No abstract

Several cases of accidental subdural injection have been reported, but only few of them are known to be accidental intradural injection during epidural block. Therefore we would like to report our experience of accidental intradural injection. A 68-year-old female was referred to our pain clinic due to severe metastatic spinal pain. We performed a diagnostic epidural injection at T9/10 interspace under the C-arm guided X-ray view. Unlike the usual process of block, onset was delayed and sensory dermatomes were irregular range. We found out a dense collection of localized radio-opaque contrast media on the reviewed X-ray findings. These are characteristic of intradural injection and clearly different from the narrow wispy bands of contrast in the subdural space.

TM(CPLA) is a relatively new supraglottic airway device that has not been sufficiently investigated.Here, we performed a prospective observational study to evaluate the efficacy of the CPLA during controlled ventilation. In 50 anesthetized and paralyzed patients undergoing elective surgery a CPLA was inserted and inflated to an intracuff pressure of 60 cm H2O. The success rate of insertion upon the first attempt was 82% (41/50), with a mean insertion time of 16.3 ± 4.5 seconds. The adequacy of ventilation was assessed by observing the end tidal CO2 waveform, movement of the chest wall, peak airway pressure (13.5 cm H2O), and leak fraction (4%). We documented the airway sealing pressure (22.5 cm H2O) and noted that the the site of gas leaks at that pressure were either at the neck (52%), the abdomen (46%), or both (2%). In 44 (88%) patients, the vocal cords were visible in the fiberoptic view through the CPLA. There was no gastric insufflation during the anesthesia. Respiratory and hemodynamic parameters remained stable during CPLA insertion. Postoperative blood staining of CPLA was minimal, occurring in 22% (11/50) of patients. Mild and moderate throat soreness was reported in 44% (22/50) and 4% (2/50) of patients, respectively. Lastly, mild dysphonia was observed in 6% (3/50) of patients and mild dysphagia in 10% (5/50) of patients. Our results indicated that the CPLA is both easy to place and allows adequate ventilation during controlled ventilation.

Background: The intrathecal (IT) GABAA receptor antagonist, bicuculline (BIC), results in tactile allodynia (TA) through disinhibition in the spinal cord. Such disinhibition is considered to be an important mechanism for neuropathic pain. Agmatine, an endogenous polyamine, has a neuro-protective effect in the central nervous system. We investigated the analgesic effects and mechanisms of agmatine action on BIC-induced TA.Methods: Male Sprague-Dawley rats, weighting 250−300 g, were subjected to implantations of PE-10 into the lumbar subarachnoid space for IT drug injection. Five days after surgery, either 10μl of normal saline (NS) or agmatine (30μg or 10μg) in 10μl NS were injected 10 min prior to BIC (10μg) or NMDA (5μg). We assessed the degree of TA (graded 0: no response, 1: mild response, 2: moderate response, 3: strong response) every 5 min for 30 min. Areas under curves and degree of TA were expressed as mean ± SEM. Results were analyzed using one-way ANOVA followed by a Tukey test for multiple comparisons. P ＜ 0.05 was considered significant.Results: IT BIC-induced strong TA reached its peak and plateaued between 10 to 15 min. IT NS-NMDA induced mild transient TA for up to 15 min. Preemptive IT AG attenuated IT BIC-induced TA dose dependently and preemptive IT AG10 completely abolished the IT NMDA-induced TA.Conclusions: Preemptive IT AG attenuated the IT BIC-induced TA through inhibitory actions on postsynaptic NMDA receptor activation. AG might be a viable therapeutic option in the treatment of neuropathic pain. (Korean J Pain 2008; 21: 173-178)

While acute pain is reasonably considered a symptom of disease or injury, chronic pain is a specific healthcare related problem as a disease in its own right. Even though the use of opioids in the management of chronic cancer pain has been growing, the chronic use of opioid medication for nonmalignant pain is still controversial. Most reports suggest that chronic opioid therapy can be effective for the reduction of chronic pain and for the improvement of function and health related quality of life. On the other hand, opioids are also associated with potentially serious harm including pharmacologic adverse effects and socio-economic problems such as abuse, addiction, and diversion. And there has been little evidence based background regarding long-term effectiveness. Although evidence is limited in the management of chronic nonmalignant pain, there are no adequate guidelines for the prescription of opioids in Korea. Hopefully, new guidelines should be developed as soon as possible to provide mechanism based and personalized medicine for carefully selected and monitored patients with chronic nonmalignant pain.