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   2013| September-December  | Volume 27 | Issue 3  
    Online since January 7, 2014

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Pre-emptive analgesia: Recent trends and evidences
Amiya K Mishra, Mumtaz Afzal, Siddhartha S Mookerjee, Kasturi H Bandyopadhyay, Abhijit Paul
September-December 2013, 27(3):114-120
Preemptive analgesia, initiated before the surgical procedure to prevent pain in the early postoperative period has the potential to be more effective than a similar analgesic treatment initiated after surgery. This article aims to review all the recent published evidences that assess the efficacy of this enigmatic concept. Materials and Methods: We reviewed original research articles, case-reports, meta-analyses, randomized control trials (RCTs), and reviews based on pain physiology for preemptive analgesia from Medline, Medscape, and PubMed from 1993 to 2013. A broad free-text search in English was undertaken with major keywords "Preemptive analgesia," "postoperative pain," "preoperative," and "preincisional". Results: Review of publications showed that intravenous (IV) nonsteroidal anti-inflammatory drugs (NSAIDs) are quite effective when used alone, as well as with low dose iv ketamine, preemptively to provide adequate postoperative analgesia. However, ketamine has a doubtful role as a standalone agent. Preemptive administration of LA at the incision site reduces postoperative pain, but achieves an analgesic effect similar to that of postincisional anesthetic infiltration as does intraperitoneal administration. Preemptive epidural analgesia has proved its efficacy in controlling perioperative immune function and pain in comparison to parenteral opioids. Gamma-amino butyric acid (GABA) analogues like gabapentin and pregabalin have great potential as preemptive analgesic with the added advantage of its anxiolytic effect. Conclusion: Multimodal approaches that address multiple sites along the pain pathway is necessary to treat pain adequately. However, we need to find an answer to the question of how to obtain the maximal clinical benefits with the use of preemptive analgesia.
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Transcutaneous electrical nerve stimulation (TENS): A potential intervention for pain management in India?
Gourav Banerjee, Mark I Johnson
September-December 2013, 27(3):132-141
Globally, the burden of pain and consequent disability on healthcare and economy is significant. Given the pain prevalence, inconsistent, and inadequate specialist health care services in India, the burden is likely to be magnified. Analgesic medication is the mainstay treatment for most types of pain; however, its side effects and financial costs for prolonged periods of time have resulted in the search for safer, inexpensive treatment options. Transcutaneous Electrical Nerve Stimulation TENS is a non-invasive, self-administered and inexpensive analgesic technique used worldwide to manage pain. Evidence suggests that TENS is effective in relieving acute and chronic pain and can be used as a stand-alone treatment for mild to moderate pain or as an adjunct for moderate to severe pain. The purpose of this study is to overview the principles, techniques, and clinical research evidence when TENS is used to manage pain with reference to health care and research studies conducted in India. A summary of evidence was formed based on Cochrane reviews, systematic reviews and meta-analyses on TENS with respect to pain management.
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Neurolytic celiac plexus block for pancreatic cancer pain: A review of literature
Sankalp Sehgal, Ahmed Ghaleb
September-December 2013, 27(3):121-131
The effective management of pancreatic cancer pain continues to be a major challenge for patients and clinicians. Up to 80% of patients with advanced pancreatic cancer present with the symptoms of severe pain. One of the most important goals in their management is achieving the highest quality of life throughout the course of disease with effective palliation of pain. Majority of the current data supports the use Neurolytic celiac plexus block (NCPB) and has been shown to be more effective in reducing pain compared with standard pharmacotherapy. NCPBs have led to decreased opioid requirements and related side effects, thus preventing deterioration in quality of life. In this article, we discuss the treatment of pancreatic cancer pain and the advances in techniques of performing NCPB. We also analyzed the incidence of complications and the quality of pain relief with the use of NCPB. NCPB is effective, has a low incidence of complications, and should be used more often in patients with pancreatic cancer pain.
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A randomized, double-blind, controlled study comparing Bupivacaine 0.125% and Ropivacaine 0.125%, both with Fentanyl 2 μg/ml, for labor epidural analgesia
Snigdha Paddalwar, Manda Nagrale, Aruna Chandak, Deepti Shrivastava, Juhi Papalkar
September-December 2013, 27(3):147-153
Objective: A prospective, randomized, double-blind study was conducted to compare the efficacy of Ropivacaine 0.125% and Bupivacaine 0.125%, both with Fentanyl 2 microgm/ml, in labor epidural analgesia and their effect on duration and course of labor. Background: Ropivacaine was introduced as S-enantiomer. In various human and animal studies, it was found to be less cardiotoxic and has high sensory:motor differential blocking property. Both these characteristics are beneficial for labor epidural analgesia. Materials and Methods: Sixty pregnant women of ASA grade I and II, who were primigravida or multigravida, with singleton vertex presentation in established labor were randomly selected and divided into two groups of 30 each. Group R patients received Ropivacaine 0.125% with Fentanyl 2 μg/ml and group B patients received Bupivacaine 0.125% with Fentanyl 2 μg/ml as intermittent bolus doses epidurally. After taking consent from them, epidural catheter was placed in L2-3/3-4 space, followed by administration of study drugs given as top-up doses intermittently. Maternal heart rate, systolic blood pressure (SBP), Visual Analogue Scale (VAS) score, fetal heart rate (FHR), Bromage score, level of sensory analgesia, APGAR score at 1 and 5 min, and duration of labor were recorded. Results: The groups were similar in demographic attributes and obstetric variables. Ropivacaine showed no difference in the mean VAS scores and the quality of analgesia, as compared to Bupivacaine. At 20 min, all the patients in both groups were absolutely pain free with the VAS score of 0. No patient in group R developed motor block, whereas five patients in group B developed grade 2 (mild) motor block. APGAR scores were comparable in both the groups. Conclusion: We conclude that Ropivacaine is equipotent, produces less motor block, has no adverse effect on the course and duration of labor, and can be used safely.
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Effect of addition of dexamethasone to ropivacaine in supraclavicular brachial plexus block
Feroz Ahmad Dar, Mohd Rafiq Najar, Neelofar Jan
September-December 2013, 27(3):165-169
Background and Objectives: We evaluated the effect of adding dexamethasone to ropivacaine for supraclavicular brachial blockade. The primary endpoints were the onset and total duration of sensory and motor block, quality of analgesia, and duration of analgesia. Materials and Methods: Eighty patients of age group 20-50 years, scheduled for various elective orthopedic surgeries on forearm and around the elbow under supraclavicular brachial block were divided into two equal groups in a randomized, double-blinded fashion. In group R (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml saline; and in group RD (n = 40), 30 ml (150 mg) of 0.5% ropivacaine + 2 ml dexamethasone (8 mg) were given. Motor and sensory block onset times, block durations, quality of intraoperative analgesia, and duration of analgesia were recorded. Results: Demographic data and surgical characteristics were similar in both groups. The sensory and motor block onset time was earlier in group RD as compared to group R (P < 0.05). Sensory and motor blockade durations were longer in group RD than in group R (P < 0.001). Duration of analgesia was longer in group RD than in group R (P < 0.001). The 24 h Visual Analogue Scale (VAS) was more in group R as compared to group RD. The quality of anesthesia was excellent in both the groups. Mean arterial blood pressure levels in groups at 5, 10, 15, 30, 45, 60, 90, 120, and 150 min were statistically insignificant between the two groups (P > 0.05). The mean pulse rate at different time intervals was statistically insignificant between the groups (P > 0.05). Conclusions: Dexamethasone added to ropivacaine for supraclavicular brachial plexus block prolongs the duration of the block and the duration of postoperative analgesia.
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Pulsed radio frequency in pain management
Gautam Das, Samarjit Dey
September-December 2013, 27(3):111-113
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Comparison of clonidine versus fentanyl as an adjuvant to intrathecal ropivacaine for major lower limb surgeries: A randomized double-blind prospective study
Anita R Chhabra, Sheetal R Jagtap, Sunny F Dawoodi
September-December 2013, 27(3):170-174
Background: Ropivacaine is a newer local anesthetic, proven to have a better safety margin than bupivacaine and lignocaine. While maintaining this advantage and improving the intraoperative quality of anesthesia, the use of analgesic adjuvants has been proven to be valuable. Aim: To compare the efficacy of clonidine and fentanyl as adjuvants to intrathecal isobaric ropivacaine for major lower limb surgeries. Settings and Designs: Randomized double-blind control trial. Materials and Methods: Seventy patients were randomly divided in two groups. Ropivacaine-Clonidine group (RC) received 60 mcg of clonidine with 15 mg of 0.5% isobaric ropivacaine, Ropivacaine Fentanyl group (RF) received 25 mcg of fentanyl with 15 mg of 0.5% isobaric ropivacaine intrathecally. The onset and duration of sensory-motor block were recorded. The total analgesia time, sedation score, hemodynamic parameters, and side-effects were noted. Statistical Analysis: SPSS statistical package was used for statistical analysis. Paired and unpaired t-test, analysis of variance and chi-square test were used for statistical calculation. Result: The duration of sensory block in RC (329.42 ± 33.86), RF (226 ± 46.98), and motor block in RC (248.51 ± 55), RF (212.60 ± 43.52) out lasted the duration of surgery (125.61 + 64.46). In clonidine group, there was significant prolongation of sensory block (P < 0.001), motor block (P < 0.01) and the total analgesia time (P < 0.001). Hypotension and bradycardia occurred in 8.6% patients in clonidine group, whereas pruritus was experienced by 8.6% patients in fentanyl group. Conclusion: Ropivacaine when combined with clonidine or fentanyl provided adequate subarachnoid block for major surgeries, wherein clonidine has advantage over fentanyl as it increased the duration of subarachnoid block and prolonged the postoperative analgesia.
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Myofibrosis in a pentazocine addict
Paresh Zanzmera, Manoj Somasekharan, Achal Srivastava
September-December 2013, 27(3):185-188
Pentazocine, a synthetic narcotic analgesic, is commonly used for the relief of moderate to severe pain, but has been rarely abused also. It is usually well tolerated; however, adverse effects are not uncommon, when higher doses are used, especially in a dependent fashion. There are reports of various complications associated with its use, including skin fibrosis, skin ulceration, abnormal skin pigmentation and symmetrical myopathy with fibrous myopathy. Fibrosis has usually been reported in the muscles at the site of injection of the drug. Being opioid in nature, it has a high abuse potential. We report a case of pentazocine-induced myofibrosis in a 33-year-old man involving muscles which were not injected with pentazocine. This case highlights the care that needs to be taken when prescribing opioid analgesics, such as pentazocine, as routine painkillers. Rare consequences such as myofibrosis are devastating and can cause significant lifelong disability.
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Drug utilization pattern in a pain clinic of a tertiary care teaching hospital in Eastern India
Debjyoti Dutta, Chanchal Kumar Dalai, Soumita Roy, Chhandasi Naskar, Dipankar Bhattacharyya
September-December 2013, 27(3):142-146
Background: Patients attend the Pain Clinic with varieties of complains of pain, like low back pain, knee pain, shoulder pain, headache, facial pain, different neuralgias and other neuropathic pain states. They receive a multimodal treatment for their pain, Multimodal pain therapy is an integrated multidisciplinary treatment in small groups with a closely coordinated therapeutic approach. Drugs that are prescribed for treatment are not only NSAIDS or Opioids, but also various groups of adjuvant pain medications like anti-epileptics, antidepressants etc. Aim: To find out the drug utilization pattern in the Pain Clinic of a tertiary care medical college hospital in Eastern India. Materials and Methods: A cross sectional; unicentric study was conducted in the Pain Clinic during April 2013 to June 2013. New patients who were willing to participate in the study were enrolled as per selection criteria. A copy of prescriptions were collected from the patients. The drugs prescription patterns were analyzed. Result: 319 patients were included in this study in three months period and their prescriptions were analyzed. Female patients (222) were more in number than male (97). As single prescription and also as combination therapy, paracetamol was found to be the most frequently prescribed drug. Frequently used adjuvant pain medications were found to be pregabalin (21.63%) and amitriptyline (16.92%.). Antacid was commonly prescribed as gastroprotective agent. Among drug combinations paracetamol (325 mg) + tramadol (37.5 mg) combination was used most frequently. (55.17%). Conclusion: In this uncentric study we found that patacetamol, tramadol, pregabalin and amitriptyline are the commonly used medications in a pain clinic. We need more multi-centric and comparative Indian studies.
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Comparison of two concentrations of isobaric intrathecal levobupivacaine for vaginal hysterectomy
Suman Chattopadhyay, Bibhas Halder, Gobindo Chandra Saha, Sukla Karmakar, Subrata Pahari
September-December 2013, 27(3):154-158
This study was performed to compare the anesthetic efficacy and safety of two concentrations of local anesthetic agent levobupivacaine in patients undergoing vaginal hysterectomy. Forty-four patients of ASA I and II, were randomized to receive an intrathecal injection of one of two local anesthetic solutions. Each patient in Group A (n = 22) received 2 ml of isobaric levobupivacaine 5 mg/ml (10 mg) with 25 μg of fentanyl, while each patient in Group B (n = 22) received 4 ml of isobaric levobupivacaune 2.5 mg/ml (10 mg) with 25 μg of fentanyl. The onset and duration of sensory block at dermatome level T10, maximum upper spread of sensory block, time for two segment regression of sensory block as well as the onset, intensity and duration of motor block were recorded, as were any adverse effects, such as bradycardia, hypotension, nausea, and/or vomiting, etc. The onset of sensory block was similar in both the groups. The onset of motor block was significantly faster in group A compared with that in group B. The duration of sensory and motor blockade was of shorter duration in group B (P < 0.05). However, patients in group A required more use of a vasoactive drug (phenylephrine) compared with group B.
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The efficacy of lumbar sympathetic nerve block for neurogenic intermittent claudication in lumbar spinal stenosis
Masataka Ifuku, Masako Iseki, Rie Hasegawa, Yoshihito Morita, Shuji Komatsu, Eiichi Inada
September-December 2013, 27(3):159-164
Background: The symptoms of LSS include radicular symptoms (RS) and IMC. IMC is thought to be caused by circulatory disturbances in the cauda equina nerves and does not often resolve naturally. There are reports of increased cauda equina nerve blood flow in canine spinal stenosis models as a result of lumbar sympathetic resection. Thus, we believed that improvement of IMC in LSS may be achieved by performing a LSNB to produce a medium-term effect. Materials and Methods: Patients with LSS suffering from IMC in both legs were enrolled in this study. Those with IMC symptoms alone were classified as cauda equina-type (CE group), while those who also suffered from RS were classified as mixed-type (M group). LSNB was performed on both sides using a neurolysis in both groups. Evaluation was using the Zurich claudication questionnaire (ZCQ). Results: Twenty-six subjects were completed the six-month observation period. In contrast to the CE group who, throughout the observation period, experienced significant improvements in Symptom Severity (SS) and Physical Function (PF) scores compared with those before treatment, no such significant differences were observed in the M group throughout the observation period. In addition, a significant decrease in the SS scores of the CE group one-month after treatment and in the PF and Patient Satisfaction (PS) scores both one-month and two-months after treatment was observed in comparison with the M group. Conclusion: Our results show that LSNB for LSS is more effective in improving neurogenic intermittent claudication than radicular symptoms, and this suggests that LSNB could become an effective treatment for cauda equina-type lumbar spinal stenosis that is resistant to other conservative treatment.
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Clinical effects of intrathecal midazolam versus intrathecal magnesium sulfate as adjunctsto hyperbaric bupivacaine: A comparative study
Sapna Shashni, Abhijit S Nair, T V S Gopal
September-December 2013, 27(3):175-181
Adjuvants are added to intrathecal local anesthetics to improve quality and duration of subarachnoid block. The present study was designed to compare the analgesic efficacy and quality of anesthesia produced by midazolam (1 mg) versus magnesium sulfate (50 mg) when given as adjuncts to hyperbaric bupivacaine intrathecally. In our study, we compared 1 mg midazolam and 50 mg magnesium sulfate as an additive to bupivacaine intrathecally. Materials and Methods: We conducted our study on 124 patients with(ASA) I and II physical status undergoing elective lower abdominal and orthopedic surgeries after approval from Institutional Ethics Committee. There were two groups; group MZ which received 3 ml of 0.5% heavy bupivacaine with 1 mg of preservative free midazolam and group MG which received 3 ml of 0.5% heavy bupivacaine with 50 mg magnesium sulfate intrathecally. The onset and duration of sensory block, onset and duration of motor block, and duration of analgesia were recorded. Results: The onset and duration of sensory block was longer in MG group as compared to the MZ group. The onset and duration of motor block was longer in MG group as compared to MZ group. Also, the total duration of analgesia was more in MG group as compared to MZ group. Conclusion: We concluded that 50 mg of intrathecal magnesium sulfate prolonged the duration of sensory and motor block and also the duration of postoperative analgesia with low pain scores as compared to midazolam group. However, it delayed the onset of sensory andmotor block. On the other hand 1 mg of intrathecal midazolam produced an early onset of sensory and motor block but the duration of analgesia was less as compared to the magnesium group.
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Role of Duloxetine in management of cervical or lumbosacral neuralgia of unknown etiology: A preliminary study
Digambar P Nawani, Sanjay Agrawal, Veena Asthana
September-December 2013, 27(3):182-184
Background: Duloxetine is a selective serotonin reuptake inhibitor (SSRI) used for treatment of neuropathic pain associated with diabetic neuropathy and fibromyalgia. Use of duloxetine for idiopathic neuropathic pain is not known. We present our experience for treatment of such painful conditions. Materials and Methods: Twenty patients, either sex, aged 30-65 years presenting for cervical and lumbosacral pain were administered duloxetine 40 mg/day in two divided doses. They were followed for a total period of 20 weeks and pain was assessed periodically using Numerical scale and Facies scale. Results: Fifteen patients showed complete resolution of pain. No major side effects were seen. No patient showed less than 50% resolution of pain. Conclusion: Duloxetine 40 mg/day is effective for control of painful neuropathic condition in our Indian setup.
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Coexisting fibromyalgia, depressive disorder, and tension headache: Chance finding or common pathology?
Supriya Vaish, Sachin Sharma, Sandeep Grover, S Bharti
September-December 2013, 27(3):189-190
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