Opioid Induced Hyperalgesia with Intrathecal Infusion of High-Dose Fentanyl.

INTRODUCTION: Despite being reported since 1943 as well as being the subject of a large body of literature since that time, no consensus has been reached regarding the etiology of opioid induced hyperalgesia (OIH). It is often described as a paradoxical increased pain response to noxious stimuli due to increased sensitization or an acute tolerance to opioids. CASE: We report the case of a 60 year old patient on chronic Intrathecal combined fentanyl and Bupivacaine who had worsening pain with increasing doses and improved after weaning off intrathecal opioids. CONCLUSION: OIH has been described in various settings including patients on methadone maintenance therapy, perioperative opioid administration, cancer patients on opioids, and healthy volunteers who are acutely exposed to opioids, including high dose intrathecal opioids such as Morphine and Sufentanil. To our knowledge, no cases of opioid induced hyperalgesia was previously reported in the case of intrathecal Fentanyl.

Concepts in pain management.

Pain has become an increasingly recognized symptom that plays a major role in the treatment of many podiatric patients. Management of this now accepted fifth vital sign can be accomplished through many avenues. Nonsteroidal anti-inflammatory medications and short- and long-acting opioids are typically used by many podiatric physicians; however, the benefits and potential hazards of other pharmaceutic approaches using antidepressants, anticonvulsants, topical medications, and other centrally acting medications must also be recognized. In addition, the role of the psychiatrist or therapist should not be neglected because many types of cognitive therapies are available to aid in treating these patients.

Anesthetic management of Turner syndrome: a systematic approach.

Turner syndrome is a complex and common genetic disorder that affects women and is associated with a wide variety of anatomic and physiological disorders. These abnormalities, especially those relating to the airway and cardiovascular system, pose a challenge to the anesthesiologist. We report a case of Turner syndrome associated with mental retardation and difficult airway, followed by a discussion of the perioperative management and review of the relevant literature. We also provide a concise tabular summary of the many problems associated with Turner syndrome and give guidelines for a systematic perioperative approach.

Upper airway obstruction caused by a double-cuffed nasal balloon after extubation.

This case report highlights a situation in which a double-cuffed nasal balloon tamponade device can cause an upper airway obstruction. An 89-year-old female required general anesthesia for an emergent embolization for right-sided epistaxis. The patient had no signs of upper airway obstruction when a double-cuffed nasal tamponade balloon was in place prior to general anesthesia. However, upper airway obstruction occurred immediately after extubation and was corrected by cuff deflation. The mechanisms of upper airway obstruction as a result of cuff dysfunction and management are discussed.

The use of botulinum toxin for the treatment of chronic facial pain.

An open label pilot study was conducted to evaluate efficacy of botulinum toxin injections for the treatment of patients with chronic facial pain seeking tertiary care at a pain clinic. Diagnoses included temporomandibular joint syndrome, postsurgical pain syndromes, essential headache, and idiopathic trigeminal neuralgia. Thirty-three (75%) of 44 patients favorably responded, including 8 of 11 patients with trigeminal neuralgia. The duration of beneficial effect ranged from 2 to 4 months, and all responding patients desired further injections. Complications were mild and included temporary facial asymmetry and weakness secondary to neuromuscular effects of botulinum toxin. Doses ranged from 25 to 75 LD 50 units with Hall strain-derived botulinum toxin type A. A small degree of facial edema during pain or erythema seemed to have predictive value when categorically evaluated against response.