Outpatient Continuous Interscalene Brachial Plexus Block in Cancer-Related Pain

This case outlines the use of a continuous interscalene brachial plexus block to treat cancer-related pain. Using an elastomeric device, the patient's previously intractable pain was controlled and he was able to return home. Furthermore, the patient developed a pragmatic and effective method of balancing loss of power and sensation against pain control using the flow restrictor. This case illustrates the potential of an integrated approach to cancer pain management to obtain rapid pain relief in the acute hospital setting.     

Ambulatory Continuous Interscalene Blocks for Cancer Pain

Continuous peripheral nerve blocks are used in the management of pain following surgical procedures. They can also be used in patients with cancer-related pain, to improve sleep quality, reduce opioid requirements and their side effects. We describe two cancer patients in whom interscalene brachial plexus catheters were used on an outpatient basis, allowing them to travel, decrease their opioid use, and improve their ability to perform routine activities.     

Preliminary Experience With a Novel Ultrasound‐Guided Supraclavicular Perineural Catheter Insertion Technique for Perioperative Analgesia of the Upper Extremity

Objective. Brachial plexus perineural catheters provide specific analgesia for upper extremity surgery. Although single‐injection ultrasound‐guided supraclavicular blocks have been described, little is known about the efficacy of perineural catheters inserted using this approach. We present our experience with ultrasound‐guided supraclavicular perineural catheters for distal upper extremity surgery. Methods. In this case series, 10 patients who underwent upper extremity surgery for orthopedic trauma at a tertiary care university hospital received a supraclavicular brachial plexus perineural catheter for postoperative pain management. In all patients, a nonstimulating catheter was inserted using an ultrasound‐guided technique with the catheter tip remaining under direct vision until placement needle withdrawal. Postoperatively, a perineural ropivacaine, 0.2%, infusion was administered at a basal rate of 6 mL/h with a patient‐controlled bolus of 4 mL and a lockout interval of 30 minutes. Results. Of the 10 patients, all had successful perineural catheter placement. Patients required a median (range) of 0 (0–100) μg of fentanyl for catheter insertion analgesia. There were no vascular punctures or other direct procedure‐related complications. Catheters were maintained for a median (range) of 4 (2–5) days in both hospitalized and ambulatory patients. Median (range) pain scores on postoperative days 1 and 2 were 5 (0–7) and 4 (3–6), respectively, on a numeric rating scale. Three patients' catheters were removed by patient request or dislodged on postoperative day 1. Conclusions. Supraclavicular brachial plexus perineural catheter insertion using ultrasound guidance is feasible and deserves further study with a randomized controlled trial comparing this relatively new technique with more established approaches.     

Abdominal Surgical Patients Randomized to Aromatherapy for Pain Management

PurposeEvaluate aromatherapy for postoperative abdominal pain in hospitalized patients.DesignA randomized controlled trial design.MethodsStudy participants (n = 172) were randomized to receive either standard care or standard care and aromatherapy (AT) for postsurgical pain up to 24 hours after admission to a nonintensive care surgical unit. A convenience sample was recruited before surgery and given instructions on self-rating pain intensity. The AT group was topically administered a drop of lavender essential oil after medication and at random for pain. Pain scores and medications data were collected.FindingsOf the evaluable patients (n = 147), demographic data were similar (standard care and AT groups). The use of aromatherapy showed no substantial benefit at improving pain scores or reducing medication use (the primary objectives of the study). A subgroup analysis of patients who received a regional nerve block for pain management, however, showed more than fivefold improvement in pain scores after the use of aromatherapy. The AT group used more medications at baseline (P = .032), whereas 70% less medications were used (P = .031) by 24 hours.ConclusionsAromatherapy aided in control of pain intensity for abdominal surgical patients. In patients who received a regional nerve block, significant improvement in pain level occurred as effects of the block diminished.     

Continuous Intravenous Lidocaine Infusion for the Management of Pain Uncontrolled by Opioid Medications

Limited data exist describing the outcomes of patients receiving continuous lidocaine infusions. The objective of this study was to evaluate the effect of use of continuous lidocaine infusions for pain management at a community teaching hospital. A retrospective chart review was performed that included adult patients receiving continuous systemic lidocaine infusions for the treatment of pain. Twenty-one patients were included in the analysis. Dosing ranged from 0.25 to 2.8 mg/kg/h, with a median infusion time of 64 hours. Eight patients (38%) experienced a response (≥20% reduction in pain score during the infusion compared with prior to the infusion). Among responding patients, there was a decrease in pain scores at rest after starting lidocaine (compared with prior to lidocaine) (6.5 vs. 3.7, P = .001) that was maintained 24 hours after lidocaine discontinuation. There were no differences in pain scores before, during, or after lidocaine in the entire study sample. A difference in oral morphine equivalent intake was present comparing usage during the infusion vs. day +1 (P = .006) and day +2 (P < .001). Similarly, a difference was present comparing morphine equivalent usage on day ?2 with day +2 (P = .008) and day ?1 with day +1 (P = .006). Continuous infusions of systemic lidocaine appear to be beneficial in some patients experiencing uncontrolled pain and may improve pain scores while decreasing opioid requirements. Overall beneficial effects of systemic lidocaine may last longer than the infusion itself.     

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.     

The Feasibility of the Ultrasound-Guided Femoral Nerve Block Procedure with Low-Dose Local Anesthetic in Intracapsular and Extracapsular Hip Fractures

BackgroundThe local anesthetic dosages used in the current literature in regional applications of local anesthetics are frequently high for surgical purposes, and there are no sufficient dosage studies for emergency department (ED) management.ObjectivesThe aim of this study was to determine the success of lower local anesthetic dosages capable of reducing costs and excessive exposure to drugs in pain control in patients with femoral neck fractures (FNFs) in the ED.MethodsPatients ≥65 years of age with FNFs and reporting Wong-Baker Pain Rating Scales scores ≥8 were included in this prospective, interventional study. Patients underwent ultrasound-guided regional femoral block with 5 mL 2% prilocaine. Pain scores before the procedure and at 30 min and 2 h postprocedure were compared with the Friedman test and Wilcoxon test with Bonferroni correction.ResultsForty patients, 20 with intracapsular and 20 with extracapsular FNFs, were enrolled. The initial pain scores of patients with both intra- and extracapsular fractures were 8 (range 8–10). A statistically significant 50% decrease in pain scores was observed in both groups 30 min after the regional block procedure (p < 0.001). A statistically significant 75% decrease in pain scores was observed in both groups 2 h after the regional block procedure (p < 0.001). No statistically significant difference was determined in the change in 30-min and 2-h pain scores between the groups.ConclusionsThe administration of 5 mL 2% prilocaine for pain control in FNFs in elderly patients in the ED can reduce systemic analgesic requirements by establishing effective analgesia in both intracapsular and extracapsular fractures.     

Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Hip arthroscopy is a minimally invasive alternative to open hip surgery. Despite its minimally invasive nature, there can still be significant reported pain following these procedures. The impact of combined sciatic and lumbar plexus nerve blocks on postoperative pain scores and opioid consumption in patients undergoing hip arthroscopy was investigated. A retrospective analysis of 176 patients revealed that compared with patients with no preoperative peripheral nerve block, significant reductions in pain scores to 24 hours were reported and decreased opioid consumption during the post anesthesia care unit (PACU) stay was recorded; no significant differences in opioid consumption out to 24 hours were discovered. A subgroup analysis comparing two approaches to the sciatic nerve block in patients receiving the additional lumbar plexus nerve block failed to reveal a significant difference for this patient population. We conclude that peripheral nerve blockade can be a useful analgesic modality for patients undergoing hip arthroscopy.     

Therapeutic Interactive Voice Response (TIVR) to Reduce Analgesic Medication Use for Chronic Pain Management

This paper examines whether a telephone-based, automated maintenance enhancement program can help to reduce opioid and nonsteroidal anti-inflamatory drugs (NSAID) analgesic use in patients with chronic pain. Following 11 weeks of group cognitive-behavioral therapy (CBT), 51 subjects with chronic musculoskeletal pain were randomized to 1 of 2 study groups. Twenty-six subjects participated in 4 months of a Therapeutic Interactive Voice Response (TIVR) program in addition to standard follow-up care, while a control group of 25 subjects received standard follow-up care only. TIVR is an automated, telephone-based tool developed for the maintenance and enhancement of CBT skills. Opioid analgesic use decreased in the experimental group in both follow-ups: 4 and 8 months postCBT. In addition, at 8-month follow-up, 21% of the TIVR subjects had discontinued the use of opioid analgesics, 23% had discontinued NSAIDS, and 10% had discontinued antidepressant medications. In contrast, the control group showed increases in opioid and NSAIDS use. Analysis of covariance (ANCOVA) revealed significant between-group differences in opioid analgesic use at 8-month follow up (P = .004). We have previously demonstrated the efficacy of TIVR to decrease pain and improve coping; this analysis demonstrates that the use of TIVR may also result in concurrent reductions in opioid analgesic and NSAID medications use.     

Pericapsular nerve group block results in a longer analgesic effect and shorter time to discharge than femoral nerve block in patients after hip fracture surgery: a single-center double-blinded randomized trial

ObjectiveThe pericapsular nerve group (PENG) block is a regional block that possibly provides better analgesia than that of the femoral nerve block (FNB) for hip fracture surgery. A randomized comparative trial performed in our institution showed that the PENG block may provide improved pain reduction compared with the FNB while preserving quadriceps strength.MethodsIn this single-center, double-blinded, randomized comparative trial, patients who underwent hip fracture surgery were randomized to receive either a FNB or PENG block for analgesia. This analysis reviews the outcomes of the block effect duration and time to discharge readiness.ResultsSixty patients with similar baseline demographics were randomized. The median FNB duration was 15 hours, 35 minutes (range (hours:minutes) 4:08–30:45), and the median PENG duration was 22 hours, 50 minutes (range 6:00–32:00). The time to discharge readiness was shorter in the PENG group (3 days, range 1–14 days) than that in the FNB group (4 days, range 2–15 days).ConclusionsThe PENG block results in a faster recovery and shorter time to discharge readiness. The duration of the PENG block appears to be longer than that of the FNB.     

Fulranumab as Adjunctive Therapy for Cancer-Related Pain: A Phase 2, Randomized,Double-Blind,Placebo-Controlled,Multicenter Study

This randomized, double-blind (DB), placebo-controlled, phase 2 study assessed the efficacy and safety of fulranumab as a pain therapy adjunctive to opioids in terminally ill cancer patients. Ninety-eight patients were randomized (2:1) to receive one subcutaneous injection of fulranumab (9 mg) or placebo in the 4-week DB phase. Seventy-one (72%) patients entered the 48-week open-label extension phase and were administered 9 mg of fulranumab every 4 weeks. The study failed to demonstrated efficacy at the end of the DB phase (primary endpoint, mean [SD] change in average cancer-related pain intensity was ?.8 (1.26) for fulranumab and ?.7 (1.56) for placebo; P?=?.592). However, potential benefit is suggested based on secondary endpoints (30% responder rate [P?=?.020], Brief Pain Inventory-Short Form [BPI-SF] pain intensity subscale [P?=?.003], and pain interference subscale [P?=?.006]). The most commonly reported treatment-emergent adverse events were (fulranumab vs placebo): asthenia (16% vs 10%), decreased appetite (12% vs 6%), fatigue (10% vs 0%), and malignant neoplasm progression (10% vs 0%). Although no differences were seen between fulranumab and placebo groups on the primary endpoint, improvements in BPI-SF pain subscale scores and responder rates support further research of anti-nerve growth factor therapy in cancer-related pain.

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.     

Reliability of a Continuous Pain Score Meter: Real Time Pain Measurement

We present a newly developed continuous pain score meter (CPSM). The CPSM is based on the principles of the visual analog score (VAS), and electronically measures pain score in a continuous, instead of a single, manner. In this study, we determine the test–retest reliability of this meter. Thirty-two healthy volunteers received a reproducible pain stimulus on the right thumbnail and forearm. After a 1-minute interval the procedure was repeated. During the stimulus, pain was continuously measured with the CPSM, providing values of peak continuous pain score (CPS) and area under the CPS curve (AUC CPS). The intra-class correlation coefficient (ICC) and the 95% limits of agreement were used to assess the agreement between measurements. ICC of peak CPS (0.89 and 0.83) and AUC CPS (0.79 and 0.86) for nail and arm showed a good reproducibility. This study has successfully established the test–retest reliability of the CPSM. The real-time continuous pain measurement may provide more detailed information on a subjects' pain perception compared to a single VAS, in particular during an interval of pain stimuli.