Sphenopalatine ganglion block for ipsilateral shoulder pain following open pancreaticoduodenectomy

A 59-year-old woman underwent an open pancreaticoduodenectomy. Thoracic patient controlled-epidural anaesthesia provided excellent incisional pain relief; however, the patient experienced intractable left shoulder pain (10/10 on the Numerical Rating Scale). To our knowledge, there is no effective established treatment for patients experiencing shoulder pain after an open pancreaticoduodenectomy. The patient’s shoulder pain did not respond to medical management with acetaminophen, ketorolac, lidocaine transdermal patch, oxycodone and hydromorphone. Then, on postoperative day 2, the acute pain service was consulted. Considering that the sphenopalatine ganglion block has been previously reported to be helpful in a number of painful conditions, including shoulder tip pain after thoracic surgery, we offered this treatment to the patient. After just one topical sphenopalatine ganglion block, using a cotton-tipped applicator, the patient’s shoulder pain entirely resolved and did not return. This is the first report of a successful treatment of intractable ipsilateral shoulder pain following an open pancreaticoduodenectomy with transnasal sphenopalatine ganglion block.

Activation of peripheral neuronal FLT3 promotes exaggerated sensorial and emotional pain-related behaviors facilitating the transition from acute to chronic pain

Background. Acute pain events have been associated with persistent pain sensitization of nociceptive pathways increasing the risk of transition from acute to chronic pain. However, it is unclear whether injury-induced persistent pain sensitization can promote long-term mood disorders. The receptor tyrosine kinase FLT3 is causally required for peripheral nerve injury-induced pain chronification, questioning its role in the development of pain-induced mood alterations. Methods. In a model of paw incisional pain, mice underwent single (SI) or double incision (DI) and went through behavioral and molecular phenotyping with the evaluation of both sensorial and emotional pain components. The role of FLT3 was then investigated either by inhibition using transgenic knock-out mice and functional antibodies or by activation with FLT3 ligand (FL) administrations. Results. DI mice showed significant anxiodepressive-like and spontaneous pain behaviors while SI mice did not. DI also promoted and extended mechanical pain hypersensitivity compared to SI. This emotional and sensorial pain exaggeration correlated with a potentiation of spinal microglial activation after DI versus SI. Intrathecal minocycline, a microglial inhibitor, specifically reversed DI induced-mechanical hypersensitivity. Finally, FL injections in naive animals provoked mechanical allodynia and anxiodepressive-like disorders concomitant with a significant microglial activation while FLT3 inhibition blunted the development of persistent pain and depression after DI. Conclusions. Our results show for the first time that the repetition of a peripheral lesion facilitates not only exaggerated nociceptive behaviors but also anxiodepressive disorders. The inhibition of FLT3 could become a promising therapy in the management of pain sensitization and related mood alterations.

The Effect of Fluoxetine and Ibuprofen on BCG-Induced Alteration in Pain Sensitivity in Mice

Clinical observations recognized the co-existence and interactions of pain and depression a long time, ago. The aim of this work was to study the effect of ibuprofen and fluoxetine on BCGinduced depressive-like behaviour, on formalin-induced pain, as well as on mechanical allodynia after planter incision in mice. BCG induced a depressive behaviour that was seen in the forced swim test (FST) and the tail suspension test (TST). It also induced a decrease in pain-related behaviour in the formalin test, and an increase in the baseline in mechanical allodynia test compared to the control group. Fluoxetine (80 mg/L of drinking water) showed a significant decrease in the immobility time in the FST and TST and enhanced pain related behaviour in formalin test in the BCG-inoculated group. However, it did not affect the increase in the pain threshold in the planter incision allodynia model. Adding ibuprofen to drinking water (0.2 g/L of drinking water), reversed the depressive like behaviour induced by BCG and enhanced pain-related behaviour in formalin test, in both the total pain-related behaviour and phase 2. It also prevented the increase in the base line induced by BCG. On the other hand, the incisional pain model was not affected by BCG inoculation except at the 2-hour time point, where it showed hypoalgesia, as well.

Comparison of Ultrasound Guided Transversus Abdominis Plane Block versus Intraperitoneal and Perioportal Bupivacaine Infiltration in Post Operative Analgesia after Laparoscopic Cholecystectomy

Background Laparoscopic cholecystectomy is one of the commonest elective laparoscopic surgeries done in our setup. We found that post-surgery most of the patients complain of incisional pain at port sites and right shoulder tip pain. Objectives The aim of this study has been to test the efficacy of TAP block versus intraperitoneal and periportal infilteration with local anesthetic agent specially to provide postoperative analgesia after laparoscopic cholecystectomy. Patients and Methods All patients were informed with the procedure US guided TAP block and were trained to use the visual analogue scale (VAS). The study was conducted on 50 randomly chosen patients aged 20 to 60 years, American Society of Anesthesiologists (ASA) class I or II scheduled for elective laparoscopic cholecystectomy in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 25 patients each: TAP block Group: received general anaesthesia and 20 ml of 0.25% bupivacaine on each side by midaxillary approach under ultrasound guidance. Intraperitoneal and periportal infiltration Group: received general anaesthesia and 20 ml of 0.25% bupivacaine was injected under the direct vision into the hepato-diaphragmatic space, near and above the hepato-duodenal ligament and above the gall bladder before removal of the probes, also 20ml of 0.25% bupivacaine was injected at the port sites at the end of operation. Results The Patients receiving TAP block had significantly lower pain scores at rest for 6 hrs and upon coughing for 6 hrs also after operation and decrease total need of analgesic in first 24 h post operative compared with patients who received Intraperitoneal and periportal infiltration. Conclusion Bilateral TAP block was effective in reducing postoperative pain scores at rest and upon coughing for 6-12 hours and lower total 24-h postoperative opioid and analgesic consumption after laparoscopic cholecystectomy under general anesthesia, compared to intraperitoneal and periportal infiltration. This technique can be a promising mode of postoperative analgesia where epidural catheter insertion is contraindicated.

Effects of a BMI1008 mixture on postoperative pain in a rat model of incisional pain

Background The purpose of this study was to evaluate the analgesic effect of BMI1008 (a new drug containing lidocaine, methylene blue, dexamethasone and vitamin B complex) and to investigate the analgesic effect of lidocaine and BMI-L (other components of BMI1008 except lidocaine) at different concentrations in a rat model of incisional pain. Methods Male Sprague-Dawley rats (250–300 g) were used for the incisional pain model simulating postoperative pain. After the operation, normal saline, various concentrations of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine were injected at the incision site. The preventive analgesic effect was evaluated using BMI1008 administered 30 min before and immediately after the operation. In addition, BMI1008 was compared with positive controls using intraperitoneal ketorolac 30 mg/kg and fentanyl 0.5 μg/kg. The mechanical withdrawal threshold was measured with a von Frey filament. Results The analgesic effect according to the concentration of BMI1008, lidocaine with a fixed concentration of BMI-L, and BMI-L with a fixed concentration of lidocaine showed a concentration-dependent response and statistically significant difference among the groups (P <0.001, P <0.001, and P <0.001, respectively). The analgesic effect according to the time point of administration (before and after the operation) showed no evidence of a statistically significant difference between the groups (P = 0.170). Compared with the positive control groups, the results showed a statistically significant difference between the groups (P = 0.024). Conclusion BMI1008 showed its analgesic effect in a rat model of incisional pain in a concentration-dependent manner. Moreover, BMI-L showed an additive effect on the analgesic effect of lidocaine.

Persistent Incisional Pain after Noncardiac Surgery: An International Prospective Cohort Study

Background The purpose of this study was to determine the incidence, characteristics, impact, and risk factors associated with persistent incisional pain. The hypothesis was that patient demographics and perioperative interventions are associated with persistent pain. Methods This was a secondary analysis of an international prospective cohort study from 2012 to 2014. This study included patients who were 45 yr of age or older who underwent major inpatient noncardiac surgery. Data were collected perioperatively and at 1 yr after surgery to assess for the development of persistent incisional pain (pain present around incision at 1 yr after surgery). Results Among 14,831 patients, 495 (3.3%; 95% CI, 3.1 to 3.6) reported persistent incisional pain at 1 yr, with an average pain intensity of 3.6 ± 2.5 (0 to 10 numeric rating scale), with 35% and 14% reporting moderate and severe pain intensities, respectively. More than half of patients with persistent pain reported needing analgesic medications, and 85% reported interference with daily activities (denominator = 495 in the above proportions). Risk factors for persistent pain included female sex (P = 0.007), Asian ethnicity (P &lt; 0.001), surgery for fracture (P &lt; 0.001), history of chronic pain (P &lt; 0.001), coronary artery disease (P &lt; 0.001), history of tobacco use (P = 0.048), postoperative patient-controlled analgesia (P &lt; 0.001), postoperative continuous nerve block (P = 0.010), insulin initiation within 24 h of surgery (P &lt; 0.001), and withholding nonsteroidal anti-inflammatory medication or cyclooxygenase-2 inhibitors on the day of surgery (P = 0.029 and P &lt; 0.001, respectively). Older age (P &lt; 0.001), endoscopic surgery (P = 0.005), and South Asian (P &lt; 0.001), Native American/Australian (P = 0.004), and Latin/Hispanic ethnicities (P &lt; 0.001) were associated with a lower risk of persistent pain. Conclusions Persistent incisional pain is a common complication of inpatient noncardiac surgery, occurring in approximately 1 in 30 adults. It results in significant morbidity, interferes with daily living, and is associated with persistent analgesic consumption. Certain demographics, ethnicities, and perioperative practices are associated with increased risk of persistent pain. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

The Value of Combined Application of Oxycodone Hydrochloride Injection and Dexmedetomidine in Anesthesia for LC for Patients with Gallbladder Lesions

Objective. To analyze the effect of combined application of oxycodone hydrochloride injection and dexmedetomidine in anesthesia for laparoscopic cholecystectomy (LC) for patients with gallbladder lesions. Method. 93 patients with gallbladder lesions in our hospital were divided into 2 groups by the random number table method. 46 patients in the control group applied oxycodone hydrochloride injection in anesthesia, and 47 patients in the observation group applied oxycodone hydrochloride injection combined with dexmedetomidine in anesthesia. Result. The T1 and T2 MAP levels in the observation group were lower than those in the control group ( P < 0.05 ), and the difference between T3 and the control group was not significantly significant ( P > 0.05 ). The T1 to T3 HR level in the observation group were lower than those in the control group ( P < 0.05 ). The rate of excessive sedation (10.64%) and sedation inefficiency (12.77%) in the observation group was lower than that in the control group (28.26% and 30.43%), and the rate of satisfactory sedation (76.60%) was higher than that in the control group (41.30%) ( P < 0.05 ). The postoperative awakening, tracheal tube removal, and first anal venting time were shorter in the observation group than in the control group ( P < 0.05 ). The WHO scores of incisional pain at 6, 12, 24, and 48 hours after the operation were lower in the observation group than in the control group ( P < 0.05 ). The T2 SOD level in the observation group was higher than that in the control group, and the ROS and MDA levels were lower than those in the control group ( P < 0.05 ). The incidence of side effects of anesthetic in the observation group was 17.02%, which was not statistically different from the control group of 13.04% ( P > 0.05 ). Conclusion. The combined application of oxycodone hydrochloride injection and dexmedetomidine in anesthesia for LC for patients with gallbladder lesions can achieve better sedation and analgesia effect, accelerate postoperative awakening and recovery, and control oxidative stress and fluctuations in signs, without increasing anesthesia-related side effects.

A Quasi Experimental Study to Assess the Effectiveness of Foot Massage on Incisional pain and sleep pattern among Post Caesarean Mothers admitted in selected hospitals, Hoshiarpur, Punjab

Aim: The aim of this study was to assess effectiveness of foot massage on incisional pain and sleep pattern among post caesarean mothers. Background: Cesarean section (C.S) is the birth of fetus through a trans-abdominal incision in the uterus. Persistent post-operative pain is a well- known consequence of caesarean section. Some studies have found alternative methods such as acuapressure, aromatherapy and massage therapy to be fairly effective for treatment of post caesarean pain and improve the quality of sleep pattern. Foot massage appears to be effective, in expensive, low risk, flexible and easily applied. So, foot massage was used to assess its effect on incisional pain and sleep pattern among post caesarean mothers. Design: A quasi-experimental pretest-posttest control group research design was used with non-probability purposive sampling technique to selected sample. Material and Methods: Sample of 60 post caesarean mothers from selected hospitals, 30 each in experimental group and control group were selected. Assessment of level of incisional pain was done by using standardized numerical pain rating scale whereas assessment of sleep pattern was done by using modified Groningen sleep quality index scale. Analysis was done by using both descriptive and inferential statistics. Findings: Findings showed that in experimental group, 93.24% post caesarean mothers had mild level of pain and 6.66% had moderate level of incisional pain. Whereas in control group, 40% had mild level of pain and 60% had moderate level of pain. On the other hand, 93.33 % post caesarean mothers had good sleep and 6.66% had poor quality of sleep pattern. Whereas in control group 100% post caesarean mothers had poor sleep pattern. Conclusion: Thus, the study concluded that the difference between mean pretest and posttest score was found statistically significant at p < 0.05 level in experimental group. Hence, research hypothesis was accepted and it revealed that there was impact of foot massage among post caesarean mothers in experimental group.