Subarachnoid Neurolytic Block

This procedure is suitable for patients who have significant cancer pain that is not responding to any other modalities. The pain should be localized into few sensory segments of the spinal cord. Sensory fibers arise from the dorsal aspect of the spinal cord while the motor fibers arise from the ventral aspect. The main goal of this block is to keep the neurolytic material around the sensory portion of the spinal cord (dorsal surface). This can be accomplished by a combination of positioning...

Opioid Analgesics

Morphine, the mainstay of pain therapy in the pediatric population, is the standard x opioid analgesic to which all other opioids are compared (Table 30.3). Derived from the opium poppy, Papaver somniferum, morphine, along with codeine, is considered a naturally occurring opiate and is often the first-line agent for management of moderate to severe pain in the emergency room, operating room, ICU, and pediatric floor. Morphine can be given orally, intravenously, intramuscularly, neuraxially (via...

Psychostimulants

Agents which are used in patients with attention deficit disorder, parkinsonism, narcolepsy, workshift sedation, and treatment-resistant depression to augment antidepressants, to counter iatrogenic sedation from opioids and other adjunctive medications, and to treat fatigue or sedation in terminal illness. The majority of psychostimulants are amphetamine based and can cause dopamine release in increasing doses, which can result in behavioral changes. Care must be taken with these drugs since...

Ankle Block

Innervations to the ankle involves five major nerve branches of the foot as indentified in Table 20.12. An ankle block is basically an infiltration block. Peripheral nerves blocked during an ankle blockade are derived from the terminal branches of the sciatic nerve (deep and superficial peroneal and sural nerves) and one from the distal branch of the femoral nerve (saphenous nerve). Motor blockade is not often needed for surgeries carried out under the influence of an ankle blockade. Table...

Ginseng

There are three main groups of ginseng that are classified based on their geographic origin (Hughes et al. 2004). These are Asian ginseng, American ginseng, and Siberian ginseng, with the pharmacologically active ingredient in ginseng being ginsenosides (Hughes et al. 2004, Leak 1999, Kaye et al. 2000). Asian and American ginsengs have been used to increase resistance to environmental stress, promote diuresis, stimulate the immune system, and aid digestion (Ng et al. 1987, Jellin et al. 2003)....

Selection of ACD versus Antidepressant Pharmacotherapy

Both antidepressants and ACDs have demonstrated comparable efficacy in a number of chronic pain conditions, e.g., migraine headache and neuropathic pain. In a review of randomized controlled trials in which TCAs and anticonvulsants were employed to treat pain associated with diabetic and postherpetic neuropathies, it was found that at least 50 of pain relief was achieved in two-thirds of the patient episodes treated with anticonvulsants and in half of those treated with antidepressants (Collins...

Sreekumar Kunnumpurath Mbbs Md Fcarcsi Frca Ffpmrca

Andrew is 75-year-old man who has been very active until about a year ago. He used to play golf twice a week. One year ago, he slowly started to get persistent lower back pain which gradually began to worsen. A few months later he noted that he was getting pain in his thigh and to his dismay his neck was becoming painful too. Finally, he had to stop playing golf altogether. He was seen by his PCP who after a careful examination made a diagnosis of non-specific back pain. Andrew was started on...

Introduction

Surgery of the upper and lower extremity presents anesthesiologists with an alternative to general anesthesia (GA), that being regional anesthesia (RA). RA is most often performed for postoperative analgesia, but RA may also be utilized as the primary technique for intraoperative anesthesia under certain circumstances and with certain patients. For years, neuraxial techniques (spinal or epidural) have been used as the sole regional anesthetic of choice for the lower limb. The advent of low...

Vitamins Vitamin A

The term vitamin A refers to a large number of related compounds preformed retinol (an alcohol) and retinal (an aldehyde). Vitamin A deficiency is common in teenagers, in lower socioeconomic groups, and in developing countries (Combs 1998). Furthermore, some studies indicate that diabetic patients are at an increased risk for vitamin A deficiency (Queiroz et al. 2000). This deficiency may manifest as night blindness, immune deterioration, birth defects, or decreased red blood cell production...

Mood Stabilizers for Bipolar Depressive Disorders Lithium

Lithium is the most frequently used agent for bipolar disease but it has a very narrow therapeutic index. Lithium is formulated as a chemical salt, of which lithium carbonate is the most commonly prescribed (citrate, sulfate, orotate are alternatives). Dosing is BID or TID. Therapeutic trough levels are typically 1.0-1.5 mEq l for acute mania and 0.6-1.2 mEq l for chronic maintenance. Regular serum lithium level testing is necessary. Important to monitor renal and thyroid function. Can be used...

Sciatic Nerve Block Proximal

The sciatic nerve is the largest nerve in the human body. It is composed of the tibial and peroneal segments and is derived from L4-S3 anterior rami. The sciatic nerve runs through the greater sciatic foramen to the gluteal region deep to gluteus maximus muscle. Most of the conventional approaches for sciatic nerve blockade at this level are relatively deep and therefore not attractive for ultrasonography in much of the adult surgical population. Once the sciatic nerve enters the dorsal side of...

Neurolytic Intercostal Nerve Block

Thoracic paravertebral nerve at each level gives anterior and posterior branches. The anterior branch is the intercostal nerve which gives lateral and anterior cutaneous branches. They provide motor supply to abdominal wall muscles via T7-T11 and muscles of the forearm and hand via T1. They provide sensory innervation of the skin of the chest and abdomen anterolaterally. The intercostal nerves travel in the inferior part of the ribs posterior to the intercostal artery. Subcostal nerve comes...

Sciatic Nerve Block

Sciatic nerve originates from the lumbosacral plexus (L4, L5, S1, S2, and S3) and is the largest nerve of the lower extremity. The sciatic nerve innervates the lower extremity as indicated in Table 20.9. As the primary anesthetic and or postoperative pain management with or without a continuous catheter. Table 20.9 Sciatic nerve innervation of the lower extremity. Table 20.9 Sciatic nerve innervation of the lower extremity. Biceps femoris and ischial head of adductor magnus muscle Semitendinous...

Tricyclic Antidepressants

Tricyclic antidepressants are used for depression and neuropathic pain. They are inhibitors of reuptake of norepinephrine and serotonin in the descending projections from the brain to the dorsal horn of the spinal cord resulting in modulation of the incoming nociceptive signals. Norepinephrine seems to be more important for analgesia whereas serotonin is more important for antidepressant effects. The sedating effects may be helpful with sleep. Usually these agents are initiated as an evening...

Occupational therapy incorporates a variety of pain management strategies to promote participation and quality of life

Personal adaptive equipment usage (such as a bathtub bench) B. Nerve gliding exercises done twice daily C. Physical agent modality usage 3. Because there is a strong psychological component to the pain experience, which OT strategy is least likely to be effective for this component D. Cognitive-behavioral approaches 4. Chris, a 48-year-old truck driver, has a history of ulnar neuropathy and generalized wrist pain. He is now presenting with Carpal Tunnel Syndrome symptoms. You determine the...

Which is a component of labor pain

Options for analgesia for the second stage of labor include all of the following EXCEPT 3. Maternal changes associated with labor include all of the following EXCEPT A. Increased minute ventilation D. Increased endogenous epinephrine 4. Labor analgesia can be administered B. Only when Lamaze techniques fail 2. The answer is B. Lumbar sympathetic block provides analgesia for the first stage oflabor but will not provide relief for the discomfort associated with vaginal and perineal pain. 1. The...

Neurolytic Visceral Sympathetic Blocks

Neurolytic sympathetic blocks can be very helpful in controlling pain that is visceral in origin. Visceral pain can occur when visceral structures are involved with cancer due to pressure, invasion, or stretching. Visceral pain can be dull, squeezing, and poorly localized. Referred pain can occur due to visceral pain. For example, patient can experience pain in the shoulder when the diaphragm is involved in the tumor. Sympathetic block can help visceral pain only. This means that other forms of...

Which of the following is true about the use of antidepressants and their analgesic effects

Analgesic effects are only seen in patients who suffer from depression B. Depressed patients require higher doses for analgesic effect C. Antidepressants do not relieve pain if the patient suffers from depression D. Depressed patients respond faster to analgesic effects of antidepressants 4. Fluoxetine may be contraindicated if the patient is suffering from D. IBS (irritable bowel syndrome) 5. A 32-year-old man is in the emergency room with a fracture of his right forearm. He is in pain and...

Classification of Pain

Pain is a complicated physiological process that can be classified in terms of its duration, etiology, and physiology. Acute pain, which usually follows trauma to tissue, is limited in duration and is associated with temporal reductions in intensity. In contrast, chronic pain is of longer duration, often 3-6 months longer than expected. Chronic pain often has an unclear etiology and its prognosis is more unpredictable when compared to acute pain. Although acute pain and chronic pain have...

Anticonvulsant Drugs

Anticonvulsant drugs (ACDs) have efficacy in mitigating neuropathic pain, including trigeminal neuralgia and phantom limb pain (McQuay et al. 1995), as well as migraine (Pappagallo 2003, Snow et al. 2002). As with the antidepressants, analgesic differences exist among the ACDs with regard to utility across types of pain conditions. Carbamazepine is Food and Drug Administration (FDA)-approved for the treatment of trigeminal neuralgia gabapentin, for treatment of postherpetic neuralgia...

Peripheral Nerve Blocks of the Lower Extremity

Femoral nerve block provides anesthesia analgesia to the anterior thigh, including the flexor muscles of the hip and extensor muscles of the knee. Historically this block was also known as the 3-in-1 block, suggesting that the femoral, lateral femoral cutaneous, and obturator nerves could be blocked from a single injection at the femoral crease. However, it has been demonstrated that the femoral and lateral femoral cutaneous nerves can be reliably blocked by a single injection, but the...

Duration and Periodicity

To determine the duration and temporal characteristics regarding one's pain, the patient should be asked whether the pain is continuous, intermittent, pulsatile, or characterized by a wavelike rise and fall in intensity. Some physicians advocate the use of time-intensity curves to characterize how the pain starts, the rapidity with which it increases, the duration, and the manner by which the pain declines (Fig. 5.1). Additionally, the relationship of the pain CONTINUOUS PAIN, FLUCTUATING...

Traditional Principle of Acupuncture

Traditionally acupuncture is embedded in a complex theoretical framework that provides conceptual and therapeutic directions. Acupuncture relies on ordinary human sensory awareness, and its fundamental assertion is similar to the kindred philosophical systems of Confucianism and Taoism (Hahn 1982). The contemplation and reflection on sensory perceptions and ordinary appearances are sufficient to understand the human condition, including both health and illness. The foreign-sounding key words of...

Pharmacologic Treatment of Cancer Pain

Modified Who Analgesic Ladder

World Health Organization (WHO) developed guidelines for treatment of cancer pain (World Health Organization 1990, Zech 1995). It includes three-step analgesic ladder for pharmacologic management ofcancer pain. Application of the World Health Organization (WHO) analgesic ladder helps provide adequate analgesia in the majority of cases (Fig. 28.1) (Jacox et al. 1994, Miguel 2000, Patt 1993). The steps in the analgesic ladder are designed to treat mild, moderate and severe cancer pain Mild pain...

References

Epidural and intrathecal narcotics for pain relief. S D J Med. 1984 37(1) 7-12. Ansari,S, Chaudhri K, Moutaery K. Neurostimulation for refractory angina pectoris. Acta Neurochir Suppl. 2007 97(Pt 1) 283-8. Bala MM, et al. Systematic review of the (cost-)effectiveness of spinal cord stimulation for people with failed back surgery syndrome. Clin J Pain 2008 24(9) 741-56. Bogduk N, Dreyfuss P, et al. International spine intervention society practice guidelines for spinal diagnostic...

Headaches Due to Meningeal Irritation

These headaches are usually due to a meningeal infection or rupture of an aneurysm. Meningitis and subarachnoid hemorrhage are the most common causes. Diagnosis is based on the patient's symptoms and imaging such as a computed tomography (CT) or a magnetic resonance imaging (MRI). The patient may present with asudden onset of intense, deep pain, often worse in the neck, and evolving in minutes to hours. The pain can be generalized, bioc-cipital, or bifrontal. The patient may present with neck...

History of Acupuncture

Acupuncture is one of many therapeutic interventions utilized in traditional Chinese medicine (TCM). The seminal TCM textbook, Huang Di Nei Jing (Inner Canon of the Yellow Emperor or The Inner Canon of Huangdi), was compiled around 305-204 BCE (Fig. 16.1). This textbook covered the theoretical foundation of Chinese medicine (Unschuld 1985). It is composed of two volumes Shu Wen and Ling Shu. Each volume has 81 chapters and is written in a question and answer format between the mythical Huangdi...

Benzodiazepines

These agents may be useful to help with insomnia, making it easier to deal with pain or to treat anxiety which can play a role in pain states especially acute pain. However, it must always be remembered that these agents do not have any analgesic properties. Therefore they must be used with caution in acute pain, especially when high doses of opioids are required, as significant sedation and respiratory depression can occur in the benzodiazepine-na'ive patient. In an anxious patient with pain,...

Popliteal Nerve Block Distal Sciatic

This is a peripheral nerve block of the sciatic nerve performed more distal in the leg proximal to the popliteal crease. With the patient in the supine or prone position, the ultrasound probe is placed to scan in the transverse plane on the posterior surface of the popliteal fossa 5 cm or more proximal to the popliteal flexion crease of the knee (Fig. 21.11a). Subtle inclination of the ultrasound probe in the caudad or cephalad direction may be needed to produce ideal visualization of the...

Spine Injections

Medial Branch Posterior Ramus

Back pain is one of the most common reasons for patients to seek medical attention. About two-thirds of adults will experience low back pain at least once in their lifetime (Rubin 2007). Its etiology is often unclear given that similar complaints and symptoms may result from various pathologic conditions and imaging studies do not always correlate. This makes accurate diagnosis and treatment difficult. Occupational injuries, compensation, and secondary gain issues confound the situation even...

Regional Anesthesia

Regional anesthesia, whether performed alone or most commonly in conjunction with general anesthesia, provides an excellent and safe source of intra-operative and postoperative analgesia for pediatric acute pain management as well as analgesia for pediatric chronic pain management. The popularity of regional anesthesia is underscored by its ability to decrease intra-operative and postoperative requirement for opioids, intra-operative titration of volatile anesthetics, and to minimize side...

Tunneled Epidural Catheter for Long Term use for Cancer Pain

As mentioned in earlier chapters, the epidural space continues from foramen magnum superiorly to the sacrococcygeal membrane inferiorly. Epidural space contains fat, blood vessels, and connective tissues (Stoelting and Miller 2000). Epidural catheter can be placed at any level in the lumbar, thoracic, or cervical level. Infusion can be delivered at either level to help pain in cancer patients. Tunneled catheter is more advantageous than non-tunneled catheter because if infection occurs at the...

Technique

Management Local Anesthesia Toxicity

Intranasal delivery of 4 lidocaine or 2 viscous lidocaine or 10 cocaine in the posterior pharynx superior to the middle turbinate is an effective and noninvasive approach. Cotton-tipped applicators soaked with local anesthetic left in the superior border of the middle turbinate for 20 min is a useful technique via the transnasal approach. This is achieved by the placement of a needle through the coronoid notch. Opening and closing the mouth helps in identifying the area anterior inferior to the...

Case Scenario

Sreekumar Kunnumpurath, MBBS, MD, FCARCSI, FRCA, FFPMRCA Meena, a 40-year-old woman is brought to the emergency department with burns affecting her chest, abdomen, and upper limbs. She sustained burns when the bed she was sleeping on caught fire from a cigarette that she had been smoking. As the physician covering emergency calls, you have been requested to attend to her urgently. When you see her, she is anxious, agitated, and screaming from pain. How would you prioritize your management Your...

Anxiolytics

Anxiety is a very common concomitant condition in patients with chronic pain, presenting as panic, PTSD, obsessive compulsive disorder (OCD), etc. Although anxiolytics do not possess intrinsic analgesic activity, anxiety is often accompanied by somatic complaints of chest pain, GI upset, or neurologic symptoms such as dysesthesias, headache, which may be relieved by anxiolysis. Benzodiazepines are also a mainstay in the treatment of restless legs syndrome (RLS). Although most RLS studies were...

Physical Management of Pain

Approaches for the physical management of pain include client education and training in methods to protect joints, prevention of pain and inflammation, work simplification, proper body mechanics, therapeutic exercise, work hardening programs, and physical agent modalities. The goal is to control pain and educate the client on strategies that can be used to more effectively manage the pain and allow engagement in enjoyable and meaningful occupations. Joint protection, work simplification, proper...

Hypogastric Plexus Block

Hypogastric Nerve Distribution

Hypogastric plexus block is located bilaterally in front of the anterolateral border of the lower 1 3 of L5 vertebral body. The ganglia are located in the retroperitoneum (Plancarte et al. 1997). Superior hypogastric plexus innervates the sympathetic structures of the lower abdominal and pelvic organs. Visceral pain is an important component in pelvic pain due to cancer. Pain relief from superior hypogastric plexus block is possible because afferent nerve fibers to the pelvic structures travel...

Headache of Temporal Arteritis

This headache is caused by inflammation of the cranial arteries and is usually seen in the elderly. It presents with increasingly intense throbbing or non-throbbing headaches. There is often a superimposed sharp, stabbing pain associated with thickened and tender arteries. The pain is usually unilateral, localized to the site of the affected arteries. However, it may also present as bilateral and explosive in nature in some patients. Pain may be present throughout the day and may be more severe...

Median Nerve Block

A brachial plexus block can be supplemented or rescued with a median nerve block for surgeries in the distribution of the median nerve or in the instance when a brachial plexus block may have spared the median nerve distribution. Fibers from C5-T1 spinal roots make up the median nerve. The nerve traverses the anterior-superior part of the axillary artery before exiting the axilla along with the brachial artery. The median nerve lies medial to the brachial artery at the level of the elbow and...

PCA Management

If the patient does not receive adequate pain relief with a given demand dose, increase the dose per activation using the parameters suggested in Table 18.6. Table 18.6 Usual patient-controlled analgesia demand dose changes for inadequate analgesia. Table 18.6 Usual patient-controlled analgesia demand dose changes for inadequate analgesia. A small subset of opioid-na'ive patients may prove that they need and can be safe with a continuous infusion. For example, if following several demand dose...

Celiac Plexus Block

The celiac plexus is the largest ganglia of the sympathetic nervous system located at prevertebral level of body of first lumbar vertebra. It innervates abdominal viscera and contains visceral afferent and efferent fibers. It also contains parasympathetic fibers from the vagus nerve. It does not contain any somatic fibers. Right-sided ganglion lies medial to inferior vena cava, while left-sided ganglia lies anterior to abdominal aorta Waldman 2001, Wong and Brown 1997 . Preganglionic axons from...

Head and Neck

Gasserian Ganglion Block

Supraorbital Nerve Blocks Indications This is a useful block for pain after herpes zoster and for supraorbital neuralgia. N. Vadivelu et al. eds. , Essentials of Pain Management, DOI 10.1007 978-0-387-87579-8_13, Springer Science Business Media, LLC 2011 The supraorbital nerve is a branch of the frontal nerve which enters the orbit via the superior orbital fissure. A smaller branch of the frontal nerve is the supratrochlear nerve. To perform this block, the supraorbital notch is identified on...

Popliteal Nerve Block Sciatic Nerve Block in Popliteal Region

The sciatic nerve is a bundle consisting of the tibial and common peroneal nerves contained in an epineural sheath. A popliteal nerve block will block components of the sciatic nerve tibial and common peroneal at the level of the popliteal fossa where the two branches typically diverge. The common peroneal nerve gives sensory innervation to the inferior portion of the knee joint and lateral and posterior portion of the upper calf. The tibial nerve is a branch of the sciatic nerve and provides...

Neuromatrix Theory and the Biopsychosocial Model

Advances in the neuroscience of pain processing have provided support for the role of higher brain centers, i.e., those responsible for emotion and cognition, in influencing pain transmission from the periphery Melzack 1999 , lending support for the biopsychosocial approach. Abandoning the archaic Cartesian viewpoint of the brain as a passive recipient of pain information from the periphery, the neuromatrix model acknowledges that the brain is dynamically involved in the processing inhibition,...

Case 2 Gareth Suneil Ramessur Mbbs Bsc Hons FRCA DipHEP

Gareth, 40-year-old man, is referred to you with persistent pain and tingling around his neck and upper limbs. The pain started following a road traffic accident during which he sustained whiplash injury several months ago. He has tried various pain killers and physiotherapy without much benefit. The attending neurologist has requested you to see Gareth. A recent MRI of cervical spine is showing arthritic changes in the cervical facet joints. Explain your approach to Gareths problem Though the...

Suprascapular Block

The fibers of C5 and C6 nerve roots and some contribution from the C4 nerve root form the suprascapular nerve that passes through the suprascapular notch under the coracoclavicular ligament. A suprascapular block is useful for the diagnosis and treatment of pain and surgery involving the shoulder girdle and shoulder joint pain. It may also be used for treatment of frozen shoulder adhesive capsulitis or complex regional pain syndrome type I. Arrange sterile towels, sterile gloves, gauze pads,...