Continuous epidural perfusion of morphine and bupivacaine for post-thoracotomy analgesia. Comparison between thoracic and lumbar epidural analgesia

Relief of postoperative pain and the incidence of side effects occurring after continuous epidural infusion of morphine and bupivacaine were evaluated in patients undergoing a thoracotomy. We also studied the relevance of a close proximity of the epidural catheter to the metameric segment were the pain originated. The study involves 17 patients divided into two groups. In one series (lumbar group) (LG) the catheter was located at the lumbar region and in the other series (thoracic group) (TG) the catheter was localized at the thoracic area. The study was carried out during the first 48 hours following surgery. Bupivacaine 2% and 0.2 mg/ml of morphine hydrochloride were administered at an initial rate of 1.5 ml/h. The total dose required for pain relief was greater in LG than in TG (p less than 0.05). There were no significant group differences in the hemodynamic and respiratory parameters measured in this study. Only respiratory rate was occasionally lower in LG. Three patients presented postoperative atelectasis (2 in TG and 1 in LG) and required bronchoscopy. One patient of LG complained pruritus and another one of the same group presented nausea and vomiting. The epidural perfusion was interrupted in only one patient of TG due to the presence of arterial hypotension. The association of narcotics and local anesthetics in continuous epidural perfusion was an excellent method for achieving pain relief with minimum side effects. We conclude that both thoracic and lumbar epidural routes are advisable for post-thoracotomy pain relief.

Patient-controlled analgesia (PCA) for postoperative pain relief. A prospective observational study for evaluating the technology in a ward routine

Patient-controlled analgesia (PCA) is rarely used on surgical wards despite described advantages of this method as compared to conventional techniques. Uncertainties in patient selection and insufficient evaluation of this technique may explain these circumstances. The aim of our study was to evaluate PCA on general surgery and traumatology wards by means of standardized criteria for technology assessment (i.e. safety, practicability, benefit for patients and medical staff) and the efficacy of pain relief. In a prospective study we investigated 120 patients. In phase I, we performed analgesic therapy with tramadol/metamizol (50 ASA status I-IV patients). In phase II, piritramid had been applied to 70 ASA status I-II patients after an intermediate analysis of phase I. In 7% of the patients technical problems led to an early interruption even at the end of the study period. There were, however, no incidents which caused vital problems for the patients. A mean postoperative pain level of 55 visual analogue scale points (0-100 point scale) was achieved with Tramadol ( Ultram )/metamizol. PCA was stopped in 16% of the patients due to the occurrence of nausea or vomiting and in two patients due to insufficient pain relief. The use of piritramid in phase II led to lower pain levels and no interruptions of PCA because of ineffectivity or nausea/vomiting.(ABSTRACT TRUNCATED AT 250 WORDS)

Heel spur: radiation therapy for refractory pain--results with three treatment concepts.

PURPOSE: To evaluate radiation therapy (RT) to treat refractory pain in plantar heel spur. MATERIALS AND METHODS: From 1984 to 1994, 141 patients with refractory painful plantar heel spur (170 heels, because of bilateral disease) underwent RT. Quantitative criteria were used to evaluate heel pain and ankle function prior to RT, 6-12 weeks after RT, and at last follow-up (median, 4 years). Patients were divided into three treatment groups: group A (n = 72 heels [two courses, 1.0-Gy fractions, 12-Gy total RT dose]), group B1 (n = 50 heels [one course, 0.3-Gy fractions, 3-Gy total dose]), and group B2 (n = 48 heels [one course, 0.5-Gy fractions, 5-Gy total dose]). RESULTS: At last follow-up, complete pain relief was achieved in 48 (67%) of 72 group A heels and in 71 (72%) of 98 group B heels. Statistically significant (P < .05) differences between groups were found for insufficient pain relief (< 80%) in patients in whom the response time after RT was longer than 4 weeks or in whom pain recurred during follow-up. The best results were achieved with the 5-Gy total RT dose (P < .05). Prognostic factors for complete pain relief were acute pain and short duration of pain prior to RT. The prognostic factor for insufficient pain relief was total RT dose. CONCLUSION: Refractory heel pain is effectively treated with RT, which should be considered a primary treatment approach rather than a last resort.

Effective bone palliation as related to various treatment regimens.

Various dose-time treatment plans have been used to obtain long duration pain relief in patients with metastatic bone disease. Very little has appeared in the literature evaluating the relationship of dose and fractionation to initial, delayed and permanent bone pain relief. At the Swedish Hospital Tumor Institute, 152 treatment fields in 110 patients were evaluated, with a clinical follow-up in many of over five years. Those treated at lower total doses with less fractionation achieved the same quality and duration of pain relief as higher doses. Treatment plans also were compared using the Ellis method of nominal standard dose.

A double-blind comparison of a propionic acid derivative (Ibuprofen ( Motrin )) and a fenamate (mefenamic acid) in the treatment of dysmenorrhea.

A double-blind three-way crossover design in the treatment of dysmenorrhea comparing a propionic acid derivative (Ibuprofen ( Motrin )) and a fenamate (mefenamic acid) with a placebo showed that both Ibuprofen ( Motrin ) and mefenamic acid are generally superior to placebo. Statistically significant results were obtained in favor of the study drugs over placebo for the pain relief afforded by the treatments (as graded by patients) and the visual analog pain relief score, which not only ranks but also indicates the degree of pain relief as a percentage of total relief (100%). Pairwise comparisons for the ranks found mefenamic acid significantly superior to placebo (P less than .001) and Ibuprofen ( Motrin ) marginally superior to placebo (P less than .06), while the visual analog pain relief scale demonstrated mefenamic acid and Ibuprofen ( Motrin ) superior to placebo (P less than .001 and P less than .01, respectively). For both the patient ranking of pain relief by treatment and the visual analog pain relief scale, the results showed no significant differences between Ibuprofen ( Motrin ) and mefenamic acid. Side effects occurred in 11 Ibuprofen ( Motrin ) cycles, five mefenamic acid cycles, and ten placebo cycles of the 48 cycles with each agent. These were generally of minor severity or importance and were not statistically different. The need for additional analgesics and the ability to pursue normal daily activity were not different for any treatment group. The findings of this study indicate no clinical difference between a propionic acid derivative such as Ibuprofen ( Motrin ) and a fenamate such as mefenamic acid in the treatment of dysmenorrhea.

Human pooled immunoglobulin in the treatment of chronic pain syndromes.

OBJECTIVE: To examine the use of intravenous immunoglobulin (i.v.i.g.) in chronic pain. DESIGN: A prospective multiple-dose, open-label cohort study in 130 consecutive patients who suffered from 12 chronic pain syndromes. The largest symptom groups were (number of patients): Fibromyalgia (48); Spinal pain (20); Complex regional pain syndrome (CRPS, 11); Peripheral neuropathic pain (12); and Atypical odontalgia or atypical facial pain (11). All patients had insufficient pain relief with established treatments. pain relief was recorded using average pain intensity values as documented in standardized diaries. A specific treatment protocol was developed, and patients were enrolled over a 36-month period. RESULTS: Overall, 20% of patients had>70% pain relief and 27.7% of patients reported relief between 25% and 70%. Six patients (4.6%) had moderately increased pain levels for a duration of up to 9 weeks. Good relief, of more than 70%, was found in all major symptom groups. Patients with pain of short duration (<2 years) reported high relief rates (33.8% of patients in this group reported relief of >70%). No serious adverse events were reported. conclusions: i.v.i.g. may be effective in patients suffering from chronic pain. Controlled studies are needed to evaluate the efficacy of i.v.i.g. in these patients. Patients with a good response to i.v.i.g. may be models for the study of neuroimmune interactions in chronic pain.

Continuous epidural infusion of morphine for pain relief after cardiac operations.

Postoperative pain relief and stress hormones were examined during the use of continuous epidural infusion of morphine at a rate of 0.1 mg/hr in 30 patients (Group B) after coronary artery bypass grafting. This was compared to our routine method of postoperative analgesia of intravenous morphine 2 mg/2 hr and as needed in another 30 patients (Group A). Continuous epidural morphine infusion required occasional supplementation with intravenous morphine and achieved effective analgesia in 80% of the patients. pain relief was adequate in 50% of the patients in Group A. The mean dose of morphine used in Group B during the first 3 postoperative days was 5 mg per patient per day and was significantly lower than that used in Group A (mean 18 mg per patient per day). Serum morphine was undetectable (below 2.5 ng/ml) in Group B and was significantly lower than that in Group A (17 ng/ml). Epidural analgesia was associated with adequate postoperative pulmonary and cardiovascular functions; nausea and vomiting occurred in two patients. Levels of postoperative stress, serum cortisol, and beta-endorphin were significantly lower in Group B than in Group A. This study shows that continuous epidural infusion of morphine at a rate of 0.1 mg/hr provides selective and effective pain relief and reduces postoperative stress after cardiac operations. This method of analgesia was also associated with minimal side effects and provides an alternate approach for treatment of pain after cardiac operations.

Cerebrospinal fluid nitric oxide metabolites are novel predictors of pain relief in degenerative lumbar diseases.

This study was undertaken to determine whether or not nitric oxide metabolites (NO(2)(-) plus NO(3)(-): NOx levels) in cerebrospinal fluid (CSF) would be predictors of treatment outcome in patients with degenerative lumbar diseases (DLD) including lumbar disc herniation (LDH) and lumbar spinal canal stenosis (LCS). The NOx levels in CSF were measured using an NO analyzer based on the Griess method. Six healthy volunteers and 18 patients with painless diseases were included in the control group. The pre- and postoperative NOx levels in 25 DLD patients, who underwent herniotomy for LDH (17 patients) or selective decompression for LCS (eight patients), were analyzed. The postoperative follow-up periods were approximately 8 months. Nineteen of 25 DLD patients, whose preoperative NOx levels were two standard deviations higher than the mean NOx levels of an age-matched control group, were included in an NO elevated (NOE) group. Among the 25 DLD patients, the preoperative NOx levels in six patients (young LDH group) were within the normal range. The pain-related Japanese Orthopaedic Association score and the Hirabayashi recovery rate were respectively used to evaluate the pain severity and the degree of pain relief. The preoperative and changes of postoperative NOx levels in the NOE group were negatively correlated with the Hirabayashi recovery rate. Normal postoperative NOx levels and excellent pain relief were achieved in young DLD patients. In conclusion, the preoperative and changes in postoperative NOx levels are quantitative predictors of postoperative pain relief in DLD patients.

Radiotherapy of plantar heel spurs: indications, technique, clinical results at different dose concepts

BACKGROUND: In a retrospective study the efficacy of orthovoltage radiotherapy for refractory painful plantar heel spur was analyzed for 3 different radiation dose concepts. PATIENTS AND METHODS: From 1.1 1984 through 1.3.1994, 182 patients with refractory painful heel symptoms and radiologically proven plantar heel spur received radiotherapy. A total of 141 patients and 170 heels (due to double-sided symptoms) were completely documented in long-term follow-up. Clearly defined semi-quantitative criteria (9-point score) were used to analyze heel pain and ankle function prior to RT, 6 to 12 weeks post-radiation, and at last follow-up. The treatment outcome, i.e. (un)favourable response, of 3 radiation dose concepts were compared: Group A (n = 72 heels) received 12 Gy total radiation dose in 3 fractions per week and 2 series (6 x 1 Gy per series) separated by 6 weeks; group B (n = 98 heels) received 3 Gy total radiation dose in 10 fractions of 0.3 Gy (n = 50) or 5 Gy (10 x 0.5 Gy) (n = 48) with conventional fractionation in 1 series. RESULTS: Radiotherapy was very effective: at last follow-up 67% (group A) and 71% (group B) remained completely free of pain. The rate of "complete pain relief" (i.e. free of any pain symptoms) was not different between the 3 radiation concepts. However, significant differences were observed with regard to "incomplete or insufficient pain relief", i.e. a subjective pain relief of less than 80%, a delayed pain relief after more than 4 weeks or a relapse of pain symptoms in long-term follow-up. More favourable results were achieved in patients receiving 5 Gy or 12 Gy total dose, while patients with 3 Gy total dose had significantly worse results. Prognostic factors for "complete pain relief" were short duration of pain symptoms and acute pain symptoms prior to radiotherapy; with regard to "in-complete or insufficient pain relief" the total dose was found to be a prognostic parameter. CONCLUSIONS: Patients with refractory heel pain can yield a high response to radiotherapy even after failing various conventional treatments previously. Thus, radiotherapy should not be solely regarded as a last resort due to its low costs and high efficacy at low radiation doses.

Assessing and treating pain in the newborn

OBJECTIVES: To update information about available neonatal pain assessment and pain relief methods.METHOD: Medical literature review of the past 10 years, including textbooks, general reviews, systematic reviews, prospective, randomized controlled studies, retrospective works and case studies. Literature was reviewed based on the author clinical and scientific experience regarding pain evaluation and treatment.RESULTS: Lack of verbal expression of pain is one of the major impediments to adequate pain relief in the neonatal period. Nowadays, several valid pain assessment tools are available, including the analysis of the neonate facial features and multidimensional tools, as NIPS, CRIES, and PIPP. Non-pharmacological pain relief can be achieved by non-nutritive suction and suction of dextrose water. Neonatal analgesia, in general, includes de the use of paracetamol, opioids and local anesthetics. Opioids remain the main resource for acute pain treatment in the neonatal intensive care unit. Sedatives are important agents to decrease patient activity and restlessness, but they do not relieve pain.CONCLUSION: Based on medical, ethical, and humanitarian grounds, neonatal pain should be considered and treated.