We performed an open, prospective, randomized, controlled study of the incidence of major organ complications in 420 patients undergoing routine coronary artery bypass graft surgery with or without thoracic epidural anesthesia and analgesia (TEA). All patients received a standardized general anesthetic. Group TEA received TEA for 96 h. Group GA (general anesthesia) received narcotic analgesia for 72 h. Both groups received supplementary oral analgesia. Twelve patients were excluded-eight in Group TEA and four in Group GA-because of incomplete data collection. New supraventricular arrhythmias occurred in 21 of 206 patients (10.2%) in Group TEA compared with 45 of 202 patients (22.3%) in Group GA (P = 0.0012). Pulmonary function (maximal inspiratory lung volume) was better in Group TEA in a subset of 93 patients (P < 0.0001). Extubation was achieved earlier (P < 0.0001) and with significantly fewer lower respiratory tract infections in Group TEA (TEA = 31 of 206, GA = 59 of 202; P = 0.0007). There were significantly fewer patients with acute confusion (GA = 11 of 202, TEA = 3 of 206; P = 0.031) and acute renal failure (GA = 14 of 202, TEA = 4 of 206; P = 0.016) in the TEA group. The incidence of stroke was insignificantly less in the TEA group (GA = 6 of 202, TEA = 2 of 206; P = 0.17). There were no neurologic complications associated with the use of TEA. We conclude that continuous TEA significantly improves the quality of recovery after coronary artery bypass graft surgery compared with conventional narcotic analgesia.

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Bupivacaine has a chiral centre and is currently available as a racemic mixture of its two enantiomers: R(+)-bupivacaine and S(-)-bupivacaine. Preclinical studies have demonstrated that there is enantiomer selectivity of action with the bulk of central nervous system and cardiovascular toxicity residing with the R(+) isomer. The aim of this study was to compare the clinical efficacy and safety of S(-)-bupivacaine with racemic RS-bupivacaine for extradural anaesthesia. We studied 88 patients undergoing elective lower limb surgery under lumbar extradural anaesthesia who received 15 ml of 0.5% or 0.75% S(-)-bupivacaine, or 0.5% RS-bupivacaine in a randomized, double-blind study. There was no difference in onset time, maximum spread of sensory block or intensity of motor block between the three groups. Duration of sensory block was significantly longer for 0.75% S(-)-bupivacaine. We conclude that S(-)-bupivacaine has similar local anaesthetic characteristics to RS-bupivacaine when used for extradural anaesthesia.

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SummaryWound infiltration with local anaesthetics is a simple, effective and inexpensive means of providing good analgesia for a variety of surgical procedures without any major side-effects. In particular, local anaesthetic toxicity, wound infection and healing do not appear to be major considerations. The purpose of this review is to outline the existing literature on a procedure-specific basis and to encourage a more widespread acceptance of the technique, ensuring that all layers are infiltrated in a controlled and meticulous manner. A thorough understanding of the pathophysiology of the surgical wound is necessary to improve both analgesia and postoperative recovery for any given operation. Crile's concept of anoci-association almost a century ago has been largely ignored by our specialty. Crile proposed that true peripheral afferent blockade prevents propagation of abnormal reflexes that cause major organ dysfunction and death [1]. Thus, postoperative complications can be minimised and recovery enhanced. Since Crile's original hypothesis, we have learnt that the major reasons for surgical morbidity and mortality are the operation itself, the surgeon's personal expertise, the stress response to that trauma and patient comorbidities.Postoperative analgesia is a major component of perioperative care and local anaesthetic (LA) techniques are more effective than systemic analgesia regardless of the operation and mode of delivery [2]. Until recently, research and clinical practice has focused on central neuraxial blockade and peripheral nerve blockade. These, although highly effective, are reserved for major thoracic and abdominal surgery, mainly because of high failure rates [3] and the risks of infection and spinal haematoma. When choosing a 'procedure-specific' technique, the simplest, safest and most effective block should be employed whenever possible [4]. Thus, the meticulous direct application of LA to each identifiable layer during a surgical procedure has considerable appeal for both surgeon and anaesthetist. Local anaesthetic infiltration for surgery itself has largely been confined to small superficial outpatient procedures. However, performed well, this is a logical means of preventing pain and other noxious stimuli from reaching the spinal cord. When combined with specific nerve blockade, e.g. ilio-inguinal nerve block or transversus abdominis plane (TAP) block during hernia repair, this allows a 'multimodal local anaesthetic' means of combating pain and anoci-association.By allowing patients to mobilise more quickly, wound infiltration may be as effective as central and proximal peripheral blocks in ensuring a safe postoperative recovery. Although untreated postsurgical pain may cause chronic pain [5], our knowledge of its pathogenesis, prevention and treatment is still basic. An individual patient's personality and pain response are important and may correlate to early postoperative pain appreciation and outcome. During surgery, multimodal analgesia combats peripheral and central 'wind-up' and sho...