Ultrasound-guided PRF for ICNs in combination with pharmacotherapy seems to be a safe and effective treatment modality for postherpetic neuralgia.

BACKGROUND: In this pilot study we examined the use of epidural ketamine as an opioid alternative for postoperative analgesia in elderly patients undergoing major abdominal surgery. METHODS: With the approval of the local REB we approached patients older than 65 years scheduled for major abdominal surgery. After obtaining written informed consent 20 patients were allocated to receive a bolus of epidural bupivacaine 0.125% supplemented either with epidural ketamine 40mg (ketamine group) or epidural morphine 2mg (morphine group) 30 minutes before surgery. Postoperative analgesia and sedation were assessed using a verbal rating score (0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain) and Ramsay's sedation score, respectively. At the patient's request five ml boluses of 0.125% bupivacaine together with ketamine (2mg/ml) or morphine (0.1mg/ml) were given until a pain score of two at rest was established. The incidence of postoperative nausea and vomiting (PONV) requiring treatment was recorded. RESULTS: We approached and randomized 20 patients with 10 patients in each group. Mean age was 69±5 years in the morphine group and 69±3 years in the ketamine group. Pain scores immediately (0h) and (6h) after surgery were significantly higher in the ketamine group than in morphine group (0h: 2.5±2.0 versus 0.0, p=0.002; 6h: 1.8±1.3 versus 0.0, p=0.001). None of the patients receiving epidural morphine requested a top up within the first 24 postoperative hours. Eight patients in the ketamine group required additional boluses. The total amount of epidural ketamine administered was 70±19mg. Thirty minutes after the operation sedation score was higher in the morphine than in the ketamine group (4.1±1.2 versus 2.7±0.5, p=0.03). In the morphine group three patients had PONV while in the ketamine group PONV was not observed. CONCLUSION: The results of this pilot study show that epidural ketamine, when compared to epidural morphine, is associated with less sedation and a smaller risk of PONV, but necessitates more frequent or continuous administration to achieve comparable analgesia.

Previous clinical reports have suggested that deep tendon reflexes of diabetic patients are delayed and experimental studies have reported differential sensitivity of motor endplates to neuromuscular blocking drugs. These observations prompted us to study the neuromuscular effect of tubocurarine in 25 diabetic and 15 non-diabetic patients during urological surgery. Anaesthesia was induced with thiopentone followed by suxamethonium and maintained with nitrous oxide in oxygen and increments of butorphanol. Muscle relaxation was provided with tubocurarine in an initial dose of 0.25 mg kg-1 and increments of 20% of the initial dose. At the end of surgery, residual neuromuscular block was antagonized with increments of neostigmine 0.5 mg and atropine 0.2 mg. There was a delay in the onset of action of tubocurarine in diabetic patients. A no-response state was obtained in some patients, and its duration correlated with post-tetanic count (PTC) in diabetic patients, and with post-tetanic twitch height percent (PTTH%) in the control group. We concluded that, in diabetic patients, the onset of action of tubocurarine was delayed compared with control patients, and the reliable predictor of the duration of the no-response time was PTC in diabetic patients and PTTH% in non-diabetic subjects.

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