Labor analgesia

Regional analgesia has become the most common method of pain relief used during labor in the United States. Epidural and spinal analgesia are two types of regional analgesia. With epidural analgesia, an indwelling catheter is directed into the epidural space, and the patient receives a continuous infusion or multiple injections of local anesthetic. Spinal injections are usually single injections into the intrathecal space. A combination of epidural and spinal analgesia, known as a walking epidural, also is available. This technique combines the rapid pain relief from the spinal regional block with the constant and consistent effects from the epidural block. It allows sufficient motor function for patients to ambulate. Complications with regional analgesia are uncommon, but may include postdural puncture headache. Rare serious complications include neurologic injury, epidural hematoma, or deep epidural infection. Regional analgesia increases the risk of instrument-assisted vaginal delivery, and family physicians should understand the contraindications and risks of complications. Continuous labor support (e.g., doula), systemic opioid analgesia, pudendal blocks, water immersion, sterile water injections into the lumbosacral spine, self-taught hypnosis, and acupuncture are other options for pain management during labor.     

Percutaneous vertebroplasty: an update.

Percutaneous vertebroplasty is an imaging-guided interventional technique in which surgical polymethylmethacrylate is injected via a large bore needle into a painful compressed vertebral body. This technique is safe and effective, and provides increased strength and pain relief in vertebrae weakened by bone diseases. Among the current indications for vertebroplasty are intractable nonradicular pain caused by compression fractures due to osteoporosis, myeloma, metastasis, and aggressive vertebral hemangioma. Contraindications include bleeding disorder, unstable fracture, and lack of definable vertebral collapse. The preprocedural evaluation, technique, complications, and expected results of performing this procedure are also reviewed.     

Acupuncture in an outpatient clinic in China: a comparison with the use of acupuncture in North America

BACKGROUND: The National Institutes of Health Consensus Panel on Acupuncture has listed as a priority the study comparing indications and patterns of use of acupuncture in different countries. METHODS: I visited an outpatient acupuncture clinic in China and reviewed the clinical files. A MEDLINE search was done to compare the use of acupuncture in North America and China. RESULTS: The most common disorder treated in the clinic was musculoskeletal pain. Less common indications included stroke rehabilitation, Bell's palsy, cholelithiasis, tinnitus, insomnia, migraine, and visceral pain. In North America, acupuncture is primarily for pain relief. Other uses include stroke rehabilitation, various emetic problems, migraine, and various addictions. CONCLUSIONS: Acupuncture is most frequently used in China and North America for pain relief. Other common indications include peripheral nerve palsy, peripheral nerve neuralgia, stroke rehabilitation, psychoemotional disorders, migraine, visceral pain, emesis, asthma, and tinnitus. Acupuncture for cholelithiasis in China but not in the United States suggests a novel use of this modality.     

Vertebroplasty

Abstract: Vertebroplasty is the percutaneous placement of polymethylmethacrylate (PMMA) into vertebral compression fractures for relief of pain. Polymethylmethacrylate is the cement used by orthopedic surgeons for rapid stable fixation of prosthetics in living bone. While the exact mechanism of pain relief is unknown, it is believed that the delivery of the PMMA into the fracture stabilizes the vertebral body, obtaining an analgesic effect. Vertebroplasty is an outpatient procedure that is performed with the aid of fluoroscopy. It has a high benefit/risk ratio with high success rates in comparison to extremely low complication rates. These patients consist of elderly osteoporotic patients that often times have underlying medical conditions or younger patients suffering from steroid or metastatic induced compression fractures. These patients are considered to be poor surgical candidates. In the past, this patient population has been relegated to epidural steroid injections, epidural catheters, or time contingent narcotics to control the pain. These conservative measures often lead to a patient with decreased activities of daily living and uncontrolled pain. Vertebroplasty provides a safe procedure that allows for long-term pain relief, decreased use of medication, and increased activities of daily living. This article is a review of the history, indications, contraindications, and key outcome studies. The technique is described along with complications, preprocedural care, and postprocedural care.     

Physiatric therapeutics. 3. Traction, manipulation, and massage

This self-directed learning module highlights advances in this topic area. It is part of the chapter on physiatric therapeutics for the Self-Directed Medical Knowledge Program Study Guide for practitioners and trainees in physical medicine and rehabilitation. This section discusses physiologic effects of, and indications and contraindications for, traction, manipulation, and massage. Advances covered in this section include hypotheses of pain relief in manipulation.     

Patient-controlled analgesia.

It has become increasingly obvious that traditional narcotic dosage schemes are not optimally effective in relieving pain. Inadequate relief of pain results in increased patient morbidity, probably due to adverse effects on the neurologic, endocrine, pulmonary and cardiovascular systems. Insufficient pain relief also contributes to patient dissatisfaction. Patient-controlled analgesia allows a patient to balance analgesic levels with the degree of pain relief required. This analgesic technique is easy to use and is well accepted by patients, physicians and nurses. Significant benefits include earlier ambulation, decreased overall narcotic use, improved postoperative pulmonary function, shorter hospital stay and reduced health care costs.     

Celiac plexus block in cancer pain management

The neurolytic celiac plexus block (NCPB) has been recommended for pain relief in patients with upper abdominal cancer by the WHO Cancer Pain Relief Program. In this article, we review the indications, techniques, and adverse effects of NCPB based on the previous findings in the literature and our own experience of 142 NCPBs during the past 11 years. No well-validated indication criteria for the NCPB have been available from invasive trials or non-invasive pain evaluations. Thus, the procedure has been employed using comprehensive pain assessment. Several modified approaches have been described for NCPB with differences in the target space where the alcohol is injected (precrural and retrocrural) and the insertion route of the needle (posterolateral and transdiscal). We have used the retrocrural transdiscal approach because of its simplicity and safety. The efficacy of the resultant pain relief does not differ among these techniques. Therefore, whether a distinction exists between blocks of the celiac plexus and those of the splanchnic nerves is controversial. The term "peri-aortic nerve block" may better describe the feature of this neurolytic intervention. The noteworthy adverse effects of alcoholic neurolysis include regional pain, hypotension, diarrhea, hypoxemia, and acute alcoholic intoxication. Most of them are transient and controllable. The diarrhea may counteract the morphine-induced constipation. NCPB relieves visceral pain in upper abdominal cancer with no serious adverse effects. We recommend this procedure to improve the quality of life of the patients suffering from abdominal cancer pain.     

Lumbar and sacral radiofrequency neurotomy

Radiofrequency (RF) neurotomy is an interventional procedure used to alleviate certain types of low back pain. RF energy is used to thermally coagulate the specific nerves that transmit pain signals. Recent evidence has shown that this procedure demonstrates significant efficacy in relieving low back pain in lumbar zygapophysial joints, and research is ongoing to determine if pain relief for the sacroiliac joint is also possible. This article provides an evidence-based background for performing RF neurotomy, discusses the relevant anatomy, and highlights the indications and technique for lumbar and sacral RF neurotomy.     

Prehospital trauma analgesia

This review aims to describe and evaluate current practices and controversies surrounding provision of pain relief in the prehospital setting. The review addresses analgesia indications and contraindications, frequency with which analgesics are used, and factors associated with improved prehospital analgesia care in Emergency Medical Services systems with both physician and non-physician staffing. As part of its evaluation of the state of the art in prehospital pharmacologic treatment of pain, the review will summarize available evidence relevant to the major drugs. Although some situations have been insufficiently studied to allow for definitive data-driven analgesia recommendations, the review will, where possible, include evidence-based recommendations concerning prehospital pain medication.     

Radiofrequency or neuromodulation treatment of chronic pain,when is it useful?

The management of chronic pain is challenging for the patient and the physician. Besides pharmacologic treatment pain therapists dispose of several minimal invasive interventional techniques. When used for the correct diagnosis and under the appropriate conditions, those techniques have been documented to provide pain relief and improve the patient's quality of life. Too often the use of interventional pain management techniques is postponed until all conservative treatment options fail to provide adequate pain relief or cause intolerable side effects. Evidence is starting to accumulate indicating that earlier use in the treatment algorithm may be beneficial for the patient in terms of pain relief, improved functionality and hence improved quality of life. Though little cost-effectiveness studies are available there are indications that the initial costs are recovered by the reduced medical needs. The interventional pain management techniques are commonly classified according to the degree of invasiveness: therapeutic blocks and epidural corticosteroid administration, (pulsed) radiofrequency techniques, spinal cord and peripheral nerve stimulation, motor cortex stimulation and spinal drug administration. In this article the place within the treatment algorithm of chronic pain for (pulsed) radiofrequency and neuromodulation techniques will be discussed.     

Besonderheiten der Behandlung des akuten Schmerzes im Kindesalter

Pain relief in children during the perioperative period can be provided by means of peripherally or centrally acting analgesics or of regional anaesthetic techniques. Narcotics or regional blockde are indicated when peripherally acting analgesics prove inadequate to abolish pain. Side effects of narcotics must be taken into account: opioids must not be administered unless continuous safety monitoring of the child's respiration is assured. If narcotics fail to relieve pain, regional anaesthesia may be indicated. All advantages and drawbacks of the various techniques that might be appropriate must be considered: the technique involving the least risk and side effects is the anaesthetic technique with a broad margin of safety when applied by an anaesthesiologist who has experience with paediatric regional blocks include topical anaesthesia, local infiltration, peripheral nerve blocks (e.g. nervi dorsalis penis, plexus axillaris) and caudal epidural blockade. Caution must be exercised whenever narcotics are administered systemically or epidurally; side effects must not be underestimated, even under conditions of intensive care observation. The provision of effective pain relief is a rewarding task-and particularly in little children.     

Labor epidural anesthetics comparing loss of resistance with air versus saline: does the choice matter?

This study examined whether air or saline, used for the loss-of-resistance (LOR) technique, resulted in a difference in pain relief or adverse events for laboring parturients. Previous studies had mixed findings regarding the onset of analgesia and subsequent pain relief. Research questions were as follows: Is there difference in analgesic onset for patients receiving air vs saline during the LOR technique? Do women receiving the air method for LOR experience any difference in the quality of pain relief from that of women receiving saline? Is there any difference in the incidence of analgesic distribution or segmental pain relief in women receiving the air vs the saline method? Is there any difference in the incidence of adverse effects in women receiving air vs saline during the LOR technique? This was an experimental, prospective study with 50 women. Subjects were randomized to receive air or saline. The visual analogue scale was used to measure pain. A dermatome level recorded the spread of analgesia. No significant differences were found between groups for onset or quality of analgesia. There was a significant increase in the number of subjects who experienced segmental blocks after receiving air during the LOR technique.     

Patient expectations for pain medication delivery

The purpose of this study was to evaluate emergency department (ED) patient expectations for the delivery of pain medication and correlation of satisfaction with meeting patient needs for pain relief. In this prospective survey of 458 ED patients with pain, the patients reported a mean of 23 minutes as a reasonable wait for pain medication versus 78 minutes for the actual delivery of pain medication. Forty-five percent of patients received pain medication and 70% had their needs for pain relief met. Mean satisfaction for patients who had their needs for pain relief met was 83 mm versus 51 mm for patients whose needs for pain relief were not met (P <.001). Patients expect rapid delivery of pain medication after arrival in the ED. Time to delivery of pain medication in this ED does not meet patient expectations. Patients who had their needs for pain relief met were more satisfied with ED care.     

Severe respiratory depression in a patient with gastroparesis while receiving opioids for pain

OBJECTIVE: To increase awareness of the possibility of severe respiratory depression when oral opioids are used in patients with gastrointestinal motility disorders. SETTING: A major county hospital affiliated with a university. PATIENT: A patient with severe pain from diabetic muscle necrosis with a history of gastroparesis. INTERVENTIONS: Attempted pain control with oral and transdermal opioids. RESULTS AND CONCLUSIONS: Pain control in our patient was attempted using potent oral opioids on two occasions. However, this patient suffered severe respiratory depression after each attempt. Transdermal delivery of fentanyl eventually provided satisfactory pain relief without side effects. We conclude that patients with gastrointestinal motility disorders may be at high risk for side effects of oral opioids due to altered absorption kinetics. Suggestions are made for alternative strategies for opiate delivery in patients with gastrointestinal motility disorders.     

Coblation: improving outcomes for children following adenotonsillectomy

Tonsillectomy and adenoidectomy, 2 of the most common childhood surgeries, are performed for a number of indications, the most common being airway obstruction caused by adenotonsillar hypertrophy. Other indications for tonsillectomy include recurrent pharyngotonsillitis, streptococcal carriage, recurrent peritonsillar abscess, halitosis, and presumed neoplasia. Although adenotonsillar surgery is a safe and effective technique for treating disease and obstruction, parents remain concerned about postoperative morbidity, for which the potential is much greater after tonsillectomy than adenoidectomy. Postoperative pain and hemorrhage are 2 unpleasant side effects that can prolong postoperative recovery. Surgeons use a variety of surgical techniques to remove the tonsils and adenoids. When compared with older techniques, such as cold steel dissection and monopolar electrocautery, a new technique named Coblation that uses lower temperatures than electrocautery to remove tonsil tissue and achieve hemostasis, has been shown to reduce pain and decrease postoperative narcotic use, leading to shorter recovery times and a quicker return to normal in children.     

Choice of analgesia in labour on neonatal outcomes,delivery and maternal satisfaction with pain relief

Aim: to examine the use of pethidine, epidural or no analgesia during labour on neonatal outcomes, delivery and maternal satisfaction with pain relief.Design: a prospective cohort study was undertaken in one maternity unit in the East Midlands. Four hundred and seventy-one consecutive women assessed as low risk were recruited to one of three groups depending on their choice of analgesia: pethidine only, epidural only or no analgesia.Outcome measures: neonatal Apgar score at 1 and 5 minutes, base excess/arterial pH, type of delivery and maternal satisfaction with pain relief during labour.Results: results indicated that type of analgesia appeared to have no significant adverse effects on neonatal outcomes, at least in the short term, with the exception of a slight reduction in arterial pH for babies in the pethidine group. Babies born of women who had epidural block had significantly lower Apgar scores at 1 minute compared with babies of mothers who had no analgesia. However, these differences did not persist for Apgar scores at 5 minutes. Women receiving epidural analgesia were significantly more satisfied with their level of pain relief during labour than women in either the pethidine or no analgesia groups. A large proportion of women requested an epidural because of dissatisfaction with the level of pain relief pethidine provided. Women who had epidural block were more likely to need oxytocin augmentation to progress labour, tended to have longer time in labour and were more likely to have instrumental delivery or caesarean section than women in either the pethidine or no analgesia groups.Conclusion: we conclude from our study that while epidural analgesia is an effective method of pain relief, for most women during labour who choose it, it is not without possible side effects on the progress of labour and the delivery. There is a need for good-quality research to investigate the long-term effects of epidural analgesia on mother and infant, as well as research into the relative effectiveness and side effects of opioids that might be used as alternatives to pethidine in the relief of labour pain. In the light of current knowledge, women need to be made aware of the benefits and possible side effects of epidural analgesia and pethidine that might be considered for use during labour.     

The role of spinal opioids in the management of cancer pain

Spinal opioids have dramatically influenced the way intractable pain of malignant origin is managed. To provide optimal pain relief, spinal opioids must be used in the context of a comprehensive cancer pain management treatment plan. The choice of epidural versus subarachnoid route of administration, as well as the specific opioids administered, require assessment of the individual needs of the patient. Factors likely to influence patient selection, including physiologic and behavioral abnormalities that may interfere with the patients' ability to assess pain relief, must be considered. During therapy, side effects must be anticipated and treated aggressively to assure patient comfort and safety. Although the chronic administration of opioids and other drugs into the epidural or subarachnoid space is in its infancy, advances in the pharmacology of spinal drugs and the development of new delivery system technology will probably expand the options available for the relief of cancer pain.     

Epidural narcotics for postoperative pain: nursing implications

The use of epidural narcotics is fast becoming an accepted technique for postoperative pain relief. Reduction of the patient's narcotic requirements, increased movement in bed and cooperation with postoperative exercises are the major advantages of this type of therapy for pain relief. Knowledge of the anatomy and physiology of pain transmission is essential in understanding how narcotics affect the central nervous system and provide pain relief. Nurses should also be knowledgeable about the technical aspects of the procedure for catheter insertion and the narcotics that might be used for postoperative pain relief. Nursing implications for patients receiving epidural narcotics for postoperative pain relief are presented.     

Continuous intrathecal morphine infusion in patients with vertebral fractures due to osteoporosis

OBJECTIVES: Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QOL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side effects. Continuous intrathecal administration of morphine via an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QOL when compared with conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures. MATERIALS AND METHODS: In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QOL, we administered the visual analog scale for pain and the Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side effects and responses to intrathecal therapy. RESULTS: Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as quality of daily life, domestic work, ambulation, and perception of health status, before and after 1 year after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28 mg/d, 7.92 mg/d at pump implantation, and 16.32 mg/d at 1-year follow-up. CONCLUSIONS: Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QOL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side effects with systemic administration of analgesics.     

Satisfaction in childbirth and perceptions of personal control in pain relief during labour

Satisfaction in childbirth is influenced by individual and environmental factors. Of specific interest in this study is the extent to which women feel that they have been able to control what happened to them during labour. The main purpose of this study was to examine the influence of personal control on women's satisfaction with pain relief during labour. A questionnaire-based retrospective study of women's pain experiences within 48 hours of delivery was carried out on the postnatal ward of one teaching hospital in Northern Ireland. One hundred women who had had a vaginal delivery consented to take part in the study. Two main measures were used in the study; personal control in and satisfaction with pain relief during labour. The key finding of this study indicates that feelings of personal control influenced positively the women's satisfaction with pain relief during labour. Demographic and other psycho-social variables had little impact on the women's satisfaction scores. These findings have implications for clinical practice and for the management of maternity services and are discussed.