Percutaneous echography-guided alcohol block of the celiac plexus as treatment of painful syndromes of the upper abdomen: study of 21 cases

Celiac plexus block is usually performed under fluoroscopic or tomodensitometric guidance. We report on a new procedure using sonographic guidance. the patient lies in supine position. We use a real-time sonograph with a 3.5 MHz probe. On a transverse plane, the celiac axis is localized emerging from the aorta. Under local anesthesia, the tip of the spinal needle (177 mm, 22 g) is placed close to the aorta (about 5 mm) on both sides. 5 to 10 ml of 1% lidocaine, then 10 to 20 ml of absolute alcohol, are injected on each side. 21 patients (10 males, 11 females, mean age: 61.4) underwent the procedure. They presented with cancer of the pancreas in 14 cases, metastatic nodes from an extra-pancreatic tumor in 5 cases and chronic calcifying pancreatitis (CCP) in 2 cases. No pain relief was secured in 3 patients (14%). One of these presented with CCP, but endoscopic cystic diversion of a small cyst was successful in eradicating pain. Partial pain relief was secured in 5 cases (24%) and total pain relief in 13 cases (62%). No treatment-related complication was observed. We conclude that sonography is a simple and safe method of guidance in performing alcohol block of the celiac plexus. The anterior approach may prevent neurologic complications occurring with other methods of guidance using a posterior approach.

Long-term pain relief produced by intrathecal morphine infusion in 53 patients.

The present report details the characteristics of the analgesic effects of morphine administered chronically by infusion pumps implanted in 53 patients suffering from terminal metastatic disease. The median postimplant survival time in these patients was 4 months. Patients (mean age 58 years) were characterized according to the duration of pain before pump implantation (mean 16 months), prior consumption of systemic opioids (mean one to six daily analgesic equivalents of morphine), and their response to a trial intrathecal dose of morphine (1 to 2 mg). The median infusion dose at 2 weeks was 3.8 mg/day. The analgesic index, calculated as (quality of pain relief x duration of pain relief in hours)/morphine dose in mg, that was observed after the trial dose of morphine was determined for each patient. A close correlation was observed between the acute (2-week) infusion dose necessary to produce pain relief and the analgesic index such that the infusion dose = -8.0 x log (analgesic index) + 17.1. By 16 weeks, the mean spinal morphine dose for the group had increased by a factor of about 2.5; however, significant variation in the dose incrementation was documented. The maximum increase was observed in patients with a low analgesic index, and this rapid incrementation was usually correlated with an unsatisfactory overall outcome. Evidence that long-term infusion continues to yield analgesia was evidenced in six cases where there was an unanticipated loss of drug infusion and a corresponding increase in parenteral narcotic consumption. These data indicate the long-term efficacy and safety of spinal opioid infusion in patients with terminal cancer, and emphasize the advantage of assessing the sensitivity of the patient to spinal opioids by a standardized trial injection prior to pump placement as a prognostic indication of outcome.

Spinal epidural stimulation for central pain caused by spinal cord lesion

Epidural spinal cord stimulation was carried out in 4 patients with denervation caused by spinal cord lesion, and we reviewed previously reported cases. Initial result showed at 1 week in 100% of our cases, but about 1/3 of the cases, even those with the same denervation caused by spinal cord lesion, had no pain relief at this stage in previously reported cases. In our cases, excellent pain relief was gained temporarily, even though the painful area and the spinal cord lesion were separated somatotopically in 2 cases (case 3, 4). Temporary success bore no relationship to quality and duration of pain. In all cases except case 1, a rapidly decreasing effectiveness was noted, and finally no pain relief was gained at all after 4, 3 and 5 months, respectively. In case 1 there was persistent pain relief estimated at 70-80% after 19 months, only when the spinal cord was stimulated. Epidural stimulation also produced sensations in the painful area. Spinal cord stimulation would suppress at least the dorsal horn neurons which were destroyed by various kinds of diseases. A decline in effectiveness with time would occur due to essential causes of the deafferentation pain, such as anatomical and regeneration factors.

Who gives pain relief to children?

OBJECTIVE: To compare pre-hospital parental administration of pain relief for children with that of the accident and emergency (A&E) department staff and to ascertain the reason why pre-hospital analgesia is not being given. DESIGN/METHODS: An anonymous prospective questionnaire was given to parents/guardians of children < 17 years. The children were all self referred with head injuries or limb problems including burns. The first part asked for details of pain relief before attendance in the A&E department. The second part of the questionnaire contained a section for the examining doctor and triage nurse to fill in. The duration of the survey was 28 days. RESULTS: Altogether 203 of 276 (74%) of children did not receive pain relief before attendance at the A&E department. Reasons for parents not giving pain relief included 57/203 (28%) who thought that giving painkillers would be harmful; 43/203 (21%) who did not give painkillers because the accident did not happen at home; and 15/203 (7%) who thought analgesia was the responsibility of the hospital. Eighty eight of the 276 (32%) did not have any painkillers, suitable for children, at home. A&E staff administered pain relief in 189/276 (68%). CONCLUSIONS: Parents often do not give their children pain relief before attending the A&E department. Parents think that giving painkillers may be harmful and often do not have simple analgesics at home. Some parents do not perceive that their child is in pain. Parents require education about appropriate pre-hospital pain relief for their children.

Ventilatory response to intractable pain.

Fifty-two patients, admitted to a pain relief unit, had a cannula placed in the radial artery to measure the paO2, paCO2 and pH of arterial blood every 2 h, for periods ranging from 12 to 24 h. The patients were divided into 3 groups: 14 had low back pain, 21 patients had pain from cancer, and 17 had pain from other causes. Twenty were male and 32 were female with a mean age of 53 years (range 16-82 years). The mean paO2 of these groups was within normal limits. The mean paCO2 and pH for the 3 groups were, low back pain paCO2 4.1 kpa, pH 7.42, others, paCO2 4.2 kpa, pH 7.42. The finding of a normal pH associated with a low paCO2 suggests that patients were "reset" to a low paCO2. Treatment, which was most commonly nerve blocks, resulted in marked pain relief in 30 patients. Ten of these patients were available for follow-up at least 1 week later (4 from the low back pain group, 6 from the cancer group), and in every patient, after pain relief, there was a rise in paCO2 which was statistically significant (P less than 0.001) and was not accompanied by a fall in pH. This suggests that intractable pain is accompanied by chronic hyperventilation and that the relief of pain is accompanied by a decrease in ventilation.

Single-dose rofecoxib for acute postoperative pain in adults: a quantitative systematic review.

BACKGROUND: Rofecoxib is a cyclo-oxygenase 2 selective inhibitor. This systematic review of rofecoxib in acute pain examined studies in adults of analgesic efficacy over six hours, the amount and quality of the evidence on extended duration of analgesia, and the quality and quantity of evidence on adverse events. METHODS: Cochrane Library (issue 4, 2001), Biological Abstracts (March 2002), MEDLINE (March 2002) and PubMed (March 2002) were searched using rofecoxib as a free text term. The area under the pain relief versus time curve was dichotomized using validated equations to derive the proportion of patients on rofecoxib 50 mg or placebo with at least 50% pain relief over six hours. This was used to calculate the number needed to treat for at least 50% pain relief over six hours for rofecoxib compared with placebo. Information on duration of analgesia and adverse events was also collected. RESULTS: Five included trials investigated 1,118 patients, of whom 211 received placebo and 464 received rofecoxib 50 mg. The NNT for rofecoxib 50 mg was 2.3 (95% confidence interval 2.0 to 2.6). The weighted mean remedication time was 1.9 hours for placebo (126 patients), 7.4 hours for Ibuprofen ( Motrin ) 400 mg (97 patients) and 13.6 hours for rofecoxib 50 mg (322 patients). CONCLUSION: Rofecoxib at 2-4 times the standard daily dose for chronic pain is an effective single dose oral analgesic in acute pain. Limitations in trial reporting constrain conclusions about longer duration of analgesia and adverse event profile.

The effect of wound perfusion on the relief of postoperative pain

The efficacy of wound perfusion (WP) with lidocaine for postoperative pain relief was studied in patients with median incision for cholecystectomy. Twenty four patients were divided into 3 groups according to the method of postoperative pain relief; group C, n = 8: intramuscular injections of penta-zocine 30 mg administered on demand, group WP, n = 8: WP with continuous lidocaine perfusion for 24 hours (plus pentazocine on demand); group EPI, n = 8: buprenorphine administered epidurally for 24 hours (plus pentazocine on demand). Pain scores at 0, 6, 12, 24, 48, hours after operation were examined. Arterial blood gas analysis, FVC and FEV1 were measured preoperatively and on the first postoperative day. Pain scores at 0 and 24 hours in group WP and EPI were significantly lower than those in group C. There were no significant differences in the scores between group WP and EPI at all the points. Analgesic requirement was significantly reduced in group WP and EPI compared with group C. FVC, FEV1 and PaO2 were significantly reduced postoperatively in every group but there were no differences among three groups. PaCO2 significantly increased postoperatively in group C and EPI. We conclude that the technique of wound perfusion with lidocaine is effective and safe for postoperative pain relief.

Attitudes to pain and pain relief in adult surgical patients.

pain relief after surgery is frequently inadequate. In the last few years much research has been devoted to improving the situation. Unfortunately, very little work has been undertaken to explore the patients' contribution to pain management. The beliefs and attitudes held by patients when they enter the hospital environment may be responsible in some instances for their not achieving optimal pain relief from the available techniques. We have studied some of these attitudes with a survey of 180 adult patients admitted for elective surgery. We found that most patients still expect pain following surgery. However, they are not afraid to ask for analgesics when in pain and do not attribute pain to their own wrong doing. There are, however, some patients who appear to have 'deviant' pain beliefs that could hinder their appropriate use of analgesics. Sadly, it is impossible to identify these patients according to age, gender, socio-economic group or previous experience of pain or surgery.

Cancer pain relief: an international perspective.

This article describes several of the key efforts being undertaken to address cancer pain and its relief worldwide. Organizations that incorporate cancer pain relief as part of their mandates include the World Health Organization (WHO), the International Association for the Study of Pain, the International Union Against Cancer (UICC [Union Internationale Contre le Cancer]), the International Society of Nurses in Cancer Care, the Wisconsin Cancer Pain Initiative, and the Oncology Nursing Society. This paper is not an exhaustive description of all of the efforts (individual and organizational) being undertaken to alleviate cancer pain worldwide but is instead an introduction to some of the activities. Readers who wish to enlarge the scope of their cancer pain relief efforts may benefit from reviewing this information.

A double-blind comparison of a propionic acid derivative (Ibuprofen ( Motrin )) and a fenamate (mefenamic acid) in the treatment of dysmenorrhea.

A double-blind three-way crossover design in the treatment of dysmenorrhea comparing a propionic acid derivative (Ibuprofen ( Motrin )) and a fenamate (mefenamic acid) with a placebo showed that both Ibuprofen ( Motrin ) and mefenamic acid are generally superior to placebo. Statistically significant results were obtained in favor of the study drugs over placebo for the pain relief afforded by the treatments (as graded by patients) and the visual analog pain relief score, which not only ranks but also indicates the degree of pain relief as a percentage of total relief (100%). Pairwise comparisons for the ranks found mefenamic acid significantly superior to placebo (P less than .001) and Ibuprofen ( Motrin ) marginally superior to placebo (P less than .06), while the visual analog pain relief scale demonstrated mefenamic acid and Ibuprofen ( Motrin ) superior to placebo (P less than .001 and P less than .01, respectively). For both the patient ranking of pain relief by treatment and the visual analog pain relief scale, the results showed no significant differences between Ibuprofen ( Motrin ) and mefenamic acid. Side effects occurred in 11 Ibuprofen ( Motrin ) cycles, five mefenamic acid cycles, and ten placebo cycles of the 48 cycles with each agent. These were generally of minor severity or importance and were not statistically different. The need for additional analgesics and the ability to pursue normal daily activity were not different for any treatment group. The findings of this study indicate no clinical difference between a propionic acid derivative such as Ibuprofen ( Motrin ) and a fenamate such as mefenamic acid in the treatment of dysmenorrhea.