Background and Objectives: In the Intensive Care Unit (ICU) of Osaka City University Hospital, five kinds of pain scales have been used to evaluate postoperative pain intensity, including the visual analog scale, face scale, patient's complaints, muscle rigidity or pain on effort, and respiratory pattern. The aim of this study was to examine problems associated with these methods of assessment using a questionnaire for nurses.
Methods: We asked 40 nurses in the ICU to fill out a questionnaire concerning postoperative pain.
Results: Thirty-four nurses replied to the questionnaire. Fifty-eight percent of these nurses answered that they kept patients free from postoperative pain with aggressive analgesic regimens, while 34% answered that they let patients endure pain if analgesia was insufficient. Seventy percent of the nurses answering the questionnaire were satisfied with the methods of analgesia currently used in the ICU. Although 94% answered that pain assessment was useful in the nursing care of postoperative patients, 38% felt that available methods are inadequate for evaluation of pain. Most nurses were satisfied with the results of assessment of pain based on patients' complaints, muscle rigidity or pain on effort, and respiratory pattern. However, 38% of nurses felt that evaluation based on facial expression was insufficient. A combination of pain scales is used by 83% of the nurses to determine whether administration of additional analgesia is necessary.
Conclusion: Most nurses in the Osaka City University Hospital ICU are satisfied with the methods of analgesia being used there, and recognize the requirement for sufficient analgesia for critically ill patients and the importance of pain assessment in nursing care. It is difficult for nurses to evaluate the intensity of patients' pain precisely, especially from facial expression. Thus, pain should be evaluated using a combination of pain scales and by comparison with a patient's previous pain intensity.

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Objective: To study retrospectively the thermograms of patients who suffered from postherpetic pain (PHP) or postherpetic neuralgia (PHN) of thoracic nerve (s) over two weeks.
Methods: Average temperatures of the affected skin in 31 patients with PHP or PHN were compared with those of the contralateral normal skin by thermographic measurement; ΔT (difference of average temperatures)=(average temperature of affected side)-(that of normal side), and their sensory disturbances (either hypesthesia or hyperesthesia) of affected segment (s) were checked. The suffering periods were classified into group A (<31 days), B (31-60 days), C (61-180 days) and D (>180 days) according to the days from the onset of herpes zoster to first visit to our clinic. Also the treatment periods during our participation as to nerve block therapy were classified into group a (<31 days), b (31-90 days) and c (>90 days). Three relations were examined; between sensory disturbances and ΔT, between suffering period and ΔT and between treatment period and ΔT.
Results: The mean±standard deviation (SD) of ΔT of group A (n=7) was 0.20±0.35°C. The mean±SD of ΔT of group B (n=13), C (n=6) and D (n=5) were -0.26±0.32°C, -0.13±0.25°C and -0.20±0.14°C, respectively. The data of group A were significantly different from group B. There were no meaningful differences, however, among three groups of a, b, c as to ΔT. On the other hand, the patients with hypesthesia visited our clinic significantly later than those with hyperesthesia. The majority (96%) of patients after a month from onset of the disease didn't show warm thermographic pattern in the affected area. The ΔT of 48% of all patients were within±0.2°C.
Conclusion: The thermograms of patients with postherpetic pain suffering within a month revealed different patterns from those suffering for more than one but less than two months; the former were warmer than the latter. There was no correlation between ΔT and sensory disturbance and between ΔT and treatment period.

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Continuous epidural infusion of local anesthetics with drug infusion ballooncatheter is voutinely employed for postoperative analgesia and pain control in pain clinic. However, the effect is insufficient clinically. We investigated the analgesic levels during continuous epidural infusion of local anesthetics with drug infusion ballooncatheter and compared the changes with and without epinephrine 1/200, 000. The analgesic levels during continuous epidural infusion of 2.0% mepivacaine 2.83±0.41ml/hr, 0.5% bupivacaine 2.90±0.77ml/hr and 2.0% mepivacaine with epinephrine 2.90±0.49ml/hr were 2.73±2.52, 4.83±3.01 and 6.87±1.73 dermatomes respectively. In conclusion, the addition of epinephrine extends the analgesic levels during continuous epidural infusion.

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Intractable hiccups is defined as hiccups lasting more than 48 hours. Emergency treatment of intractable hiccups is divided into pharmacological and nonpharmacological management. It has been reported that nerve block therapy may be useful for stopping hiccups that are unresponsive to both physical maneuvers and drug therapy.
We treated seven patients who had intractable hiccups with cervical or thoracic epidural block, or stellate ganglion block (SGB). Of those seven patients, three patients had hiccups after upper abdominal surgery; two patients had hiccups that originated in the central nervous system and abdominal organ, respectively; and two patients had idiopathic hiccups. We were able to stop the intractable hiccups in six of seven (86 per cent) patients using epidural block or SGB, without any complication. The duration of treatment ranged from 1 to 60 days (average, 15 days). Epidural block or SGB inhibits the pathway of the hiccup reflex arc, including the phrenic nerve and the thoracic sympathetic chain. Our results indicate that an epidural block or SGB is a useful method for treating intractable hiccups.

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The postoperative pain relieving effect of epidural buprenorphine infusion was evaluated in 40 patients who underwent upper abdominal surgery under anesthesia with propofol and low dose fentanyl (less than 10μg/kg). At the end of surgery, patients were randomly divided into 2 groups. 20 patients (group C) were given initially 5ml of 0.25% bupivacaine and another 20 patients (group B) were given 0.1mg of buprenorphine in 5ml 0.25% bupivacaine in bolus. Following an epidural bolus injection, continuous epidural infusion of 0.25% bupivacaine alone (group C) or 0.8mg buprenorphine in 92ml 0.25% bupivacaine (group B) was started at a rate of 2ml/hr for 48hrs with a portable disposable device. Postoperative analgesic effect at 4, 12, 24 and 48hrs after surgery was assessed by the demands for supplemental analgesic (none, once and more than twice), visual analogue scale (VAS) at rest graded from 0 to 100mm, and Prince Henry Pain Scale graded from point 0 to 4. In group B, the average VAS was less than 20mm and nobody at rest had pain. Postoperative analgesia in group B was significantly superior to that in group C at all points in the study. We conclude that buprenorphine is effective for postoperative pain relief after anesthesia with low dose fentanyl.

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We treated 23 patients with sudden hearling loss by intravenous administration of amidotrizoate (60% Urografin) after conventional therapy. The patients were initially treated with prednisolone, Vitamine B12, stellate ganglion block, and hyperbaric oxygen. Conventional therapy led to a partial recovery of hearing acuity and vertigo in 26.1% of the patients. However, there was no change in symptoms in the other patients. Twenty milliliters of amidotrizoate was intravenously administered every day for a week. Following treatment with amidotrizoate, a complete, marked, and partial recovery of symptoms was observed in 4.3%, 17.4%, and 34.8% of the patients, respectively. However, 43.5% of the patients showed no change in symptoms. No side effects were observed following amidotrizoate therapy. We conclude that intravenous administration of amidotrizoate may recover hearing in patients with sudden deafness.

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This report deals with a case of spinal dural arterio-venous malformation associated with pain in the back and lower extremities.
A 53-year-old male patient presented with intermittent claudication and dysuria as well as pain in the back and lower extremities. After detailed examinations, he was diagnosed as having spinal dural arterio-venous malformation fed mostly through Th7-8 intercostal arteries. Embolization was performed successfully for the arterio-venous malformation, but the pain in the back and lower extremities persisted. For the pain relief, caudal block was repeated and carbamazepine as well as mianserin were administered. These treatments led to the successful relief of his pain.
Spinal dural arterio-venous malformation is a rare disease, but it is important to take this disease into consideration when a patient presents with severe pain in the back and lower extremities. This case also suggests that pain may persist after the successful embolization of the malformation.

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Postoperative nausea and vomiting (PONV) are commonly observed, undesirable consequences of gynecological surgery. This study was undertaken to evaluate epidural droperidol as prophylaxis against PONV after gynecological surgery. Women with ASA classified physical status 1 or 2, scheduled for gynecological surgery, participated in a randomized double-blind clinical trial using a general anesthesia combined with epidural anesthesia. Group D (n=35) received epidurally a single dose of 2.5mg morphine and 2.5mg of droperidol together with 2.5mg/day morphine and droperidol each in the infusion syringe for 3 days. Group C (n=29) received epidurally a single dose of 2.5mg morphine and saline placebo together with 2.5mg/day morphine. Postoperativelly, the incidence and severity of PONV, pruritus, and pain were recorded according to our criteria for 3 days. There was no significant difference in the incidence of PONV between group D (46%) and group C (48%) [χ² test]. There was also no significant difference in the severity of PONV in any period of the investigation (Mann-Whitney U test). Epidural droperidol potentiated analgestic effect of epidural morphine. We conclude that epidural droperidol cannot prevent PONV after gynecological surgery with postoperative analgesia by epidural morphine.

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