Daniel C. Moore

Abdominal pain and alcohol celiac plexus nerve block

Alcohol celiac plexus nerve blocks were done in 100 patients, of whom 97 had intractable abdominal pain from cancer. In most cases, an initial diagnostic block with bupivacaine was followed by the therapeutic block performed by injecting 50 ml of 50 percent ethyl alcohol. Good to excellent pain relief occurred in 94 percent of patients. Fourteen blocks were repeated for recurrent pain. Life duration ranged from 2 days to 14 months after the block. Complications and side effects were infrequently seen but did include a 10 percent incidence of postural hypotension and 1 case of partial leg paralysis. This block is remarkably safe as well as effective and should be employed more frequently.

Bupivacaine: a review of 11,080 cases.

Bupivacaine (Marcaine®) hydrochloride, a long-acting local anesthetic drug, was used in concentrations of 0.25, 0.5, or 0.75 percent with and without a vasoconstrictor, in amounts ranging from 25 to over 600 mg, for caudal, epidural (peridural), or peripheral nerve block for 11,080 surgical, obstetrical, diagnostic, or therapeutic procedures. Onset of anesthesia occurred in 4 to 10 minutes and maximum anesthesia in 15 to 35 minutes. Concentrations of 0.25, 0.5, and 0.75 percent consistently produced complete sensory anesthesia of the integumentary and musculoskeletal systems. With 0.25 and 0.5 percent, motor blockade ranged from minimal to complete. In intra-abdominal surgery, only 0.75 percent consistently produced profound muscle relaxation. Fifteen systemic toxic reactions occurred, but no untoward sequelae resulted from them. One inadvertent subarach- noid injection of 110 mg resulted in a total spinal block with an uneventful recovery.

Arterial and venous plasma levels of bupivacaine following peripheral nerve blocks.

Mean arterial plasma (MAP) and peripheral mean venous plasma (MVP) levels of bupivacaine were ascertained in 3 groups of 10 patients each for: (1) intercostal nerve block, 400 mg; (2) block of the sciatic, femoral, and lateral femoral cutaneous nerves, with or without block of the obturator nerve, 400 mg; and (3) supraclavicular brachial plexus block, 300 mg. MAP levels were consistently higher than simultaneously sampled MVP levels, the highest levels occurring from bilateral intercostal nerve block. No evidence of systemic toxicity was observed. The results suggest that bupivacaine has a much wider margin of safety in humans than is now stated.

Commentary: neurotoxicity of local anesthetics--an issue or a scapegoat?

Background and Objectives. To evaluate the etiologies of cauda equina syndrome (CES) and transient radicular irritation (TRI) or transient neurologic symptoms (TNSs) following hyperbaric spinal anesthesia. Methods. A review of recent (since 1991) and prior (since 1941) investigations regarding CES and TRI (TNSs) was conducted. Results. Recent publications fail to recognize significant prior information regarding CES and TRI (TNSs). Conclusions. Cauda equina syndrome is, in all probability, explainable. Further investigation to pinpoint the etiology of TRI (TNSs) is needed.

The dreaded complications from neurolytic celiac plexus blocks are preventable

To the Editor: Over the past few years, I have noticed an increasing number of courses aimed at teaching injectional techniques for pain management. Unfortunately, over this same period of time, I have also noticed an increasing number of doctors claiming to be pain physicians. They are able to do a few procedures but do not have training or expertise to truly be qualified as pain-management physicians. What particularly concerns me is the tendency to instruct anybody and everybody who wants to stick a needle in a patient. This tendency is resulting in poorly trained physicians claiming to be pain physicians, overall weakening the quality of pain management. This trend cheapens the specialty as a whole because of decreasing quality of treatment. I have nothing against instructional courses, as I have gone to many myself. I find them quite helpful. However, I do feel the need for restrictions as to who is able to attend, and attendees should provide proof as to degree of qualifications or preliminary training; that is, residency training, fellowship, or board certification. I somehow cannot imagine surgeons allowing anybody who wants to hold a scalpel into a course for the latest surgical technique. Many physicians use these certificates from courses to gain credentials for procedures at their local hospital, although they have never performed anything similar and have no expertise in the specialty. Ultimately, if this trend continues, we will see a pain physician on every corner, we will have a bad reputation in the public eye, and we will find it increasingly difficult to get reimbursement for our work. Now is the time to take a look at ourselves and make sure we are not creating a monster that will eventually be to our own detriment.

Alterations in capillary and venous blood gases after regional-block anesthesia.

LTERATIONS of the circulation after A spinal and epidural anesthesial-6 are primarily due to sympathetic blockade. COcaine is known to act, locally, as a vasoconstrictor; and prilocaine, in higher doses, to cause methemoglobinemia and cyanosis. However, little is known about the direct effect on the vascular bed of other local anesthetic agents beyond the contributions of Kennedy and associates7~8 on the circulatory effects of epinephrine added to local anesthetic solutions.

Bupivacaine compared with etidocaine for vaginal delivery.

A comparison of 0.5 percent etidocaine with 0.25 and 0.5 percent bupivacaine, using continuous (intermittent) caudal block in 60 vaginal deliveries, showed the latter two solutions to be the agents of choice. All solutions contained a final concentration of 1:200,000 epinephrine. In 40 parturients given either 0.25 or 0.5 percent bupivacaine, all had pain relief after the initial dose, while 5 of 20 given etidocaine required a refill dose within 30 to 50 minutes for complete pain relief. The duration of action of the initial dose with both concentrations of bupivacaine was longer than that of etidocaine. The degree of motor blockade with 0.5 percent etidocaine was greater than with 0.5 percent bupivacaine, and with 0.5 percent concentrations of either etidocaine or bupivacaine was greater than with 0.25 percent bupivacaine. The duration of motor blockade of 0.5 percent etidocaine and bupivacaine was comparable. The duration of motor blockade of the 0.25 percent concentration of bupivacaine was shorter than with the 0.5 percent concentration of both etidocaine and bupivacaine; and with both bupivacaine concentrations the duration of sensory anesthesia in the extremities was longer than motor blockade; with etidocaine, the opposite occurred.

A double-blind study of bupivacaine and etidocaine for epidural (peridural) block.

In a double-blind comparison of two long-acting local anesthetic agents, 0.75 percent bupivacaine and 1 percent etidocaine, using epidural block for abdominal hysterectomy, no significant differences occurred in: (1) onset of sensory anesthesia, (2) time for establishment of maximum sensory anesthesia, (3) maximum dermatome level of sensory anesthesia, (4) relaxation of the abdominal musculature, or (5) degree of motor blockade of the extremities.However, the following significant differences between the two agents were noted: (1) satisfactory anesthesia occurred in 24 of 25 patients with 0.75 percent bupivacaine and in only 12 of 25 patients with 1 percent etidocaine; (2) motor anesthesia of the extremities occurred more rapidly with etidocaine; (3) duration of motor anesthesia of the extremities, time for regression of sensory anesthesia, and duration of sensory anesthesia were markedly longer with bupivacaine; and (4) the time from injection of local anesthetic solution into the epidural space until the patient requested a narcotic for pain in the operative site was also longer with bupivacaine.

The Role of Intercostal Block and Three General Anesthetic Agents as Predisposing Factors to Postoperative Pulmonary Problems

N 1933, Prinzmetal and associates1 and I Beecher,* in separate papers, described the hypoventilation seen after upper abdominal operations. Beecher reasoned that this must reflect varying degrees of pulmonary collapse, complete collapse of segments of the lung, or else “atelectasis of small local areas of lung.” Bendixen and coworkers3 drew attention to the drop in Pao, associated with decreased compliance in patients receiving constant-volume ventilation. They felt that shallow tidal volumes led to atelectasis, increased shunting, and impaired oxygenation, which in turn could account for hypoxia in postoperative patients breathing room air, despite normal minute ventilation, especially if pain or central depression by anesthetic agents or narcotic drugs inhibited periodic deep breaths.

Memories of the early years of regional anesthesia for childbirth.

Cleland, MD,* from investigations in cats and ogs at McGill University, Montreal, Canada (1927929) and in humans at the Oregon City Hospital hile in the Department of Physiology, University f Oregon (1930-1932), established conclusively he following. First, the pains of the first stage of abor are transmitted by afferent fibers through the 1th and 12th thoracic roots and those of the secnd and third stages through “certain undeterined sacral roots.” Second, paravertebral block ith local anesthetics of 11th and 12th thoracic erve roots abolishes the pain of the first stage of abor without appreciably affecting the tone of the terus or the degree, frequency, or duration of conractions. Third, the pain of the second and third tages of labor could be abolished by caudal block ithout depressing the tone or contractions of the terus. Lastly, the combination of paravertebral and