A Review of the Use of Fentanyl Analgesia in the Management of Acute Pain in Adults

SPINAL anesthesia is commonly used for cesarean section, and it has become a popular practice to add opioids to spinal solutions to enhance and prolong intraoperative and postoperative analgesia. Morphine and fentanyl are the opioids most often used for this purpose, but there is not a general consensus about the benefits of the various regimens, and the incidence of side effects with different opioids and doses is controversial. Recently, a number of systematic reviews have been published in the field of pain and perioperative medicine. The aim of a systematic review is to summarize available information from controlled clinical trials to produce evidence-based estimates of the true clinical effect of an intervention. The purpose of this systematic review was to investigate the effect of intrathecal opioids added to spinal anesthesia on intraoperative and postoperative pain and to evaluate adverse effects in patients scheduled for cesarean section, using evidence from all relevant randomized controlled and blinded trials.

Intraoperative and postoperative analgesic efficacy and adverse effects of intrathecal opioids in patients undergoing cesarean section with spinal anesthesia: a qualitative and quantitative systematic review of randomized controlled trials.

Purpose
Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency onset, and duration of PDPH.

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PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies

ANESTHESIA has become remarkably safe, and while death and permanent damage have become rare occurrences, other sequelae of anesthesia are gaining more importance. Postoperative nausea and vomiting (PONV) still is the most troublesome adverse event encountered in the recovery room, despite advances in prevention and treatment. The incidence of PONV has remained high and has a major negative impact on patient satisfaction about the overall surgical experience. Furthermore, the ongoing trend toward ambulatory procedures has increased the focus on PONV as its occurrence may delay discharge or cause unanticipated hospital admission. General anesthesia has long been considered as causing a greater frequency and severity of PONV than regional anesthetic techniques. Recent studies investigating this time-honored dictum in a controlled manner mostly, but not unanimously, confirmed it. Accordingly, considerable effort has been invested to examine etiology, define patients at risk, and outline preventive and therapeutic strategies in patients undergoing general anesthesia. Reviews dealing with PONV have discussed almost exclusively general anesthesia and largely ignored regional anesthesia. This contrasts with the increasing popularity of regional anesthesia. A survey in Europe showed that one third of patients are undergoing regional anesthesia for their operative procedure. In France, the proportion of regional anesthesia increased from 15 to 25% of all anesthetics administered from 1980 to 1996. The number of local anesthetic and analgesic agents available for regional anesthesia has increased over the last two decades. Since the introduction of intrathecal and epidural morphine in 1979, a multitude of medications, such as synthetic opioids, 2-agonists, and cholinesterase inhibitors, have been introduced in an attempt to enhance the action of local anesthetics. The decision about their usefulness will not only rely on their effects on nerve blockade and pain relief, but also on their influence on side effects such as PONV. This review focuses on PONV in the setting of perioperative regional anesthesia. General aspects of PONV, such as physiology, patient, and perioperative factors involved are discussed. Few studies regarding these issues have been specifically devoted to regional anesthesia. Therefore, much information must be derived from investigations of general anesthesia. Specific regional anesthetic techniques and the influence of adjunctive medications on PONV are also presented. Combined general–regional anesthesia is purposefully excluded, avoiding the many variables introduced by general anesthesia. A final section is devoted to continuous peripheral nerve blocks and their possible impact on PONV.

Postoperative nausea and vomiting in regional anesthesia: a review.

/pdf/consensus-guidelines-for-lumbar-puncture-in-patients-with-3pjsqxq9gy.pdf

Consensus guidelines for lumbar puncture in patients with neurological diseases

Addition of fentanyl to bupivacaine administered for spinal anesthesia for cesarean delivery was evaluated in 56 ASA physical status 1 term parturients. Preservative-free saline was added to 0, 2.5, 5, 6.25, 12.5, 25, 37.5, or 50 μg featanyl to make a 1 ml total volume, which was injected intratheca

Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery.

Background and Objectives Postdural puncture headache (PDPH) is a morbidity that occurs frequently after lumbar puncture. The purpose of this study was to evaluate the role of needle diameter and tip configuration in causing PDPH. The incidence of PDPH was evaluated in parturients because this group of patients is at high risk for developing PDPH and because they often undergo lumbar puncture for spinal anesthesia. Methods The incidence of PDPH after spinal anesthesia with 26- and 27-gauge Quincke and 25-gauge Whitacre needles was studied in a series of 4,125 parturients undergoing spinal anesthesia over a 4-year period. Data were also collected on the incidence of PDPH with 17-gauge Huber-tipped Weiss needles in 21,578 parturients receiving lumbar epidural analgesia and/or anesthesia over the same interval. Additionally, the need to treat PDPH with epidural blood patch in all of these patients was studied. Results The incidence of PDPH was 5.2% with 26-gauge Quincke needles (1987-1989), 2.7% with 27-gauge Quincke needles (1989-1990), and 1.2% with 25-gauge Whitacre needles (1990-1991). During the same periods, the incidence of PDPH with 17-gauge Weiss needles averaged 1.1%, 1.7% and 1.2%, respectively. As compared with the 26-gauge Quincke needle, there was a lower incidence of PDPH with the 27-gauge Quincke (P Conclusions The morbidity associated with lumbar puncture can be decreased by selecting the proper needle gauge and tip configuration. Use of the smallest gauge needle and one that has a noncutting Whitacre tip produces the lowest incidence of PDPH in parturients, a group of patients at increased risk for developing PDPH.

https://rapm.bmj.com/content/rapm/22/1/66.full.pdf

Role of Needle Gauge and Tip Configuration in the Production of Lumbar Puncture Headache

A total of 2,511 patients who received spinal anesthesia for cesarean delivery were observed for the development of postdural puncture headache (PDPH); 804 patients received a mixture of tetracaine and procaine, 942 received bupivacaine-glucose, and 765 received lidocaine-glucose. They were observed for the development of PDPH for a minimum of 72 h. PDPH occurred in 9.54% of patients who received lidocaine-glucose during the first 36 h compared with 7.64% of patients who received bupivacaine-glucose and 5.85% of patients who received tetracaine-procaine. The differences between all groups was statistically significant. No differences were found in the percentage of patients who ultimately required epidural blood patch for relief of symptoms after 36 h.

Hertwig L

Papers

Perioperative analgesia with subarachnoid fentanyl-bupivacaine for cesarean delivery.

Role of Needle Gauge and Tip Configuration in the Production of Lumbar Puncture Headache

Influence of local anesthetic solution on postdural puncture headache.

Influence of Local Anesthetic Solution on Postdural Puncture Headache

Duration of analgesia of epidural fentanyl following cesarean delivery- effects of local anesthetic drug selection