Katsushi Doi

Intercostal nerve block with 5% tetracaine for chronic pain syndromes

Treating chronic pain syndromes is always challenging. We describe an effective use of an intercostal nerve block using 5% tetracaine in three patients with postherpetic intercostal neuralgia or postoperative intercostal neuralgia.

Lumbar sympathetic block for pain relief in two patients with interstitial cystitis

Background and Objectives Interstitial cystitis (IC) is characterized clinically by lower abdominal pain, pain during urination, and increased frequency of urination. Treatment of the symptoms in IC remains challenging. We report effective treatment using lumbar sympathetic block for 2 patients with IC. Case Report A 63-year-old and 78-year-old woman were diagnosed with IC. Medical therapy with nonsteroidal anti-inflammatory drugs (NSAID), anticholinergics, and hydrodistention of the bladder failed to improve their symptoms. Subsequently, a continuous lumbar epidural block using 1% mepivacaine was used in these patients. A transient reduction of the symptoms in both patients was achieved. A lumbar sympathetic block with a neurolytic agent produced almost complete, and long-lasting relief of their symptoms. Conclusion Lumbar sympathetic block using a neurolytic agent produced long-lasting pain relief in 2 patients with IC.

Breath-holding spells in somatoform disorder.

Breath-holding spells (BHS) are commonly seen in childhood. However, there are no case reports of BHS occurring in adolescents or young adults. We report two young adult cases and discuss the pathogensis, both physically and psychologically. BHS occurred for 1–2 minutes after hyperventilation accompanied by cyanosis in both cases. Oxygen saturation was markedly decreased. Each patient had shown distress and a regressed state psychologically. These cyanotic BHS occurred after hyperventilation, and we considered that a complex interplay of hyperventilation followed by expiratory apnea increased intrathoracic pressure and respiratory spasm. Breath-holding spells can occur beyond childhood.

Anesthetic management for a patient with Jansky-Bielschowsky disease

PurposeTo describe the anesthetic management of a patient with Jansky-Bielschowsky disease (JBD), the late infantile form of neuronal ceroid lipofuscinosis, characterized by dementia, severe and drug resistant grand mal, myoclonic seizures, and blindness.Clinical featuresA 14-yr-old girl with JBD was scheduled for resection of a gingival tumour and an infected sinus in the sacral area. Her preanesthetic examination revealed extreme muscle atrophy and dementia. Grand mal, myoclonic seizures, and upper airway obstruction were frequent. Followingiv induction with thiamylal, anesthesia was maintained with sevoflurane, N2O and O2. Her trachea was intubated without using muscle relaxants. Muscle relaxants were not used during the operation. Apart from an intractable hypothermia, the intraoperative course was uneventful. The emergence of anesthesia was smooth, except for persisting seizures.ConclusionGeneral anesthesia using thiamylal and sevoflurane provided satisfactory conditions during operation in a patient with JBD. Intraoperative hypothermia required particular attention.RésuméObjectifDécrire l’anesthésie d’une patiente atteinte d’idiotie amaurotique de type Bielschowsky (IAB), la forme infantile tardive d’une lipofuscinose céroïde neuronale, caractérisée par de la démence, un grand mal sévère et pharmacorésistant, des crises myocloniques et de la cécité.Éléments cliniquesUne fillette de 14 ans atteinte d’IAB était opérée pour la résection d’une tumeur gingivale et une infection d’un sinus de la région sacrée. L’examen préanesthésique a révélé une amyotrophie extrême et de la démence. Le grand mal, les crises myocloniques et l’obstruction des voies aériennes supérieures étaient fréquents. Induite avec du thiamylal iv, l’anesthésie a été maintenue avec du sévoflurane, du N2O et de l’O2. L’intubation endotrachéale s’est faite sans myorelaxants, et ces derniers n’ont pas été utilisés pendant l’opération. Mis à part l’hypothermie réfractaire, l’opération s’est déroulée sans incident. Le retour à la conscience a été calme, sauf pour des convulsions persistantes.ConclusionL’anesthésie générale au thiamylal et sévoflurane est satisfaisante pendant l’opération d’une patiente atteinte d’IAB. L’hypothermie peropératoire exige une attention particulière.

Prophylactic Pentazocine Reduces the Incidence of Pruritus After Cesarean Delivery Under Spinal Anesthesia With Opioids: A Prospective Randomized Clinical Trial.

BACKGROUND: The incidence of pruritus after cesarean delivery under spinal anesthesia with opioids is high, ranging from 50% to 100%. Pruritus is difficult to prevent; however, pentazocine has been shown to be an effective treatment. Despite this, the prophylactic effect of pentazocine on pruritus has not been defined. This randomized double-blind trial aimed to evaluate the effect of intraoperative IV pentazocine on the incidence of opioid-induced pruritus within the first 24 hours after administration of neuraxial opioids. METHODS: We obtained institutional review board approval and written informed consent from the 122 patients (American Society of Anesthesiologists [ASA] physical status II; aged 20–40 years) scheduled for elective cesarean delivery who were included in this study. Spinal anesthesia was performed with 10 mg of 0.5% hyperbaric bupivacaine, 10 &mgr;g of fentanyl, and 100 &mgr;g of morphine. After delivery of the baby and placenta, the parturient women were randomized to intravenously receive 15 mg (1 mL) of pentazocine or 1 mL of saline. All women received postoperative analgesia with the epidural infusion of 0.15% levobupivacaine. The presence of pruritus within the first 24 hours after intrathecal administration of opioids was recorded, and severity of itch, numerical rating scale (NRS) for pain, and adverse effects were also recorded at the time of the arrival on the ward, as well as 3, 6, 12, and 24 hours after the intrathecal administration of opioids. RESULTS: A total of 119 women completed the study. IV pentazocine reduced the overall incidence of pruritus within the first 24 hours compared to IV saline, with an estimated relative risk of 69% (95% confidence interval [CI], 52%, 90%; P = .007). IV pentazocine also reduced the severity of pruritus. The incidence of nausea and vomiting was not significantly different. There were no significant differences in postoperative NRS scores. CONCLUSIONS: A single 15-mg dose of IV pentazocine after delivery can reduce both the incidence and severity of pruritus in women who have received subarachnoid opioids during cesarean delivery.

Preoperative epidural fentanyl reduces postoperative pain after upper abdominal surgery

Forty patients, American Society of Anesthesiology (ASA) physical status 1–2, undergoing subtotal gastrectomy were enrolled in this study. The patients were allocated to two groups with or (group P) and without (group C) preoperative epidural fentanyl 100 µg. Postoperatively, all patients received continuous infusion of the study solution, containing fentanyl 30 µg·ml−1 and 2 mg/ml bupivacaine, at a rate of 0.7 ml·h−1 for 72 h. The scores on the Prince Henry Hospital self-assessed pain scale (PHPS) were recorded at 0, 4, 12, 24, 48, and 72 h after the surgery. We compared the total rescue doses of analgesics during each period of 24 h until 72 h postoperatively. Although the total rescue doses of analgesics were not different between the groups, the median PHPS score was lower in group P than in group C, except at 0 h after the surgery. Preoperative epidural fentanyl 100 µg may increase the analgesic potency of postoperative epidural low-dose infusion of bupivacaine with fentanyl.

Evaluation of peripheral nerve function using current perception threshold in the herpes zoster patients and the development of post-herpetic neuralgia

Abstract Background: We performed this study to evaluate peripheral nerve function in patients with herpes zoster (HZ) using current perception threshold (CPT) and to compare results between patients who developed post-herpetic neuralgia (PHN) and those who did not. Methods: With Institutional Review Board (IRB) approval and informed consent, 27 patients with HZ were enrolled in the study. At the first visit, all patients were examined clinically and neurophysiologically. CPTs were determined at stimulus frequencies of 2000, 250, and 5 Hz in the affected region and in the contralateral site. Patients were re-examined 6 months after the onset of their symptoms. Patients who still had pain were defined as PHN patients and the others as non-PHN patients. Results: CPT values in affected areas were significantly higher than those in unaffected areas. Thirteen patients were included in the PHN group, and 14 patients in the non-PHN group. Visual analogue scale (VAS) values at the first visit were significantly h...

Characteristics of µ opioid receptor internalization caused by fentanyl in the rat spinal dorsal horn

Introduction: μ-opioid receptor (MOR) internalization is caused by (DAMGO) and etorphine, but not by morphine in vitro and in vivo. MOR internalization caused by fentanyl is demonstrated only in vitro. The relationship between MOR internalization and analgesic effect caused by fentanyl has not been studied. In addition, the role of MOR internalization caused by opioid agonists in the analgesic effect in vivo has not been well established. In the present study, therefore, we examined whether fentanyl causes MOR internalization in vivo or not and also studied the relationship between MOR internalization and analgesic effect of opioid agonists. Methods: The protocol was approved by our animal research and use committee. Male SpragueDawley rats weighing 300–330 g were implanted with intrathecal catheters at the level of L4–5. Tail flick test was performed at 30 min after intrathecal administration of morphine, DAMGO, fentanyl, or saline. Immediately after the test, rats were perfused and the spinal cord was removed. MOR distribution was assessed by immunohistochemical staining of MOR in the dorsal horn neurons. Results: The opioid agonists exerted analgesic effect assessed by tail flick test at 30 min after injection. In morphine treated rats, no MOR internalization was observed in the laminae I and II neurons of the spinal cord, as was seen with saline. DAMGO caused MOR internalization in almost all of the neurons expressing MOR. Though fentanyl also produced internalization in the laminae I and II neurons, the internalization was observed in approximately half of the neurons expressing MOR, and the distribution of internalized MOR was different from that induced by DAMGO. Conclusion: Intrathecally administered fentanyl caused MOR internalization in the rat spinal dorsal horn neurons. MOR distribution showed different patterns depending on opioid agonists used. These results suggest that the MOR internalization does not seem to be involved in analgesic effect produced by opioid agonist.