Postoperative pain relief by continuous epidural infusion: a comparison of three solutions

The effect of three solutions on postoperative pain relief by continuous epidural infusion was studied. Seventy-five patients after upper or lower abdominal surgeries were assigned to one of three groups and the postoperative pain relief was evaluated for 48 hours. Group I: bolus injection of buprenorphine (Bn) 0.1 mg + saline (S) 8 ml and continuous infusion (2 ml.h-1) of Bn 0.8 mg + S 92 ml; Group II: bolus injection of Bn 0.1 mg + 0.5% bupivacaine (Bc) 4 ml + S 4 ml and continuous infusion of Bn 0.8 mg + S 92 ml; Group III: bolus injection of Bn 0.1 mg + 0.5% Bc 4 ml + S 4 ml and continuous infusion of Bn 0.8 mg + 0.5% Bc 40 ml + S 60 ml. The combination of buprenorphine with low-dose bupivacaine (Group III) offered the most effective postoperative analgesia in three groups without increasing the frequency of adverse effects induced by epidural administration of local anesthetics. However, even in Group III, the percentage of patients complaining of pain at bed rest was still high during early postoperative period (56% at 6 hours postoperatively). The results suggest that further consideration is necessary on agents selection and dosage adjustment for the postoperative epidural analgesia.

A survey of pain relief clinics in the South Western Region.

All the district general hospitals in the South Western Health Region have a pain relief service in existence or planned for the immediate future. Almost all are recognized by the allocation of anaesthetic consultant sessions. In most cases, this allocation is less than the time required for pain relief. All the consultants concerned work in single disciplinary clinics and accept both in-patient and out-patient referrals. They provide an advisory and therapeutic service to patients in the care of other clinicians and give tuition, mainly to junior anaesthetists. Most also undertake domiciliary assessment and treatment. In most clinics the pain relief Service is hampered by inadequate facilities. The minimum facilities for a basic efficient service are here reviewed.

Long-term outcome of spinal cord stimulation and hardware complications.

Spinal cord stimulation (SCS) is a treatment modality for medically intractable chronic pain. This study reports an 11-year experience with SCS assessing long-term pain relief and specifically evaluating complications and revisions. It took the form of a retrospective review of medical/surgical records with a postal questionnaire. The subjects were 102 patients with medically intractable chronic pain who underwent SCS implantation between 1989 and 2000. There were 64 revision operations carried out on 35 patients. These comprised electrode replacement/repositioning (29), generator replacement (23), cable failure (3) and implant removal (5). Five (4.9%) implants became infected and 2 required removal. Clinician-reported pain relief was substantial in 69 (68%) patients. This study adds to the weight of evidence that patients undergoing SCS derive significant benefits in terms of pain relief. However, revision rates remain high due to technical and biological factors. Copyright 2003 S. Karger AG, Basel

Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent long-term outcome analysis.

OBJECTIVE: The authors sought to provide a framework through outcome analysis to evaluate operations directed toward the intractable abdominal pain of severe chronic pancreatitis centered in the pancreatic head. Pancreatoduodenectomy (PD) was used as an example. SUMMARY BACKGROUND DATA: Head resection for severe chronic pancreatitis is the treatment of choice for a ductal system in the head obliterated by severe disease when associated with intractable abdominal pain. To evaluate the effectiveness of promising head resection substitutes for PD, a framework is necessary to provide a reference standard (i.e., an outcome analysis) of PD. METHODS: Inclusion criteria were severe chronic pancreatitis centered in the pancreatic head, intractable abdominal pain, and a main pancreatic duct obstruction or stricture resulting in absent drainage into the duodenum from the uncinate process and adjacent pancreatic head areas or the entire gland. Since 1986, 57 consecutive cases with these criteria underwent PD (47 head only and 10 total pancreatectomy). Clinical and anatomic predictor variables were derived from the history, imaging studies, and pathologic examination. These variables then were tested for association with the following outcome events gathered during annual follow-up: pain relief, onset of diabetes, body weight maintenance, and peptic ulceration. RESULTS: Operative mortality was zero. In 57 patients with a mean follow-up of 42 months, the 5-year outcome event for survival was 93% and the onset of diabetes was 32%. All new cases of diabetes occurred more than 1 year after resection. In 43 cases > or =1 year postoperative with a mean follow-up of 55 months, all patients indicated significant pain relief and 76% were pain free. pain relief was more common in patients with diabetes or in those patients with a pancreatic duct disruption. Death was more common in patients with diabetes. Weight maintenance was more common if preoperatively severe ductal changes were not present. Total pancreatectomy was associated with peptic ulceration. CONCLUSIONS: Using selection criteria, the outcome analysis standardized anatomic and clinical variables as to how they were associated with the outcome events (calibrated the effects of the operation with each variable). In these selected patients, PD is safe and significantly relieves pain. Sequelae are from diabetes, provided total pancreatectomy is avoided.

Percutaneous stereotactic radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia.

BACKGROUND: Trigeminal neuralgia (TN) is the most common cephalic neuralgia in people over the age of fifty, with a mean incidence of 4 per 100,000. Percutaneous stereotactic differential radiofrequency thermal rhizotomy (RTR) is a well-recognized surgical treatment for TN. The purpose of this study was to evaluate a management algorithm for TN and to evaluate the effectiveness of RTR for TN after failure of pharmacologic management. METHODS: Two hundred and fifty-eight (258) patients underwent RTR from 1992-1996 and were prospectively evaluated. These patients were characterized by age, sex, side of the face and division(s) involved. Patients were evaluated for pain relief, recurrence requiring or not requiring re-operation, and the type and rate of complications. They were followed by serial clinical evaluation and telephone interview. Patients were grouped according to results: (A) Successful Result--excellent or good pain relief; (B) Unsuccessful Result--fair, poor or no pain relief. The RTR group was compared to historical controls. Follow-up ranged from 12-80 months (mean = 38 months). RESULTS: At early follow-up (defined as median postoperative period up to 6 months), pain relief that was excellent or good (successful results) occurred in 224/258 (87%). At long-term follow-up (> 6 months) recurrence of tic pain required re-operation in 31 patients (12%). In 37 patients (14%), recurrence of tic pain did not require re-operation. Dysesthesia developed in 20 patients (8%); corneal analgesia developed in 8 patients (3%). "Anesthesia dolorosa" developed in 5 patients (2%) and was medically managed. At the conclusion of the long-term follow-up period, 214/258 patients (83%) had excellent to good pain relief (successful result). There were no mortalities, no significant morbidity and a low rate of minor complications. CONCLUSION: With the use of this specific diagnostic and management algorithm, patients with TN can be successfully managed with RTR.

pain relief with morphine, intrathecally or peridurally?

We investigated pain relief following 1-2 mg morphine intrathecally applied in 7 patients with cancer pains and in 5 patients with multiple rib fractures (group 1). For postoperative pain relief (group 2) we applied 1-2 mg morphine intrathecally in 26 patients immediately before the induction of the anaesthesia. In 30 patients we applied 4 mg morphine epidurally in 10-20 ml saline solution for postoperative pain relief (group 3). In the first group the duration of the pain relief was 25,2 hours, in the second group 31 hours and in the third group 15,7 hours. In the second group a respiratory depression occurred in 3 cases and was successfully treated with naloxon. In the third group a bladder disorder occurred in two cases. Because of the risk of respiratory depression following intrathecally applied morphine, we recommend the epidural way of application.

Predictive factors in advanced cancer pain treated only by analgesics.

Analgesic response, incidental pain and pain mechanism were evaluated in order to predict the chances of pain relief in advanced cancer patients. In an observation period of about 2 months, 130 patients were followed at home until death using only a pharmacological approach to control pain according to the WHO ladders. Ninety-eight patients were considered. pain relief was considered good if less than moderate. Pain was assessed during the course of examinations (2-3 a week) by independent observers. If other techniques were needed the result was considered negative. The patients were tested with an NSAID (Diclofenac) and assigned to group 1 if the pain became slight in 3 days. If the response was negative, a 4-day trial with opioids was started. If the pain was slight the patient was included in group 3, otherwise in group 5. Every patient belonging to these groups but with incidentical pain was included in groups 2, 4 and 6, respectively. For each group a subdivision was made according to the pain characteristics. There was a progressive worsening in pain relief in groups 4, 5 and 6, suggesting a good correlation between response to the drugs and future chances of pain control in a period of 2 months. This study demonstrates that incidental pain reduces the possibility of pain control (50%) with the exclusive administration of analgesics in patients with a mean life expectation of about 2 months. This negative influence is counterbalanced by the possible individual response to analgesics administered sequentially during a 1-week period (85.8% good pain relief with NSAID, 74% with opioids).(ABSTRACT TRUNCATED AT 250 WORDS)

Motor cortex stimulation as treatment of trigeminal neuropathic pain.

A report is given on first experiences with motor cortex stimulation in 10 patients with different forms of neuropathic pain. Three of them had central pain as sequelae of cerebrovascular disease. In none of them did the stimulation provide pain relief. Two patients had pain from peripheral nerve injuries. One did not respond, but the other obtained about 50% pain relief. The remaining 5 patients with trigeminal neuropathy experienced definite pain relief varying between 60 and 90%. During test stimulation most patients had one or two short-lasting generalized seizures. But no one had any motor effects after permanent implantation. Motor cortex stimulation appears to be a new and promising possibility of pain treatment, especially in cases with trigeminal neuropathy, but many problems have yet to be solved, before a clear indication could be given.

Pilot study on disposition and pain relief after i.m. administration of meperidine during the day or night.

Two groups (four patients each) of sickle cell anemia patients with severe pain were studied. One group comprised patients admitted to emergency unit in the morning (5:40 to 9:15) and the other patients admitted in the evening (18:53 to 22:50). All patients received intramuscular meperidine (1.5 mg/kg). Pain intensity and pain relief were followed for 4 h; blood samples were taken up to 6 h after drug administration. Significant differences in drug disposition were found between the day and night groups, as the elimination half-life was 46% shorter during the night and the total serum clearance was 70% greater during the night. Whereas a positive correlation was found between drug concentration and pain relief for the day group, no such correlation was found for th night group. Even though peak concentrations were higher during the night, analgesia was lower. This pilot study suggests that much higher meperidine doses might be required during the night to achieve equieffective analgesia.

Anesthetic pain management in Siriraj Hospital: a retrospective review.

Neural blockade has been used as the single method to anesthetize a part of the body or used in combination with general anesthesia to lessen perioperative pain. Currently, nerve blocks are used for diagnostic, prognostic, therapeutic and prophylactic proposes for management of chronic, acute and cancer pain in a Pain Clinic. Reviewing the records of the 3,349 patients at Siriraj Pain Clinic, we found 2,662 and 687 cases had chronic and acute pain problems respectively, and only 646 patients were treated with anesthetic interventions during 1990 to 1998. They consisted of 317 male and 329 female. The techniques included stellate ganglion block, paravertebral nerve block, celiac plexus block, hypogastric plexus block, mesenteric plexus block, sacral nerve block, epidural steroid, lumbar sympathectomy, first and second thoracic sympatholysis, facet joints injection, sacroiliac joint injection, intravenous regional block with guanethidine or ketanserin, continuous opioid infusion, intravenous lidocaine infusion, and a phentolamine test. The common problems of pain included brachial plexus injury, chronic spinal pain, herpetic neuralgia, ischemic pain, central post-stroke pain, and causalgia. This retrospective review showed that 38 per cent of them reported 50 per cent pain relief with temporary effect. 34 per cent experienced good and satisfactory pain relief while 9 per cent reported excellent pain relief. 17 per cent did not gain benefit from any technique of pain relief and about 2 per cent could not be evaluated due to they did not return for follow-up. One serious complication after thoracic sympatholysis was brachial plexus injury. The neural blockade is proven to be one of the useful adjunct in the management of chronic pain but the selection of the technique is subjected to its critical appraisal.