Neuropathic cancer pain represents a major challenge. Treatment often requires adjuvant analgesics, including gabapentin, to complement the effects of opioids. This study aimed to compare the effectiveness and safety of gabapentin combined with an opioid versus opioid monotherapy for the management of neuropathic cancer pain. Seventy-five cancer patients who were receiving opioid therapy and reported sufficient pain relief of nociceptive, but not neuropathic, pain were enrolled. Sixty-three patients completed the study. Patients were randomized to one of the following treatment protocols: 1) gabapentin adjuvant to ongoing opioid treatment titrated according to pain response while opioid dose was kept constant (group GO), and 2) continuation of opioid monotherapy according to the World Health Organization treatment ladder approach (group OO). Changes in pain intensity, allodynia, and analgesic drug consumption were evaluated at Day 4 and Day 13. Side effects were also recorded. Both treatments resulted in a significant reduction of pain intensity at Day 4 and Day 13 compared to baseline. However, mean pain intensity for burning and shooting pain was significantly higher in the OO group compared to the GO group at both the fourth (P=0.0001) and 13th (P=0.0001) days of the study. An earlier significant decrease (at Day 4, P=0.002) was observed for allodynia in the GO group compared to the OO group. The rate of side effects in the GO group was significantly lower than that in the OO group (P=0.015). These data suggest that gabapentin added to an opioid provides better relief of neuropathic pain in cancer patients than opioid monotherapy; this combination of gabapentin and an opioid may represent a potential first-line regimen for the management of pain in these patients.

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Although safe and there are signals for a true analgesic efficacy, our results failed to confirm any benefits of add-on treatment with intravenous administration of paracetamol. However, the study was underpowered, and future studies in this important area need to be wary of background noise and the risk of a type II error.

Sir,We herein present a case of a female patient who presented for emergency exploratory laparotomy following a motor vehicle accident (MVA) in which she was thrown into the windshield, sustaining multiple facial and abdominal injuries. The pregnancy was not known to be present preoperatively.A 25-year-old G3P2 female was admitted in hypotensive shock following a high-speed collision as an unrestrained passenger. The patient was initially thought to be dead at the scene; however, she was resuscitated in the field (by the paramedics), brought to the hospital, and then immediately taken to the operating room for an emergency exploratory laparotomy under general anesthesia. While resuscitation with blood, colloid and crystalloid solutions through a rapid infuser was under way, the patient was preoxygenated with FiO2 ¼ 100%, monitors were placed and she was positioned on the operating table. Rapid sequence induction of general anesthesia was performed in a standard manner with midazolam, 2 mg i.v., fentanyl, 3 mg kg À1 i.v., and succinylcholine, 1.5 mg kg À1 i.v., while cricoid pressure was continuously applied and in-line stabilization of the cervical spine was performed for an uneventful direct intubation of the trachea. The surgery was promptly embarked upon.Hypotension persisted for the first 30 min of the case and was successfully treated with continuous intravascular volume resuscitation. Intraoperatively, the patient received 20 U of packet red blood cells (PRBCs), 15 U of fresh frozen plasma (FFP), two packs of platelets, two doses of Factor VII, 12 l of crystalloids and 2 l of colloids. Severe injuries to the spleen and left kidney were repaired. During surgery, the patient was noted to have an enlarged uterus and an obstetric ultrasound revealed a non-viable fetus with an approximate gestational age of 22 weeks. Placenta was not evaluated due to the urgency of the case. Fetal heart rate at that time was agonal at about 1 beat per minute. It was decided not to deliver the fetus, and then to minimize the amount of blood loss. The uterus was pink (unlikely in the case of placental abruption) and the patient did not appear to be in disseminated intravascular coagulation.Postoperatively, the patient was hemodynamically stable, however, she did require an additional 5 U of PRBCs, 4 U of FFP, and one pack of platelets. Mechanical lung ventilation was continued. Two days later, she spontaneously delivered demised fetus and an intact placenta. The patient later improved cognitively, was extubated, and then transferred to the ward for further care. Placental pathology revealed infarction covering >30% of the placenta. There was no evidence of abruption. The uniformity and size of the infarction were consistent with hypotensive shock.Fetal death resulting from injuries to the obstetric patient is most commonly associated with placental abruption (1). Most studies have found separation of the placenta to be the number one cause of fetal demise in mothers surviving MVAs (2). What is of interest to anesthesiologists and ...

A peripherally administered bupivacaine plus morphine combination provided better and longer analgesia for ischemic pain compared to bupivacaine alone for the short term, but not for the long term. On the other hand, our results show that continuous popliteal treatment is an effective, safe, and comfortable modality for long-term use in the home setting for patients with intractable chronic pain.