Ketamine as an adjuvant in sympathetic blocks for management of central sensitization following peripheral nerve injury

Proliferation of NMDA receptors and role of glutamate in producing central sensitization and 'wind up' phenomena in CRPS [complex regional pain syndrome] forms a strong basis for the use of Ketamine to block the cellular mechanisms that initiate and maintain these changes. In this case series, we describe 3 patients of CRPS Type II with debilitating central sensitization, heat/mechano allodynia and cognitive symptoms that we termed 'vicarious pain'. Each of these patients had dramatic relief with addition of Ketamine as an adjuvant to the sympathetic blocks after conventional therapy failed

Evidence and consensus recommendations for the pharmacological management of pain in India

Gur Prasad Dureja,1 Rajagopalan N Iyer,2 Gautam Das,3 Jaishid Ahdal,4 Prashant Narang4 On behalf of the Pain Working Group 1Delhi Pain Management Centre, New Delhi, Delhi, 2Department of Orthopaedics, Raja Rajeswari Medical College and Hospital, Bengaluru, Karnataka, 3Daradia Pain Clinic, Kolkata, West Bengal, 4Department of Medical Affairs, Janssen India, Johnson & Johnson Pvt Ltd, Mumbai, Maharashtra, India Abstract: Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events – particularly with opioids and surgical methods of analgesia – are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case–control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making. Keywords: clinical practice guidelines, consensus recommendations, expert opinion, pain management, treatment algorith