Surgical pneumothorax under spontaneous ventilation-effect on oxygenation and ventilation

Surgical pneumothorax allows obtaining comfortable surgical space for minimally invasive thoracic surgery, under spontaneous ventilation and thoracic epidural anesthesia, without need to provide general anesthesia and neuromuscular blockade. One lung ventilation (OLV) by iatrogenic lung collapse, associated with spontaneous breathing and lateral position required for the surgery, involves pathophysiological consequences for the patient, giving rise to hypoxia, hypercapnia, and hypoxic pulmonary vasoconstriction (HPV). Knowledge of these changes is critical to safely conduct this type of surgery. Surgical pneumothorax can be now considered a safe technique that allows the realization of minimally invasive thoracic surgery in awake patients with spontaneous breathing, avoiding the risks of general anesthesia and ensuring a more physiological surgical course

Long-term efficacy of OROS® hydromorphone combined with pregabalin for chronic non-cancer neuropathic pain.

BACKGROUND AND OBJECTIVES: Treatment for chronic non-cancer neuropathic pain can be complicated by side effects and drug interactions. Combining opioid analgesics and calcium channel modulators may overcome these and improve efficacy. The objective of the present study was to evaluate the efficacy and safety of OROS® hydromorphone combined with pregabalin in patients with chronic non-cancer neuropathic pain. METHODS: This retrospective observational study was conducted on clinical records from patients aged ≥18 years with chronic non-cancer neuropathic [>4 on the Douleur Neuropathique en 4 questions (DN4) scale] pain of ≥6 months duration, with severe intensity [>4 on the Numerical Rating Scale (NRS); range 0-10], who attended all visits and had ≥12 months of follow-up at the Tor Vergata University Polyclinic Hospital, from November 2008 to February 2011. Patients received an oral combination of OROS® hydromorphone and pregabalin. Pain was evaluated at each visit (months 1, 3, 6, 9, and 12) using the NRS and DN4 scale; Patients' Global Impression of Change (PGIC) was administered at months 1, 6, and 12. Dosage and side effects were recorded at each visit. RESULTS: Of 1,292 patients (32 % men, mean ± SD age 67.6 ± 11.9 years), 1,126 attended all visits. Seventeen percent (n = 224) had purely neuropathic pain. Initial mean dosage was 6.06 ± 2.00 mg/day for OROS® hydromorphone, 113.02 ± 21.94 mg/day for pregabalin. Dosages increased up to month 6, and returned to near initial dosages at month 12 (range 4-120 mg/day for OROS® hydromorphone; 75-600 mg/day for pregabalin). NRS pain scores (mean ± standard deviation) were 7.25 ± 1.34 at baseline and 1.85 ± 1.36 at 12 months (p < 0.0001); DN4 scores were 6.19 ± 1.65 at baseline, reduced to 1.84 ± 1.25 at 12 months (p < 0.0001), reductions of 74.4 and 70.2 %, respectively. More than 90 % of patients had a ≥50 % score reduction on both scales after 12 months. The PGIC scale showed that >75 % of patients felt improvement at 1 month, increasing to 91 % and 93 % at 6 and 12 months. The incidence of side effects was similar between elderly (aged >65 years) and younger subjects; there were no cases of addiction. CONCLUSIONS: The OROS® hydromorphone and pregabalin combination was efficacious for chronic non-cancer neuropathic pain and well tolerated, providing significant pain reduction without the risk of addiction and with a good tolerability profile, regardless of age

The challenge of perioperative pain management in opioid-tolerant patients

The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone

Gabapentin and pregabalin for the acute post-operative pain management. A systematic-narrative review of the recent clinical evidences

Background: Gabapentin and pregabalin inhibit Ca2+ currents via high-voltage-activated channels containing the α2δ-1 subunit, reducing neurotransmitter release and attenuating the postsynaptic excitability. They are antiepileptic drugs successfully used also for the chronic pain treatment. A large number of clinical trials indicate that gabapentin and pregabalin could be effective as postoperative analgesics. This systematic-narrative review aims to analyse the most recent evidences regarding the effect of gabapentinoids on postoperative pain treatment. Methods: Medline, The Cochrane Library, EMBASE and CINHAL were searched for recent (2006-2009) randomized clinical trials (RCTs) of gabapentin-pregabalin for postoperative pain relief in adults. Quality of RCTs was evaluated according to Jadad method. Visual analogue scale (VAS), opioid consumption and side-effects (nausea, vomiting, dizziness and sedation) were considered the most important outcomes. Results: An overall of 22 gabapentin (1640 patients), 8 pregabalin (707 patients) RCTs and seven meta-analysis were involved in this review. Gabapentin provided better post-operative analgesia and rescue analgesics sparing than placebo in 6 of the 10 RCTs that administered only pre-emptive analgesia. Fourteen RCTs suggested that gabapentin did not reduce PONV when compared with placebo, clonidine or lornoxicam. Pregabalin provided better post-operative analgesia and rescue analgesics sparing than placebo in two of the three RCTs that evaluated the effects of pregabalin alone vs placebo. Four studies reported no pregabalin effects on preventing the PONV. Conclusion: Gabapentin and pregabalin reduce pain and opioid consumption after surgery in confront with placebo, but comparisons with other standard post-operative regimens are not sufficient. Gabapentin and pregabalin seem not to have any influence on the prevention of PONV

Comparing continuous lumbar plexus block, continuous epidural block and continuous lumbar plexus block with a parasacral sciatic nerve block on post-operative analgesia after hip arthroplasty

Study Objective: To compare post-operative analgesia obtained by continuous lumbar epidural block (CLEB) versus continuous lumbar plexus block (CLPB) versus CLPB associated with a single shot parasacral sciatic nerve block (CLEBS) after total hip arthroplasty (THA). Study design: Randomized clinical trial. Setting: Operating room, postoperative care unit, orthopedic surgical ward. Methods: 78 ASA I-III patients undergoing elective THA were randomly assigned to receive CLEB (n=24, 15-20 ml of 5 mg/ml ropivacaine, sufentanil 10 mg, clonidine 1 mg/ml), CLPB (n=22, 3mg/kg of 5 mg/ml of ropivacaine, max. 40 ml, clonidine 1 mg/ml, sufentanil 10 mg) or CLPBS (n=23, CLPB as described above; sciatic nerve: 20 ml of ropivacaine 5 mg/ml, clonidine 1 mg/ml). All patients received continuous infusion of 2 mg/ml of ropivacaine, 8 ml/h for 48 hours. Primary outcome was pain intensity assessment (VAS and VS). Secondary outcomes were postoperative total opioid consumption, hemodynamic stability, motor blockade, blood loss, intraoperative sufentanil and propofol consumption, patient satisfaction and complications. Results: VAS was lower in the CLEB group than in the CLPB and CLPBS groups respectively for 6 and 12 hours postoperatively (post-surgery p<0.001, 2h p<0.001, 6h p<0.001, 12h p<0.03)(Table 2). Moreover, CLPSB patients reported lower VAS than CLPB patients from the end of the surgery till the 12th follow up hour (Table 2). VS was lower in the CLEB group from the end of surgery to 6h postoperatively (Table 3). The CLPB group showed higher morphine consumption than the CLPSB and CLEB groups over 12 h postoperatively (p=0.05); thereafter, no statistically significant diferences were observed between groups at the end of follow up (48h) (p=0.4) (Table 4). onclusion: In conclusion, continuous lumbar plexus block in association with single shot sciatic nerve block is a valid alternative to epidural technique in managing postoperative analgesia after THA, with an improved risk-benefit balanc

Switching to low-dose oral prolonged-release oxycodone/naloxone from WHO-step i drugs in elderly patients with chronic pain at high risk of early opioid discontinuation

Chronic pain has a high prevalence in the aging population. Strong opioids also should be considered in older people for the treatment of moderate to severe pain or for pain that impairs functioning and the quality of life. This study aimed to assess the efficacy and safety of the direct switch to low-dose strong opioids (World Health Organization-Step III drugs) in elderly, opioid-naive patients

The comparing of ultrasound-guided techniques:sciatic block with continous lumbar plexus block or continous femoral nerve block for aneshtesia and analgesia of total knee replacement

Abstract: Background and Aims: This double blind prospective randomized clinical trial evaluated the efficacy and safety of continuous ultrasound-guided lumbar plexus block compared to continuous ultrasound-guided femoral nerve block, in the intra-operative and postoperative periods after total knee replacement. Methods: Forty ASA I-III patients were randomized to receive: continuous femoral block (n= 20, 30 ml of ropivacaine 5 mg/ml) or continuous lumbar plexus block (n= 20, 30 ml of ropivacaine 5 mg/ml) both in association with single injection sciatic nerve block. All patients received continuous infusion of 2 mg/ml of ropivacaine at 8 ml/h for 48 hours and intra- venous morphine for patient-controlled analgesia. Primary outcomes were intra-operative sufentanil consumption and verbal analogue scale (VAS) score at rest at 24h follow up. Results: Intra-operative sufentanil consumption was higher in the femoral block (FEM) group compared to the lumbar plexus block (PSOAS) group (FEM: 10.00 (10.00, 17.50) μg; PSOAS: 2.50 (0.00, 10.00) μg. p= 0.002). Obturator motor blockade occurred more frequently in the PSOAS group (70%) than in the FEM group (40%) (p=0.1); however, we found no differences in sensory blockade (p=0.6). VAS at rest was similar in the two groups at 24h postoperatively (FEM: 29.50 ± 14.74 mm; PSOAS: 25.60 ±17.42 mm. p=0.4), and throughout the follow-up period. No differences were detected in pain scores during physiotherapy. Conclusion: Continuous femoral and lumbar plexus blocks, both in association with sciatic nerve block, provided similar VAS scores at 24h, and throughout the follow-up period; intra-operative sufentanil consumption was, however, lower in the lumbar plexus block group

Italian Oncological Pain Survey (IOPS) A Multicentre Italian Study of Breakthrough Pain Performed in Different Settings

Objective: A survey of breakthrough pain (BTP) was performed in five palliative care units (PCU), seven oncology departments (ONC), and nine pain clinics (OPC). Methods: A standard algorithm was used to confirm the diagnosis of BTP of patients refereed to different settings. Results: 1,412 evaluable cancer patients were enrolled. 53.9% were males and the mean age was 63.7±13.1 years. The mean intensity of background pain was 2.8±0.73. Patients reported 2.4±1.1 BTP episodes/day with a mean intensity of 7.37±1.28. 80.6% patients reported that the BTP had a significant negative impact in everyday life. The majority of patients reported a fast onset of BTP, which was predictable in 50.7% of cases, while BTP with a gradual onset (>10 min) was less predictable (29%) (P=0.001). PCU patients were older, had lower Karnofsky levels, a lower number of BTP episodes/day, a slow onset of BTP onset, and a less predictable BTP. Cancer diagnosis was performed a mean of 23.5 months (SD±32.8) before the assessment. The mean duration of background pain was 3.5 months (SD±3.5), and the mean duration of any analgesic treatment was 2.5 months (SD±3). BTP started a mean of 2.2 months (SD±1.9) before the assessment. Characteristics of BTP were influenced by the course of disease, as well as the duration of background pain and initiation of BTP. Most patients took rapid onset opioids and were satisfied with the treatment. BTP diagnosis was prevalently made by ONC and OPC physicians, and rarely by GPs. Conclusion: This survey performed by an Italian observatory expert review group, has confirmed that the BTP represents a clinically relevant condition with a negative impact on the patient’s quality of life. BTP was detected in all settings involved. A number of factors are associated with the BTP. Also factors regarding the course of disease and setting of care have been assessed. This information may help in stratifying patients or predicting the risk of development of BTP with specific characteristics

Selective uterine artery embolization in the management of uterine myomas

Objective: To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms. Design: A pilot study on 26 women affected by uterine single myoma. Setting: Tertiary level care in an university hospital. Patient(s): Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization. Intervention(s): Selective uterine artery embolization performed under peridural anesthesia. Main Outcome Measure(s): We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure. Result(s): Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination. Conclusion(s): Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery. © 2003 by American Society for Reproductive Medicine