We evaluated the efficacy, safety, and disadvantages of pain management associated with fentanyl intravenous nurse-controlled analgesia (iv-NCA) following cardiac surgery with sternotomy. Fifty-two adult patients who underwent cardiac surgeries with sternotomy were enrolled into a prospective study. The general anesthesia and care in ICU were performed in standard manner. Patients received either fentanyl iv-NCA (group F 25: 25mcg/hr+25mcg fentanyl/dose, lockout time 10 minutes; n=27) or fentanyl iv-NCA (group F 50: 50mcg/hr+25mcg fentanyl/dose, lockout time 10 minutes; n=25) after extubation in the ICU. Bolus requests, total given dose of fentanyl, vital signs, and adverse effects were compared between the groups. Bolus requests were similar between the groups, whereas 6 patients in group F 25 had a need for other analgesics. On the other hand, we discontinued iv-NCA in 6 patients in group F 50 because of adverse effects. We conclude that fentanyl iv-NCA (25mcg/hr+25mcg fentanyl/dose, lockout time 10 minutes) can be safely used as adjuvant treatment whereas fentanyl iv-NCA (50mcg/hr+25mcg fentanyl/dose, lockout time 10 minutes) may be overdose after cardiac surgery with sternotomy.

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Cerebrospinal fluid hypovolemia (CFH) is caused by reduced cerebrospinal fluid (CSF) volume. CFH is characterized clinically by orthostatic headache. Although epidural blood patch (EBP) is widely done for the treatment of CFH, epidural physiologic saline injection (EPI) is recommended for diagnosis of CFH. We report the results of EPI with contrast medium under fluoroscopic guidance for the treatment of 10 patients with CFH (post-traumatic, n=8; spontaneous, n=1; and post-spinal, n=1). The duration of symptoms and signs in these patients ranged from 2 months to 30 years. Six patients had received EBP before our treatment. Radioisotope cisternography detected CSF leakage in 3 patients, and early accumulation of radioisotope in the urinary bladder in 5 patients. Orthostatic headache and auditory and vestibular symptoms improved in all patients after EPI. Seven patients received single EPI, and 3 patients required two injections. We conclude that EPI is effective for selected CFH patients who still have symptoms and signs of CFH despite conservative therapy.

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The efficacy of opioid rotation of 20% of morphine to intravenous compound oxycodone, while giving 80% of the original dose of morphine, for morphine-induced delirium in cancer patients was studied. Thirty-two consecutive patients who were admitted and treated with intravenous morphine and developed delirium in a palliative ward were prospectively studied. Opioids were given by patient-controlled analgesia method. The degree of delirium, pain, and sleepiness was assessed by the Japanese version of Memorial Delirium Assessment Scale (MDAS-J), face scale (FS), and the Japanese version of Schedule for Treatment Assessment Scale (STAS-J), respectively, before and 3 days after partial opioid rotation to compound oxycodone. Five patients were excluded from the analyses because of changed management of pain control (n=2) and brain metastases (n=3). The results were analyzed in the remaining 27 patients. Delirium improved after partial rotation to compound oxycodone in 21 (78%) of the 27 patients. The mean degree of delirium improved from 16.2 to 9.2 on MDAS-J, pain from 2.2 to 1.7 on FS, and sleepiness from 2.6 to 1.7 on STAS. We conclude that partial rotation of morphine to compound oxycodone is effective to improve morphine-induced delirium in patients with cancer pain.

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We report a patient who developed conversion disorder after spinal anesthesia. A 42-year-old woman was scheduled for hysteroscopic polypectomy under spinal anesthesia.However, since the spinal anesthesia did not attain adequate block level she was managed with general anesthesia. Although she had sufficient muscle strength of grasping and flexion and extension of knee joints and both feet shortly after emergency from anesthesia, she complained of loss of muscle power of four limbs and sensory impairment in lower limbs 4.5 h after spinal anesthesia. She claimed that the sensory impairment went up to the 3rd cervical dermatome; however, there was no respiratory or cardiovascular impairment. The symptoms spontaneously disappeared with time.

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We report a patient having advanced pancreatic cancer with severe pain who declined oral opioids and was treated with repeated neurolytic celiac plexus blocks to control the pain. A 56-year-old woman with pancreatic cancer developed pain 2 months after surgery. The pain was not controlled satisfactorily with non-steroidal anti-inflammatory drugs; however, the patient declined taking oral opioids so as to continue her daily job. The pain in the shoulders, back, and abdomen worsened with enlargement of the tumor. The patient received repeated neurolytic celiac plexus block (4 times) in addition to non-steroidal anti-inflammatory drugs. The patient continued her job until retirement. Thereafter, she took oral opioid, which controlled the pain until her death. Repeated neurolytic celiac plexus block may be an option for the treatment of pancreatic cancer pain in patients who decline opioids.

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We report a patient with acute exacerbation of chronic alcoholic pancreatitis whose pain was relieved with Saikokeishito. A 62-year-old man on maintenance hemodialysis developed severe upper abdominal and back pain due to acute exacerbation of chronic alcoholic pancreatitis. He was referred to us for the treatment of the pain. Intravenous morphine relieved the pain and was continued for 2 weeks. However, the pain recurred after commencement of oral intake. Although intravenous morphine, fentanyl, atropine, and non-steroidal anti-inflammatory drug did not relieve the pain, the pain disappeared within 10 days after the patient started oral Saikokeishito. Parenteral opioids were withheld. Abdominal computed tomography suggested improvement of inflammatory changes of the pancreas. We conclude that Saikokeishito might not only have relieved the pain but also improved inflammation of the pancreas in our patient.

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