Epidural Infusion of Opiates and Local Anesthetics for Complex Regional Pain Syndrome

Abstract: Complex Regional Pain Syndrome Type‐I (CRPS‐I) is a neuropathic pain syndrome resulting from complex pain mechanisms that involve several levels and components of the nervous system. CRPS‐I consists of multiple signs, including autonomic dysfunction, in the form of edema, vasomotor changes, motor dysfunctions, muscle spasms, tremors and dystonia, as well as burning pain, hypersensitivity and allodynia that could present in any combination. The treatment is progressive physical therapy rehabilitation program. Multiple analgesic modalities have been used to facilitate the rehabilitation program with varying rates of success. The most successful treatment is a multi‐disciplinary comprehensive approach, where initial pain control allows for physical and psychological interventions that are believed to be the basis for successful treatment. ¹ The pain in CRPS‐I may be mediated through the sympathetic nervous system, sympathetic maintained pain (SMP) or sympathetic independent pain (SIP) ² .     

Postoperative Pain Trajectories in Chronic Pain Patients Undergoing Surgery: The Effects of Chronic Opioid Pharmacotherapy on Acute Pain

For 2 weeks following surgery, 55 patients with preexisting chronic pain (CP) reported daily postoperative pain with movement and at rest. Of these, 30 CP patients used opioid pharmacotherapy for CP management and 25 did not. We modeled pain resolution in each patient using a linear fit so that each patient yielded 2 scores for each pain rating: 1) an intercept, or initial level of pain, immediately after surgery; and 2) a slope, or rate of pain resolution. The patients not using opioid pharmacotherapy had a mean pain with movement intercept of 5.4 and a slope of −.20, while the patients using opioid pharmacotherapy had a significantly higher mean intercept of 7.68 (P = .001) and a slope of −.21, sustaining higher pain levels over days. The opioid pharmacotherapy patients had the same rate of pain resolution as the other CP patients, and both groups resolved their pain more slowly than normal surgery patients. Preexisting CP may predispose a patient undergoing surgery to a slower rate of postoperative pain resolution. Chronic pain patients who use opioids share this predisposition but in addition, they are at risk for markedly higher postoperative pain across the entire pain resolution trajectory.

Perspective

This is an observational rather than a randomized controlled study, and as such is less definitive. Nonetheless, these findings are consistent with those of animal studies showing that prolonged exposure to opioids can produce opioid-induced hyperalgesia. Patients with opioid pharmacotherapy for chronic pain who undergo surgery merit special attention for acute pain management.     

基于复合多聚体材料的缓释局麻药在慢性痛动物模型中的应用

  目的  对复合多聚体材料组成的局麻药缓释载体的药物释放特征和镇痛效果进行测评。  方法  使用静电纺丝技术制备含盐酸布比卡因的PLGA(聚乳酸-羟基乙酸共聚物)缓释膜(静电纺丝膜, M组), 并以PLGA-PEG(聚乙二醇)-PLGA温敏凝胶包裹纺丝膜制备成含盐酸布比卡因的缓释递送系统(凝胶包裹静电纺丝膜形成的复合缓释载体, G组), 评定两组体外释放特征、体内镇痛效果及安全性。  结果  体外条件下, M组对盐酸布比卡因的累积释放时间可达5 d以上, G组累积释放时间可延长至10 d。体内条件下, M组和G组对坐骨神经慢性压迫损伤大鼠模型的镇痛时间均可达14 d, 两组镇痛效果无显著差异(P＞0.05)。M组盐酸布比卡因血药浓度在术后第1天达峰值[(0.294±0.029)μg/L], G组于术后第3天达峰值[(0.192±0.064)μg/L], 且峰值较M组降低, 两组盐酸布比卡因血药浓度均在安全范围内。HE染色示, M组、G组大鼠的心脏、肝脏、脾脏、肺、肾脏组织均未见明显病理改变。  结论  本研究制备的以盐酸布比卡因纳米纺丝缓释膜为基础, PLGA-PEG-PLGA温敏凝胶包裹为介质的复合缓释材料, 可进一步延长盐酸布比卡因缓释时间, 具有长效镇痛效果且无毒性作用。     

局麻药液中加入芬太尼对硬膜外麻醉效果的影响

目的探讨局麻药液中加入芬太尼对硬膜外麻醉效果的影响及芬太尼最佳剂量。方法将 4 5例择期妇科手术病人 ,根据硬膜外局麻药液中所含芬太尼剂量不同 ,随机分为A、B、C三组 :即分别在 0 .75 %布比卡因 1 5ml中加入①生理盐水 2ml;②芬太尼 5 0 μg和生理盐水 1ml;③芬太尼 1 0 0 μg ,使 1 7ml局麻药液中B、C组分别含芬太尼 2 .94和 5 .8μg/ml。观察三组麻醉效果、副作用发生率及术后肛门排气、排便时间。结果与A组比较 :B组、C组的麻醉起效时间、运动阻滞起效时间明显缩短 (P均 <0 .0 5 ) ;C组感觉阻滞平面升高 ,术后镇痛时间则明显延长 (P <0 .0 5 )。C组与B组之间 ,上述指标差异亦有显著性 (P <0 .0 5 )。三组间副作用发生率、肛门排气、排便时间无明显区别。结论局麻药液中加入芬太尼能提高硬膜外麻醉效果 ,其剂量以 5 .88μg/ml最佳而又不增强其副作用     

Postoperative Pain

Postoperative pain is often a big problem after gastrointestinal surgery. The aim of the present investigation was two-fold; To see whether supplying of lidocaine spray in the surgical wound influences postoperative pain and to evaluate the role of patients and caring factors on the perception of postoperative pain. Sixty consecutive patients undergoing major abdominal surgery were randomized into a control or a treatment group. Pain relief, apart from lidocaine, was given according to routine. The methods included interviews, pain registration on a visual analogue scale and registration of administered analgesics. No effect could be attributed to lidocaine. Nurses' ability to predict pain was unreliable, patients predicted pain better. Younger patients suffered greater pain than elderly. Preoperative anxiety correlated to postoperative pain, whereas malignant diagnoses did not. Most of the studied patients had considerable postoperative pain. Routines for postoperative pain relief should be improved.     

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.     

The Effect of Music on Postoperative Pain and Anxiety

The purpose of this study was to determine if listening to music or having a quiet rest period just before and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, respiratory rate, and/or oxygen saturation in patients who underwent a total knee arthroplasty. Fifty-six patients having a total knee arthroplasty were randomly assigned to either a music intervention group or a quiet rest group. A visual analog scale was used to measure pain and anxiety. Physiologic measures, including blood pressure, heart rate, oxygen saturation, and respiratory rate, were also obtained. Statistical findings between groups indicated that the music group's decrease in pain and anxiety was not significantly different from the comparison rest group's decrease in pain (F = 1.120; p = .337) or anxiety (F = 1.566; p = .206) at any measurement point. However, statistical findings within groups indicated that the sample had a statistically significant decrease in pain (F = 6.699; p = .001) and anxiety (F = 4.08; p = .013) over time. Results of this research provide evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety. The interventions pose no risks and have the benefits of improved pain reports and decreased anxiety. It potentially could be opioid sparing in some individuals, limiting the negative effects from opioids. Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with confidence, knowing there is evidence to support its efficacy.     

术前疼痛教育对腹部手术患者术后疼痛控制的影响

目的：了解术前疼痛知识的教育对术后疼痛控制的影响。方法：89例接受腹部手术患者，按入住区域分为术前教育组及非术前教育组，对术前教育组进行疼痛知识宣讲，术后对两组分别予以疼痛评估。结果：术前教育组术后12小时MPQ （McGill Pain Questionare,McGill疼痛问卷）评分显著低于非术前教育组，并且对镇痛药物的需要量也明显少于非术前教育组。结论：术前疼痛教育有助于术后疼痛的控制，应在临床护理工作中推广运用。     

The Effects of Inhalation Aromatherapy on Postoperative Abdominal Pain: A Three-Arm Randomized Controlled Clinical Trial

PurposeThis study compares the effects of inhalation aromatherapy using essential oils of sweet orange and damask rose on postoperative abdominal pain.DesignA randomized three-arm controlled trial.MethodsIn this randomized double-blinded, and parallel-group controlled trial, a total of 120 patients who underwent open abdominal surgeries were enrolled using a sequential sampling method. Participants were then randomly assigned to three groups of sweet orange, damask rose, and placebo (distilled water) using the permuted block randomization. When the patients regained full consciousness, a clean gauze impregnated with four drops of either distilled water or essential oils of sweet orange or damask rose were attached to the collar of the patients, and they were asked to inhale the aroma through normal breathing for 30 minutes. Abdominal pain severity was recorded using the visual analog scale at four time points including before the intervention (baseline) and 4, 8, and 12 hours after the intervention.FindingsPain reduction after sweet orange inhalation was significantly greater than placebo (at 8 and 12 hours after the intervention) and damask rose (at 12 hours after the intervention). The differences in the mean score of pain severity between all before-and-after observations were statistically significant in the three groups, except in the placebo group between the baseline score of pain severity and the pain severity score at 4 hours after the intervention.ConclusionsInhalation aromatherapy using sweet orange seems to be more effective than the damask rose in reducing pain severity after open abdominal surgeries.     

曲马多直肠给药预防妇科腹部术后疼痛的观察

应用曲马多控释片直肠给药预防妇科腹部术后疼痛。将１３４ 例患者随机分为两组,实验组在术后下肢肌张力恢复时予曲马多控释片２００ｍｇ 塞肛,对照组采用常规间断肌注度冷丁镇痛。结果表明两组使用不同镇痛方法后２４ｈ 内疼痛分值评定有显著性差异（ Ｐ＜０．００１） ,２４ｈ 内睡眠时间比较有显著性差异（ Ｐ＜ ０ ．００１） ,肠蠕动恢复及肛门排气时间两组有显著性差异（ Ｐ均＜ ０．０１）。恶心、呕吐等胃肠道不良反应实验组小于对照组（ Ｐ＜ ０ ．０１ 及０．０５）。结果显示：曲马多控释片是预防妇科腹部术后疼痛较为理想的药物     

术后疼痛应激及术后镇痛对血小板功能的影响

目的:观察术后疼痛应激与术后镇痛对患者血小板功能的影响。方法:40例择期腹部手术患者(ASAⅡ～Ⅲ级,年龄45～68岁),随机分为硬膜外镇痛组(E组)和对照组(C组),每组20例。E组采用全麻联合硬膜外阻滞 术后硬膜外镇痛,C组采用全麻 术后间断肌注哌替啶镇痛。分别于术后8、24、36、48、60、72h用视觉模拟评分法(VAS)评定疼痛程度;于术前及术后1、2、3、4、5d抽取外周静脉血测定血小板表面膜糖蛋白CD_(41)/CD_(61)、CD_(62p)和CD_(63)的表达量及血小板聚集率。结果:E组术后镇痛效果良好,术后8、24、36、48h的VAS评分显著低于C组(P<0.05,P<0.01)。与术前比较,两组术后第1天的血小板表面膜糖蛋白CD_(41)/CD_(61)、CD_(62p)和CD_(63)的表达量及血小板聚集率均有明显升高(P<0.05,P<0.01);与E组比较,C组术后1～4d血小板表面膜糖蛋白CD_(41)/CD_(61)、CD_(62p)和CD_(63)的表达量及血小板聚集率明显增加,两组之间差异显著(P<0.05,P<0.01)。结论:血小板聚集率与血小板表面膜糖蛋白的表达量呈正相关。术后疼痛应激可促进血小板活化及血小板聚集,增强血小板功能及血液凝集性,使机体处于相对高血凝状态;良好的术后镇痛有利于抑制机体的有害应激反应,降低血小板活性,减少血小板聚集,抑制血小板功能,降低血液凝集性,改善术后患者的高血凝状态,从而可作为减少术后血栓性并发症、提高手术患者康复质量的有效措施之一。     

硫酸镁对腹腔镜胆囊摘除术术后疼痛的影响

【目的】观察腹腔镜胆囊摘除术的患者应用硫酸镁是否具有围术期镇痛作用。【方法】选择50例择期腹腔镜胆囊摘除术的患者,随机分为两组,每组25例。A组为硫酸镁组,于麻醉诱导时静注硫酸镁40mg/kg,随后以15 mg/(kg.h)的速度持续输注至手术结束;B组为对照组,在麻醉诱导时及麻醉维持阶段未予输注硫酸镁。两组病人术中以5 ml/min的速度持续静脉输注林格液。【结果】在气管插管后1 min、气腹后1 min和气腹后5 min,对照组的SBP、DBP和HR均明显高于硫酸镁组(P均<0.05);在整个手术期间,硫酸镁组和对照组异丙酚的用量恒定,在气管插管后即刻、气管插管后5 min、手术开始时和手术开始后20 min,硫酸镁组所需异氟醚的MAC值较对照组明显降低(P均<0.05);与对照组比较,术后1、2、4、6、8、16和24 h的疼痛VAS评分明显降低(P均<0.05);硫酸镁组在气管插管后5 min、手术结束时和术后第1日的血清镁浓度分别(1.31±0.24)mmol/L,(1.53±0.32)mmol/L和(0.91±0.16)mmol/L,与麻醉前基础水平比较均存在统计学差异(P均<0.05)。【结论】硫酸镁用于腹腔镜胆囊摘除术能减少术中全麻药用量,并具有良好的术后镇痛作用。     

认知行为干预减轻青少年脊柱侧弯矫形术后疼痛的效果

目的观察认知行为干预疗法（cognitive—behavior intervention,CBI）对脊柱侧弯矫形术后青少年患者疼痛的治疗效果。方法将40例患者按人组顺序编号,单号设为对照组（20例）,双号设为观察组（20例）。对照组行常规护理,观察组患者在进行护理常规的同时增加CBI治疗。术后第2、4天使用视觉疼痛量表（visual analog scale,VAS）测量其疼痛程度。结果术后第4天VAS评分较第2天的评分各组均有明显降低。术后第2天,观察组疼痛评分显著低于对照组,差异有统计学意义（P〈0．05）。术后第4天,观察组疼痛评分低于对照组,差异有统计学意义（P〈0．01）。结论青少年脊柱侧弯矫形术后,对患者进行认知重组干预和教导患者疼痛应对技巧,能有效地减轻术后疼痛。     

Effects of Intravenous Small Dose Ketamine and Midazolam on Postoperative Pain Following Knee Arthroscopy

Background:   The aim of this randomized, double blind, controlled study was to assess the effect of intravenous coadministration of small dose midazolam with ketamine on postoperative pain and spinal block level.
Methods:   Sixty patients undergoing arthroscopic knee surgery under spinal anesthesia were randomized into three groups: Group I (saline control); group II (ketamine 0.15 mg/kg i.v.); and group III (ketamine 0.15 mg/kg +  midazolam 0.01 mg/kg i.v.). Sedation scores, visual analogue scores, time to first postoperative analgesic, total meperidine consumption, patient satisfaction, sensory and motor block levels, and two segments regression times were assessed.
Results:   Sedation scores were significantly lower in group I when compared with groups II and III at 1, 3, 5, and 10 minutes after administration of the spinal anesthetic ( P  = 0.001). Sensory block was significantly higher in group III ( P  = 0.001) in comparison with group II. Two segment regression time was significantly longer in group II than group I, whereas no difference was found between groups II and III. Total meperidine consumption was significantly higher in group I ( P  = 0,001). Patient satisfaction was significantly higher in group III compared with group I ( P  = 0.001), but no difference was found between groups II and III ( P  = 0.3).
Conclusion:   Ketamine improved the postoperative pain patient satisfaction, increased the maximal sensory level, and was associated with lower sedation scores in the first 15 minutes after administration. Group I was also associated with decreased total meperidine consumption and delayed the time to first recue analgesic administration. Coadministration of ketamine and midazolam did not provide any further benefit over ketamine alone.     

多模式镇痛方法对脊柱融合术患者止痛效果的影响

目的观察多模式镇痛方法对脊柱融合术患者止痛效果的影响。方法将2012年2月至2013年2月42例脊柱融合术患者按随机数字表法分为两组,观察组采用多模式镇痛方法,对照组采用常规镇痛方法,比较两组患者术后不同时间点的疼痛评分以及疼痛对患者的影响。结果观察组患者术后不同时间点疼痛评分均低于对照组,差异有统计学意义(P0.01);观察组患者术后1~3d的活动次数均多于对照组,恶心和嗜睡的发生率低于对照组,对住院过程及康复效果的满意度高于对照组,差异有统计学意义(P0.05或P0.01)。结论采用多模式镇痛方法可以有效缓解脊柱融合术后患者的疼痛,提高患者术后活动能力,减少不良反应的发生,为脊柱融合术后早期镇痛提供了一种有益的选择。