Faculty Bibliography

Shoulder tip pain may occur after thoracic surgical procedures. The pain is caused by diaphragmatic irritation and is referred to the shoulder. Shoulder tip pain is often resistant to treatment with conventional analgesics. The sphenopalatine ganglion block has been described to manage many painful conditions. We report here the first use of this block to treat shoulder tip pain in 2 thoracic surgical patients. In both patients, the block produced rapid and sustained relief of the shoulder tip pain. We suggest that sphenopalatine ganglion block be considered to treat postoperative shoulder tip pain after thoracic surgical procedures.

STUDY OBJECTIVE: At our hospital, although >90% of nulliparous parturients eventually choose epidural analgesia for labor, many delay its initiation, experiencing considerable pain in the interim. This survey probed parturients' views about the timing of initiation of epidural labor analgesia. DESIGN: Single-center, nonrandomized quantitative survey. SETTING: Labor and delivery suite in a large tertiary academic medical center. PATIENTS: Two hundred laboring nulliparous women admitted to the labor and delivery suite. INTERVENTIONS: After their pain was relieved, parturients completed a questionnaire regarding their decision to request labor epidural analgesia. MEASUREMENTS: A variety of factors regarding epidural use were assessed including the influence of painful contractions and of childbirth education class attendance on the decision to request epidural analgesia, and parturients' perception of the timing of epidural initiation on the progress and outcome of labor. MAIN RESULTS: Analysis revealed that the desire of parturients to use epidural analgesia was increased from 27.9% before the onset of painful contractions to 48.2% after (p<0.01). Two-thirds of participants attended a non-physician taught childbirth education class. An antepartum plan to definitely forgo an epidural was 1.8 times more likely among women who attended a childbirth class when compared to those who did not attend. (OR=1.8; 95%CI:1.1-3.1; p=0.04). The most common views affecting decision-making were that epidural analgesia should not be administered "too early" (67.5%), and that it would slow labor (68.5%). Both of these views were more likely to be held if the parturient had attended a childbirth class, OR=2.0 (95%CI:1.1-3.8; p=0.03) and OR=2.0 (95% CI: 1.1 to 3.7; p=0.03), respectively. CONCLUSIONS: We found that nulliparous parturients have misconceptions about epidurals, which are not supported by evidence-based medicine. Moreover, we found that attendance at childbirth education classes was associated with believing these misconceptions.

BACKGROUND: Wound infiltration with local anesthetics does not reliably produce satisfactory postoperative analgesia, and the dose of local anesthetic which may be safely administered is limited by the potential for systemic toxicity. This study evaluated the efficacy of a slow-release liposomal bupivacaine formulation on duration of wound analgesia. METHODS: Multilammelar liposomes containing bupivacaine were assessed using a rat paw wound model. Twenty-four hours after surgical incision, paw wounds determined to be hyperalgesic to graded force testing with von Frey hairs were infiltrated with 0.3 ml of 2% liposomal bupivacaine, 0.5% plain bupivacaine, saline, or 'empty' (normal saline) liposomes (n = 6/group). The duration of analgesia was measured. The 0.5% plain concentration was chosen because, in preliminary experiments, larger doses were often fatal. Analgesia duration was compared using Mann-Whitney U test at P 0.05. In other rats, plasma bupivacaine levels after wound infiltration with either 2% liposomal formulation or 0.5% plain formulation were assessed (n = 8/group). RESULTS: The mean duration of analgesia was 23 +/- 3 (SD) min for plain bupivacaine and 180 +/- 30 min for liposomal bupivacaine. No wound analgesia was detected in animals given normal saline or 'empty' liposomes. Plasma bupivacaine levels tended to be lower after liposomal than plain bupivacaine. CONCLUSIONS: The 8-fold increase in duration of wound analgesia and the lower plasma levels seen with the liposomal formulation are explained by gradual drug release from the liposomal depot. These results may have important implications for achieving safe and effective analgesia with wound infiltration techniques in humans