Ahmed Ghaleb

Buprenorphine added to the local anesthetic for axillary brachial plexus block prolongs postoperative analgesia

Background and Objectives Buprenorphine added to local anesthetic solutions for supraclavicular block was found to triple postoperative analgesia duration in a previous study when compared with local anesthetic block alone. That study, however, did not control for potentially confounding factors, such as the possibility that buprenorphine was affecting analgesia through intramuscular absorption or via a spinal mechanism. To specifically delineate the role of buprenorphine in peripherally mediated opioid analgesia, the present study controlled for these 2 factors. Methods Sixty American Society of Anesthesiologists (ASA) P.S. I and II, consenting adults for upper extremity surgery, were prospectively assigned randomly in double-blind fashion to 1 of 3 groups. Group I received local anesthetic (1% mepivacaine, 0.2% tetracaine, epinephrine 1:200,000), 40 mL, plus buprenorphine, 0.3 mg, for axillary block, and intramuscular (IM) saline. Group II received local anesthetic-only axillary block, and IM buprenorphine 0.3 mg. Group III received local anesthetic-only axillary block and IM saline. Postoperative pain onset and intensity were compared, as was analgesic medication use. Results The mean duration of postoperative analgesia was 22.3 hours in Group I; 12.5 hours in group II, and 6.6 hours in group III. Differences between groups I and II were statistically significant (P = .0012). Differences both between groups I and III and II and III were also statistically significant (P < .001). Conclusions Buprenorphine-local anesthetic axillary perivascular brachial plexus block provided postoperative analgesia lasting 3 times longer than local anesthetic block alone and twice as long as buprenorphine given by IM injection plus local anesthetic-only block. This supports the concept of peripherally mediated opioid analgesia by buprenorphine.

Post-dural puncture headache.

Since August Bier reported the first case in 1898, post-dural puncture headache (PDPH) has been a problem for patients following dural puncture. Clinical and laboratory research over the last 30 years has shown that use of smaller-gauge needles, particularly of the pencil-point design, are associated with a lower risk of PDPH than traditional cutting point needle tips (Quincke-point needle). A careful history can rule out other causes of headache. A postural component of headache is the sine qua non of PDPH. In high-risk patients < 50 years, post-partum, in the event a large-gauge needle puncture is initiated, an epidural blood patch should be performed within 24–48 hours of dural puncture. The optimum volume of blood has been shown to be 12–20 mL for adult patients. Complications caused by autologous epidural blood patching (AEBP) are rare.

Are diagnostic lumbar facet injections influenced by pain of muscular origin

Introduction:  Nonradicular low back pain can be a difficult entity to accurately diagnose and treat. Facet joints, muscle, ligaments, and fascia have all been reported to be etiologies of acute and chronic low back pain. However, the facet joint as a source of low back pain is controversial. The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. The purpose of this study was to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections.

Postdural Puncture Headache

Postdural puncture headache (PDPH) has been a problem for patients, following dural puncture, since August Bier reported the first case in 1898. His paper discussed the pathophysiology of low-pressure headache resulting from leakage of cerebrospinal fluid (CSF) from the subarachnoid to the epidural space. Clinical and laboratory research over the last 30 years has shown that use of small-gauge needles, particularly of the pencil-point design, is associated with a lower risk of PDPH than traditional cutting point needle tips (Quincke-point needle). A careful history can rule out other causes of headache. A postural component of headache is the sine qua non of PDPH. In high-risk patients , for example, age < 50 years, postpartum, large-gauge needle puncture, epidural blood patch should be performed within 24–48 h of dural puncture. The optimum volume of blood has been shown to be 12–20 mL for adult patients. Complications of AEBP are rare.

Canister tip orientation and residual volume have significant impact on the dose of benzocaine delivered by hurricaine® spray

Delivered quantities of 20% benzocaine spray (Hurricaine; Beutlich L.P. Pharmaceuticals, Waukegan, IL) are estimated by counting the number of sprays or the spraying time. Because Hurricaine spray supplies a continuous (albeit nonmetered) stream of benzocaine, neither method addresses delivered dose. We hypothesized that dose per time is a function of canister content and orientation. Thirty full canisters of Hurricaine were placed into three equal orientations (upright, inverted, or horizontal). Extrapolating from a full canister, four different estimates of benzocaine residual volume were determined before spraying out the contents (80%, 60%, 40%, and 20% full). Each canister was then sprayed for 10-s intervals, and the quantity delivered was calculated and compared statistically. Upright canisters 100% full emitted more benzocaine than canisters with residual volume 20% full (190 +/- 10 vs 172 +/- 10 mg/s). Inverted canisters emitted significantly less benzocaine from 100% full to residual volume 20% full (188 +/- 14 vs 70 +/- 10 mg/s). Oriented horizontally, two full canisters emitted <76 mg/s benzocaine, contrasted with the remaining eight in that group (186 +/- 20 mg/s). We conclude that the benzocaine (Hurricaine) sprayed in milligrams per second depends on canister content and orientation. When residual volumes diminish, there is a reduction in spraying volume per time. This diminution occurs progressively from larger to smaller residual volumes with canisters oriented horizontally, inverted, or upright. Arbitrary documentation of spraying time bears no relationship to dose delivered. Perhaps affixing an atomization device to a graduated syringe filled with benzocaine will help increase accuracy and precision in dosing.

Impaired Insulin Signaling as a Potential Trigger of Pain in Diabetes and Prediabetes

Chronic sensorimotor distal symmetric polyneuropathy (DPN) is a common neurologic complication of diabetes mellitus. Prevalence of DPN approaches 50% in people living with diabetes, and about 10% of these cases are painful neuropathy.1,2 Like other symptoms of DPN (loss of reflexes or somatic sensations), ‘‘positive’’ symptoms (pain and paresthesias) of DPN have symmetrical distribution and distal-toproximal progression. Nocturnal intensification seems to be another general characteristic of pain in DPN. Otherwise, there is a great variety of individual presentations of this syndrome. Pain may be evoked or spontaneous, persistent or intermittent, and chronic, lasting for years or remitting within 1 year of onset. The persistent, spontaneous pain may be described as superficial or deep, dull, aching, cramp-like, burning, or crushing. The intermittent, chronic pain is frequently perceived as electric-like, shooting, or lancinating. Mechanical allodynia (painful perception of normally nonpainful stimuli) and hyperalgesia (exaggerated pain in response to moderately painful mechanical stimuli) are common types of evoked pain. Paresthesias described in some cases

Cervical spinal cord stimulation for the management of pain from brachial plexus avulsion.

Dear Editor, Almost 80% of patients with brachial plexus avulsion develop chronic pain. The pain can be treated medically or with more invasive surgical procedures. However, in most cases, the pain is resistant to medical treatment and has a high-recurrence rate after invasive procedures like dorsal root entry zone (DREZ) lesioning. Cervical spinal cord stimulation (SCS) is one of the underutilized treatment modalities with several reports of good outcome. We report a case of significant improvement in pain from brachial plexus avulsion injury after implanting a cervical SCS. A 25-year-old male patient was involved in a motor vehicle accident 5 years ago. He suffered from multiple injuries including injury to his right brachial plexus. Magnetic resonance imaging (MRI) showed complete nerve root avulsion from C6 to T1. He lost sensation and motor function below the deltoid in his right upper extremity, however his main debilitating problem was severe chronic pain. He described his pain as burning, stabbing, and sometime like an electric shock, starting at the shoulder and radiating to the arm and his five fingers, with an intensity of 7/10 on a numeric pain rating scale. On examination, he had no sensation or motor function below the deltoid. He was not interested in functional recovery and was only concerned about relieving the pain. Medical management with a combination of an antidepressant, an anticonvulsant, a …

Neurolytic celiac plexus block for pancreatic cancer pain: A review of literature

The effective management of pancreatic cancer pain continues to be a major challenge for patients and clinicians. Up to 80% of patients with advanced pancreatic cancer present with the symptoms of severe pain. One of the most important goals in their management is achieving the highest quality of life throughout the course of disease with effective palliation of pain. Majority of the current data supports the use Neurolytic celiac plexus block (NCPB) and has been shown to be more effective in reducing pain compared with standard pharmacotherapy. NCPBs have led to decreased opioid requirements and related side effects, thus preventing deterioration in quality of life. In this article, we discuss the treatment of pancreatic cancer pain and the advances in techniques of performing NCPB. We also analyzed the incidence of complications and the quality of pain relief with the use of NCPB. NCPB is effective, has a low incidence of complications, and should be used more often in patients with pancreatic cancer pain.

Post-dural puncture headache [Retraction]

[This retracts the article on p. 45 in vol. 5, PMID: 22287846.].

Anesthesia for Shoulder Surgery: A Review of the Interscalene Block and a Discussion of Regional vs. General Anesthesia

A review of the literature regarding anesthesia for shoulder surgery was performed. Current anesthetic tech- niques available include regional, general, or a combination of regional and general. We discuss each of these techniques, with an emphasis on regional (specifically interscalene block), in detail. Current evidence supports both regional and gen- eral anesthesia to be safe and efficient techniques. The interscalene block is considered by most to provide the best surgi- cal anesthesia and is the most commonly performed block for shoulder surgery. This paper aims to review the perform- ance of the interscalene block and to discuss alternative choices for shoulder surgery, namely general anesthesia and a combined general/regional technique. We also aim to provide considerations to aid in the performance of a safely admin- istered anesthetic.