John Penning

Reversal of epidural morphine-induced respiratory depression and pruritus with nalbuphine

The effect of nalbuphine on the respiratory depression, pruritus and analgesia induced by epidural morphine was determined in a randomized, prospective, double-blind, placebo-controlled fashion. Twenty ASA physical status I women received 0.1 mg·kg-1 epidural morphine at induction of general anaesthesia for elective total abdominal hysterectomy. Group 1 (n = 14) received 0.3 mg·kg-1 nalbuphine intravenously six hours after the epidural morphine administration. Group 2 (n = 6) received saline. Prior to agent administration, six patients from the nalbuphine group and four patients from the saline group had respiratory depression indicated by a PaCO2 greater than 45 mmHg. After nalbuphine administration the PaCO2 (mean ± SE) decreased from 49.5 ± 1.2 mmHg to 42.5 ± 0.7 mmHg (p < 0.005) while there was no significant change after saline administration. Nine of the 14 patients receiving nalbuphine appeared to become more sedated, despite an improvement in ventilation. Pruritus was antagonized by 0.1 mg·kg-1 nalbuphine (p < 0.006). There was no reversal of analgesia after administration of 0.3 mg·kg-1 nalbuphine.RésuméLes auteurs ont étudié ľeffet de la nalbuphine sur la dépression respiratoire, le prurit et ľanalgésie produits par la morphine administrée par voie épidurale. Ľétude fut conduite à double insu, prospectivement et avec placebo. Vingt patientes ASA I reçurent 0.1 mg·kg-1 de morphine par voie épidurale à ľinduction de ľanesthésie générale pour une hystérectomie abdominale élective. Les patientes du groupe I (n = 14) reçurent 0.3 mg·kg-1 de nalbuphine intraveneusement six heures après ľadministration de la morphine épidurale. Les patientes du group II (n = 6) reçurent du placebo. Avant ľadministration de ces agents, six patientes du premier groupe et quatre du deuxième groupe avaient une dépression respiratoire manifestée par un PaCO2 plus élevé que 45 mmHg. Les patientes furent assignées ľun ou ľautre de ces groupes au hazard. Après ľadministration de la nalbuphine, le PaCO2 fut réduit de 49.5 ± 1.2 mmHg à 42.5 ± 0.7mmHg (p < 0.005) alors qu’il n’y eut aucune amélioration après ľadministration du placebo. Ľamélioration du PaCO2 démontrée après ľadministration de la nalbuphine se manifesta en dépit ďune augmentation du niveau de sédation observé chez ces patientes. Le prurit fût antagonisé par 0.1 mg·kg-1 de nalbuphine (p < 0.006). Ľanalgésie produite par la morphine épidurale ne fût pas antagonisée après ľadministration intraveneuse de 0.3 mg·kg-1 de nalbuphine.

Perioperative use of pregabalin for acute pain-a systematic review and meta-analysis.

Abstract Evidence supporting postoperative pain management using pregabalin as an adjunct intervention across various surgical pain models is lacking. The objective of this systematic review was to evaluate “model-specific” comparative effectiveness and harms of pregabalin following a previously published systematic review protocol. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched from inception through August 2013. Data were screened and single extraction with independent verification and dual risk of bias assessment was performed. Quality of evidence (QoE) was rated using the GRADE approach. Primary outcomes were pain relief at rest and on movement and reduction in postoperative analgesic consumption. A total of 1423 records were screened, and 43 studies were included. Perioperative pregabalin resulted in: 16% (95% confidence interval [CI], 9%-21%) reduction in analgesic consumption (moderate QoE, 24 trials) and a small reduction in the magnitude of pain in surgeries associated with pronociceptive pain. Per 1000 patients, 10 more will experience blurred vision (95% CI, 5-20 more; moderate QoE, 17 trials) and 41 more sedation (95% CI, 13-77 more, 17 trials). To prevent 1 case of perioperative nausea and vomiting, the number needed to treat is 11 (95% CI: 7-28, 25 trials). Inadequate evidence addressed outcomes of enhanced recovery and serious harms. Pregabalin analgesic effectiveness is largely restricted to surgical procedures associated with pronociceptive mechanisms. The clinical significance of observed pregabalin benefits must be weighed against the uncertainties about serious harms and enhanced recovery to inform the careful selection of surgical patients. Recommendations for future research are proposed.

Visualization of a looped and knotted epidural catheter with a guidewire

Purpose: To describe the management of a looped and knotted epidural catheter after analgesia for labour and delivery.Clinical Features: Obstetrical epidural pain relief was provided for a 37-yr old woman in early labour. A 20-gauge Portex® catheter was inserted at the L2 – L3 interspace. Six centimetres of catheter was left in the epidural space. After vaginal delivery the catheter could not be removed. The catheter was leftin situ for 24 hr. Repeated attempts at removal were again unsuccessful. The epidural catheter was not visible with fluoroscopy and it was impossible to inject radiopaque dye into the catheter. However, we successfully advanced a 0.016 inch guidewire through the epidural catheter and radiologically demonstrated a knot and part of a loop. The catheter was removed by an orthopedic surgeon using blunt dissection under local anesthetic from the soft tissue just lateral to the interspinous ligament.Conclusions: A knot can be a rare cause of a trapped epidural catheter. A suggested approach to the trapped lumbar epidural catheter: 1) Gentle traction on the catheter with the patient in various positions and in various degrees of lumbar flexion. 2) Test for catheter patency by injecting sterile, preservative-free, normal saline through the catheter. 3) Radiological imaging to determine if a knot is present and to determine its location, using radiopaque contrast for patent catheters or a guidewire for occluded catheters. 4) The approach to definitive management is based on the position of the knot. This can range from excision under local anesthetic to consultation with a surgical specialty for more invasive retrieval.RésuméObjectif: Présenter la démarche visant à retirer un cathéter péridural retrouvé enroulé et noué après une analgésie pour le travail obstétrical et l’accouchement.Éléments cliniques: Au début du travail, l’analgésie a été administrée par voie péridurale à une femme de 37 ans. On a inséré un cathéter Portex® de calibre 20 dans l’espace entre L2 et L3. Six centimètres de cathéter ont été laissés dans l’espace péridural. Après l’accouchement vaginal, on ne pouvait plus retirer le cathéter. II a donc été laisséin situ pendant 24 h. Les essais subséquents pour le retirer ont assui échoué. Le cathéter n’était pas visible à la fluoroscopie et l’injection de colorant radio-opaque à l’intérieur était impossible. Toutefois, nous avons réussi à y insérer un guide souple de 0,016 pouce et nous avons pu, par radiographie, démontrer un noeud et un début d’enroulement. Le cathéter a été retiré par un chirurgien orthopédiste en utilisant la dissection par clivage, sous anesthésie locale, à partir des tissus mous juste à côté du ligament interépineux.Conclusion: Un noeud peut empêcher, dans de rares cas, le retrait d’un cathéter péridural. Une démarche possible, dans le cas d’un cathéter péridural lombaire bloqué, consiste à: 1) Appliquer une faible traction sur le cathéter, le patient adoptant diverses positions selon différents degrés de flexion lombaire. 2) Tester la perméabilité du cathéter en y injectant un soluté physiologique, stérile et sans agent conservateur. 3) Vérifier, par imagerie radiologique, la présence d’un noeud et en dðerminer la localisation en utilisant des produits de contraste radioopaques, si le cathéter est perméable, ou un guide souple si le cathéter est obstrué. 4) Procéder finalement en se basant sur la position du noeud. Ce qui peut aller de l’excision sous anesthésie locale à la consultation d’un chirurgien spécialisé qui utilisera une technique plus effractive pour retirer le cathéter.

Prevention of epidural morphine-induced respiratory depression with intravenous nalbuphine infusion in post-thoracotomy patients

The efficacy of nalbuphine, an agonistlantagonist opioid, in preventing respiratory depression from epidural morphine analgesia after thoracotomy, was assessed in a randomized double-blind placebo controlled trial. After a standardized general anaesthetic and 0.15 mg· kg− of epidural morphine, patients received a bolus and then a 24 h infusion of nalbuphine (200μg·kg−1 + 50μg·kg−1·−1, 100μg·kg−1 + 25μg·kg−1· hr−1, or 50 μg·kg−1 + 12.5μg·kg−1 ·hr−1) or placebo. Blood gases, analgesia, sedation, side effects, and blood nalbuphine concentrations were assessed every two hours for the next 24 h. Fifty-three per cent of placebo-treated patients had a PaCO2 > 50 mmHg and 89 per cent of these received naloxone. A 200 μg·kg−1 bolus of nalbuphine followed by a 50 μg · kg−1· hr−1infusion achieved a mean steady state blood level of 38.2 ng · ml−1 and prevented CO2 retention greater than 50 mmHg in all but two patients, neither of whom required naloxone. There was no difference in the incidence of side effects among groups, and analgesia appeared to be unaffected by nalbuphine.RésuméUne étude a doubte-insue et avec placebo a été faite pour évaluer la nalbuphine, un opioid agoniste-antagoniste, comme agent prophylactique de la dépression respiratoire subséquente à l’injection épidurale de morphine après une thoracotomie. Après une anesthésie générale uniformisée et une injection épidurale de 0.15 mg · kg−1 de morphine, un bolus suivi d’une infusion de nalbuphine ou placebo pendant 24 heures furent administrés aux patients (soit 200 μ·kg−1 + 50μg·kg−1 hr−1, ou 100μgkg−1 + 25μg·−1· hr−1, or 50μg·kg−1 + 12.5 μg·kg−1hr−1 ou un placebo). Lagazométrie, ranalgésie, la sédation, les effets secondaires, et les niveaux sanguins de nalbuphine furent évalués aux deux heures pendant 24 heures. Cinquante-trois pourcent des patients ayant reçu le placebo eurent un PaCO2 > 50 mmHg et 89% de ces patients eurent besoin de naloxone. Les patients ayant reçu un bolus de 200μg·kg−1 et une infusion de 50μg·kg−1·hr−1 eurent des concentrations sanguines stables de 38.2 ng·mt−1; de plus, aucun de ces patients n’eut besoin de naloxone et tous sauf deux eurent des PaCO2 < 50 mmHg. L’incidence des effets secondaires fut la méme dans tous les groupes el l’analgésie de base de ces patients ne fut pas modifiée par la nalbuphine.

Does nalbuphine reverse opioid obtuned laryngeal reflexes

bronchoscopic suction channel into the pharynx and the larynx. The airway is visualized during the injection to assure adequate delivery of the lidocaine. I f the patient gags when the bronchoscope is passed into the trachea, this is a sign of inadequate airway anaesthesia. Further injection of lidocaine through the bronchoscope, or inhaled aerosolized lidocaine are good options at this point. Superior laryngeal and glossopharyngeal nerve blocks and cricothyroid membrane puncture with lidocaine injection are accepted techniques to use in the older cooperative subject. These techniques are more invasive and should be rarely be necessary. Drs. Oxorn and Whatley should be praised for their thoughtful approach to their patient. They avoided compounding the initial problems with intubation, and they stopped to analyze the case rather than proceeding aggressively.

From the Journal archives: Apparatus for demand analgesia with parenteral opioids: from leading role to supporting cast

As part of the Journal’s 60 anniversary Diamond Jubilee Celebration, a number of seminal articles from the Journal archives are highlighted in the Journal’s 61 printed volume and online at: www.springer.com/12630. The following article was selected on the basis of its novelty at the time of publication, its scientific merit, and its overall importance to clinical practice: Keeri-Szanto M. Apparatus for demand analgesia. Can Anaesth Soc J 1971 18: 581-2. In this article Dr. John Penning presents expert commentary on a prototype patient-controlled analgesia apparatus described by Dr. Keeri-Szanto in the legacy Canadian Anaesthetists’ Society Journal, published in 1971. The prototype utilized a compact, relatively inexpensive syringe driven motor mechanism a system that could be employed with safety, for the first time, on surgical wards.

Acute pain management in an unusual case of psoriasis

To the Editor, We report the acute pain management of a patient with psoriasis who presented to the Emergency Department (ED). The patient has consented to the reporting and publication of this case report. A 40-yr-old patient presented with a four-week history of worsening long-standing psoriasis. She had been recently prescribed adalimumab and subsequently developed acute pustular eruptions on the soles of her feet and palms of her hands. As her symptoms progressively worsened, an adverse reaction to adalimumab was suspected, and the drug was discontinued. The lesions continued to worsen considerably and were associated with increasing pain and blistering. Her pain had been treated until then with doses of combination pills containing acetaminophen and codeine (325 mg and 30 mg, respectively) taken as required, with little relief. She now presented to the ED with excruciating pain and extensive lesions that prevented her from using her feet or hands (Figure). There was no other significant past medical history, chronic pain, or drug or substance abuse. The dermatology service was consulted, and palmoplantar psoriasis (PPP) was diagnosed. They advised that sterile occlusive dressings be applied to the hands and feet and prescribed oral hydromorphone 1-2 mg, as required, for the pain. The patient found that application of the dressing was unbearably painful, and the analgesics were changed to subcutaneous hydromorphone 0.5 mg every three hours. The severe pain continued, preventing her discharge from the hospital. The Acute Pain Service (APS) was then urgently consulted for advice on pain management. The APS team reviewed her history, findings, and investigations. The patient reported a pain score of 9/10 at rest and 12/10 with movement; the pain was often continuous and localized to the palms of the hands and soles of the feet. The quality of the pain was described as tingling with burning or searing, with areas of numbness and itching. She complained of worsening of the pain and altered sensation under the occlusive dressing. On examination she was alert, oriented, and hemodynamically stable but in obviously excruciating pain and severe discomfort. The preliminary diagnosis was neuropathic pain with acute hyperalgesia. The APS prescribed oral acetaminophen 650 mg q4 h, ibuprofen 400 mg q6 h, tramadol 75 mg q4 h, pregabalin 50 mg q8 h, long-acting hydromorphone 3 mg q12 h, and hydromorphone immediate release 2 mg every four hours if required. After the first dose of the drugs and observation for another four hours, the pain score had reduced to 6/10 at rest and 8/10 with activity, and its quality was described as dull aching. The patient was reassured, and it was decided that the medications would be continued for five days. She was advised to maintain a pain diary and wean herself from the hydromorphone. After one week and as the lesions healed, the pain was rated as 3/10 at rest and 5/10 with activity, and she was able to return to her previous level of activity. She took only acetaminophen, tramadol, and pregabalin for another week and was subsequently followed up in the chronic pain outpatient clinic. When followed up six weeks after her ED visit, the lesions had almost completely healed, and her pain was well controlled with the pregabalin 50 mg taken twice daily and tramadol 50 mg as required. Palmoplantar psoriasis is an uncommon form of chronic psoriasis. It affects the palms of the hands and the soles of the feet and appears as chronic flaky patches that crack and bleed. In severe cases, the condition can be disabling as N. Eipe, MD (&) J. Penning, MD The Ottawa Hospital, University of Ottawa, Ottawa, ON K1Y 4E9, Canada e-mail: neipe@toh.on.ca

Bowel Surgery and Multimodal Analgesia: Same Game, New Team?

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