Fentanyl Bupivacaine

Different combinations of fentanyl, bupivacaine, and clonidine were investigated in a multicenter (6 sites) trial of 78 women undergoing elective cesarean section under spinal block (30). In some cases, this appeared to imply intrathecal administration, and in others combined intrathecal and epidural administration. Patients received hyperbaric bupivacaine alone, or with 75 pg of clonidine, or with 75 pg of clonidine and 12.5 pg of fentanyl. There were no reported hemodjmamic differences between the groups, but sedation and pruritus were significantly more common in those who received fentanyl, occurring in 65% and 25% of... 

Mahon SV, Berry PD, Jackson M, Russell GN, Pennefather SH. Thoracic epidural infusions for postthoracotomy pain a comparison of fentanyl-bupivacaine mixtures vs. fentanyl alone. Anaesthesia 1999 54(7) 641-6. 

Epidural analgesia is frequently used for lower extremity procedures and pain (e.g., knee surgery, labor pain, and some abdominal procedures). Intermittent bolus or continuous infusion of preservative-free opioids (morphine, hydromorphone, or fentanyl) and local anesthetics (bupivacaine) may be used for epidural analgesia. Opiates given by this route may cause pruritus that is relieved by naloxone. Adverse effects including respiratory depression, hypotension, and urinary retention may occur. When epidural routes are used in narcotic-dependent patients, systemic analgesics must also be used to prevent withdrawal since the opioid is not absorbed and remains in the epidural space. Doses of opioids used in epidural analgesia are 10 times less than intravenous doses, and intrathecal doses are 10 times less than epidural doses (i.e., 10 mg of IV morphine is equivalent to 1 mg epidural morphine and 0.1 mg of intrathecally administered morphine).45... 

Parenterals are administered to the body by injection. They must be sterile, nonpyro-genie, and particulate-free. Examples of compoimded parenterals include high-dose analgesics for patient controlled analgesia (morphine sulfate 50 mg/mL), antiemetic injections, fentanyl and bupivacaine injections for ambulatory pump reservoirs, oncology combinations, and others (Table 10). 

Fentanyl citrate—bupivacaine hydrochloride-epinephrine hydrochloride injection (100 mL)... 

For continuous epidural analgesia, levobupivacaine may be administered in combination with fentanyl or clonidine. Levobupivacaine has been approved in European Union states for ilio-inguinal and iliohypogastric nerve blockade in children. (See also bupivacaine, above.)... 

Fentanyl citrate is stable if stored at room temperature up to 48 hours under normal conditions. Fentanyl should not be formulated with alkaline drugs and stored in PVC containers for product stability reasons. Formulations containing fentanyl and bupivacaine were found to be adsorbed in PVC containers. The formulation containing adrenaline or fentanyl citrate becomes degraded.55-57... 

Y.-H. Tu, et al., Stability of fentanyl citrate and bupivacaine hydrochloride in portable pump reservoirs. Am. J. Hosp. Pharm. 47 2037-2040, 1990. 

The addition of droperidol 2.5 mg to fentanyl 0.4 mg in 40 ml of 0.125% bupivacaine lowered the incidence of postoperative nausea and vomiting compared with a solution without droperidol or with butorphanol added instead in patients undergoing anorectal surgery in a prospective randomized, single-blind study (28). 

A 26-year-old woman with a history of multiple substance abuse required emergency caesarean section at 30 weeks of gestation as a result of crack cocaine-induced placental abruption and fetal distress (251). Her admission blood pressure was 145/95 mmHg, heart rate 95/minute and respiratory rate 20/minute. The fetal heart rate was 130/minute and non-reactive, with late and variable decelerations and no response to maternal oxygen administration. Spinal block with bupivacaine, fentanyl, and morphine was performed with the patient in a sitting position. No maternal or neonatal postoperative complications were reported. 

Cowan CM, Kendall JB, Barclay PM, Wilkes RG. Comparison of intrathecal fentanyl and diamorphine in addition to bupivacaine for caesarean section under spinal anaesthesia. Br J Anaesth 2002 89(3) 452-8. 

The analgesic efficacy of the addition of clonidine to an epidural solution of bupivacaine plus fentanyl has been subjected to a randomized, double-blind study in 61 parturients who received bupivacaine plus fentanyl with or without clonidine (median dose 28micrograms/hour). There was no difference between the groups in pruritus or nausea score, but those given clonidine had less shivering and better analgesia (25). 

In another randomized, double-blind study, a combination of clonidine and neostigmine was added to intrathecal bupivacaine plus fentanyl in 45 parturients (26). The combination increased the duration of labor analgesia by 83%, but was associated with significantly more nausea. However, the results were equivocal, and larger studies are needed. 

Paech Ml, Pavy TJ, Orlikowski CE, Evans SF. Patient-controlled epidural analgesia in labor the addition of cloni-dine to bupivacaine-fentanyl. Reg Anesth Pain Med 2000 25(l) 34-40. 

Owen MD, Ozsarac O, Sahin S, Uckunkaya N, Kaplan N, Magunaci I. Low-dose clonidine and neostigmine prolong the duration of intrathecal bupivacaine-fentanyl for labor analgesia. Anesthesiology 2000 92(2) 361-6. 

Like other opioids, fentanyl can cause pruritus. Prophylactic intravenous ondansetron 8 mg with hyperbaric bupivacaine 7-10 mg and fentanyl 25 pg significantly reduced the incidence of intrathecal fentanyl-induced pruritus in 125 patients undergoing knee arthroscopy or urological surgery in a randomized, double-blind, placebo-controlled trial (17). The incidence of pruritus was 39% with ondansetron and 68% with placebo. 

The addition of bupivacaine and/or adrenaline to epidural fentanyl analgesia has also been studied in 100 women after elective cesarean section. AU received fentanyl (3 pg/ml) by patient-controUed analgesia (PCA) for 48 hours and were randomly assigned double-bUnd to receive either bupivacaine 0.01%, ephedrine 0.5 pg/ml, both, or neither (25). Patients who received fentanyl alone made more attempts at PCA than the other groups, suggesting that this regimen was less effective and the higher dose of fentanyl used perhaps contributed to a... 

Effective postoperative pain relief can be obtained with a mixture of fentanyl and bupivacaine, which not only provides better analgesia than either drug alone, but also fewer adverse effects. There have been several studies of the efficacy of this mixture, using different doses and routes of administration, the addition of clonidine, and in comparison with morphine. 

In a randomized, double-blind study in 56 patients, continuous infusion of fentanyl (1 qg/kg/hour or 0.5 pg/ kg/hour) and bupivacaine 0.1 mg/kg/hour, with intravenous morphine PCA as rescue analgesia, produced better pain relief after knee hgament operations than epidural saline combined with intravenous morphine PCA (26). There was a non-significant increase in nausea in the fentanyl group. 

In another randomized, double-blind study, 84 parturients requesting epidural analgesia were given either bupivacaine 20 ml only, followed by intravenous fentanyl 60 pg or bupivacaine 20 ml with fentanyl 60 pg followed by intravenous saline (27). The minimum local analgesia concentration (MLAC) of bupivacaine + intravenous fentanyl was 0.064% w/v and the MLAC of bupivacaine + epidural fentanyl was 0.034% w/v. The epidural fentanyl solution significantly increased the analgesic potency of bupivacaine by a factor of 1.88 compared with intravenous fentanyl. This was associated with increased pruritus with epidural fentanyl. 

Women scheduled for cesarean section (n = 32) were given spinal bupivacaine 10 mg (0.5%) or spinal bupivacaine 5 mg (0.5%) plus fentanyl 25 pg (28). Those given fentanyl had adequate spinal anesthesia for cesarean section with fewer adverse effects (nausea and hjrpotension). This observation was reproduced by spinal anesthesia with bupivacaine 4 mg plus fentanyl 20 pg, which provided adequate spinal anesthesia for surgical repair of hip fracture in elderly patients, with fewer adverse effects than bupivacaine 10 mg (29). 

The addition of fentanyl 1 pg/ml to ropivacaine 7.5 mg/ml did not improve nerve blockade by axillary brachial plexus anesthesia in a double-blind, randomized study in 30 patients undergoing orthopedic procedures (31). In another double-blind, randomized study, 60 patients receiving axillary brachial plexus blockade were given 0.25% bupivacaine 40 mg, 0.25% bupivacaine 40 mg plus fentanyl 2.5 pg/ml, or 0.125% bnpivacaine 40 mg plus fentanyl 2.5 pg/ml (32). The addition of fentanyl 2.5 pg/ml prolonged sensory and motor blockade without any improvement in the onset of anesthesia and no significant increase in adverse effects. These two studies have reaffirmed the current position of conflicting results in studies of the benefits of adding fentanyl to local anesthetics for peripheral nerve blockade. 

Transdermal fentanyl was the cause of an opioid overdose when a 77-year-old man with a history of severe arthritis developed respiratory failure after starting epidural diamorphine-bupivacaine mixture for postoperative pain (50). The fentanyl patch was removed, the epidural infusion was stopped, and naloxone was given to counteract the excessive opioid effects. 

Cohen S, Lowenwirt I, Pantnck CB, Amar D, Pantnck EJ. Bupivacaine 0.01% and/or epmephrme 0.5 microg/ml improve epidural fentanyl analgesia after cesarean section. Anesthesiology 1998 89(6) 1354-61. 

SUvasti M, Pitkanen M. Continnous epidural analgesia with bupivacaine-fentanyl versus patient-controlled analgesia with i.v. morphine for postoperative pain relief after knee ligament surgery. Acta Anaesthesiol Scand 2000 44(1) 37 2. 

PoUey LS, Columb MO, Naughton NN, Wagner DS, Dorantes DM, van de Ven CJ. Effect of intravenous versus epidural fentanyl on the minimum local analgesic concentration of epidural bupivacaine in labor. Anesthesiology 2000 93(l) 122-8. 

Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000 25(3) 235-9. 

Ben-David B, Frankel R, Arzumonov T, Marchevsky Y, Volpin G. Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged. Anesthesiology 2000 92(1) 6-10. 

Benhamou D, Thorin D, Brichant JF, Dailland P, Milon D, Schneider M. Intrathecal clonidine and fentanyl with hyperbaric bupivacaine improves analgesia during cesarean section. Anesth Analg 1998 87(3) 609-13. 

Karakaya D, Buyukgoz F, Baris S, Guldogus F, Tur A. Addition of fentanyl to bupivacaine prolongs anesthesia and analgesia in axUlaiy brachial plexus block. Reg Anesth Pain Med 2001 26(5) 434-8. 

Liu SS, Allen HW, Olsson GL. Patient-controlled epidural analgesia with bupivacaine and fentanyl on hospital wards prospective experience with 1030 surgical patients. Anesthesiology 1998 88(3) 688-95. 

Niemi G, Breivik H. Epidural fentanyl markedly improves thoracic epidural analgesia in a low-dose infusion of bupivacaine, adrenaline and fentanyl. A randomized, dou-ble-bhnd crossover study with and without fentanyl. Acta Anaesthesiol Scand 2001 45(2) 221-32. 

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