Peripheral nerve catheterization in the management of terminal cancer pain

BACKGROUND AND OBJECTIVES

Peripheral nerve catheterization techniques were used in two patients with severe pain associated with the terminal stages of metastatic cancer. The first patient had severe upper limb pain and lymphedema secondary to breast carcinoma, and the second patient had an acutely ischemic leg secondary to pelvic obstruction from an ovarian tumor. The goal of treatment was to relieve the pain, which was resistant to opioid drugs, and to optimize the quality of life that remained, estimated to be only a few weeks.

METHODS

The first patient received a continuous brachial plexus block via an epidural catheter, introduced by means of a Tuohy needle and a peripheral nerve stimulator to locate the plexus accurately. The second patient required catheterization of both the sciatic and femoral nerves, again with a peripheral nerve stimulator used to locate the nerves prior to inserting the catheters.

RESULTS

Analgesia was established with a bolus of local anesthetic and maintained with a continuous infusion of local anesthetic in the first patient. For the second patient, fentanyl was added to the local anesthetic, as it had been shown to improve analgesia in the lower limb in previous work. In the first patient, the analgesia allowed active treatment of the lymphedema and mobilization of the limb, and she remained pain free until her death 2 weeks later. In the second patient, the infusions controlled the pain both before and after surgical amputation of the limb, until the stump was well healed.

CONCLUSIONS

Peripheral nerve catheterization proved beneficial in two patients who presented with difficult pain management problems and should be more widely considered for the relief of severe cancer-related pain in both the upper and lower limbs.

High frequency jet ventilation in intensive care--a review of 63 patients

High frequency jet ventilation has been used clinically in this unit for over 2 years. During this time we have treated 63 intensive care patients for whom the mean duration of ventilatory support was 3.4 days, which represents more than 5000 patient hours in total, with the Penlon Bromsgrove humidified jet ventilator. The series comprises a wide variety of general intensive care patients; a review of these cases is presented.

Continuous sciatic nerve block

A technique of continuous sciatic nerve block is described. The method was used to relieve pain from ischaemic gangrene of the foot for 2 days before below-knee amputation and, combined with a continuous inguinal paravascular block, to provide regional anaesthesia both for the surgery and for the first 2 postoperative days.

Spinal opiate analgesia and facial pruritus: a neural theory

Facial pruritus associated with spinal opiate analgesia in man is thought to result either from release of histamine or from imbalance of sensory modulation secondary to spread of opiate to the medulla or fourth ventricle. There is another possibility: the sensory imbalance may be secondary to rostral spread of opiate effect by nervous transmission. Evidence is adduced in support of possible anatomical pathways, and in support of a medullary ‘itching centre’ in man.

Intraspinal opiates and itching: a new reflex?

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Day case anaesthesia and memory

Two simple anaesthetic techniques were administered to forty healthy women undergoing minor gynaecological surgery. There was a significantly shorter immediate recovery period following the use of a fentanyl and methohexitone technique. Memory function testing revealed an impairment of the ability to retain new information following anaesthesia. This returned to normal within 3 hr.