Chronic Cancer-Related Pain: Continuous Perineural Infusion of Local Anesthetics as Alternative to Systemic Analgesic Drugs

Pain is a major concern for patients suffering from cancer. Although opioid drugs remain the gold standard for treatment of pain, little is known about the interest of continuous analgesia techniques as alternative. The aim of the present article is to detail the feasibility and to present the diversity of continuous perineural infusion of local anesthetic. A series of five patients suffering from different cancer-related pain is presented. A continuous perineural block was proposed to patients presenting with unbearable pain in an area innervated by a plexus or a nerve despite parenteral analgesic pharmacotherapy. All blocks were performed in a surgical theatre under sterile conditions. An initial bolus dose with 3.75 mg/mL ropivacaine was injected followed by a continuous infusion of 2 mg/mL of ropivacaine. Patient-controlled perineural analgesia was started at home by a nursing network. The technique, the efficacy, and the side effects were reported. Complete pain relief was noted 15 minutes after local anesthetic injection in the five cases, and efficacy was maintained during the following days at home, with no other analgesic treatment required. One patient restarted working a few weeks after catheter insertion. The catheter duration lasted for 12 to 110 days. One catheter was removed because of local anesthetic leak at the puncture point. Some paresthesia was noted in one patient. No other side effect was noted. No infection was reported. In selected patients, continuous perineural infusion of local anesthetics appears to be an attractive alternative to parenteral opioids for cancer-related pain. Further investigation is warranted to better define the place of these techniques in the armamentarium of cancer-related pain treatment.     

Ultrasound‐Guided Transversus Abdominis Plane Catheter for Chronic Abdominal Pain

Abstract Background and Objectives: Neural blockade of the thoracolumbar nerves supplying the anterior abdominal wall through transversus abdominis plane (TAP) has been investigated for different applications mainly for the acute pain management following abdominal surgical procedures. The role of this block for chronic pain syndromes is still to be discovered, and its value in chronic abdominal pain needs to be studied. We are presenting new application of the TAP technique for management of chronic abdominal pain syndrome using the continuous infusion. Case report: We present a case of an 18‐year‐old girl who underwent an uneventful laparoscopic cholecystectomy. Postoperatively, patient complained of chronic pain at the site of the surgery. All diagnostic and imaging studies were negative for a surgical or a medical cause. Multiple interventions including epidural blocks, transcutaneous electrical neural stimulation, and celiac plexus blocks had failed to relieve the pain. After discussion with the patient about the diagnostic nature of the procedure and the likelihood of recurrence of pain, TAP block was performed on the right side with significant improvement of pain for about 24 hours. The degree of pain relief experienced by the patient was very dramatic, which encouraged us to proceed with an indwelling TAP catheter to allow for continuous infusion of a local anesthetic. The patient was sent home with the continuous infusion through a TAP catheter for 2 weeks. From the day of catheter insertion and up to 9 months of follow‐up, patient had marked improvement of her pain level as well as her functional status and ability to perform her daily activities, after which our acute pain team stopped following the patient. Conclusion: A successful TAP block confirmed the peripheral (somatic) source of the abdominal pain and provided temporary analgesia after which an indwelling catheter was inserted, which provided prolonged pain relief.     

Continuous peripheral nerve blocks in acute pain management

Continuous peripheral nerve block techniques offer many benefits for the surgical patient in terms of target-specific pain control and avoidance of opioid-related side effects. There are many acceptable techniques for perineural catheter placement and infusion management, and practitioners are encouraged to obtain specialized training to develop a consistent practice and ensure patient safety. Emerging technology in ultrasound guidance may offer advantages in perineural catheter insertion accuracy and procedural efficiency. Various infusion devices are available that permit delivery of a basal rate and patient-controlled bolus for use in the event of breakthrough pain. A successful outpatient continuous peripheral nerve block program should include thorough patient education, detailed written instructions, daily telephone follow-up, and contact information for a healthcare provider familiar with these techniques who can answer questions and intervene when necessary.     

16. Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The disease is often therapy resistant, the natural course not always favorable. The diagnosis of CRPS is based on signs and symptoms derived from medical history and physical examination. Pharmacological pain management and physical rehabilitation of limb function are the main pillars of therapy and should be started as early as possible. If, however, there is no improvement of limb function and persistent severe pain, interventional pain management techniques may be considered. Intravenous regional blocks with guanethidine did not prove superior to placebo but frequent side effects occurred.Therefore this technique receives a negative recommendation (2 A–). Sympathetic block is the interventional treatment of first choice and has a 2 B+ rating. Ganglion stellatum (stellate ganglion) block with repeated local anesthetic injections or by radiofrequency denervation after positive diagnostic block is documented in prospective and retrospective trials in patients suffering from upper limb CRPS. Lumbar sympathetic blocks can be performed with repeated local anesthetic injections. For a more prolonged lumbar sympathetic block radiofrequency treatment is preferred over phenol neurolysis because effects are comparable whereas the risk for side effects is lower (2 B+). For patients suffering from CRPS refractory to conventional treatment and sympathetic blocks, plexus brachialis block or continuous epidural infusion analgesia coupled with exercise therapy may be tried (2 C+). Spinal cord stimulation is recommended if other treatments fail to improve pain and dysfunction (2 B+). Alternatively peripheral nerve stimulation can be considered, preferentially in study conditions (2 C+).     

Prolonged relief of neuralgia after regional anesthetic blocks. A call for further experimental and systematic clinical studies.

Thirty-eight consecutive patients with neuralgia after peripheral nerve injury were treated with one or two series of peripheral local anesthetic blocks. All patients experienced an initial total relief of ongoing pain for 4-12 h. Evoked pain (hyperalgesia or allodynia), which occurred in 17 patients, was blocked simultaneously with the spontaneous pain. In 18 patients the analgesia outlasted the conduction block and there was a period of complete pain relief of 12-48 h in 13 patients and of 2-6 days in the other 5. In 8 patients there was a second phase of analgesia of 4 h to 6 days duration occurring within 12 h of pain recurrence. Thus, mono- or biphasic prolonged complete analgesia occurred in 25 out of 38 patients. A prolonged analgesia may be the result of a central action of the local anesthetic at the spinal level after intra-axonal incorporation and centripetal axoplasmic transport. To test this hypothesis, an experimental study with [3H]lidocaine was performed in 6 rats. The radioactive local anesthetic was injected into one hind limb foot with the other side serving as a control. Tissue samples from the peripheral nerve, nerve root and the lumbosacral spinal cord segment were analyzed for radioactivity using a scintillation counter technique at various time intervals after the [3H]lidocaine injection. There was a low grade of activity in all samples and no difference between the test side and the control side. Thus these experiments provided no evidence in support of this hypothesis. Various alternative peripheral and central mechanisms are discussed. Further studies specifically directed to these alternatives and with longitudinal controls are prompted.     

Continuous peripheral nerve block for ambulatory surgery. (Duke University, Durham, NC) Reg Anesth Pain Med 2001;26:209–214.

In this study data was prospectively gathered for 1 year from 228 patients in an ambulatory surgery center. All continuous peripheral nerve blocks (CPNB) were performed using the Contiplex system to provide anesthesia and postoperative analgesia. CPNB were performed using 5 upper and lower extremity techniques. Postsurgery local anesthetic was infused and at 24 hours, a rebolus of local anesthetic was performed. The CPNB catheter was removed and patients were examined for a loss of sensation. Patients were then discharged. The initial peripheral block was successful in 94% of the patients. Failed nerve block requiring general anesthesia occurred in 6%. The catheter was patent and functional in 90% of the patients at 24 hours, and 8% of the patients required more than 10 mg of intravenous morphine by 24 hours postsurgery. In the postanesthesia care unit, only 4 patients (1.7%) required treatment for nausea. At 24 hours and 7 days postsurgery, no patient reported a dysesthesia. Conclude that CPNB using the insulated Tuohy catheter system offered acceptable anesthesia and prolonged pain relief postsurgery. There were few side effects. Comment by Alan David Kaye, M.D., Ph.D., Erin Bayer, M.D. This study demonstrates the efficacy of the Contiplex system (CPNB) in providing surgical anesthesia and postoperative analgesia through CPNB. Despite the efficacy of CPNB, which could provide longer duration of postoperative analgesia than single injection block, it is not widely used due to lack of available equipment. Contiplex system utilizes a connector for a nerve stimulator attached to a 18‐gauge Tuohy needle. It allows for aspiration of blood, injection of local anesthesia and passage of a peripheral nerve catheter. This study demonstrated in an ambulatory surgery center with 228 patients, CPNB was used for 27 different types of surgical procedures which involved 5 different block sites. Success rates were 94% for initial peripheral block while 6% required general anesthesia. Patients required less postoperative analgesia. The incidence of postoperative side effects such as nausea and vomiting were minimal. Not a single patient reported dissatisfied with a 7‐day telephone follow‐up. A disadvantage of this technique is the use of an 18‐gauge needle and potential for vascular and/or nerve injuries, which did not occur in this study. Though previous studies have demonstrated the efficacy of the CPNB in inpatients, this is an important study focused on outpatients. A larger study group will be valuable in future studies.     

Monitoring of skin conductance in anesthesiology and intensive care

The purpose of the study is to examine the efficacy and safety through the introduction of a local anesthetic wound irrigation catheter for continuous postoperative analgesia in newborns. The study was conducted during the postoperative period of 33 full-term newborns. In the study group (n = 15), analgesia was carried out through the wound catheter with infusion of local anesthetic, for the control group (n = 18) continuous intravenous infusion promedol was used. The effectiveness of postoperative analgesia was rated by CRIES postoperative pain control scale, monitoring of skin conductance, cardiointervalogram and hormone level control in the blood. The study showed that the use of wound catheter for continuous postoperative analgesia with local anesthetics provides effective level of analgesia in newborns, which is comparable with the introduction of opioid analgesics. There were no severe postoperative complications. The method of analgesia by administering a local anesthetic through the wound catheter can be recommended for postoperative analgesia in newborns, especially during major surgeries.     

An anesthetic approach to amputation and pain syndromes

Primary anesthetic intervention is a very effective modality in the prevention of phantom limb pain. The first phase is reduction of the preamputation pain by epidural or intrathecal infusion with local anesthetic and opioid. The catheter can be used for the operative phase, along with an intraneural catheter placement, if necessary. The epidural/intrathecal infusion can continue for 2 to 3 days and eventually be converted to a pharmacologic regimen. This can include opioids for surgical pain, along with a tricyclic antidepressant and an alpha-2 adrenergic agonist. If phantom sensation or phantom limb pain develops, gabapentin (Neurontin) is an effective agent for neuropathic pain. Surgical ablative therapy consists of cordotomy, rhizotomy, dorsal root entry zone lesion, or thalamotomy. Other modalities include dorsal column stimulation to facilitate inhibitory descending pathways. An intrathecal delivery system can be placed to infuse clonidine, local anesthetic, and opioid. For pain management, implantable intrathecal delivery systems may become an important tool for the future management of postamputation pain syndrome.     

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.     

Ultrasound‐Guided Continuous Superficial Peroneal Nerve Block below the Knee for the Treatment of Nerve Injury

(CRPS) describes a constellation of symptoms including pain, trophic changes, hyperesthesia, allodynia, and dysregulation of local blood flow often following trauma. It is often confined to the extremities. Treatment of this disorder consists of a variety of modalities including systemic pharmacotherapy, local anesthetic injections or infusions, psychological nonpharmacotherapy, physical rehabilitation, and surgical intervention. Chronic pain not related to CRPS can also be treated with similar interventions. Despite the array of available therapies, it can still be difficult to manage. We report a case of a 19‐year‐old patient diagnosed by her surgeon as having CRPS Type II, secondary to foot trauma, which was treated with a continuous infusion of local anesthetic at the superficial peroneal nerve (SPN). While placement of peripheral nerve block catheters to augment chronic pain therapy is not novel, the application of a perineural catheter at the SPN has not been previously described.     

Nurse Practitioner-Administered Chloroprocaine in Children with Postoperative Pain

Background: Pain is a complex physical and emotional experience. Therefore, assessment of acute pain requires self-report when possible, observations of emotional and behavioral responses and changes in vital signs. Peripheral nerve and epidural catheters often provide postoperative analgesia in children. Administration of chloroprocaine (a short acting local anesthetic) via a peripheral nerve or epidural catheter allows for a comparison of pain scores, observations of emotional and behavioral responses and changes in vital signs to determine catheter function. Aims: The aims of this study are to describe the use chloroprocaine injections for testing catheters; patient response; and how changes to pain management are guided by the patient response. Methods: This study describes the use of chloroprocaine injections to manage pain and assess the function of peripheral nerve or epidural catheters in a pediatric population. We examined 128 surgical patients, (0-25 years old), who received chloroprocaine injections for testing peripheral nerve or epidural catheters. Patient outcomes included: blood pressure, respiratory rate, heart rate and pain intensity scores. Results: There were no significant adverse events. The injection guided intervention by determining the function of regional analgesia in the majority (98.5%) of patients. Discussion: Chloroprocaine injections appear to be useful to evaluate functionality of peripheral nerve and epidural catheters after surgery in a pediatric population.     

神经刺激器引导用于臂丛神经阻滞及术后镇痛研究

目的 观察神经刺激器定位下经斜角肌间沟留置导管用于持续臂丛神经阻滞及术后镇痛的临床效果和可行性。方法 ASAⅠ～Ⅱ级上肢手术患者60例。随机分为套管针组（A组）和留置导管组（B组），每组30例。A组患者用20G静脉穿刺套管针行常规方法臂丛神经阻滞留置，B组患者在周围神经刺激器引导下穿刺置入专用的柔软导管，手术结束后两组患者均连接一电子镇痛泵行持续术后臂丛神经阻滞镇痛。结果 术中需辅助用药患者两组无统计学差异（P〉0．05）。A组患者术后镇痛失败率达23．3％，B组无镇痛失败患者，两组比较差异有显著性（P〈0．05）。剔除A组镇痛失败患者后，两组患者术后48h内的VAS评分、Ramsay评分和PCA按压次数无统计学差异（P〉0．05）。结论 周围神经刺激器精确引导下经斜角肌间沟留置导管行臂丛神经阻滞和持续术后镇痛是一种可行性好、镇痛效果确切、不良反应少的方法。     

Pain Management in Four‐Limb Amputation: A Case Report

Acute pain following amputation can be challenging to treat due to multiple underlying mechanisms and variable clinical responses to treatment. Furthermore, poorly controlled preoperative pain is a risk factor for developing chronic pain. Evidence suggests that epidural analgesia and peripheral nerve blockade may decrease the severity of residual limb pain and the prevalence of phantom pain after lower extremity amputation. We present the perioperative analgesic management of a patient with gangrene of the bilateral upper and lower extremities as a result of septic shock and prolonged vasopressor administration who underwent four‐limb amputation in a single procedure. A multimodal analgesic regimen was utilized, including titration of preoperative opioid and neuropathic pain agents, perioperative intravenous, epidural and peripheral nerve catheter infusions, and postoperative oral medication titration. More than 8 months postoperatively, the patient has satisfactory pain control with no evidence for phantom limb pain. To our knowledge, there have been no publications to date concerning analgesic regimens in four‐limb amputation.     

Nerve blocks

Local and regional analgesia, achieved by injecting a local anesthetic into tissues, or in proximity to certain parts of the peripheral nervous system, or into the epidural/subarachnoid space, to relieve pain has been used widely for many years. While nerve blocks no longer have the preeminent role as the pain management in cancer patients, they will remain useful tools in managing pain and increasing 'quality of life' of the cancer patients, only if they properly applied. The purpose of this chapter is to present an updated version of the regional analgesia in cancer pain management.     

Peripheral nerve blocks for postoperative analgesia

Peripheral nerve blocks are used as part of a preemptive and multimodal analgesic technique to provide safe and effective postoperative pain management with minimal side effects. They are used for a variety of surgical procedures in both inpatient and outpatient settings. Peripheral nerve blocks have resulted in shorter recovery times, decreased anesthesia-related complications, and better postoperative pain management. Peripheral nerve blocks, as part of a multimodal analgesic regimen, have decreased recovery times by lessening side effects (eg, nausea, vomiting, drowsiness). Nerve blocks have allowed procedures previously performed only in hospitals to be performed on an outpatient basis by providing extended surgical area analgesia. The use of peripheral nerve blocks, however, requires skilled and knowledgeable clinicians. This article discusses the mechanism of action and the role of peripheral nerve blocks in multimodal analgesia, as well as perioperative nursing implications and management for upper and lower extremity peripheral nerve blocks. AORN J 75 (Jan 2002) 136-147.     

Anesthetic and procedural sedation techniques for wound management

Emergency physicians come across a wide variety of painful conditions and perform a large number of uncomfortable procedures on a typical shift. This article describes the local anesthetic agents and their potential applications. The peripheral nerve blocks that are regularly done in the emergency department are described. Lastly, procedural sedation and analgesia are covered, to include general principles and specific agents for its use in the emergency department.     

Der postoperative Schmerz

A short survey about the different methods available for producing postoperative analgesia is given, the goal being to make it clear to the clinician that there are quite a number of techniques to be used although the everyday clinical practice often sticks to simple and not too effective methods of pain treatment following surgery. Initially presenting short informations about the neurophysiology of pain and the pathogenesis and causes of postoperative pain two main groups of producing analgesia are then discussed.Thefirst group deals with the systemic use of analgesics be it nonnarcotic analgesic antipyretics or narcotic analgesics (opioids). As for the first subgroup the peripheral action of these drugs (metamizol, acetylsalicylic acid, paracetamol) is brought about by blocking the synthesis of prostaglandins. These substances can only be used for very moderate postoperative pain f.i. following head and neck surgery. The strong acting opioids belong to the second subgroup. Recent informations on receptor sites in the brain and cord and the subgrouping of the receptors throws new light on the understanding of the different effects of these drugs and on the pathomechanisms of agonistic, antagonistic and mixed activities. The clinically used opioids then are mentioned (morphine, fentanyl, methadon, pethidin, piritramide, tilidin, buprenorphin and pentazocine) and dosage, duration of action, antagonisms and untoward side effects are presented. Stress is laid on the recent development of patient-controlled analgesia with all its advantages. Thesecond main group of methods for postoperative analgesia consists of regional anesthesia techniques as there are brachial plexus block, intercostal block and the continuous epidural analgesia using both local anesthetics and spinal opioids. The brachial plexus block in continuous form is absolutely able to prevent pain after operations in the shoulder-arm-region and can be prolonged even for weeks using catheter techniques. The intercostal block on the other hand practically can be performed only as single injection technique being relatively simple however from the technical point of view. The catheter epidural analgesia is the most important method within this group. In comparison to the centrally acting opioids the epidural technique brings some distinct advantages especially in the cardiorespiratory risk case. Choosing between "top up"-technique and continuous infusion of the local anaesthetic depends on the individual circumstances the latter method apparently giving a more steady level of analgesia. The spinal opioid techniques finally gain more and more importance during the last years. They present clear advantages over the local anesthetic methods as there are the long lasting analgesia and the selective blockade of pain not touching motor and sympathetic nerve fibers. A delayed respiratory depression however might be a serious danger showing an incidence of 0,3% in the epidural and some 10% in the subarachnoid route. Aiming to inform the clinician once again about the vast field of possibilities available to make the postoperative course painfree it is hoped that this important task in the postoperative period will be handled with more consequence and effectivity in the future.     

Principles of safety for ultrasound-guided single injection blocks in the emergency department

Ultrasound-guided nerve blocks (UGNBs) allow emergency physicians an opportunity to provide optimal pain management for acute traumatic conditions. Over the past decade, a growing body of literature has detailed the novel ways clinicians have incorporated UGNBs for analgesia and an alternative to procedural sedation. UGNBs are considered a relatively safe procedure, and have been shown to increase rates of success and reduce complications (as compared to older techniques). Ultrasound allows the operator needle visualization and a clear anatomic overview. Even with the presumed level of increased safety, we recommend that any clinician who performs ultrasound-guided nerve blocks be aware of complications that could arise during and after the procedure. Peripheral nerve injury (PNI) post block, local anesthetic systemic toxicity (LAST) and the role of single peripheral nerve blocks in patients with a risk for compartment syndrome are common safety issues discussed when performing ultrasound-guided nerve blocks.     

Innovations in postoperative pain management: continuous infusion of local anesthetics

•

PATIENTS AND HEALTH CARE PROVIDERS alike struggle with alleviating postoperative pain. Patients with unrelieved pain are less likely to cough, breathe deeply, or move easily after surgery, which adversely affects their recovery.

•

INNOVATIONS IN TECHNOLOGY, such as continuous infusion of local anesthetics, have revolutionized postoperative pain management. Technological improvements in needles, catheter insertion techniques, and effortless drug delivery systems are facilitating prolonged analgesia with few adverse effects, increasing patient satisfaction, and expediting postoperative recovery. AORN J 85 (May 2007) 904-914. © AORN, Inc, 2007.