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Purpose Prediction of the response to transdermal fentanyl (FENtd) before its use for chronic pain is desirable. We tested the hypothesis that the response to intravenous fentanyl infusion (FENiv) can predict the response to FENtd, including the analgesic and adverse effects. Methods The study subjects were 70 consecutive patients with chronic pain. The response to fentanyl at 0.1 mg diluted in 50 ml of physiological saline and infused over 30 min was tested. This was followed by treatment with FENtd (Durotep MT patch 2.1 mg) at a dose of 12.5 [micro]g/h for 2 weeks. Pain intensity before and after FENiv and 2 weeks after FENtd, and the response to treatment, were assessed by the numerical rating scale (NRS), clinical global impression-improvement scale (CGI-I), satisfaction scale (SS), and adverse effects. Results The NRS score decreased significantly from 7 (4-9) [median (range)] at baseline to 3 (0-8) after FENiv (p < 0.001), and to 4 (1-8) after FENtd (p < 0.001). The effects of FENiv, as evaluated by [DELTA]NRS, CGI-I, and SS, were significantly greater than those of FENtd (p 0.04, each). Conclusions The analgesic and side effects after intravenous fentanyl infusion can be used to predict the response to short-term transdermal treatment with fentanyl., Author(s): Norihito Hayashi[sup.1] , Akifumi Kanai[sup.2] , Asaha Suzuki[sup.1] , Yuki Nagahara[sup.1] , Hirotsugu Okamoto[sup.1] Author Affiliations: (1) Department of Anesthesiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, 252-0374, [...]

(Case 1) A 45-year-old male was diagnosed with prostate cancer. Treatment was administered using bicalutamide and leuprorelin acetate, while a transdermal fentanyl (TDF) was applied for pain relief. However, TDF continued to peel off owing to excessive sweating, even when reinforced by a protective layer. As such, TDF was discontinued and pain control was initiated using other medicines. Sweating occurred irregularly because of hot flashes, approximately four to five times per day. (Case 2) A 37-year-old male was diagnosed with a malignant thymoma and sacral metastasis. For analgesic control, etodolac tablets, carbamazepine tablets, and TDF were administered. Subsequently, the dose of the TDF was gradually increased, but the analgesic effect was low; thus, fentanyl blood concentration was measured. The measurements showed that even higher TDF doses did not increase fentanyl blood levels. During this period, full body sweating began to occur to a large extent due to unknown causes, and it was thought that the absorption of fentanyl decreased. When using a TDF, it is necessary to monitor patients for any sweating during treatment, while also considering changes in medication in some cases. This should promote the maintenance and improvement of the quality of life of the affected patients. [ABSTRACT FROM AUTHOR]

Objective: It is often difficult to alleviate foot pain associated with critical limb ischemia (CLI) using common analgesics. Neuraxial block is contraindicated in anticoagulant therapy. This study was designed to determine the response to subcutaneous injection of lidocaine around the network of peripheral nerves around the ankle in patients with CLI pain on anticoagulants and antiplatelets., Methods: Sixteen patients with CLI pain in the foot were enrolled in this double-blind placebo-controlled crossover study. Patients were randomized to receive either 2% lidocaine or saline via catheters inserted into the subcutaneous area around the ankle. After recurrence of pain, the patients were crossed over to receive the alternative treatment. Pain was assessed with a numerical rating scale (NRS) before and 15 min after injection. Patients used a descriptive scale to grade pain control and were asked to determine the duration of analgesia in each arm of the study., Results: No serious complications including protracted bleeding occurred. Lidocaine significantly decreased the NRS on movement from 10 (6, 10) [median (range)] to 2 (0, 10) ( p < .001), and the differences in the Δ change in NRS between lidocaine and placebo were significant ( p = .009). Of the 16 patients, 14 patients were very satisfied after lidocaine but only one described the same after saline. The effect of lidocaine and placebo lasted 11 (0, 28) and 1 (0, 22) h, respectively., Conclusion: Subcutaneous injection of lidocaine around the ischemic ankle affectively alleviated pain in patients with CLI without serious adverse effects under anticoagulant therapy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The objective of our study was to evaluate the efficacy and adverse effects of opioid switching to tapentadol(TP). It was a retrospective survey carried out at the Kitasato University Hospital outpatient clinic between September 2014 and May 2016. We evaluated pain intensity using the visual analogue scale and the occurrence of adverse effects before switching, at the first evaluation after switching, and during the steady state of TP administration. We included 10 patients; of these, 3 patients discontinued TP owing to uncontrolled pain. The conversion ratio of the previously administered opioids to TP was 1.17 at the time of the first evaluation after switching and 1.42 during the steady state. The mean(±SD)pain intensity was 4.2±2.2 before opioid switching and 4.6±2.2 at the time of the first evaluation after switching. The mean(±SD)pain intensity in the 7 patients excluding the 3 patients who discontinued TP was 4.3±2.0 before opioid switching and 2.7±1.9 during the steady state. Somnolence improved in 5 patients and constipation improved in 2 patients when a stable dose was achieved. Opioid switching to TP was appropriately accomplished using the conversion ratio. Furthermore, pain, sleepiness, and constipation improved following successful titration. These data suggest that TP can be useful in the treatment of cancer pain, in addition to the currently used opioid preparations.

Three patients with severe neck and radicular pain due to cervical disc herniation was not relieved of pain by common drug medication such as NSAIDs and anticonvulsants. Patients underwent oral mini-pulse therapy of betamethasone as the initial dose of 8 mg x day(-1) in the form of 8 tablets of 0.5 mg in a single dose twice a day (after breakfast and after lunch). The daily dose was reduced by half every 4 days, and the therapy was continued for 16 days. In all patients, the pain disappeared completely within the opening 10 days of the therapy, and the pain did not relapse after the therapy. All adverse events of betamethasone including irritation, insomnia and overeating disappeared without medication within several days.

The xenon light, generated by high-intensity electrical stimulation of xenon gas, is used to sterilize wounds, aid tissue repair, and relieve pain as a low-level light therapy. The light produced consists of non-coherent beams of multiple wavelengths in the ultraviolet to infrared spectrum. This broad-band light can be emitted in a continuous wave or pulsed mode, with the wave band chosen and the energy distribution controlled for the purpose. Specifically, wavelengths in the 500-700 nm range are suitable for treating superficial tissue, and wavelengths between 800 and 1,000 nm are suitable for deeper-seated tissues, due to longer optical penetration distances through tissue. One of the most common benefits in the xenon light therapy is considered to be the wide and deep irradiation of optimal rays to living tissue. Research into the use of xenon light for tissue repair and pain reduction is restricted within open-label studies and case reports. The present review expounded the effects of xenon light therapy on the basis of the available evidence in vitro and in vivo studies using a laser beam of single wavelength.

A 73-year-old man suffering from ankylosing spondylitis with limited motion of the whole spine was scheduled for right total hip arthroplasty. Ten years before, the patient had undergone left total hip arthroplasty under general anesthesia, in which epidural anesthesia impossible, intrathecal anesthesia insufficient, and tracheal intubation difficult. In the present operation, an 18 gauge epidural catheter was inserted into the epidural space at L3-4 using paramedian approach. Six ml of contrast medium was administered via the catheter, with high resistance on injection and the spread of epidural contrast medium was limited to L2 and L3. Therefore, the catheter was removed and reinserted into the intrathecal space at L3-4. Two ml of contrast medium demonstrated good spread in the intrathecal space from T12 to S2. Next injection of 0.5% isobaric bupivacaine 2.4ml produced bilateral cold sensory blockade from T10 to S5. Two hours after this injection, a single bolus of 1 ml followed by a continuous infusion at a rate of 0.5 ml x hr(-1) with 0.5% isobaric bupivacaine was commenced. There was no pain at rest and on movement, and no additional analgesics and hypertensive drugs were used until 4 hours following the discontinuation of the continuous intrathecal anesthesia in the morning after the operation. No adverse events including post-dural puncture headache were observed. Continuous intrathecal anesthesia may be effective for total hip arthroplasty in patients with ankylosing spondylitis.

Background: Incidence and intensity of pain on intravenous injection of propofol LCT were compared with those of propofol MCT/LCT., Methods: Eighty adult patients scheduled to receive general anesthesia were divided into two groups, propofol LCT (Group L, AstraZeneca) and propofol MCT/LCT (Group M, Maruishi Pharmaceutical). The peripheral vein was inserted with an 18 gauge intravenous catheter at the dorsal hand, the wrist, or the anterior brachial region. Propofol 2.0 mg x kg(-1) was injected at the speed of 5 mg x sec(-1). Noninvasive arterial blood pressure, heart rate, a BIS value and a degree of pain were measured. We used chi2 analysis and Wilcoxon t-test for statistical evaluation., Results: There was a significantly larger incidence of injection pain in the Group L than the Group M (70% vs. 30%). The pain at the brachial region was significantly less as compared with the wrist or the dorsal hand in both groups. The ratio of patients having the memory of pain on the next day to those complaing the injection pain was 50% in the Group L and 36% in the Group M. There were no significant differences between the two groups in changes in BIS values and doses of propofol necessary for the loss of consciousness., Conclusions: The results suggest that propofol MCT/LCT elicits less pain on injection than propofol LCT. The injection pain is less at the brachial region than the wrist or the hand. Amnesia of pain may be obtained both with propofol MCT/ LCT and propofol LCT.

Intracranial subdural haematoma has been reported to be an exceptionally rare complication of accidental dural puncture. An accidental lumbar dural puncture occurred in a 36-yr-old male undergoing orthopedic knee surgery. On the morning after the operation, the patient complained of severe occipital headache, although this was relieved with loxoprofen and rest. This was assumed to be a postdural puncture headache (PDPH) because it had a postural component (it was worse on sitting up). On the third day after the operation, the patient developed a severe diffuse headache together with nausea, which did not subside with analgesia and bed rest. Magnetic resonance imaging of the head showed a small acute subdural hematoma in the bilateral temporooccipital region with no mass effect. The patient was conscious and oriented. There was no focal neurological deficit. The patient was managed conservatively with bed rest and intravenous fluids. His condition improved without surgical decompression and was discharged on the 40 th day after the operation. Severe and prolonged PDPH shoud be considered as a warning sign of an intracranial complication.

Purpose: When used intraoperatively, mepivacaine can produce a satisfactory sensory block. However, insufficient information is available concerning the factors that affect the speed of nerve blockade with epidural analgesia. The optimal rate of injection of mepivacaine has not been determined. We examined whether the speed of epidural infusion of mepivacaine affects the speed of nerve blockade., Methods: Forty patients, physical status ASA I-II, scheduled for gynecological abdominal surgery, were enrolled in this double blind randomized trial. A catheter was inserted 4 cm in the epidural space in the midline at L1-L2. Three minutes after a test dose of 2 mL plain 1% mepivacaine over four seconds, 8 mL were injected epidurally at a rate of 1 mL.sec(-1) (fast group) or 0.05 mL.sec(-1) (slow group). Sensory and motor blockade, blood pressure, and heart rate were assessed at five, ten, and 15 min after the epidural injection., Results: There was a significant difference in the spread of sensory blockade at five minutes after the epidural injection between the two groups, but not at ten and 15 min. Blood pressure decreased at five and ten minutes, recovered at 15 min in the fast group, and remained stable in the slow group., Conclusion: Rapid injection of mepivacaine in the epidural space produced a more rapid onset of epidural block than slow injection, but there was no difference in the final extent of the block.

Background: Epidural administration of local anesthetics may lead to effective pain relief. However, tachyphylaxis or other problems following prolonged epidural anesthesia may develop and in many cases difficulties exist in the maintenance of the similar degree of sensory blockade. The present study was therefore performed to investigate the analgesic effect of continuous postoperative epidural infusion of ropivacaine with fentanyl in comparison with that of bupivacaine or ropivacaine alone., Methods: After leg orthopedic surgery with lumbar combined spinal-epidural anesthesia, thirty-six patients were randomized to one of the three postoperative epidural infusion groups: bupivacaine 0.125%, ropivacaine 0.2%, or ropivacaine 0.2% with 2.2 microg x ml(-1) (400 microg x 180 ml(-1)) of fentanyl. Continuous epidural infusion was started at a rate of 6 ml x h(-1) with possibility of an additional bolus injection of 3 ml at least every 60 min. Pain was assessed using a 10-cm visual analog scale (VAS) just before and 15 min after epidural bolus injections, and 15-20 h after the start of continuous epidural infusion as the severe at pain through the observation. The spread of analgesia (loss of sharpness in pinprick perception) and motor block (Bromage scale) were evaluated bilaterally. Systolic and diastolic blood pressure and heart rate were also measured., Results: The epidural bolus infusion was associated with a significant decrease of VAS (P < 0.001) and stable blood pressure and heart rate in all groups. The maximal VAS in patients receiving 0.2% ropivacaine+fentanyl was significantly less compared to that in the other two groups. The regression of sensory blockade was significantly prolonged in patients treated with ropivacaine+fentanyl. There was no significant difference in the spread of sensory analgesia between 20 min and 15-20 h after the continuous epidural anesthesia in this group. None of the patients developed adverse effects such as respiratory depression, nausea, and pruritus., Conclusions: Epidural injection of ropivacaine with fentanyl decreased postoperative pain with stable vital signs in patients undergoing leg orthopedic surgery, as compared to bupivacaine or ropivacaine alone, possibly because of the maintenance of sensory blockade by ropivacaine and enhancement of this sensory blockade by fentanyl.

Background: Epidural ropivacaine is now a common drug used for postoperative analgesia. However, little information is available concerning regression of sensory blockade and analgesia following prolonged epidural infusion of ropivacaine. We investigated the efficacy of ropivacaine and fentanyl for postoperative analgesia after thoracic surgery., Methods: Thirty patients undergoing thoracic surgery were enrolled. After surgery with general and thoracic epidural anesthesia, continuous epidural infusion of 0.2% ropivacaine+fentanyl (1.67 microg x ml(-1)) was started at a rate of 6 ml x h(-1) for patients whose height was more than 155 cm and 4 ml x h(-1) for those below 155 cm with possibility of an additional bolus injection of 3 ml at least every 60 min., Results: An additional epidural injection of 3 ml produced a decrease in VAS without significant changes of vital signs. The greatest VAS was 10+/-25 mm in the incision site and 36+/-38 mm in the ipsilateral shoulder. Sensory blockade was sustained until the morning after the day of surgery. Also blood pressure and heart rate were stable throughout the observation period. There were no adverse effects except for slight nausea in three patients., Conclusions: A bolus of 3 ml with continuous 4-6 ml x h(-1) epidural injection of ropivacaine plus a small dose of fentanyl would decrease postoperative pain with stable vital signs in patients after thoracic surgery.

A 38-year-old man diagnosed as esophageal achalasia developed masseter muscle rigidity after intravenous suxamethonium during anesthetic induction. Anesthesia was maintained with intravenous agents and epidural blockade, while the masseter muscle rigidity continued. After the surgery, his body temperature increased to 38.8 degrees C concomitantly with the appearance of myoglobinuria suggesting the occurrence of abortive malignant hyperthermia. These symptoms were dissolved by dantrolene administration. He was later proved to be negative with CICR test.

Background: Epidural bupivacaine infusion is a commonly used technique for postoperative analgesia because of its motor-sparing properties. Recently a new long acting local anesthetic, ropivacaine, has become available. The aim of this study was to investigate the efficacy of ropivacaine and bupivacaine with regard to postoperative analgesia when administered continuously into the lumbar epidural space., Methods: All patients were ASA I II and undergoing ipsi-lateral leg orthopedic surgery with epidural or combined spinal-epidural anesthesia. Patients were randomly assigned to following three groups: 0.1% ropivacaine (0.1 R); 0.2% ropivacaine (0.2 R); 0.125% bupivacaine (0.125 B). At the end of surgery, continuous infusion was begun at a rate of 6 ml.hr 1 after a bolus epidural administration of 5 ml of 0.2% ropivacaine in R groups and 0.25% bupivacaine in B group. Sensory and motor block, blood pressure, pulse rate, verbal pain score (VPS), analgesic consumption were assessed at 20 min, 1, 3, 10-20 hrs following the beginning of continuous infusion., Results: Vital signs were stable at every measuring point in all groups. In 0.1 R group (n = 20), the spread of sensory block at 3 hrs after infusion was lower than 0.2 R group (n = 19), and VPS during the study was higher than 0.125 B group (n = 17). Bromage scale after 3 hrs was higher in 0.2 R group compared with 0.125 B group. The degree of sensory and motor block gradually decreased, resulting in little difference between the groups. When epidural anesthesia was spread over the surgical area throughout the study, 0.2 R or 0.125 B was sufficiently relieved from postoperative pain., Conclusions: After leg orthopedic surgery, 6 ml.hr-1 of 0.2 R or 0.125 B provided enough postoperative analgesia when the spread of anesthesia covered the operated area. 0.2 R would be better compared to 0.125 B in continuous epidural infusion for postoperative analgesia due to less systemic toxicity, even though it accompanies a little more intense motor block.