Pain
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While there are increasing demands for improved post-operative analgesia and the implementation of Acute Pain Services (APS), the safety of such an approach remains under discussion. This paper analyses the safety outcome of 3016 consecutive post-operative patients treated under the care of a formalised Acute Pain Service. No serious complication resulting in morbidity or mortality occurred. ⋯ Patient-controlled analgesia (PCA) alone had a significantly lower rate of respiratory depression than PCA with a background infusion or continuous morphine infusion. In 1069 patients receiving continuous regional analgesia (epidural, interpleural, peripheral) no trauma to nervous structures, no infection and no local anaesthetic toxicity occurred. In conclusion, an anaesthesiology-based APS can provide postoperative pain relief using a wide range of relatively invasive techniques without endangering patient safety.
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An experimental arthritis induced by injection of kaolin and carrageenan into the knee joint resulted in a temporal relationship between glutamate dorsal horn content and paw withdrawal latency (PWL) which was positively correlated. Limping, guarding, increased response to heat stimuli (hyperalgesia) and altered staining patterns for glutamate (GLU), substance P (SP), and calcitonin gene-related peptide (CGRP) were monitored in the awake behaving arthritic rat over a 1 week time course. A decrease in PWL occurred on the side ipsilateral to the inflamed knee as early as 4 h after the induction of arthritis indicating the animals are hyperalgesic. ⋯ Rather, there was an increase in CGRP content in the middle portion of the superficial dorsal horn which is the termination site of knee joint afferents. These data indicate that the development of heat hyperalgesia is dependent on GLU and possibly SP. Since inflammation of the knee joint does not involve the foot pad, the heat hyperalgesia observed during the first 24 h following induction of arthritis represents a central neuronal sensitization.
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Over a 3-year period, neurolytic abdominal visceral sympathectomy was performed bilaterally with 15 ml of alcohol solution (14 ml of alcohol and 1 ml of contrast material) through each needle under CT guidance to relieve upper abdominal or back pain in 27 cancer patients. Using the CT monitor, our intention was to achieve splanchnic nerve neurolysis rather than celiac plexus neurolysis. After determining the trajectory for needle placement on the CT image at the L1 level, the needles were inserted bilaterally with a simple guide apparatus. ⋯ It was speculated that the alcohol spread through the aortic hiatus or gaps of the diaphragmatic crura. No neurologic complications were encountered. It is concluded that CT guided alcohol splanchnic nerve neurolysis is an effective treatment for upper abdominal cancer pain, and that 15 ml of alcohol solution through each needle is enough for splanchnic nerve neurolysis.
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In this open, uncontrolled trial, 20 patients with upper trapezius muscle trigger point pain and ipsilateral masseter muscle pain received a single trigger point injection of 2% lidocaine solution (without epinephrine) in the upper trapezius muscle. Following the trapezius injection, there was a significant (P < 0.001) reduction in pain intensity ratings for pain in the masseter region. ⋯ Overall, however, a significant relationship between EMG activity in the masseter and the self-report of pain was not found with the present data set. These clinical findings support the contention that sources of deep pain can produce heterotopic sensory and motor changes in distant anatomical regions.
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Review Case Reports
Reflex sympathetic dystrophy treated by electroconvulsive therapy: intractable pain, depression, and bilateral electrode ECT.
An adult female patient without previous history of pain or psychiatric disorder developed reflex sympathetic dystrophy (RSD) in her left hand and arm after 2 separate injuries, and subsequent arthroscopy and arthroscopic surgery. Traditional management with systemic medications, nerve blocks, and behavioral pain management were unsuccessful. With subsequent development of depression and suicide attempt, electroconvulsive therapy (ECT) was administered using bilateral lead placement. ⋯ A review of the literature from the 1940s revealed numerous cases of chronic, intractable pain treated successfully by ECT, although none of the case series were controlled studies. More recent literature questions if 'modified' ECT, using unilateral lead placement, is less effective than bilateral lead placement, in treating pain syndromes. Resolution of the vascular changes of RSD after ECT raises questions of possible cerebral contributions to the pathophysiology of RSD.