• The Korean Journal of Pain
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• v.1 no.1
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• pp.106-119
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• 1988

For the relief of pain in 3 cases of whiplash syndromes (case I, II and IV) and in one of reflex sympathetic dystrophy (case III), we have carried out six intentional. total spinal blocks (TSB) which attempted two times in case I, three in case II and one in carte III whoso various symptoms were chronically unresponsive to the usual conservative treatments, and a time of cervical epidural and right suprascapular nerve block in case W whose acute symptom lasted 4 drys following the cervical injury (see fables from 1 to 9). During the 753, we have observed clinically the sequential charges of respiration, lid and pupil reflexes, body motion and consciousness. And checked the blood pressure, pulse rate and arterial Pco2. The effectiveness of those blocks has been assessed by using the Visual Analog Scale which is designed to measure the patient$\acute{s}$ subjective intensity of pain and also we have found out the sequelae following those blocks. The methods of the blocks were as the following: 1. Under the N.P.O. for 8~10 hours, the preparations of immediate cardiopulmonary resuscitation and premedication with atropine 0.5mg at thirty minutes before the TSB, it was performed by injecting the mixture of 2% mepivacaine 10 or 15ml and normal saline 10 or 5ml through No. 23 G. spinal needle into the subarachnoid space of $C_7-T_1$ interspinous region with fully flexed neck on the lateral posture. Immediately after the injection of the local anesthetic in the lateral position, the patient$\acute{s}$ were hasten to change Trendelenburg$\acute{s}$ position in order to act the drugs cephalad and to make easy controlled respiration with oxygen. 2. The cervical epidural block was done by injecting the mixture of 0.5% bupivacaine 4ml, normal saline 4ml and triamcinolone 15mg through No. 18 G. Tuohy needle into the epidural space on the same region and posture as the above without premedication.7he suprascapular nerve block was done by injecting of 0.5% bupivacaine 3ml only into the right suprascapular fossa on the sitting posture. The results were as the following: 1. The cessation of respiration was seen within 5 minutes following the subarachnoidal injection of the above 20ml mixture in 2 to 3 minutes and then soon the consciousness began to disappear. The loss of Lid and pupil reflexes noted between 5 to 10 minutes and the size of the dilated pupils was equal between 5 to 20 minutes, but the pupil of the dependent side on tile lateral position was dilated 1 to 3 minutes earlier than that of the independent. The patients had r=ever responded to any stimulations during the TSB except their heart funtion. 2. The recovery of the TSB was as the following, firstly the ankle and lower limb of the independent side began to move slightly with in 34 to 75 minutes after the injection and then that of the dependent Secondly the neck and upper limb moved 6 to 15 minutes later than the lower limb. Thirdly the self respiration began to appear between 40 to 80 minutes from the block. The lid and pupil reacted to touch and light respectively between 40 to 80 minutes but the pupil of the independent side responded earlier than that of the depends. Lastly the consciousness recovered completely between 80 to 125 minutes from the block. 3. In the cardiopulmonary function during the TSB, the blood pressure were stable except the 210/130 tory at the and block of case I. There were bradycardias between 65 to 85 minutes in case I and II but no arrythmia on the EKG. The level of the arterial Pco2 was maintained to 43~45 torr during the TSB. 4. The effectiveness of the above blocks was no pain(0%) in case IV, and light (10~20%) in case I and II but no improvement in case III. 5. The right arm weakness has been complicated as to be Injected accidently the "COLD" local anesthetic at the End block of case I.

• The Korean Journal of Pain
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• v.1 no.1
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• pp.64-73
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• 1988

Recent studios have shown that narcotic drags produce an unusually intense, prolonged and segmental analgesic action in man whoa injected into the spinal subarachnoid or epidural space (Wang et al, 1979; Behar et al, 1979; Cousins et al, 1979; Magora et a., 1980, Johnston and McCaughey, 1980). Since 1960, many investigators claimed that low molecular weight(LMW) dextran increased the clinical duration of lidocaine(Loder, 1960; Loder, 1962), tetracaine (Chinn and Wirjoatmadja, 1967) and bupivacaine(Kaplan et al, 1975) in man but the mechanism of the action of dextran was unclear. But Curtiss and Scurlock(1979), and Buckled and Fink(1979) claimed that LMW dextran has no effect on the duration of action of bupivacaine in animal studies. The present study was performed to evaluate the clinical efficacy of analgesia by the thoracic epidural injection of morphine and bupivacaine mixture for the relief of pain due to fractured or contused ribs, to evaluate the duration of analgesic effect by the use of the above mixture in a hypertonic solution(dextran 70 or 50% dextrose in water) and to observe the possibility of improvement in the lung function after the pain block. The complications following the pain block were also observed. The 50 single thoracic epidural injections of the mixture were divided into three groups : Group 1(n=15) served as a control group and drags used for the relief of pain were as follows(Mean$\pm$S.D.): morphine($2.13{\pm}1.64\;mg$), 0.5% bupivacaine($3.10{\pm}1.04\;ml$) and 0.9% saline($3.64{\pm}1.11\;ml$). Group 2(n=16) serves as an experimental group and drugs were as follows(Mean$\pm$S.D.): morphine($2.13{\pm}0.72\;mg$), 0.5% bupivacaine($3.06{\pm}0.77\;ml$) and dextran 70($3.75{\pm}1.29\;ml$). Group 3 (n=19) served as an experimental group and drags were as follows(Mean$\pm$S.D.) : morphine($2.42{\pm}0.51\;mg$), 0.5% bupivacaine($3.21{\pm}0.71\;ml$) and 50% dextrose in water($3.58{\pm}1.11\;ml$). The results are were follows: 1) The Dumber of patients who obtained excellent and good analgesic effects following the block were greater in the experimental Croup 2(94%) and Group 3 (90%) than theme of the control Group 1 (80%). 2) The duration of pain relief which lasted more than 3 days after the epidural block was longer in the experimental Group 2 (81%) and Group 3 (75%) than those of the control Croup 1(67%). 3) The pulmonary reserve(FVC%+FEV 1.0%) of 27 cases who were treated by the pain block between 1 and 31 drys following the chest injury was increased to about 13% than those before the block, and that of 13 cases between 32 and 82 days following the chest injury was decreased to about 4% than those before the block. 4) Of the complications following the pain block, there were 5 cased(10%) of nausea within 2 hours following the block, 4 cases(8%) of vomiting after 2 hours following the block, 10 cases(20%) of pruritus after 3~4 hours following the block, 17 cases(34%) of transient urinary retention which tasted 8 to 19 hours, 3 cases(6%) of headache within 2 hoers following the block and 2 cases(4%) of dural puncture. In conclusion, it is suggested that the clinical duration of analgesic effect produced by morphine and bupivacaine mixture can be prolonged by addition of the hypertonic solution to the mixture.