Epidural catheters: the long and winding road.

Entrapment and knotting of epidural catheters has been described, as well as techniques for removal. Several cases of successful removal have been reported; however, significant resistance was encountered during removal. Following the techniques described previously, we successfully removed a knotted epidural catheter.

Anesthesia for electroconvulsive therapy: a review.

Anesthetic techniques have evolved to improve the comfort and safety of modern electroconvulsive therapy (ECT). The authors review the literature and discuss the selection, preparation, and management from an anesthetic perspective. Specifically, the management of medications preprocedure and coexisting diseases is discussed. A review of induction agents, muscle relaxants, and other medications utilized in ECT is included.

Revision of a spinal column stimulator lead without lead replacement.

OBJECTIVE: The objective of this case report is to describe a technique for percutaneous spinal column stimulator (SCS) revision without lead replacement. CASE REPORT: A 35-year-old woman with a single-lead SCS implanted for control for left lower extremity pain underwent revision of her SCS lead because of loss of stimulation paresthesia in the area of pain. Using the method described, the lead was revised without lead replacement. CONCLUSION: SCS leads can be revised without placement of a new lead.

Continuous intrathecal meperidine via an implantable infusion pump for chronic, nonmalignant pain.

OBJECTIVE: To report a continuous infusion of intrathecal meperidine via an implanted infusion pump for nonmalignant, chronic pain. CASE SUMMARY: A 69-year-old white woman had chronic, nonmalignant low-back pain and bilateral leg pain. Multiple drug therapies and other interventional techniques had failed. The patient achieved significant pain relief by a continuous infusion of intrathecal meperidine via an implanted infusion pump. DISCUSSION: To our knowledge, this is the first report of meperidine administered intrathecally by continuous infusion. Continuous infusion of intrathecal and epidural opiates by implanted infusion pumps is becoming more widely recognized as an alternative treatment for patients with chronic, benign pain. Epidural and intrathecal meperidine is an effective analgesic for short-term surgical procedures. Data reporting effective relief and safety with continuous intrathecal meperidine remain limited. CONCLUSIONS: Continuous intrathecal meperidine via an implantable infusion pump may be an effective alternative in the treatment of chronic pain.

Norepinephrine and epinephrine levels in affected versus unaffected limbs in sympathetically maintained pain.

OBJECTIVE: To test the hypothesis that there is relative sympathetic hyperactivity in the affected limb in patients with sympathetically maintained pain syndromes by measuring serum norepinephrine and epinephrine in the affected versus the unaffected sides. DESIGN: Venous pool samples were drawn just proximal to the affected area and from an identical site on the unaffected side. Serum norepinephrine and epinephrine were measured by high-pressure liquid chromatography with electrochemical detection. SUBJECTS: Sixteen women and seven men with a mean age of 44.4 years diagnosed as having sympathetically maintained pain on the basis of a positive response to paravertebral block and a criteria-based diagnostic scheme. RESULTS: The serum norepinephrine level was significantly lower in the affected limbs than the unaffected limbs (p = 0.024). The serum epinephrine level was not significantly different. CONCLUSIONS: These results are not consistent with the hypothesis of segmental sympathetic hyperactivity in the affected limb in sympathetically maintained pain and support a hypothesis of peripheral receptor upregulation with pathologic response to circulating catecholamines. Other possible explanations are discussed.

Postoperative analgesia after major shoulder surgery with interscalene brachial plexus blockade: etidocaine versus bupivacaine.

Postoperative pain is commonly treated with significant doses of narcotics, occasionally resulting in side effects including nausea, pruritus, and respiratory depression. One potential advantage of regional anesthesia is profound postoperative analgesia that reduces exposure to potent narcotics. To evaluate the efficacy of two long-acting local anesthetics, bupivacaine and etidocaine, in providing pain relief after major shoulder surgery, we randomized 20 patients to receive either bupivacaine or etidocaine for brachial plexus block as the primary anesthetic for shoulder surgery. Surgeons, patients, and the acute pain service were blinded as to drug selection. After the patient was sedated, an interscalene block was placed with the use of a nerve stimulator to facilitate proper needle placement. Forty milliliters of either 0.5% bupivacaine or 0.75% etidocaine containing 5 micrograms/mL epinephrine was injected into the brachial plexus sheath. An additional 8 mL of local anesthetic was administered for superficial cervical plexus blockade. Intraoperative sedation was accomplished with an intravenous infusion of methohexital as needed. After surgery, patients received a standard patient-controlled analgesia protocol providing incremental doses of morphine. The degree of postoperative analgesia resulting from residual local anesthetic effect was expressed as the time until first morphine requirement and the total dose of morphine required during the first 24 hours postoperatively. We found no statistically significant intergroup differences either in time of initial use of morphine or in the total dose of morphine required in the first 24 hours. Both etidocaine and bupivacaine provide prolonged analgesia after major shoulder surgery when injected into the brachial plexus. Bupivacaine, however, possesses significant cardiotoxicity and has a relatively delayed onset in peripheral neural blockade. Etidocaine is less cardiotoxic and also has a more rapid onset of effect. Thus etidocaine may be a preferable agent for interscalene block for major shoulder surgery.