Drug-induced gingival hyperplasia and its management--a literature review

The purpose of our study was to find out whether patient-controlled epidural administration (PCEA) of a mixture containing a low-dose local anaesthetic, opioid and alpha 2-agonist provides as good or better postoperative analgesia as continuous epidural administration of the same analgetic solution. METHODS: 30 patients (ASA I-III), scheduled for major abdominal surgery, were randomly divided into 2 groups. 90 minutes after induction of general anaesthesia all patients received a continuous epidural infusion of 5 ml/h of the analgetic solution (50 micrograms sufentanil + 150 micrograms clonidine in 50 ml 0.125% bupivacaine) until the end of surgery. Immediately postoperatively the patients of group A received a continuous infusion of the study solution (5-8 ml/h), the patients of group B received a baseline continuous epidural infusion (3 ml/h), additionally they could self-administer 5 ml boli via a PCEA device. Measurements included the total dose of infused drug solution, pain at rest and on exercise by a visual analogue scale, cardiorespiratory data and side effects within the first 24 hours postoperatively. A standardised interview on analgesia and side effects was held 2 days after surgery. RESULTS: The PCEA group demanded less epidural analgesics (gr. B: 112 +/- 33 ml vs. gr. A: 135 +/- 20 ml) p < 0.01). Both continuous epidural infusion and patient-controlled administration provided very good analgesia at rest (gr. A: VAS 0.4 +/- 0.4 and gr. B: VAS 0.4 +/- 0.5) (n.s.). On exercise continuous epidural infusion of analgesics resulted in significantly lower pain scores (gr. A: 1.9 +/- 1.1) than patient-controlled application (gr. B: 3.4 +/- 1.1) (p < 0.01). We did not notice severe side effects such as respiratory depression or drop of heart rate or blood pressure. CONCLUSION: In patients at rest both continuous and patient-controlled epidural administration of analgesics provides excellent analgesia after major abdominal surgery. Contrariwise, patients on exercise who could use a PCA-device experienced more pain compared to those with a continuous epidural infusion technique. On the other hand the patients of the PCA-group consumed less epidural analgesics. We did not notice any severe side effects such as respiratory depression or cardiovascular instability during the study.     

Diagnosis of trypanosomiasis in experimental mice and field-infected camels by detection of antibody to trypanosome tyrosine aminotransferase

We designed this double-blind study to evaluate the effect of adding small-dose ketamine in a multimodal regimen of postoperative patient-controlled epidural analgesia (PCEA). Ninety-one patients, ASA physical status I-III, undergoing major surgery, received a standardized general anesthesia and epidural catheterization in an appropriate intervertebral space after surgery. A PCEA device was programmed to deliver a regimen of morphine 0.02 mg/mL, bupivacaine 0.8 mg/mL, and epinephrine 4 microg/mL, with the addition of ketamine 0.4 mg/mL (ketamine, n = 45) or without (control, n = 46). The mean visual analog pain scale (VAS) scores during cough or movement for the first 3 days after surgery were higher in the control group than in the ketamine group (P < 0.05), whereas the mean VAS score at rest for the first 2 days were higher in the control group than in the ketamine group (P < 0.05). Furthermore, patients in the control group consumed more multimodal analgesics than patients in the ketamine group for the first 2 days (P < 0.05). The sedation scores and the incidence of side effects (pruritus, nausea, emesis, sleep deprivation, motor block, and respiration depression) were similar between the two groups. We conclude that adding ketamine 0.4 mg/mL in a multimodal PCEA regimen provides better postoperative pain relief and decreases consumption of analgesics. Implications: Many studies have evaluated one or a combination of two analgesics for postoperative pain control, but few have examined a multimodal approach using three or four different epidural analgesics. This study demonstrates an additive analgesic effect when ketamine is added to a multimodal analgesic treatment.     

Estimating the prevalence of delayed median nerve conduction in the general population

In a double-blind, randomized, crossover study of 25 patients after abdominal aortic surgery, we compared patient-controlled analgesia (PCA) with epidural versus intravenous pethidine. All patients received continuous epidural infusions of 0.125% bupivacaine adjusted to maintain appropriate sensory levels. The 48 hour study period commenced 36 to 48 hours after surgery and covered postoperative days 2 and 3. There was a crossover in PCA mode (epidural or intravenous) after 24 hours. Plasma pethidine concentration at the end of each 24 hour period and the total 24 hour pethidine dose did not change significantly between postoperative days 2 and 3. Pethidine plasma concentration was lower after 24 hours epidural than after intravenous PCA [125 (SD 108) ng/ml versus 171 (SD 107) ng/ml, P = 0.03], although pethidine dose did not differ significantly [mean 147 (SD 124) mg/24 h]. Visual analog pain scores (VAS) did not differ significantly between postoperative days 2 and 3, or at rest between epidural and i.v. groups. However, VAS with coughing and with abdominal palpation were lower in the epidural PCA group (P = 0.05, 0.008). With a background epidural infusion of 0.125% bupivacaine, PCA with epidural pethidine provided better pain control than PCA intravenous pethidine and this was achieved at lower plasma pethidine concentrations.     

Pharmacokinetics and efficacy of long-term epidural ropivacaine infusion for postoperative analgesia

The aim of this study was to evaluate the pharmacokinetics and efficacy of the new local anesthetic ropivacaine when used for epidural infusion for up to 72 h after major orthopedic surgery. Immediately after surgery, an epidural infusion of ropivacaine 2 mg/mL was begun at a rate of 6 mL/h in 11 patients. The infusion rate was then adjusted according to patient analgesic needs or side effects. Blood samples were taken during and after the infusion to determine total and unbound ropivacaine and alpha1-acid glycoprotein (AAG) concentrations. Patients were assessed regularly for sensory and motor block and pain using a visual analog scale (VAS) score (0-100 mm). Ten patients received 63-72 h of infusion. Total plasma concentrations of ropivacaine and binding protein (AAG) increased during the infusion such that free concentrations plateaued or began to fall over time. VAS values during mobilization were less than 40 mm in 93% of patients. The majority of patients had no measurable motor block once the surgical block had regressed. When epidural ropivacaine was titrated to achieve a stable sensory block, there was a low incidence of motor block, and free plasma ropivacaine levels were well below the toxic range. Implications: The pharmacokinetics of continuous epidural infusions of ropivacaine are described in patients for up to 72 h postoperatively. Clinical efficacy and side effects are also reported. An understanding of the plasma concentrations obtained and modes of elimination during prolonged epidural infusion is important for safe, routine clinical use in postoperative analgesia.     

Pain therapy after thoracotomies--systemic patient-controlled analgesia (PCA) with opioid versus intercostal block and interpleural analgesia

Both regional analgesia and systemic opioid therapy (e.g. PCA) are commonly used for pain relief following thoracic surgery. Many anaesthesiologists are reluctant to use thoracic epidural analgesia on general surgical wards. Therefore, we investigated in a prospective randomised study the efficacy of intercostal blocks (ICB) or interpleural analgesia (IPA) compared to PCA with systemic opioids (PCA). Following ethics committee approval and informed consent, 45 thoracotomy patients were randomised for postoperative pain management: group 1: intravenous PCA with piritramide (PCA-control), group 2: intercostal blocks of the segments concerned with 5 ml bupivacaine 0.5% at the end of surgery and 6 hours thereafter (ICB), group 3: interpleural analgesia with 20 ml bupivacaine 0.25% applied every 4 hours using a catheter placed during surgery near the apex of the pleural space (IPA). Patients in the ICB and IPA groups were able to obtain additional pain relief by PCA with piritramide. Alternative medication for all groups in case of insufficient analgesia was metamizol. Both regional analgesia groups used significantly less piritramide up to the 3rd (IPA) or 7th (ICB) postoperative day than the control group (p < 0.05). The consumption of metamizol was lower as well (n. s.). No significant differences between the study groups were observed with regard to pain scores (visual analogue scale VAS) at rest, during deep inspiration, coughing or mobilisation. Respiratory parameters as forced vital capacity, forced expiratory volume (1 sec) and peak flow (FVC; FEV1; PF) were reduced significantly following thoracotomy and showed a slow restitution in all three study groups without major inter-group differences. Intercostal blocks and interpleural analgesia significantly reduce opioid demand following thoracotomy and are effective means of postoperative pain management. Nevertheless, in contrast to epidural analgesia, both methods have to be supplemented by, or combined with, systemic analgesics in most patients. On the other hand, compared to epidural analgesia, ICB and IPA are less invasive and easier to manage on general surgical wards.     

Comparative study of postoperative analgesia with methadone and fentanyl in continuous peridural perfusion

OBJECTIVE: To determine whether continuous epidural perfusion of fentanyl, which is more liposoluble than methadone, provides a similar level of analgesia with fewer side effects than methadone administered by the same route for postoperative pain. PATIENTS AND METHODS: Prospective double blind study of 40 patients, randomly assigned to two groups. Group F (n = 20) received 300 micrograms-1200 micrograms/24 h in epidural perfusion. Group M (n = 20) received 9 mg-18 mg/24 h in epidural perfusion. In both cases treatment was for pain in the first 72 h after abdominal surgery. Analgesia quality was evaluated on a visual analog (VAS) scale from 1 to 10 at rest and moving. Need for complementary analgesia was also recorded, as were side effects related to the technique. RESULTS: Quality of analgesia was good and similar which both drugs. Postoperative pain did not surpass 3 on the VAS at rest or 4.5 while moving, although group F patients' need for complementary analgesia was significantly greater (p < 0.05). The incidence of hypoxemia was greater in group M than in group F (p = 0.05). CONCLUSIONS: Continuous epidural perfusion of fentanyl provides good analgesia and is associated with less hypoxemia than is methadone.     

Respiration and circulation after total hip replacement surgery. A comparison between parenteral analgesics and continuous lumbar epidural block

The cardiopulmonary effects of two different types of postoperative analgesic regimes were compared in 31 cardiorespiratorily healthy patients subjected to total hip replacement surgery. The investigation was performed preoperatively on the morning of the day of surgery and during the first 3 days postoperatively. All patients received continuous lumbar epidural analgesia preoperatively, during surgery and up to the end of the first measurement period, which started 2.5 h after surgery. Ten patients were subseuqently given pentazocine (Fortalgesic) intramuscularly on demand for pain relief throughout the investigation, while 14 patients received 0.4% plain lidocaine (Xylocain), and seven patients 0.4% lidocaine with adrenaline (1/400,000) as a continuous lumbar epidural drip for analgesia thorughout the investigation. It was confirmed that the operative procedure itself did not significantly influence the postoperative arterial oxygenation, while the type of postoperative analgesic regimen was of considerable importance in this respect. Thus, patients given pentazocine showed a significant increase in pulmonary venous admixture, due both to an increase in true shunt and to an increase in ventilation/perfusion disturbances. This pattern of poor pulmonary function still persisted on the third postoperatively. In patients given an epidural block no significant changes in pulmonary venous admixture were noted postoperatively, and thus there was no reduction in PaO2. All patients, irrespective of the type of analgesic regimen used, had a significantly increased cardiac index and oxygen uptake postoperatively, although patients given an epidural block showed a greater increase in cardiac index, and thus a tendency towards a more hyperkinetic circulation than those given pentazocine.     

Schizophrenia and the dopamine-beta-hydroxylase gene: results of a linkage and association study

PURPOSE: A dose-finding study to investigate the use of epidural infusions of ropivacaine for postoperative analgesia following orthopaedic surgery. METHODS: This was a randomized, double-blind study. Surgery was performed using a combination of a lumbar epidural block utilizing ropivacaine 0.5% and a standardized general anaesthetic. Postoperatively, an epidural infusion of the study solution (saline, ropivacaine 0.1%, 0.2% or 0.3%) was started at the rate of 10 ml.hr-1 and continued for 21 hr after arrival in the PACU. Analgesia was supplemented with PCA morphine (dose = 1.0 mg, lock-out = 5 min). RESULTS: Forty-four patients completed the study. The ropivacaine 0.1%, 0.2%, 0.3% groups required less morphine over the 21 hr than the saline group (P < 0.01). The VAS pain scores were also lower in the three ropivacaine groups (P < 0.001). The ropivacaine groups maintained sensory anaesthesia to pinprick when compared with saline (P < 0.05). The motor block in the 0.3% group was significantly higher than the saline group at all times (P < 0.05), and higher than the 0.1% group at eight hours (P < 0.01), while the 0.2% group had higher Bromage scores than saline at 4 and 21 hr (P < 0.05). CONCLUSIONS: The use of continuous epidural infusions of ropivacaine 0.1%, 0.2% and 0.3% at 10 ml.hr-1 improved postoperative pain relief and decreased PCA morphine requirements in patients undergoing major orthopaedic surgery. The 0.1% and 0.2% concentrations produced similar sensory anaesthesia with less motor blockade than the 0.3% concentration.     

The epidural use of morphine and alpha 2-agonists for postoperative analgesia

Three protocols of postoperative pain relief after gastric surgery were used in 60 male patients: regular intramuscular morphine, epidural morphine, and epidural morphine with 0.1 mg of clonidine. Pain relief was more effective with the epidural route of administration. Addition of clonidine in a daily dose of 0.1 mg allowed a twofold decrease of epidural morphine dose, involving lesser hyperdynamic postoperative cardiovascular changes and complete elimination of psychotic complications and delirium in alcohol-dependent patients.     

Complications during and after surgery and childbirth where spinal or epidural analgesia is used. Guidelines for safe practice

When complications and neurological sequelae occur during a spinal or epidural anaesthetic the causes are clearly related to the procedures in the following cases: severe haemodynamic or respiratory derangement, documented needle trauma of nerve fibres, intraspinal haematoma in anticoagulated or heparinized patients, and epidural infection where an infected epidural catheter entry site is documented. A number of well documented cases have been published in which surgery or patient-related pathology were primary causes of "typical" spinal or epidural neurological complications. These emphasize the importance of searching for other risk factors of neurological sequelae after surgery or child birth in cases where there is no obvious deviation from the normal epidural or spinal procedures. Increased focus on the infrequent, but serious complications of these essentially very safe techniques for surgical anaesthesia and pain relief should serve to increase our vigilance, but should not reduce the application of spinal and epidural analgesia. Guidelines are offered for the effective and safe practice of spinal and epidural anaesthesia and pain relief: adequate supervision of trainee anaesthetists, vigilant monitoring for early detection and handling of complications, and trained nurses on surgical wards to monitor and handle patients during epidural analgesia are important. Sufficient readiness for urgent handling of the very rare, but devastating complications of intraspinal bleeding or infection is an absolute necessity.     

Intraoperative intravenous ketamine in combination with epidural analgesia: postoperative analgesia after renal surgery

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV ketamine. IMPLICATIONS: Renal nociception conducted multisegmentally by both the spinal nerves (T10 to L1) and the vagus nerve cannot be blocked by epidural analgesia alone. We demonstrated that IV ketamine had an improved analgesic or opioid-sparing effect when it was combined with epidural bupivacaine and morphine after renal surgery.     

Thoracic epidural anaesthesia for coronary artery bypass graft surgery. Effects on postoperative complications

We have performed a retrospective analysis of the peri-operative course of 218 consecutive patients who underwent routine coronary artery bypass graft surgery in this institution. All patients received a standardised general anaesthetic using target-controlled infusions of alfentanil and propofol. One hundred patients also received thoracic epidural anaesthesia with bupivacaine and clonidine, started before surgery and continued for 5 days after surgery. The remaining 118 patients received target-controlled infusion of alfentanil for analgesia for the first 24 h after surgery, followed by intravenous patient-controlled morphine analgesia for a further 48 h. Using computerised patient medical records, we analysed the frequency of respiratory, neurological, renal, gastrointestinal, haematological and cardiovascular complications in these two groups. New arrhythmias requiring treatment occurred in 18% of the thoracic epidural anaesthesia group of patients compared with 32% of the general anaesthesia group (p = 0.02). There was also a trend towards a reduced incidence of respiratory complications in the thoracic epidural anaesthesia group. The time to tracheal extubation was decreased in the epidural group, with the tracheas of 21% of the patients being extubated immediately after surgery compared with 2% in the general anaesthesia group (p < 0.001). There were no serious neurological problems resulting from the use of thoracic epidural analgesia.     

Continuous thoracic epidural blockade in combination with general anesthesia with nitrous oxide, oxygen, and sevoflurane in two patients with myasthenia gravis

Continuous thoracic epidural anesthesia (T4/5) using 4-5 ml.h-1 of 1.5% lidocaine with 1:200,000 epinephrine and inhaled anesthesia using nitrous oxide, oxygen and sevoflurane were performed in two patients, (40 and 22 yr-old females) with myasthenia gravis. This combined anesthetic technique provided muscle relaxation for endotracheal intubation and optimal operating conditions, including muscle relaxation and stability of hemodynamics during transsternal thymectomy. Further, continuous epidural anesthesia using 4 ml.h-1 of 0.25% bupivacaine provided postoperative pain relief without other analgesics and stable postoperative respiratory conditions. In conclusion, we confirm the benefits of this technique which provides not only safe and stable conditions during the surgery, but also an improved comfort for patients in the postoperative period following transsternal thymectomy for myasthenia gravis.     

The effect of supervision of residents on quality of care in five university-affiliated emergency departments

BACKGROUND: The purpose of the study was to compare the analgesic and side effects of two epidurally administered mixtures of bupivacaine and fentanyl with the same drug ratios. METHODS: One hundred patients scheduled for colorectal surgery were randomized to receive a thoracic epidural infusion of either bupivacaine 0.12% with fentanyl 2 micrograms/ml or bupivacaine 0.24% with fentanyl 4 micrograms/ml during 48 h postoperatively. The pumps were adjusted to keep the visual analogue scale (VAS) pain score at 3 or less (on a scale of 0-10) with a minimum of adverse effects. RESULTS: There were no statistically significantly differences between the two groups in VAS pain scores. The average VAS pain score resting varied between 0.5 and 1, and coughing between 1.9 and 3.4. One case of respiratory depression with breathing frequency 7 occurred in each group, but none of the patients required naloxone. One patient in the low concentration group developed partial motor weakness in both legs 36 h postoperatively. Equal drug amounts--bupivacaine 10.8-11 mg/h and fentanyl 18-18.4 micrograms/h--were given in both groups throughout the study. CONCLUSIONS: Both groups had low pain scores with few and comparable adverse effects. It thus seems that the volume is not important when mixtures of bupivacaine and fentanyl in the studies concentrations are infused epidurally at a low thoracic level. Practical reasons favour the higher concentration mixture.     

A two-year experience of an acute pain service in Singapore

The first anaesthesia-based acute pain service in Singapore is described. The benefits, risks and resource implications of such a service during its first two years are reviewed. One thousand two hundred and sixty-eight (1,268) post-operative patients were treated with either patient-controlled analgesia (310 patients) or epidural opioid analgesia (958 patients). Retrospective analysis of the data revealed good patient satisfaction with a low incidence of potentially life threatening side-effects: more than 79% of patients reported satisfaction with pain control while only 0.2% of patients receiving epidural opioid analgesia experienced clinically significant respiratory depression. There were no reports of respiratory depression in the patient-controlled analgesia group. The authors conclude that the provision of an acute pain service in the local context was safe and resulted in excellent post-operative patient satisfaction.     

Psychosocial concerns of Nigerian women with breast and cervical cancer

Many studies have demonstrated that the management of pain after surgery was unsatisfactory. New pain management techniques have been developed in recent years (patient-controlled analgesia, epidural analgesia). To extend the number of patients who may benefit from these recent techniques and/or to obtain the best efficacy from existing methods of pain relief, re-organisation should take place on surgical wards. For example, protocols describing pain management strategies should be written. Surveys and audits should be carried out regularly to check their efficacy. Moreover, patients should be fully informed of the range of treatments available and their adverse effects. Finally, all staff involved in providing acute pain relief should undergo training.     

Measurement of cerebral venous oxyhemoglobin saturation in children by near-infrared spectroscopy and partial jugular venous occlusion

Surgery of the anterior cruciate ligament causes severe postoperative pain. This study aimed to compare efficacy and side effects of two postoperative analgesia methods, during 24 hours. Twenty healthy patients were assigned to two groups (n = 10): the patients of the first group were given by an epidural catheter 3 mg of morphine hydrochloride, every twelve hours. The patients of the second group received 2 mg h-1 of intravenous nalbuphine. The degree of pain was studied with a visual analogue scale. After the third postoperative hour, it was significantly higher in the second group, but the nalbuphine dose was low. The incidence of respiratory depression, nausea, pruritus was not statistically different between the groups, but 7/10 patients in the first group suffered of urinary retention (the first micturition was obtained 10.5 hours after the end of surgery in the first group and 5.3 h in the second one). Two patients needed an uretral catheter. These results might tend to show a greater efficactly of epidural morphine, with a higher incidence of urinary side effects.     

Postoperative patient-controlled epidural analgesia with opioid bupivacaine mixtures

PURPOSE: To determine the efficacy and safety of patient-controlled epidural analgesia of morphine or fentanyl in combination with bupivacaine for postoperative pain relief. METHODS: Forty ASA I-II patients scheduled for major abdominal surgery were studied. After insertion of a lumbar epidural catheter, patients were given a non-opioid general anaesthetic. After surgery patients complaining of pain, received a loading dose of 2 mg morphine (Group I) or 50 micrograms fentanyl (Group II). For continuing pain, 1 mg morphine in 4 ml bupivacaine 0.125% (0.25 mg.ml-1 morphine and 1 mg.ml-1 bupivacaine, Group I) or 20 micrograms fentanyl in 4 ml bupivacaine 0.125% (5 micrograms.ml-1 fentanyl and 1 mg.ml-1 bupivacaine Group II) were administered. Blood pressure, heart rate, respiratory rate and SpO2 were monitored. Assessments of pain (VAS), nausea-vomiting, motor block, pruritus and sedation were recorded for 24 hr. RESULTS: No difference in pain or sedation was observed between groups. The 24 hr postoperative opioid consumption was 15.50 +/- 7.53 mg morphine and 555.10 +/- 183.85 micrograms fentanyl. Total bupivacaine 0.125% consumption was 58.00 +/- 30.14 ml in Group I and 101.05 +/- 36.77 ml in Group II. One patient in Group II complained of motor weakness in one leg. The incidence of nausea (Group I 45%, Group II 10% P < 0.05) and pruritus (Group I 30%, Group II 5% P < 0.05) was less in patients receiving fentanyl. CONCLUSION: Both methods were effective in the prevention of pain but, because of fewer side effects, fentanyl may be preferable to morphine.     

Epidural fentanyl, adrenaline and clonidine as adjuvants to local anaesthetics for surgical analgesia: meta-analyses of analgesia and side-effects

BACKGROUND: The risk/benefit ratio of adding fentanyl, adrenaline and clonidine to epidural local anaesthetics for improving intraoperative analgesia is unclear. This meta-analysis was performed to clarify this issue. METHODS: Trials retrieved by search were considered if they were prospective, controlled, epidural analgesia (without combining general anaesthesia) was planned and occurrence of pain during surgery or side-effects were reported. Papers entered meta-analysis if they reached a predefined minimum quality score. Pooled odds ratios (OR) and confidence intervals (CI) were computed. P < 0.05 was considered as significant. RESULTS: Eighteen trials were included in the analysis for fentanyl. Fentanyl decreased the likelihood of pain (OR = 0.21, 95% CI = 0.15-0.30, P < 0.001) and increased the incidence of pruritus (OR = 5.59, 95% CI = 3.12-10.05, P < 0.001) and sedation (OR = 1.88, 95% CI = 1.19-2.98, P = 0.003), compared to control (local anaesthetic without fentanyl). Fentanyl had no effect on respiratory depression, nausea, vomiting and Apgar score. One case of respiratory depression of a newborn was observed. Because of the very low number of trials selected, evaluation of adrenaline and clonidine was not feasible. CONCLUSION: The analysis of current literature shows that the addition of fentanyl to local anaesthetics for intraoperative epidural analgesia is safe and advantageous. The reduction in the incidence of pain during surgery is quantitatively high and therefore clinically significant. Side-effects are mild. Randomized, controlled trials have to be performed in order to clarify the role of adrenaline and clonidine as epidural adjuvants for surgical analgesia.     

The NMDA-receptor antagonist ketamine abolishes neuropathic pain after epidural administration in a clinical case

A 14-year-old male patient developed severe right limb pain after traumatic sciatic nerve injury. His pain was diagnosed as neuropathic pain (complex regional pain syndrome, type II). He did not respond to any conventional therapy for limb pain including non-steroidal antiinflammatory drugs, antidepressants, anticonvulsants, continuous epidural administration of local anesthetics and psychotherapy. Following continuous epidural administration of a very low dose of ketamine, an N-methyl-D-aspartic acid (NMDA) receptor antagonist, 25 microg/kg per h for 10 days, complete pain relief was obtained without any side-effects. There has been no recurrence of pain for 8 months after discontinuation of epidural ketamine. The symptoms related to dysfunction of the sympathetic nervous system still remained after complete pain relief. We discuss pain mechanisms, pain relief and the use of ketamine in this case.