Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.

Thirty-six patients undergoing lower abdominal surgery were included in a prospective randomized controlled study to compare the effects of patient-controlled analgesia (PCA) and a standard intramuscular/intravenous treatment (conventional analgesia, CA) of postoperative pain. Morphine was used in both groups. There were no significant differences between the two analgesic regimens in respect of linear analogue pain scores, verbal pain-relief scores, amount of morphine used or side-effects. No treatment-induced alterations in vital values were experienced.

SummaryIn ti double-blind, randomised ronirolled cross-over

SummaryIn n ilouhlr Hind, rnticiomised, controlled Blockade ol' the lumbar plexus by tlic inguinal paravascular technique (three-in-onc block) was described by Winnie in 197.3.' The femoral. thc latcral cutaneous femoral, and the obturator nerves are blocked by this method, Nhich results in analgesia of major parts of thc lower extremity. The introduction o f a cathetcr in thc fascial sheath of the femoral nerve permits a continuous block of the lumbarThe clinical application of this method is, however. not yet evident and only a fcw controlled investigations have attcmptcd to clucidate this.Thc use of the three-in-one block in uncontrolled studies and case reports is clainicd to relieve pain after surgery o n both the femoral n e~k~.~ and the knee joint.2 Patel ei (11.~ in a controllcd invcstigation found the method suitable for arthroscopy of the knee in day clinic patients. The purposes of this invcstigalion werc to evaluate the analgesic effect of a continuous block of the lumbar plexus after knee-joint surgery and to measure the venous plasma concentrations of bupivacaine during the treatment. MethodsTwenty patients undergoing clectivc opcn knee-joint surger) participated. All gave their informed consent in accordance with thc Helsinki 11 dcclat-ation. and the investigation was approved by the regional Ethics Committee and the Danish National Hcalth Service.Premedication consistcd of diazcpain 0.75 mg/kg given orally. Anaesthesia was induced with thiopcntone and pcthidiiic given intravenously and maintained with cnfluranc, nitrous oxide and pethidine when needed. Tracheal intubation was facilitated by atracurium and ventilation controllcd. Rcsidual neuromuscular block was reverscd with ncostigiiiinc and atropine at the cnd of the operation. A cathctcr (Portcx, epidural, 16-G) was placed in the fascial shcath according to the technique described elsewhere al'tcr surgery but bcforc thc patients were awake.6 The catheter was advanccd 15-20 cm cranially. The patients werc sclcctcd randomly into two groups to bc treatcd with the samc volumc of cithcr bupivacainc or isotonic sodium chloride through the cathetcr. A bolus dose, 2 mg/kg bodywcight, of bupivacainc 5 mg/ml was injected in the patients trcatcd with bupivacaine immediately after the catheter insertion. This was followed by a constant infusion of bupivacaine 2.5 mgiml. 0.35 mg/kg:' hour. Isotonic sodium chloride was given lo thc control group as a bolus dose, 0.4 mllkg, followed by a constant infusion of sodium chloride 0.14 ml/kgjhour; blinded syringes and infusion Set5 were used. The patients were unaware of thc natiire of thc block and the infusion was maintained for I h hours. All patients also received suppositories with acetylsalicylic acid. 1 . S g every h hours.Patients rcccived morphine 2.5 mg intravenously on dcmand during thc first 2 hours aftcr opcration and over the next 14 hours morphine 0.125 mgikg was given intramuscularly on demand. This treatment was administered by

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