The current model is consistent with behavioral aspects of postoperative pain seen clinically. The effects of morphine and ketorolac alone and in combination were consistent with the reported analgesic efficacy and occurrence of side effects found with these agents clinically.

ObjectiveTo evaluate systemic versus epidural opioid administration for analgesia in patients sustaining thoracic trauma. Summary Background DataThe authors have previously shown that epidural analgesia significantly reduces the pain associated with significant chest wall injury. Recent studies report that epidural analgesia is associated with a lower catecholamine and cytokine response in patients undergoing elective thoracotomy compared with patient-controlled analgesia (PCA). This study compares the effect of epidural analgesia and PCA on pain relief, pulmonary function, cathechol release, and immune response in patients sustaining significant thoracic trauma. MethodsPatients (ages 18 to 60 years) sustaining thoracic injury were prospectively randomized to receive epidural analgesia or PCA during an 18-month period. Levels of serum interleukin (IL)-1␤, IL-2, IL-6, IL-8, and tumor necrosis factor-alpha (TNF-␣) were measured every 12 hours for 3 days by enzyme-linked immunosorbent assay. Urinary catecholamine levels were measured every 24 hours. Independent observers assessed pulmonary function using standard techniques and analgesia using a verbal rating score. ResultsTwenty-four patients of the 34 enrolled completed the study. Age, injury severity score, thoracic abbreviated injury score, and length of hospital stay did not differ between the two groups. There was no significant difference in plasma levels of IL-1␤, IL-2, IL-6, or TNF-␣ or urinary catecholamines between the two groups at any time point. Epidural analgesia was associated with significantly reduced plasma levels of IL-8 at days 2 and 3, verbal rating score of pain on days 1 and 3, and maximal inspiratory force and tidal volume on day 3 versus PCA. ConclusionsEpidural analgesia significantly reduced pain with chest wall excursion compared with PCA. The route of analgesia did not affect the catecholamine response. However, serum levels of IL-8, a proinflammatory chemoattractant that has been implicated in acute lung injury, were significantly reduced in patients receiving epidural analgesia on days 2 and 3. This may have important clinical implications because lower levels of IL-8 may reduce infectious or inflammatory complications in the trauma patient. Also, tidal volume and maximal inspiratory force were improved with epidural analgesia by day 3. These results demonstrate that epidural analgesia is superior to PCA in providing analgesia, improving pulmonary function, and modifying the immune response in patients with severe chest injury.Thoracic trauma is a significant cause of morbidity and mortality in our society. It ranks second only to head injury as a cause of traumatic death in the United States. One of every four deaths resulting from trauma is attributable to a thoracic etiology.1 Pain associated with flail chest or multiple rib fractures can result in voluntary splinting and muscle spasms, which subsequently leads to decreased ventilation and atelectasis. Compromise of pulmonary function can also cause hypoxemia, an increase in shunt...

Anesthesia-based pain services are facilitating improvements in the quality of care of surgical patients by developing and directing institution-wide perioperative analgesia programs that include interdisciplinary collaborations. However, the impact of anesthesia-based pain services has not been evaluated in a systematic fashion. This prospective multisite study (n = 23 hospitals) utilized a standardized approach to evaluate the quality of pain care provided to patients who were and who were not cared for by an anesthesia-based pain service. A total of 5837 patients were evaluated using a standardized survey that consisted of a medical record review and a patient interview. The data were collected as part of the hospitals' quality improvement activities. Forty-nine percent of the patients were cared for by an anesthesia-based pain service. Patients who received pain service care reported significantly lower pain intensity scores; had lower levels of pain in the postoperative period; had a lower incidence of pruritus, sedation, and nausea; and experienced significantly less pain than expected. In addition, these patients were more likely to receive patient education about postoperative pain management; were more satisfied with their postoperative pain management; and were discharged sooner from the hospital. The findings from this study demonstrate that the care provided by anesthesia-based pain services has a significant impact on patient outcomes.

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Background. Development of tolerance to opioid analgesics occurs often in patients with cancer‐related pain. Cross‐tolerance among opioid analgesics provides the physician with a major management problem. Incomplete cross‐tolerance among opioid analgesics has been demonstrated to occur in animals and humans. The current study provides clinical evidence of the incomplete cross‐tolerance of methadone with a number of μ‐opioid agonist analgesics in patients with advanced cancer‐related pain. Results. Patients presented in the current study had cancer‐related pain refractory to other μ—opioid receptor agonist analgesics as evidenced by inadequate analgesia despite escalation of opioid dose. All patients were adequately managed by conversion of their opioid dose to methadone. Additionally, the dose of methadone required to establish and maintain analgesia in these patients was modest compared with previous opioid dose requirements. Conclusions. Methadone is a potent opioid analgesic that demonstrates incomplete cross‐tolerance with other μ‐opioid receptor agonist analgesics. Conversion of the opioid‐tolerant patient with cancer‐related pain to methadone may represent an important therapeutic option in the management of patients with this difficult problem.

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The results of this study indicate that nerve compression and ischemia results in block of input to LTM neurons having RFs distal to the tourniquet cuff and an increase in spontaneous activity and expansion of the RFs of NRs, especially those with RFs located proximal to the tourniquet. Increases in spontaneous firing activity and expansion of the RFs of nociresponsive dorsal horn neurons receiving input from primary afferent nociceptors proximal to the tourniquet may explain, in part, the neurophysiologic mechanism of tourniquet-related pain.

This case report describes a patient who demonstrated generalized seizure activity after an injection of 30 mL of levobupivacaine 0.5% for interscalene brachial plexus block. No evidence of cardiovascular toxicity was noted.