Chih-Shung Wong

Pre-incisional epidural ketamine, morphine and bupivacaine combined with epidural and general anaesthesia provides pre-emptive analgesia for upper abdominal surgery.

Background: Previous studies have shown that N‐methyl‐D‐asparate (NMDA) receptor antagonists provide a pre‐emptive analgesic effect in humans. This study investigated the benefits of pre‐emptive analgesia for upper abdominal surgery, using pre‐incisional epidural ketamine + morphine + bupivacaine (K+M+B) treatment for achieving postoperative pain relief.

Pre‐medication with intravenous clonidine suppresses fentanyl‐induced cough

Background:  A reflex cough is often observed after an intravenous bolus of fentanyl. This study was conducted to determine whether pre‐treatment with intravenous clonidine could effectively attenuate fentanyl‐induced cough.

Long-term epidural ketamine, morphine and bupivacaine attenuate reflex sympathetic dystrophy neuralgia

PurposeThere is considerable evidence that NMDA receptor antagonists can abolish nociceptor hypersensitivity in animals. In the present case report, two patients with reflex sympathetic dystrophy were treated with ketamine, a NMDA antagonist, morphine and bupivacaine.Clinical featuresTwo patients were referred suffering from severe pain, allodynia, hyperaesthesia, swelling and disability over their right lower legs, diagnosed as reflex sympathetic dystrophy. They had received conventional treatments with non-steroid anti-inflammatory drugs (NSAIDs), steroids, anticonvulsant, antidepressant, epidural lidocaine sympathetectomy and rehabilitation which failed to provide satisfactory pain relief. We administered subanalgesic doses of ketamine (7.5 mg), morphine (0.75 mg) and 6 ml bupivacaine 0.1% via a lumbar epidural catheter three times per day. After several courses of treatment over three and six months, satisfactory pain relief was achieved in each patient. Both are now able to walk with slight weight bearing with the assistance of crutch. The treatment is continuing with further improvement of symptoms and signs.ConclusionEpidural coadministration of low doses of morphine, ketamine and bupivacaine provided effective pain relief in two patients. This suggests synergy from this combination that provides an alternative treatment for reflex sympathetic dystrophy.RésuméObjectifII existe de nombreuses preuves que les antagonistes des récepteurs N-méthyl-D-aspartate (NMDA) peuvent abolir l’hypersensibilité nociceptive chez les animaux. Dans cette présentation de cas, deux patients présentant une dystrophie sympathique réflexe ont été traités avec de la kétamine, un antagoniste NMDA, de la morphine et de la bupivacaine.Éléments cliniquesDeux patients ont été adressés pour dystrophie sympathique réflexe de leur jambe droite distale. Ils présentaient de la douleur sévère, de l’allodynie, de l’hyperesthésie, du gonflement et de l’invalidité du membre. Ils avaient reçu des traitements conventionnels, soit anti-inflammatoires non-stéroïdiens (AINS), anticonvulsivant, antidépresseur, sympathectomie chimique par lidocaïne péridurale et réhabilitation, le tout sans soulagement adéquat de la douleur. Nous avons administré 3 fois par jour des doses subanalgésiques de kétamine (7.5 mg), de morphine (0,75 mg) avec 6 ml de bupivacaïne 0,1 % par un cathéter péridural lombaire. Après plusieurs périodes de traitement réparties sur trois et six mois, un soulagement satisfaisant de la douleur a été obtenu chez chaque patient. Les deux sont maintenant capables de marcher avec mise en charge partielle et assistance d’une béquille. Le traitement se poursuit avec amélioration continuelle des signes et symptômes.ConclusionL’administration concomitante de doses faibles de kétamine, de morphine et de bupivacaïne a entraîné un soulagement efficace de la douleur chez deux patients. Ceci suggère une combinaison synergique qui permet une autre option thérapeutique pour la dystrophie sympathique réflexe.

Preincisional dextromethorphan decreases postoperative pain and opioid requirement after modified radical mastectomy.

PurposeTo examine whether preincisional dextromethorphan (DM) improved analgesia after modified radical mastectomy (MRM).MethodsSixty patients (ASA I–II) scheduled for MRM were included and randomly allocated into two groups. Patients in the treatment group (DM) received 40 mg DM and 20 mg chlorpheniramine maleate (CPM) im, and those in the control group received 20 mg CPMim alone 30 min before skin incision. Meperidine, 1 mg·kg−1im, was given for postoperative pain relief as required. The time to first meperidine injection, total meperidine consumption, worst pain score, bed-rest time, and side effects were recorded every 24 hr for 48 hr after surgery by a resident anesthesiologist on a double-blind basis.ResultsA longer time to first meperidine injection (19.2 ± 1.6vs 1.5 ± 0.23 hr,P < 0.001) and lower meperidine consumption (0[10]vs 75[50] mg, median [interquartile range],P < 0.001) were observed in the DM group than in the control group. The bed-rest time was shorter in the DM than in the control group (18.0[4]vs 23.0[19] hr,P < 0.001). No difference was noted in worst VAS pain score. Meperidine-related side effects (nausea, vomiting, pruritus, dizziness, headache) were more frequent in the control (10/30) than in the DM group (3/30,P < 0.05). The number of patients who required meperidine injection for pain relief was lower in the DM (7/30) than in the control group (25/30,P < 0.005). No DM- or CPM-associated side effects were observed.ConclusionPreincisional IM. DM treatment decreased postoperative pain and opioid requirement after MRM surgery.RésuméObjectifDéterminer si l’administration préincision de dextrométhorphane (DM) améliore l’analgésie à la suite d’une mastectomie radicale modifiée (MRM).MéthodeSoixante patientes (ASA I–II) qui devaient subir une MRM ont participé à l’étude et ont été réparties au hasard en deux groupes. Les patientes du groupe de traitement (DM) ont reçu 40 mg de DM et 20 mg de maléate de chlorphéniramine (MCP)im, et celles du groupe témoin ont reçu 20 mg de MCPim seulement, 30 min avant l’incision cutanée. De la mépéridine, 1 mg·kg−1 im, a été administrée sur demande après l’opération pour soulager la douleur. Ont été enregistrés par un anesthésiologiste en service selon un mode à double insu : le temps écoulé avant la première injection de mépéridine, la consommation totale de mépéridine, la douleur la plus intense, le temps de repos au lit et les effets secondaires.RésultatsUn délai plus long avant la première injection de mépéridine (19,2 ± 1,6vs 1,5 ± 0,23 h,P < 0,001) et une plus faible consommation de mépéridine (0[10]vs 75[50] mg, médiane [étendue interquartile],P < 0,001) ont été observés dans le groupe DM comparé au groupe témoin. Le temps de repos au lit a été plus court dans le groupe DM que dans le groupe témoin (18,0[4]vs 23,0[19] h,P < 0,001). Aucune différence n’a toutefois été notée quant à la douleur la plus intense selon I’EVA. Les effets secondaires reliés à la mépéridine (nausées, vomissements, prurit, étourdissements, céphalées) ont été plus fréquents dans le groupe témoin (10/30) que dans le groupe DM (3/30,P < 0,05). Moins de patientes du groupe DM (7/30) que du groupe témoin (25/30) ont demandé une injection de mépéridine pour soulager la douleur,P < 0,005). On n’a pas observé d’effets secondaires associés au DM ou au MCP.ConclusionL’administration préincision et intramusculaire de dextrométhorphane a réduit la douleur et les besoins d’opioïdes postopératoires à la suite d’une mastectomie radicale modifiée.

Analgesic effects of preincisional administration of dextromethorphan and tenoxicam following laparoscopic cholecystectomy

Background:  Pre‐incisional treatment with either N‐methyl‐D‐aspartate (NMDA) receptor antagonists or non‐steroidal anti‐inflammatory drugs (NSAIDs) improves postoperative pain relief. This study examines the effect on postlaparoscopic cholecystectomy (LC) pain of a combination of dextromethorphan (DM), a NMDA‐receptor antagonist, and tenoxicam, a NSAID, given preoperatively.

Overview of Collateral Meridian Therapy in Pain Management: A Modified Structured Formulated Chinese Acupressure

Collateral meridian therapy (CMT) is a recent developed technique according to the traditional Chinese medicine (TCM) experiences; it differs from traditional Chinese acupuncture (TCA) in many ways. In addition to TCA, CMT offers an alternative for different types of pain management. This article introduces the theory of CMT, acupoints localization, general treatment protocol principle, and some published reports. CMT is developed by Dr. Shan-Chih Ko, he combined the TCM and Western medicine, by using two-point acupressure technique, manipulating the control C-point and treatment functional F-point. CMT differs from TCA in three major points. CMT follows a standard formulated treatment protocols, instead of individual experiences in TCA. Secondly, CMT is based on a two-point acupressure maneuver on the C-point and F-point rather than manipulation of a single point as advocated by TCA. The third, CMT provides a standard set of 108 acupoints, instead of 361 in TCA. It allows redistribution of body energy, ”Qi”, from one meridian to another in order to augment or remove the unbalanced ”Qi”. CMT has been used effectively in our pain clinic to treat musculoskeletal pain and even intractable pains. Dr. Ko simplifies the theory and technique that makes CMT easy to learn and perform, by using English letters, it can be used world-widely. The role of CMT in pain management is promising for both acute and chronic pains. Randomized controlled trials are needed to strengthen its scientific evidence.

Ketamine-induced emergence reactions after desflurane anaesthesia.

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Epidural clonidine for tka postoperative analgesia — a dose finding study

Introduction: The aim of this double-blind randomized study was to evaluate the optimal epidural dose of clonidine administrated after total knee arthroplasty (TKA).1 The optimal epidural dose was defined as that providing minimal analgesic request, stable hemodynamic profile, and a minimal side effect during 72 h after surgery. Methods: This double-blind study was approved by our Institutional Review Board. Written informed consent was obtained from all patients in the study. Eighty adult patients, ASA physical status I-III, undergoing TKA were included in the study. All the patients were randomly assigned to one of four study groups (C0, C1, C2, C4), 20 patients each. After surgery, group C1, C2 and C4 patients received patient-controlled epidural analgesia (PCEA) with morphine (0.1 mg/mL) and clonidine (1, 2, 4 μg/mL, respectively) in 0.2% ropivacaine 100 mL, while group C0 patients received only PCEA morphine (0.1 mg/mL) and 0.2% ropivacaine for postoperative control. Pain relief was evaluated by the total PCEA consumption and visual analog scale. Systolic blood pressure (SBP), heart rate (HR), sedation, and sensory and motor blockade were also recorded during the 72 h postoperatively. The degree of knee flexion also record daily until discharge. Results: Group C0,C1, C2 and C4 patients requested 71.8±19.5, 49.6±12.3, 48.1±9.3 and 39.4±9.0 mL respectively. Patients in the clonidine groups experienced less postoperative pain during the 72 hours after surgery. There was no significant different among groups in SBP, HR, and degree of knee flexion. In C4 group, there were four patients had prolonged sensory blockade and one patient had both severe sedation and prolonged sensory motor blockade. Discussion: The concentration of clonidine 1 μg/mL mixture with morphine and ropivacaine has to be considered the optimal epidural dose. The higher dose of epidural clonidine (4 μg/mL) produced the best analgesia but the degree of sedation and sensory blockade were more severe and longer lasting; it required careful monitoring of the patient.

Dextromethorphan in the Management of Acute Postoperative Pain, a Review

Dextromethorphan (DM) is a well known N-methyl-D-aspartate (NMDA) receptor antagonist and has a long history of clinical safety as an antititussive drug for 5 decades. The discovery of the N-methyl-D-aspartate (NMDA) receptor and its links to pain processing and spinal neural hyper-excitability provoked renewed interest in DM as a potential post-operative analgesic drug. This paper reviews the use and results of DM in the management of acute postoperative pain. Animal studies show that NMDA receptor antagonists may prevent induction of spinal hyper-excitability and development of central excitability. The previous review article by McCartney et al. showed that DM can produce significant preventive analgesia in 67% of DM studies reviewed. A preventive analgesia may reduce central sensitization induced by perioperative inputs. The efficacy of preventive analgesia is demonstrated as a reduction in postoperative pain intensity and/or analgesic use exceeds the expected clinical duration of action of the target preventive drug. Studies show that oral route or low doses of DM correlated with poor analgesia. In addition, DM administered parenteral routes (IM or IV) provided superior analgesia postoperatively with reduction of acute postoperative pain and analgesic consumption. The literature reviews suggest that postoperative pain control can be improved with the perioperative proper usage of DM as an adjunct to opioids, NSAIDs and local anesthetics in patients receiving various surgeries. The enhanced perioperatively analgesic effects of DM with negligible side effects appear to depend on the route of administration (oral, IV. or IM) as well as proper dosages (oral 90mg, IM 40mg, IV 0.5mg/kg).