Sequential Supraclavicular Brachial Plexus and Stellate Ganglion Neurolysis for Upper Limb Pain in Metastatic Breast Cancer.

Neuropathic pain in cancer can result in severe debilitation to a patient with limited treatment options. Interventional modalities like nerve destruction can provide relief but at the expense of motor paralysis. Sympathetic pain is often an undiagnosed and undertreated condition that may accompany cases of chronic pain. We describe a case of severe neuropathic pain in brachial plexopathy in a middle-aged woman caused by metastatic breast cancer that was managed by chemical neurolysis of brachial plexus. Residual pain was treated by neurolysis of stellate ganglion due to the presence of sympathetic pain. This case report highlights the importance of the dual nature of pain and its management by chemical neurolysis in severe refractory neuropathic and sympathetic mediated pain.

Intradiscal Platelet-Rich Plasma Injection for Discogenic Low Back Pain and Correlation with Platelet Concentration: A Prospective Clinical Trial.

OBJECTIVE: Discogenic pain is common cause of low back ache and may result in significant morbidity. Platelet-rich plasma (PRP) is an upcoming regenerative therapy that has treatment potential for this condition. The objective of this study was to correlate platelet concentration in intradiscal PRP injection with improvement in low back pain and functional status at three and six months. DESIGN: Prospective single-arm interventional study. SETTING: Outpatient pain clinic and operation theater. SUBJECTS: Twenty-five patients with discogenic pain diagnosed by clinical means and imaging with confirmation by provocative discography were recruited. METHODS: The patients received PRP injection at a single or multiple disc levels. Preprocedure numerical rating scale (NRS) pain scores and Oswestry Disability Index (ODI) scores were calculated. Platelet counts of patients and PRP samples were measured. At three and six months postprocedure, NRS and ODI scores were measured, and improvement in these scores was correlated with platelet concentrations in the PRP sample. RESULTS: Twenty patients completed the study. The improvement in NRS and ODI scores positively correlated with platelet concentrations in the PRP sample. We determined the correlation coefficient (r) of platelet concentrations with a reduction in NRS at three months (r = 0.65) and six months (r = 0.73) and in ODI score at three months (r = 0.72) and six months (r = 0.7). CONCLUSIONS: This study supports the use of intradiscal PRP for treatment of discogenic pain with preferably higher platelet counts to elicit a favorable response.

A prospective, randomized, double blind and placebo-control study comparing the additive effect of oral midazolam and clonidine for postoperative nausea and vomiting prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystecomy.

BACKGROUND: Reduction of postoperative nausea and vomiting (PONV) continues to be a major challenge in perioperative care in spite of introduction of newer antiemetics with better efficacy and safety profiles. Therefore, we evaluated the additive effect of oral midazolam and clonidine for PONV prophylaxis in granisetron premedicated patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS: In a prospective, randomized fashion, 120 selected cases were randomized into three groups: I, II or III to receive a tablet of midazolam (15 mg, n = 36), clonidine (150 mcg, n = 40), or glucose as placebo (5 g, n = 44) orally, 1 h before anesthesia. Occurrence of PONV along with need for rescue antiemetic during the first postoperative day was compared between groups as a primary outcome. RESULTS: Episodes of PONV reduced significantly in Group II (15%) as compared to group I and III (22.2%, 59%) at various time points during the period of observation (P = 0.002). Need for rescue antiemetic was significantly lower in group I (13.88%) and II (5%) as compared to group III (52.27%, P < 0.001). CONCLUSION: Oral clonidine is better adjuvant for PONV prophylaxis, as compared to midazolam, in granisetron premedicated patients undergoing laparoscopic cholecystectomy.

Use of the pro-seal laryngeal mask airway facilitates percutaneous dilatational tracheostomy in an intensive care unit.

PURPOSE: To study the feasibility of using the pro-seal laryngeal mask airway (LMA) for airway maintenance during bronchoscopic-guided percutaneous tracheostomy. MATERIALS AND METHODS: Observational study of 60 patients in a 16-bed intensive care unit. The patient's tracheal tube was exchanged for a pro-seal LMA before undertaking percutaneous tracheostomy. RESULTS: Inspiratory pressure and tidal volumes achieved during the procedure were recorded. The median peak inspiratory pressure was 25 (standard deviation 4.4) cm H2O. There was no loss of tidal volume in 30 patients, a loss of less than 100 mL/breath in 27, and loss of more than 100 mL in 3 patients. A pro-seal LMA successfully maintained the airway and allowed adequate ventilation during per-cutaneous tracheostomy in all 60 patients. In all patients, fiber optic bronchoscopy through the pro-seal LMA provided a clear view of the cords and trachea and there was no laryngeal or tracheal soiling at any stage of the procedure. CONCLUSION: The pro-seal LMA provides a reliable airway and allows effective ventilation during percutaneous tracheostomy. The passage of a fiberscope through the pro-seal LMA and glottis is easy and provides a clear view of the upper trachea.