest in R+S1 ) , and there was no covariation between plasma levels and pain relief . Free ropivacaine plasma concentrations remained stable for 96 h. No severe side effects were detected , although pruritus correlated with an increasing dose of sufentanil . We conclude that the combination of ropivacaine 0.2 % wt/vol and 0.75 & mgr;g/mL sufentanil provided the best analgesia with the fewest side effects of the three combinations tested . Implication s : Sufentanil is added to epidural infusions of ropivacaine 0.2 % wt/vol to improve the effectiveness of postoperative pain management . Regarding the risk of side effects , however , it is still unclear what concentration of sufentanil should be added to the local anesthetic . For postoperative thoracic epidural analgesia after major abdominal surgery , the combination of ropivacaine 0.2 % wt/vol and 0.75 & mgr;g/mL sufentanil result ed in an appropriate cost : benefit ratio between good analgesia and side effects The authors conducted a r and omized controlled clinical trial to evaluate the effect of epidural anesthesia and postoperative analgesia ( EAA ) on postoperative morbidity in a group of high-risk surgical patients . A total of 53 patients were admitted to the study , 28 received EAA , and 25 received st and ard anesthetic and analgesic techniques without EAA . Surgical “ risk ” was evaluated preoperatively and found to be comparable in the two groups . When compared to control patients , patients who received EAA had a reduction in the overall postoperative complication rate ( P = 0.002 ) and in the incidence of cardiovascular failure ( P = 0.007 ) and major infectious complications ( P = 0.007 ) . Urinary cortisol excretion , a marker of the stress response , was significantly diminished during the first 24 postoperative hours in the group receiving EAA ( P = 0.025 ) . Finally , hospital costs were significantly reduced for patients who received EAA ( P = 0.02 ) . The authors conclude that EAA exerted a significant beneficial effect on operative outcome in a group of high risk surgical patients UNLABELLED The aim of our study was to compare epidural anesthesia and analgesia ( EDA ) with ropivacaine versus general anesthesia followed by IV patient-controlled analgesia with morphine ( GA/PCA )  after hip replacement regarding pain , side effects , and discharge from the postanesthesia care unit . After ethics committee approval , r and omization , and informed consent , 90 patients were enrolled . In Group EDA , epidural anesthesia ( ropivacaine 10 mg/mL , 15 - 25 mL ) was followed by an epidural infusion ( 2 mg/mL , 4 - 6 mL/h for 24 h , plus top-up doses of 6 - 10 mL for 48 h ) . GA/PCA patients received general anesthesia ( isoflurane/N2O/fentanyl ) followed by IV patient-controlled analgesia with morphine postoperatively .  Pain was assessed by using visual analog scales ( 0 - 100 mm ) at rest and during physiotherapy . Pain at rest was less in the EDA ( n = 43 ) group than in the GA/PCA ( n = 45 ) group ( at 10 h : 11.8+/-12.9 vs. 28.4+/-17.1 [ P < 0.001 ] ; at 24 h : 14.3+/-11.7 vs. 24.0+/-17 [ P<0.01 ] ; in 48 h : 14.3+/-9.3 vs. 21.1+/-17.4 [ P = 0.1 ] ) . Whereas EDA patients were deemed ready for discharge from the postanesthesia care unit earlier than GA/PCA patients ( 5.6+/-8.9 vs. 39.7+/-41.5 min ) , the actual discharge time was comparable . The median time for first passage of flatus was shorter in the EDA group than in the GA/PCA group ( 26 vs. 47 h ) . Nausea and vomiting were more common in the GA/PCA group than in the EDA group ( 16 % vs. 28 % and 11 % vs. 22 % , respectively ) , whereas hypotension ( 11 % vs. 4 % ) and bradycardia ( 14 % vs. 2 % ) were less frequent . Under the conditions of the present study , EDA with ropivacaine provided pain control after hip replacement superior to that provided by IV patient-controlled analgesia with morphine , particularly during the first 24 h. Both approaches to pain management were equally safe . IMPLICATION S Compared with general anesthesia and postoperative IV patient-controlled analgesia with morphine , epidural anesthesia and analgesia with the new local anesthetic ropivacaine enables patients to be discharged sooner from a postanesthesia care unit and provides superior pain relief during the first 24 h after hip replacement Forty – two patients scheduled for total knee arthroplasty ( n = 20 ) or hip arthroplasty ( n = 22 ) were r and omly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam , or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen .  Patients undergoing knee– or hip arthroplasty treated with epidural analgesia  had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment , while no important differences were observed after cessation of the epidural regimen . However , the achieved pain relief had no impact on postoperative convalescence parameters , such as ambulation , patient activity including need for nursing care , fatigue or hospital stay . Late postoperative pain , fatigue and conservative attitudes and routines in the postoperative care , were the most important reasons limiting mobilization and activity . We conclude that effective early ( 48 h ) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on  bowel function after abdominal hysterectomy . The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces . Twenty – two patients were r and omly allocated to two equal groups . An “ epidural morphine ” group received general anesthesia and epidural morphine for postoperative pain relief , and an “ epidural bupivacaine ” group was given combined general anesthesia and epidural anesthesia with 0.5 % bupivacaine intraoperatively and epidural analgesia with 0.25 % bupivacaine postoperatively . Epidural morphine or bupivacaine was given for 42 h postoperatively . Pain intensity ( visual analog scale ) was low in both groups , but lower ( P < 0.05 ) in the epidural bupivacaine group . The time to first passage of flatus was 22 16 h in the epidural bupivacaine group and 56 22 h in the epidural morphine group ( P < 0.001 ) . The time to first postoperative passage of feces was shorter ( P < 0.05 ) in the former than in the latter ( 57 44 h vs 92 22 h ) . The patients of the epidural bupivacaine group started intake of oral fluids earlier ( P<0.01 ) and to a greater extent ( P < 0.05 ) than those in the epidural morphine group . It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine Summary Twenty-one patients who had undergone total hip replacement were r and omly assigned to one of three groups in order to compare a single dose of 1 mg/kg of pethidine i m ( I ) and 20 mg ( II ) or 60 mg of extradural pethidine ( III ) in a double-blind design .The degree of analgesia , the adverse effects , and the kinetics were studied for 18 h. Pain was monitored using a visual analogue scale ( VAS ) . Supplementary doses of oxycodone if required were given no earlier than 0.75 h after pethidine . Plasma concentrations of pethidine  were measured with gas chromatography mass spectrometry ( GCMS ) . Hypoalgesia to pin prick test was evaluated . Low pain scores were observed in the extradural groups between 0.25 and 1.5 h after the dose . A significant difference in pain score compared with the i m group was found after the higher extradural dose only between 0.5 and 1 h (p<0.05).The area under the curve ( AUC ) of pain score versus time ( 0–18 h ) was not significantly different between groups . The recorded adverse effects were minor in all three groups . The terminal half-lives and plasma clearances of pethidine , and the time to peak concentration were not different between the groups . Single patients in the extradural groups showed hypoalgesia to pin prick in parallel to the effect . The present study shows that extradural pethidine produces shortlived analgesia , in contrast to the long-lasting effect of morphine found in other studies Cardiovascular and hormonal responses to reconstructive abdominal aortic surgery were studied in 20 patients anaesthetized either with moderate-dose fentanyl ( 20 micrograms kg-1 ) combined with isoflurane , nitrous oxide and oxygen ( n = 10 ) , or with thoracolumbar epidural bupivacaine combined with isoflurane , nitrous oxide and oxygen ( n = 10 ) . After the start of operation , hypotension occurred in four patients in the epidural group . In both groups , the aortic cross-clamping caused slight increases both in mean arterial pressure and in calculated systemic vascular resistance , and a significant decrease in cardiac index . At the same time , a marked increase in plasma vasopressin was seen in the fentanyl group . Plasma catecholamines were low in both groups . After aortic declamping , the cardiac index improved in both groups , although two patients in the fentanyl group and four patients in the epidural group were hypotensive . Post-operatively , eight patients in the fentanyl group were hypertensive , versus none in the epidural group , in which bupivacaine-fentanyl was administered epidurally . At the same time , plasma vasopressin and adrenaline increased significantly in both groups , whereas plasma noradrenaline did so only in the fentanyl group . The results suggest that thoracolumbar epidural bupivacaine combined with low-dose isoflurane in nitrous-oxide-oxygen prevents intra-operative hypertension and tachycardia , but it may cause hypotension . Post-operative hypertension and tachycardia as well as the increase in plasma noradrenaline are prevented by epidural administration of bupivacaine-fentanyl The efficacy of epidurally administered tramadol hydrochloride , a weak central ly acting analgesic , was studied for the relief of postoperative pain . Sixty patients undergoing abdominal surgery were r and omly allocated to three treatment groups to be given the following agents by the epidural route : group 1 tramadol 50 mg ; group 2 tramadol 100 mg ; group 3 10 ml of bupivacaine 0.25 % . The drugs were administered at the patients ' request with each patient being allowed four doses in the first 24 h following surgery . Blood pressure , pulse rate , respiratory rate , arterial blood gas analyses , pain scores , the interval between doses and the occurrence of any side effects were recorded . Pain scores ( assessed using a visual analogue scale ) were significantly less ( p < 0.05 ) at 3 , 12 , and 24 h in patients receiving tramadol 100 mg than in those receiving tramadol 50 mg or bupivacaine . The mean interval between doses for groups 1 , 2 and 3 was 7.40 h , 9.36 h and 5.98 h respectively . The mean interval in group 2 was significantly longer than in group 3 ( p < 0.05 ) . The incidence of nausea and vomiting in group 2 was significantly higher than in group 3 ( p < 0.05 ) In a primary analysis of a large recently completed r and omized trial in 915 high-risk patients undergoing major abdominal surgery , we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids  , apart from the incidence of respiratory failure . Therefore , we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia . We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery , nor in a subgroup with failed epidural block ( all P > 0.05 ) . There was a small reduction in the duration of postoperative ventilation ( geometric mean [ SD ] : control group , 0.3 [ 6.5 ] h , versus epidural group , 0.2 [ 4.8 ] h ; P = 0.048 ) . No differences were found in length of stay in intensive care or in the hospital . There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial . We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery Background Choice of perioperative analgesia may affect the rate of recovery of gastrointestinal function and thus duration and cost of hospitalization after colonic surgery UNLABELLED Influence of anesthetic technique on mental status in elderly patients su bmi tted to major orthopedic procedures of lower limbs . Mental impairment is a common occurrence in elderly patients after major orthopedic surgery . Few studies have been published so far on this topic in spite of its relevant clinical and economic implication s. OBJECTIVE 1 ) To verify whether anesthesia has a causative role in postoperative mental confusion in elderly patients ; 2 ) to compare the effects of General Anesthesia ( GA ) and Spinal Anesthesia ( SA ) on mental status . DESIGN Controlled , comparative study . PATIENTS Sixty patients aged > or = 70 , ASA I-II , su bmi tted to femoral neck repair . SETTING Anesthesia Dept . and Orthopedic Dept . of a District Hospital in Italy . METHOD The day before surgery the mental status of elected patients was evaluated employing a modified Organic Brain Syndrome ( OBS ) scale ( Gustafsson ) . The better the mental status , the lesser the OBS score . It was possible therefore to distinguish " oriented " from " confuse " patients ( 38 vs 22 ) if they scored < or = 6 or > 6 respectively . Patients from each group were than r and omly assigned to receive either GA or selective SA . Neither group was premedicated . GA was induced with propofol 1 mg/kg and maintained with O2/N2O 40/60 % and isoflurane ; atracurium was employed to facilitate mioresolution . Spinal anesthesia was performed with hyperbaric 1 % bupivacaine . All patients were monitored in the Recovery Room ( RR ) for at least one hour . Occurrence of hypotension and /or hypoxia in the Operating Room ( OR ) or the RR was immediately treated . Mental status was reassessed on the 1st and 2nd postoperative day and results were compared with the corresponding preoperative OBS scores both in GA patients and in SA patients . RESULTS No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group , whether " oriented " or " confuse " . CONCLUSIONS Mental status of elderly patients su bmi tted to femoral neck repair does n't seem to be influenced by the anesthetic technique chosen , independent of preoperative psychic conditions Thirty-six former preterm infants undergoing inguinal hernia repair were studied . All were less than or equal to 51 weeks postconceptual age at the time of operation . Patients were r and omly assigned to receive general or spinal anesthesia . Group 1 patients received general inhalational anesthesia with neuromuscular blockade . Group 2 patients received spinal anesthesia using 1 % tetracaine 0.4 - 0.6 mg/kg in conjunction with an equal volume of 10 % dextrose and 0.02 ml epinephrine 1:1000 . In the first part of the study , infants r and omized to receive spinal anesthesia  also received sedation with i m ketamine 1 - 2 mg/kg prior to placement of the spinal anesthetic ( group 2 A ) . The remainder of group 2 patients did not receive sedation ( group 2 B ) . Respiratory pattern and heart rate were monitored using an impedance pneumograph for at least 12 h postoperatively . Tracings were analyzed for evidence of apnea , periodic breathing and /or bradycardia by a pulmonologist unaware of the anesthetic technique utilized . None of the patients who received spinal anesthesia without ketamine sedation developed postoperative bradycardia , prolonged apnea , or periodic breathing . Eight of nine infants ( 89 % ) who received spinal anesthesia and adjunct intraoperative sedation with ketamine developed prolonged apnea with bradycardia . Two of the eight infants had no prior history of apnea . Five of the 16 patients ( 31 % ) who received general anesthesia developed prolonged apnea with bradycardia . Two of these five infants had no prior history of apnea . When infants with no prior history of apnea were analyzed separately , there was no statistically significant increased incidence of apnea in children receiving general versus spinal anesthesia with or without ketamine sedation . Because of the small numbers of patients studied , and the multiple factors that may influence the incidence of postoperative apnea ( e.g. , prior history of neonatal apnea ) , st and ard postoperative respiratory monitoring of these high-risk infants is still recommended following all anesthetic techniques A clinical trial was performed to compare the effects of intramuscular dihydrocodeine with caudal bupivacaine on postoperative pain and recovery in 181 children who had undergone either circumcision , inguinal herniotomy or orchidopexy performed under general anaesthesia . Linear analogues were used to assess level of consciousness and apparent pain . Recovery of consciousness was slower after caudal analgesia . For 90 minutes following circumcision there was significantly less pain with caudal analgesia , but better pain relief could not be demonstrated following inguinal herniotomy and orchidopexy Objective To evaluate the maternal and fetal effects of three anesthetic methods used r and omly in women with severe preeclampsia who required cesarean delivery . Methods Eighty women with severe preeclampsia , who were to be delivered by cesarean , were r and omized to general ( 26 women ) , epidural ( 27 ) , or combined spinalepidural ( 27 ) anesthesia .  The mean preoperative blood pressure ( BP ) was approximately 170/110 mmHg , and all women had proteinuria . Anesthetic and obstetric management included antihypertensive drug therapy and limited intravenous ( IV ) fluid and drug therapy . Results The mean  gestational age  at delivery was 34.8 weeks . All infants were born in good condition  as assessed by Apgar scores and umbilical arterial blood gas determinations . Maternal hypotension result ing from regional anesthesia was managed without excessive IV fluid administration . Similarly , maternal BP was managed without severe hypertensive effects in women undergoing general anesthesia . There were no serious maternal or fetal complications attributable to any of the three anesthetic methods . Conclusion General as well as regional anesthetic methods are equally acceptable for cesarean delivery in pregnancies complicated by severe preeclampsia if steps are taken to ensure a careful approach to either method Purpose The goal of this r and omized study was to determine whether combined general and epidural anaesthesia with postoperative epidural analgesia , compared with general anaesthesia and postoperative intravenous analgesia , reduced the incidence of perioperative myocardial ischaemia in patients undergoing elective aortic surgery . Method Patients were r and omly assigned to one of two groups . One group ( EPI , n = 48 ) received combined general and epidural anaesthesia and postoperative epidural analgesia for 48 hrs . The other group ( GA , n = 51 ) received general anaesthesia followed by postoperative intravenous analgesia . Anaesthetic goals were to maintain haemodynamic stability ( ± 20 % of preoperative values ) , and a stroke volume > 1 ml · kg−1 . A Holter monitor was attached to each patient the day before surgery . Leads 11 , V2 , and V5 were monitored . Myocardial ischaemia was defined as ST segment depression > 1 mm measured at 80 millisec beyond the J point or an elevation of 2 mm 60 millisec beyond the J point which lasted > 60 sec. An event that lasted > 60 sec but returned to the baseline for > 60 sec and then recurred , was counted as two separate events . The Holter tapes were review ed by a cardiologist blind to the patient ’s group . Results There were no demographic differences between the two groups . Myocardial ischaemia was common ; it occurred in 55 % of patients . In hospital , preoperative ischaemia was uncommon ( CA = 3 , EP1 = 8) . Intraoperative ischaemia was common ( GA = 18 , EP1 = 25 ) . Mesenteric traction produced the largest number of ischaemic ( GA = 11 , EP1 = 11 ) events . Postoperative ischaemia was most common on the day of surgery . Termination of epidural analgesia produced a burst of ischaemia ( 60 events in 9 patients ) Conclusion Combined general and epidural anaesthesia and postoperative epidural analgesia do not reduce the incidence of myocardial ischaemia or morbidity compared with general anaesthesia and postoperative intravenous analgesia . RésuméObjectifDéterminer avec une élude r and omisée si l’anesthésie générale et épidurale combinée suivie d’une analgésie épidurale postopératoire comparée à l’anesthésie générale suivie d’une analgésie intraveineuse postopératoire diminuait l’incidence de l’ischémie myocardique périopératoire chez des patients soumis à une chirurgie aortique non urgente . MéthodeLes patients étaient répartis au hasard en deux groupes . Un groupe ( IEP1 , n = 48 ) recevait une anesthésie générale et épidurale combinée et une analgésie épidurale postopératoire pendant 48 h. L’autre groupe ( AG , n = 51 ) recevait une anesthésie générale suivie d’une analgésie intraveineuse postopératoire . Les objectifs anesthésiques étaient de maintenir la stabilité hémodynamique ( ± 20 % des valeurs préopératoires ) , et un volume d’éjection > 1 ml · kg−1 . Un jour avant l’intervention , un moniteur de Holter avec les dérivations 11 , V2 et V5 était relié au patient . Une depression du segment ST plus gr and e que 1 mm mesurée 80 millisec après le point J ou une élévation de 2 mm mesurée 60 millisec après le point J était considérée comme une ischémie myocardique si elle durait plus de 60 sec. Un épisode de plus de 60 sec avec un retour à la ligne de base pendant 60 sec et plus avec récurrence , était considéré comme 2 épisodes séparés . Les bobines du Holter était révisée par un cardiologue neutre . RésultatsLes données démographiques étaient entre les groupes . L’ischémie myocardique était fréquente , survenant chez 55 % des patients . A l’hôpital , l’ischémie préopératoire était rare ( AG = 3 , EP1 = 8) . L’ischémie peropératoire était fréquente ( AG = 18 , EP1 = 25 ) . La traction mésentérique provoquait le plus gr and nombre d’épisodes d’ischémie ( AG = 11 , EP1 = 11 ) . L’ischémie postopératoire survenait le plus fréquemment le jour même de la chirurgie . L’arrêt de l’analgésie épidurale provoquait des poussées ischémiques ( 60 épisodes chez 9 patients ) . Conclusion L’anesthésie générale et épidurale combinée à l’analgésie épidurale ne réduit pas l’incidence de l’ischémie myocardique et de la morbidité comparativement à l’anesthésie générale suivie d’une l’analgésie intraveineuese Background : After total knee arthroplasty , patients regularly suffer from severe pain . It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief , patients ’ comfort and side effects . A new therapeutic approach , intraarticular opioids , has been suggested with the detection of opioid receptors in inflamed tissue . This method has proven suitable for clinical use in small operations ( e.g. knee arthroscopy ) . In this study , we compared epidural analgesia and intraarticular application of morphine plus “ on‐dem and ” intravenous analgesia to “ on‐dem and ” intravenous analgesia alone Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia , most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences . This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease . Methods Four hundred twenty‐three patients , between 1988 and 1991 , were r and omly assigned to receive general ( n = 138 ) , epidural ( n = 149 ) , or spinal anesthesia ( n = 136 ) for femoral to distal artery bypass surgery . All patients were monitored with radial artery and pulmonary artery catheters . Postoperatively , patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3 , then daily for 4 days . Cardiac outcomes recorded were myocardial infa rct ion , angina , and congestive heart failure . Results Baseline clinical characteristics were not different between anesthetic groups . Overall , the patient population included 86 % who were diabetic , 69 % with hypertension , 36 % with a history of a prior myocardial infa rct ion , and 41 % with a history of smoking . Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received . In the intention to treat analysis , incidences of cardiac event or death for general , spinal , and epidural groups were 16.7 % , 21.3 % , and 15.4 % , respectively . The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6 % ( 95 % confidence interval ‐9.2 % , 6.1 % ) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia . Conclusions The choice of anesthesia , when delivered as described , does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery In a prospect i ve study , patients undergoing cholecystectomy were r and omly allocated to receive ( a ) intermittent intramuscular morphine ( n = 25 ) , ( b ) continuous intravenous morphine infusion ( n = 25 ) or ( c ) epidural bupivacaine ( n = 25 ) for postoperative pain relief . Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine ; there was no significant difference in the incidence of postoperative pulmonary complications . Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine ( P < 0.001 ) . Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days ( P < 0.05 ) . Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications ( P < 0.01 ) and chest infection ( P < 0.05 ) Umbilical arterial blood gas analysis is the most objective method to assess fetal well being at birth , is the gold st and ard assessment of uteroplacental function and fetal oxygenation/acid-base status at birth , and it excludes the diagnosis of birth asphyxia in approximately 80 % of depressed newborns at term . This study was design ed to determine the effect of the type of delivery on umbilical cord blood gases and on free radical activity together with antioxidation in the fetus . Ninety-six pregnant women between 37 and 42 weeks of gestation were included to the study and r and omly assigned to the one of three groups : Group 1 ( n = 40 ) were vaginally delivered , Group 2 ( n = 26 ) had cesarean section with epidural anaesthesia  , and Group 3 ( n = 30 ) had cesarean section under general anaesthesia .  Umbilical artery blood gas analysis  was performed just after the delivery of the fetus together with melondealdehyde and glutathione . The umbilical arterial PO2 was found to be higher in Group 3 , and malondealdehyde and glutathione levels were lower in newborns of Group 2 . It can be concluded that cesarean section with epidural anaesthesia is safer when lipid peroxides are concerned We evaluated changes in dementia rating scale scores in the revised version of Hasegawa 's dementia scale ( HDS-R ) , and rated dementia , 2 days before and 7 days after surgery in the elderly patients with femoral neck fracture . The 50 patients examined ranged in age from 70 years to 101 years . A perfect score in the HDS-R is 30 points , and a score below 20 points strongly suggests dementia . The results were as follows . In septuagenarian and octogenarian patients , the scale score was higher after surgery than the value before the surgery . Although the preoperative and postoperative scores of the patients who had been under epidural anesthesia were not significantly different , the score of patients who had been under general anesthesia was higher in the postoperative period than in the preoperative period . In octogenarian patients , there was a negative correlation between " postoperative score minus preoperative score " and " the number of the days from suffering fracture to surgery " . These results showed that general anesthesia is more advantageous than epidural anesthesia from the viewpoint of the intellectual faculty in septuagenarian and octogenarian patients with femoral neck fracture , and it is within the bounds of possibility that the intellectual faculty may decline if an octogenarian patient is operated after a long delay from the occurrence of fracture . To prevent this decline , patients must be operated on as soon as possible In this prospect i ve , r and omised , double-blind study , we investigated the effect of epidural anaesthesia and an antifibrinolytic agent , Aprotinin ( 500,000 KIU in bolus before surgery and 500,000 KIU h-1 in drip form during surgery ) , on intra and postoperative blood loss and transfusion requirements in total hip arthroplasty . Sixty patients were allocated r and omly to four groups ( A : epidural + general anesthesia + Aprotinin , B : epidural + general anesthesia + placebo ( equal volume ) , C : general anaesthesia + Aprotinin , D : general anaesthesia + placebo ) . Postoperative analgesia : epidural analgesia in groups A and B , systemic analgesia with opiates in groups C and D. Blood loss during surgery was monitored and salvaged with the Compact-A Dideco , and postoperative blood loss with the BT 797 Recovery Dideco for the first 24 hours . Perioperative blood loss , frequency and quantity of transfusions were significantly higher in group D ( p < 0.0001 ) . Total blood loss was reduced by 31.3 % by epidural anaesthesia , 20.4 % by Aprotinin and 51.4 % using a combination of the two techiniques There are few consistent guidelines in choosing anesthesia for cesarean section for a parturient with placenta previa . This prospect i ve r and omized trial was organized to compare the maternal hemodynamics , blood loss and neonatal outcome of general versus epidural anesthesia  for cesarean section with the diagnosis of grade 4 placenta previa . After giving informed consent , 12 patients received general anesthesia and 13 received epidural .  Intraoperative blood pressures demonstrated a more stable course in the epidural group than in the general group . Blood loss did not differ significantly between the groups ( 1622 + /- 775 mL vs. 1418 + /- 996 mL ) . General anesthesia result ed in lower immediate postoperative hematocrit level ( 28.1 + /- 3.5 % vs. 32.5 + /- 5.0 % , P < 0.05 ) . The patients in the general group received a significantly larger transfusion than the epidural group ( 1.08 + /- 1.6 vs. 0.38 + /- 0.9 units , P < 0.05 ) . The Apgar scores at 1 and 5 min were similar in the two groups ( 8 [ 4 - 9 ] vs. 8 [ 7 - 9 ] and 10 [ 6 - 10 ] vs. 9 [ 9 - 10 ] , respectively ) . We concluded that epidural anesthesia is superior to general anesthesia in elective cesarean section for grade 4 placenta previa with regard to maternal hemodynamics and blood loss . There was no difference in neonatal outcome Sixty patients scheduled for colonic surgery were r and omly allocated to four groups according to postoperative pain medication : I. Control group , the patients received oxycodone intramuscularly ( 0.15 mg kg1 ) on request . II . Epidural bupivacaine ( 0.25 % ) continuously administered by infusion pump , 66 ml h‐1 , for 48 h. III . Epidural morphine , 2–6 mg , at the end of operation and repeated on the first and second postoperative mornings . IV . Epidural morphine , 2–6 mg per die , administered for 48 h continuously by infusion pump . All patients received a balanced anaesthesia with enflurane , fentanyl and vecuronium . Postoperatively , intramuscular oxycodone was given on request . There were no significant differences between the groups in changes in peak flow , spirometry and blood‐gas analyses postoperatively . Pain intensity ( visual analogue scale ) was lower in Groups II and III at 3 h and in Group IV at 24 h compared to the control Group I. All the epidurally treated groups needed less additional analgesics than the control Group I. Postoperatively bowel movements occurred on the second day in Group II ( bupivacaine ) as compared to the fourth day in all other groups ( P < 0.05 ) We have compared the incidence of preoperative and postoperative oxygen desaturation in 20 elderly patients undergoing dynamic hip screw insertion for fractured neck of femur , allocated r and omly to two groups to receive subarachnoid anaesthesia ( SA , n = 10 ) or a general anaesthetic ( GA , n = 10 ) .  Oximetry data  were recorded during the preoperative night and the first 48 hours after surgery using Satmaster . ™ Data associated with zero amplitude signal were automatically invali date d by the software and decreases in SpO2 which were preceded by contemporaneous changes in signal amplitude which conformed to a previously described template were assumed to be artefactual and were discarded from final data analysis . Data demonstrated a wide interpatient variability . However , those patients who desaturated preoperatively continued to do so in the postoperative period . The differences between the preoperative and postoperative oximetry profiles were examined for each patient and demonstrated a significantly longer time spent with SpO2 < 90 % in the GA group compared with the SA group , in all the recorded time periods , except on the day of surgery . The SA group showed an improvement in oxygen saturation postoperatively when compared to the preoperative night , spending less time with an SpO2 < 85 % . We conclude that the subarachnoid anaesthetic technique was associated with a lower incidence of postoperative oximetry desaturation when compared with general anaesthetic for these elderly patients undergoing repair of fractured neck of femur Background Improvement in patient outcome and reduced use of medical re sources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids , although the relative importance of intraoperative versus postoperative technique has not been studied . This prospect i ve , double-masked , r and omized clinical trial was design ed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta . Methods One hundred sixty-eight patients undergoing surgery of the abdominal aorta were r and omly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively ( four treatment groups ) . Patient-controlled analgesia was continued for at least 72 h. Protocol s were used to st and ardize perioperative medical management and to preserve masking intraoperatively and postoperatively . A uniform surveillance strategy was used for the identification of prospect ively defined postoperative complications . Outcome evaluation included postoperative hospital length of stay , direct medical costs , selected postoperative morbidities , and postoperative recovery milestones . Results Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups . Postoperative outcomes were similar among the four treatment groups with respect to death , myocardial infa rct ion , myocardial ischemia , reoperation , pneumonia , and renal failure . Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation ( P = 0.002 ) . Times to intensive care unit discharge , ward admission , first bowel sounds , first flatus , tolerating clear liquids , tolerating regular diet , and independent ambulation were similar among the four treatment groups . Postoperative pain scores were also similar among the four treatment groups . Conclusions In patients undergoing surgery of the abdominal aorta , thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia , offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia Ketamine has been compared with ' relaxant ' anaesthesia in operations for fractured neck of femur in elderly women . Ketamine was found to reduce early mortality principally by a reduction in thromboembolic complications , but at the expense of more unsatisfactory surgical results . It is suggested that the mortality after relaxant anaesthesia for these operations is unacceptable Background : Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist 's choice of either regional or general anesthesia . This clinical trial compared outcomes between epidural ( EA ) and general ( GA ) anesthesia/analgesia regimens In a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures . Methods : One hundred patients scheduled for elective vascular reconstruction of the lower extremities were r and omized to receive either EA for surgery followed by epidural analgesia , or GA for surgery followed by intravenous patient-controlled analgesia .  Hemodynamic monitoring , blood pressure , and heart rate limits were determined prior to r and omization . Management of anesthesia in the immediate postoperative period was st and ardized . The data collected included continuous electrocardiographic monitoring from the day before surgery through the third postoperative day , serial electrocardiograms , and cardiac enzymes . Cardiac ischemia , myocardial infa rct ion , unstable angina , and cardiac death were identified by a cardiologist blinded to the type of anesthesia received . Other major morbidity was determined at the time of hospital discharge and at 1 and 6 months after surgery . Results : Eleven patients who received GA required regrafting or an embolectomy during their hospital stay , compared with two patients who received EA . This association of GA with reoperation remained significant after adjustment for baseline differences . Cardiac outcomes were similar in the two groups with respect to perioperative death ( 1 EA and 1 GA ) , death within 6 months ( 4 EA and 3 GA ) , nonfatal myocardial infa rct ion within 7 days ( 2 EA and 2 GA ) , unstable angina ( 0 EA and 2 GA ) , and myocardial ischemia following r and omization ( 17 EA and 23 GA ) . Rates of major infections in the two groups ( 1 EA and 2 GA ) , renal failure ( 3 EA and 3 GA ) , and pulmonary complications ( 3 EA and 7 GA ) also were similar . Conclusions : Carefully conducted epidural and general anesthesia appear to be associated with comparable rates of cardiac and most other morbidity in patients undergoing lower extremity vascular surgery . However , compared with general anesthesia , epidural anesthesia is associated with a lower incidence of reoperatlon for inadequate tissue perfusion and , therefore , may be advantageous for this surgical population We assessed the influence of anesthetic technique for  cesarean section on neonatal outcome . Thirty parturient women ( ASA I/II ) were r and omly allocated into two groups . In Group GA general anesthesia was induced with 4 mg·kg–1 thiopental and 1.5 mg·kg–1 succinylcholine . In group EA epidural anesthesia was performed with 20 ml 0.375 % bupivacaine through L3–4 inter-space  . 1-min Apgar scores were significantly higher in group EA ( p < 0.001 ) . Neurologic and Adaptive Capacity scores at 2 and 24 h were higher in group EA ( p < 0.001 ) . In terms of blood gas values , umbilical arterial pH and pO2 values were higher in group EA ( p < 0.05 and p < 0.001 , respectively ) . The first breast-feeding intervals were found to be shorter in group EA ( p < 0.001 ) . We conclude that in terms of better Apgar and NAC scores , acid-base status and earlier initiation of breast-feeding , the epidural anesthesia may be preferred to general anesthesia in cesarean section The effects of cementation on arterial blood pressure , arterial oxygen tension and plasma levels of cortisol were studied in 30 patients with femoral neck fracture treated with the Thompson prosthesis in spinal ( n = 15 ) or general ( n= 15 ) anaesthesia . In spinal anaesthesia  hypotension of clinical importance was observed coincidentally with the use of methylmethacrylate , while the levels of plasma cortisol remained unchanged . A significant rise was noted in arterial blood pressure and plasma levels of cortisol after cementation in general anaesthesia . Arterial oxygen tension fell in both groups . These findings indicate that the hypotension frequently reported in connection with cementation is triggered by a complex mechanism which can be modified by the anaesthetic technique In a prospect i ve , r and omized study , continuous infusion of epidural fentanyl citrate ( group E ) was compared with patient-controlled intravenously administered morphine sulfate ( group P ) for analgesia in 66 men after radical retropubic prostatectomy . Although both methods provided satisfactory analgesia , the mean comfort level scores were lower ( that is , greater comfort ) in group E than in group P at all observation times . The difference in mean resting comfort level scores between groups E and P was statistically significant ( P < or = 0.05 ) at 9 of the 11 observation times . In addition , significant differences in comfort level scores were noted at 8 of the 11 observation times during deep breathing , 5 of 11 during coughing , and 3 of 9 during ambulation . Maximal and minimal comfort level scores recorded by each patient during the course of the study were significantly lower ( that is , less pain ) in group E than in group P for all four categories of activity . The percentage of patients who reported no pain was significantly higher in group E than in group P at 9 of 11 observation times during resting and 5 of 11 observation times during deep breathing . No significant differences were noted in side effect profiles or duration of hospital stay . In summary , when two effective methods of analgesia used after radical retropubic prostatectomy were compared prospect ively , patients who received epidural infusion of fentanyl were more comfortable than those with patient-controlled intravenous administration of morphine , as evidence d by lower mean , maximal , and minimal comfort level scores and a greater proportion of patients with complete relief of pain OBJECTIVE A prospect i ve r and omized trial was organized to compare the effectiveness of general and regional anesthesia for cesarean section ( C/S ) . METHOD Three hundred and forty-one patients were r and omized into the general anesthesia group ( GA ) , epidural anesthesia group ( EA ) and spinal anesthesia group ( SA ) . The effectiveness of interest was success rate , blood loss and patient satisfaction . RESULT We found that the success rates of EA and SA were lower than GA . Success in EA should be improved by using an epidural catheter to add more local anesthetic drug instead of a single shot ; and the surgeon should allow more time for the block to work adequately . Success in SA should be improved by using bupivacaine instead of lidocaine . GA result ed in significantly more blood loss , lower postoperative hematocrit , and higher proportion of patients who had postoperative hematocrit < 30 per cent than EA and SA . The patients ' satisfaction scores were not different among the 3 techniques . This meant that , given adequate explanation and perioperative care , Thai women were satisfied with regional anesthesia . CONCLUSION Regional anesthesia is a better choice of anesthesia for C/S than general anesthesia . However , the availability of different techniques and ability to change the technique when needed were very useful and important . If GA is chosen , all safety procedures must be followed . Oxygen supplement and endotracheal intubation facilities must be available in all techniques . Guidelines of anesthesia for C/S at a national level should be agreed upon , including the type of personnel , monitoring equipment and postoperative care Thirty patients who had undergone elective abdominal aortic surgery were studied in a prospect i ve , r and omised double‐blind comparison of thoracic epidural 0.2 % bupivacaine alone , thoracic epidural fentanyl alone and thoracic epidural 0.2 % bupivacaine combined with fentanyl .  Pain relief , pulmonary function , cardiovascular stability and side effects were assessed . Pain relief was excellent in the combined bupivacaine‐fentanyl series , being significantly better than the other groups ( p < 0.05 ) during the entire study period and was not accompanied by hypotension . Forced expiratory parameters were reduced in all groups throughout the study to 50–60 % of the pre‐operative values , but there were no significant differences between groups . The incidence of side effects attributable to either epidural bupivacaine or fentanyl was low . This study supports the increasing use of epidural infusion analgesia for postoperative pain management after abdominal surgery One hundred and twenty women undergoing gynaecological abdominal operations were r and omized to receive either epidural bupivacaine 0.0625%+fentanyl 3.3μg/ml infusion ( Group EPI , n=57 ) , or patient-controlled intravenous morphine analgesia ( Group PCA , n=54 ) for postoperative pain relief . The groups were comparable in demographic data , types and duration of operation . Group EPI achieved significantly lower verbal rating scale of pain ( VRS ) at rest at 0 , 4 , 12 , 16 , 20 , 28 and 40th postoperative hours . The VRS during cough were also significantly lower in Group EPI at 0 , 4 , 8 , 12 , 28 and 36th postoperative hours . None of the patients had respiratory depression or hypotension . Nausea/vomiting occurred in 52.6%/33.3 % of patients in Group EPI and 52.7%/37.0 % in Group PCA . Most patients ( 84.2 % in Group EPI and 72.2 % in Group PCA ) rated their pain management as “ good ” . We conclude that epidural infusion of bupivacaine 0.0625 % and fentanyl 3.3μg/ml provide better analgesia than patient-controlled intravenous morphine after gynaecological Twenty – one ASA I or II patients undergoing upper abdominal surgery were studied for 24 hours after operation . They were entered into a prospect i ve , r and omised study of patient – controlled intravenous morphine compared with continuous thoracic epidural fentanyl combined with 0.2 % bupivacaine .  Pain relief was superior in the bupivacaine series ( P < 0.05 ) throughout the 24 hour study period and this was associated with significantly greater pulmonary ventilation compared with the PCA series . Forced expiratory parameters were reduced in both series after the operation but significantly less so in the epidural group . There was a reduced incidence of emetic symptoms in the epidural group ( P < 0.05 ) but the incidence of other minor side effects did not differ significantly . Thoracic epidural fentanyl/bupivacaine results in significantly better analgesia than patient – controlled intravenous morphine Background : Gastric emptying is delayed in patients receiving postoperative pain relief with epidural morphine  compared to patients receiving epidural bupivacaine .  The electrophysiological basis for this effect is unknown . The aim of this study was to compare the effects of epidural morphine with epidural bupivacaine on gastroduodenal myoelectric activity ( EMG ) in patients after surgery During a period of one year , all patients above the age of 60 with surgical repair of fractured neck of femur were investigated in a prospect ively r and omized design . A follow-up study included a total number of 56 patients , 32 were allocated to halothane anaesthesia with intubation , 24 received spinal anaesthesia .  In addition , 15 patients of the halothane group and 17 patients with spinal anaesthesia  were investigated with regard to endocrine stress response . Total mortality was 12.5 % , and different anaesthetic management had no influence on the postoperative course . During the operation , adrenaline and ADH increased in both groups . This increase was attenuated by spinal anaesthesia .  Noradrenaline was markedly increased even before the operation , and concentrations increased in the halothane group in the course of the operation . There was a linear correlation to time between accident and the beginning of the operation . With regard to endocrine parameters , prompt surgical treatment is beneficial Sixty patients with fractured neck of femur and scheduled for surgical correction were r and omly allocated to receive one of three anaesthetic techniques : general anaesthesia ; spinal analgesia ; psoas compartment block . The patients in the local anaesthetic groups also received a light general anaesthetic . There was little difference in the pre‐ , intra‐ and postoperative events , and no difference in postoperative mortality In a prospect i ve r and omized multi-centre study , the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general ( narcotic-relaxant ) anaesthesia .  The 28-day mortality was 6.6 % with subarachnoid , and 5.9 % with general , anaesthesia . The difference was not significant ( 95 % confidence limits : -3.5 to + 4.8 ) . At 1 year following surgery , the mortality was 20.4 % . Increasing age , ischaemic heart disease , cardiac failure , preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality . A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality . Senile dementia and admission other than from the patient 's own home , were factors associated with a poorer long term outcome . From the point of view of mortality , subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly Fifty-seven patients , all over the age of 64 , with femoral neck fracture were r and omized to receive epidural or halothane anesthesia  to see if the anesthetic technique influenced the incidence of postoperative confusion . All patients were lucid on admission . Using the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders ( DSM-III ) as criteria for confusion , we found that 44 % of the patients developed confusion that correlated closely to a history of mental depression ( P < 0.01 ) and to the use of drugs with anticholinergic effect ( P < 0.005 ) . There was no difference in the incidence of confusion between the two anesthetic groups . In patients given halothane , however , early postoperative hypoxemia was associated with confusion ( P < 0.05 ) . Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times . It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique The analgesic efficacy and side‐effects of combined epidural infusion of bupivacaine and morphine , in comparison with these drugs alone , for postoperative analgesia after hysterectomy ( 60 patients ) were evaluated . Before general anaesthesia , all patients had an epidural catheter placed ( Th11‐12 ) and 20 ml of 0.5 % bupivacaine was injected . In r and om order , epidural infusion was continued for 24 h with either 0.25 % bupivacaine 4 ml‐ h‐1 ( BUPI‐group ) , a bolus of 2 mg of morphine followed by morphine 0.2 mg‐ h‐1 ( MO‐group ) , or a combination of the two drugs ( COMB‐group ) . A urinary bladder catheter was kept for 24 h. Supplementary postoperative pain medications were i.m . morphine 0.1 mg‐ kg‐1 or rectal indomethacin 50 mg , on request . Immediately after awakening from general anaesthesia and transfer to the recovery room , 18/20 of the BUPI‐group patients , 17/20 of the MO‐group patients and 19/20 of the COMB‐group patients were pain‐free . In the postoperative evening and the first postoperative morning , the corresponding figures were 7/20 and 10/20 in the BUPI‐group , 15/20 and 15/20 in the MO‐group , and 18/20 and 15/20 in the COMB‐group ( postop . evening ; P<0.01 BUPI vs. others ) . The number of patients requiring supplementary analgesics ( morphine and indomethacin )  during the first 24 h was greatest in the BUPI‐group ( P<0.01 ) . The number of patients who vomited during the 24‐h period was 3 in the BUPI‐group , 9 in the MO‐group and 5 in the COMB‐group . Postoperatively , normal bowel function was restored after 1.9 days in the BUPI‐group , 2.2 days in the MO‐group and 2.6 days in the COMB‐group , on average ( P<0.01 BUPI vs. COMB ) . Recatheterization of the urinary bladder ( once ) was required in 4 patients in the MO‐group and 2 in the COMB‐group , but in none of the BUPI‐group . It is concluded that although the morphine‐containing epidural infusions ( 6.8 mg 24 h‐1 ) were superior to that containing bupivacaine alone with respect to postoperative analgesia after hysterectomy , the occurrence of disturbing emetic and urinary side‐effects made the therapy not totally satisfactory Objective To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures . Summary Background Data Even though many beneficial aspects of epidural anesthesia have been reported , clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results . Methods The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic , gastric , biliary , or colon operations . They were assigned r and omly to receive either general anesthesia and postoperative analgesia with parenteral opioids ( group 1 ) or epidural plus light general anesthesia and postoperative epidural morphine ( group 2 ) . The patients were monitored for death and major complications during and for 30 days after surgery , as well as for postoperative pain , time of ambulation , and length of hospital stay . Results Overall , there was no significant difference in the incidence of death and major complications between the two groups . For abdominal aortic surgical patients , unlike the other three types of surgical patients , the overall incidence of death and major complications was significantly lower in group 2 patients ( 22 % ) than in group 1 patients ( 37 % ) , stemming from differences in the incidence of new myocardial infa rct ion , stroke , and respiratory failure between the two groups . Overall , group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients . In group 2 aortic patients , endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter . Conclusions The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed . Overall , epidural analgesia provides better postoperative pain relief . Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations Purpose To compare caudal and penile block for post-operative analgesia in children undergoing circumcision with respect to efficacy , complication rates , and parental satisfaction . Methods The study population consisted of 100 ASA 1 and 2 boys aged 3 to 8 years who were undergoing circumcision for religious reasons . In all participants , inhalation anesthesia was administered with oxygen : nitrous oxide ( 1 : 2 ) and halothane . The participants were allocated r and omly into two groups of 50 children each . Group 1 received penile block and Group 2 caudal block . The penile block was achieved by injecting bupivacaine into the two compartments of the subpubic space , with an additional ventral infiltration of a small volume of bupivacaine along the raphe of the penis . For caudal block , 1 ml·kg−1 body weight of 0.25 % bupivacaine was administered . Results Penile block shortened the induction-incision time and enabled earlier discharge home compared with caudal block . One patient undergoing penile block and nine patients undergoing caudal block vomited . Conclusions Penile and caudal block are equally effective for postcircumcision analgesia and neither is associated with serious complications . Anesthesiologist preference should be the deciding factor in choosing one technique over the other BACKGROUND Ketamine has been shown to prolong analgesia produced by caudal local anaesthetic block and is now in common use . This study compares caudal block using bupivacaine/ketamine with dorsal nerve block of the penis . METHODS Sixty boys undergoing elective circumcision were given either 0.5 ml x kg-1 of bupivacaine 0.15 % with ketamine 0.5 mg x kg-1 ( n = 30 ) or dorsal nerve block of the penis with bupivacaine 0.5 % ( n = 30 ) as a supplement to general anaesthesia .  Postoperative pain was assessed by parents using a modified objective pain score , and the time taken to first requirement of analgesia was recorded . Motor weakness , time to first micturition , postoperative nausea and vomiting ( PONV ) , eating habits , sleep disturbance and behaviour were also assessed . RESULTS There was no difference between the groups in time to first requirement for analgesia or number of doses of paracetamol given in the first 24 h. Almost half the boys in the caudal group had motor weakness , and there was a significant increase in time to first micturition in that group . There was no difference between the groups in PONV , eating , sleeping or behavioural disturbance . CONCLUSIONS Caudal anaesthesia with bupivacaine/ketamine does not confer any advantage over a dorsal nerve block with the doses used in this study . Because of the higher incidence of side-effects and technique failure in the caudal group , dorsal nerve block is perhaps the preferred technique Quantitative assessment of myocardial ischaemia during incremental spinal , single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteo synthesis of hip fractures in the elderly atherosclerotic individual . Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia ( bupivacaine 0.5 % plain ) ( A ) , single-dose spinal anaesthesia ( 2.5 mL of bupivacaine 0.5 % plain ) ( B ) or general anaesthesia ( fentanyl , thiopentone , atracurium , enflurane , N2O/O2 ) ( C ) for hip surgery .  ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h , and perioperative hypotension , blood loss and fluid therapy were recorded . ST depression developed in two out of 14 ( A ) , seven out of 15 ( B ) and six out of 14 ( C ) patients ( P = 0.14 ) . In ( A ) , a total of seven ST depressions occurred in the observation period as opposed to 125 in ( B ) and 16 in ( C ) ( P < 0.05 ) . Intra-operative ST depression only occurred in ( B ) . Three ( A ) , 33 ( B ) and 40 ( C ) hypotensive events were recorded ( P < 0.002 ) . Altogether , 56 % of hypotensive patients developed ST depression compared with 10 % of normotensive patients ( P < 0.003 ) . In ( A ) , 1.6 mL of 0.5 % bupivacaine were used as opposed to the fixed 2.5 mL dose in ( B ) ( P < 0.001 ) . In the first post-operative week , mortality was higher in ( B ) ( P < 0.05 ) but , after 1 month , there was no significant difference in mortality between the three groups . The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia Fifty patients undergoing elective abdominal aortic surgery were r and omised to receive either combined epidural and general anaesthesia and postoperative epidural analgesia ( CEGA ) or general anaesthesia and postoperative intravenous morphine infusion ( GA ) . Prospect i ve data was collected in order to compare the two groups . This included intraoperative cardiovascular changes and postoperative complications . The use of intraoperative vasopressors was significantly higher in the CEGA group ( P < 0.01 ) but the use of intravenous glyceryl trinitrate was significantly lower ( P < 0.01 ) . There was no significant difference between groups in regard to blood loss , volume replacement or in the number of patients requiring postoperative ventilation . Two patients in the CEGA group died postoperatively compared to one in the GA group ( not significant ) . There was no significant difference between groups in the total number or type of postoperative complications . Combining epidural anaesthesia with general anaesthesia altered intraoperative cardiovascular management but did not affect postoperative outcome Postoperative hypothermia initiates an increased oxygen dem and in the postoperative period and may endanger patients with restricted cardiopulmonary reserves . In order to compare net heat losses and gains , we studied 28 women undergoing hip fracture surgery , using either general anaesthesia or spinal analgesia .  The superficial and central temperatures were followed in the per‐ and postoperative period . Total body heat was calculated from temperature measurements . Temperature changes were unrelated to the type of anaesthesia . Large net heat losses occurred on transfer to the recovery room In this study , we assessed the influence of three analgesic techniques on  postoperative knee rehabilitation after total knee arthroplasty (TKA).Forty-five patients scheduled for elective TKA under general anesthesia were r and omly divided into three groups . Postoperative analgesia was provided with IV patient-controlled analgesia ( PCA ) with morphine in Group A , continuous 3-in-1 block in Group B , and epidural analgesia in Group C. Immediately after surgery , the three groups started identical physical therapy regimens . Pain scores , supplemental analgesia , side effects , degree of maximal knee flexion , day of first walk , and duration of hospital stay were recorded . Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups . Compared with Groups A and C , a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion ( until 6 wk after surgery ) , faster ambulation , and shorter hospital stay were noted in Groups B and C. However , these benefits did not affect outcome at 3 mo . We conclude that , after TKA , continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than IV PCA with morphine . Because it induces fewer side effects , continuous 3-in-1 block should be considered the technique of choice . Implication s : In this study , we determined that , after total knee arthroplasty , loco-regional analgesic techniques ( epidural analgesia or continuous 3-in-1 block ) provide better pain relief and faster postoperative knee rehabilitation than IV patient-controlled analgesia with morphine . Because it causes fewer side effects than epidural analgesia , continuous 3-in-1 block is the technique of choice . ( Anesth Analg 1998;87:88 - 92 In a prospect i ve r and omized trial the effects of continuous peridural analgesia on gastrointestinal motility and the postoperative course was studied in 48 consecutive patients with elective colorectal resections . 24 patients had peridural analgesia ( PDA ) with bupivacaine while 24 patients received intravenous analgesia ( IVA ) with pentazocine . With PDA the first passage of flatus and faeces was significantly accelerated . PDA was not associated with an increased rate of anastomotic breakdown and there were no respiratory complications in the PDA group Background The efficacy and effects of epidural analgesia compared with patient-controlled analgesia ( PCA ) have not been reported in patients undergoing major vascular surgery . We compared the effects of epidural bupivacaine-morphine with those of intravenous PCA morphine  after elective infrarenal aortic surgery . Methods Forty patients classified as American Society of Anesthesiologists physical status 2 or 3 received  general anesthesia plus postoperative PCA using morphine sulfate ( group PCA ; n = 21 ) or general anesthesia plus perioperative epidural morphine - bupivacaine ( group EPI ; n = 19 ) during a period of 48 h. During operation , EPI patients received 0.05 mg/kg epidural morphine and 5 ml 0.25 % bupivacaine followed by an infusion of 0.125 % bupivacaine with 0.1 % morphine ( 0.1 mg/ml ) ; group PCA received 0.1 mg/kg intravenous morphine sulfate .  Continuous electrocardiographic monitoring ( V4 and V5 leads ) was performed from the night before surgery until 48 h afterward . Respiratory inductive plethysmographic data were recorded after tracheal extubation . Visual analog pain scores at rest and after movement were performed every 4 h after extubation . Results Nurse-administered intravenous morphine  and time to tracheal extubation were less in group EPI , as were visual analog pain scores at rest and after movement from 20 to 48 h. Complications and the duration of intensive care unit and hospital stay were comparable . There was a similar , low incidence of postoperative apneas , slow respiratory rates , desaturation , and S-T segment depression . Conclusions Epidural morphine-bupivacaine is associated with reduced early postoperative intravenous opioid requirements , more rapid tracheal extubation , and superior analgesia after abdominal aortic surgery , with comparable respiratory effects The analgesic effects of systemically administered diamorphine , caudal analgesia with 0.5 % bupivacaine plain and caudal analgesia with 0.5 % bupivacaine plain to which morphine sulphate had been added were studied in boys undergoing circumcision . Postoperative analgesia was assessed using a linear analogue scale . The time interval between operation and subsequent analgesic administration and the number of analgesic doses in 24 h were compared . The frequency of vomiting was noted . All three methods provided satisfactory results . The only detectable difference between the groups was a more rapid , but transient , recovery in the group receiving plain bupivacaine only . The frequency of vomiting was high in all groups . Caudal analgesia , with or without the addition of morphine , did not confer any advantage over injected diamorphine , and did not justify the extra time , risk and expense required to carry it out In a double-blind , r and omized study , we have compared the effects of i.v . ketoprofen 200 mg followed by 12.5 mg h-1 over 13 h , with those of extradural morphine 4 mg in 32 patients after hip and knee arthroplasty . A visual analogue scale was used to score pain before analgesic administration ( first complaint after operation ) , 1 h after and every 2 h subsequently . Pain reduction 1 h after the start of analgesia was mean 44 % ( SEM 17 % ) in the extradural morphine group and 54 % ( 9 % ) in the ketoprofen group ( ns ) . There were no significant differences between groups in pain scores , pain reduction and additional analgesia requirement ( i.v . paracetamol ) .  Naloxone 5 micrograms kg-1 h-1 was required for hypercapnia exceeding 6.0 kPa in three patients in the extradural morphine group ( vs none in the ketoprofen group ; ns ) . There were no differences between groups in side effects , except for urinary retention , which was more frequent in the extradural morphine group ( P < 0.05 ) . As there were few differences between i.v . ketoprofen and extradural morphine , we conclude that ketoprofen may be an efficient alternative to extradural morphine after hip and knee arthroplasty A prospect i ve r and omised double blind study was carried out to compare the use of epidural methadone , morphine and bupivacaine for  pain relief after Caesarean section . The results indicate that methadone is the most effective agent with few side effects . Subsequently this method was used routinely for postoperative analgesia in all patients undergoing Caesarean section . A retrospective study of 178 patients having this method of analgesia was carried out and indicated that epidural methadone is an effective and safe method of postoperative pain relief
target: Compared with general anaesthesia , a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk ( level of evidence , moderate ) .
background: BACKGROUND Various beneficial effects derived from neuraxial blocks have been reported .
  However , it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications .
  OBJECTIVES Our primary objective was to summarize Cochrane systematic review s that assess the effects of neuraxial blockade on perioperative rates of death , chest infection and myocardial infa rct ion by integrating the evidence from all such review s that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various population s. Our secondary objective was to summarize the evidence on adverse effects ( an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility ) of neuraxial blockade .