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The clinical management of acute pain has been impeded by traditions and misconceptions which have resulted in suboptimal application to the patient of the currently available methods of pain control. The search for new drugs and exotic ways to deliver them has further obscured many of the basic principles which should guide management. Standard regimens fail because of the wide, unpredictable variability in pain intensity, patient characteristics, and pharmacological responses. Treatment needs to be individualized for each patient. Unrelieved acute pain produces psychological, physiological and socioeconomic consequences. Pre-emptive analgesia may damp down the development of both immediate and long-term pain following surgery and adequate psychological preparation can improve coping abilities. The delivery of opioid analgesics can be improved using patient controlled analgesia or spinal administration in some cases. Regional analgesia, often using simple techniques, can produce excellent pain relief. Overall management and staff education should be delegated to an acute pain service.

Access to pain relief is an integral part of peri-operative care jointly managed by clinicians and nursing staff. Simple regimens, relying on inexpensive drugs, are often not followed due to inadequate healthcare systems. This article describes some of the common challenges, and suggests practical approaches to overcoming them.

Surgical lumbar sympathectomy was commonly performed on patients with painful obliterative arterial disease. Percutaneous chemical sympathectomy is an alternative to surgery and was described by Mandl in 1926. His approach depended upon the needle contacting the transverse process to gauge depth before being inserted more deeply. Variations of this technique were subsequently described, but it was the introduction of radiographic techniques that allowed identification of landmarks and precise positioning of the needle.

In a double-blind trial carried out on patients in the first stage of labour, either fentanyl 80 micrograms (n = 35) or physiological saline (n = 33) was added to the test dose of bupivacaine and administered extradurally. Thereafter analgesia was maintained as necessary with 0.5% bupivacaine alone. Supplementary bupivacaine (a further dose within 1 h) was required to produce satisfactory analgesia in eight patients in the fentanyl group and in 26 patients in the control group. Analgesia was more rapid in onset and more complete in the fentanyl group, and the duration from first dose to first top-up was 2.36 h, compared with 1.66 h (supplements notwithstanding) in the control group. No serious side-effects were encountered in either group, although eight patients in the fentanyl group experienced mild itching, compared with one in the control group.

Summary A case of transient sympathetic block of the arm following percutaneous intercostal nerve injections is described and the possible aetiology discussed.

In a randomised double blind trial, 36 patients in the first stage of labour received either epidural or intramuscular fentanyl at the same time as the epidural test dose of bupivacaine. Analgesia was more rapid in onset and more complete in the epidural fentanyl group. Supplementary doses of bupivacaine were required within the first hour in 62% of the intramuscular fentanyl group compared with only 16% in the epidural group. Plasma fentanyl concentrations showed wide interindividual variation, but after epidural fentanyl the peak occurred earlier. There was no correlation between analgesia and plasma fentanyl concentration, and epidural fentanyl produced superior analgesia but a systemic contribution to this effect cannot be ruled out.