Am J Emerg Med 2001 Oct;19(6):533-4
Emergency Services, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.
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PMID: 11593486, UI: 21476798
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Am J Emerg Med 2001 Oct;19(6):531-2
Department of Emergency Medicine, Baystate Medical Center, Springfield, MA.
PMID: 11593484, UI: 21476796
Am J Emerg Med 2001 Oct;19(6):529-30
Department of Medicine and Division of Nephrology, Lincoln Medical Center, Bronx, NY.
PMID: 11593483, UI: 21476795
Anesthesiology 2001 Sep;95(3):771-80
Department of Anesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories. karmakar@cuhk.edu.hk
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PMID: 11575553, UI: 21459374
Anesthesiology 2001 Sep;95(3):640-6
Department of Anesthesiology and Institute of Cardiovascular Research, Chonbuk National University Medical School and Hospital, South Korea. shko@moak.chonbuk.ac.kr
BACKGROUND: Because magnesium blocks the N-methyl-D-aspartate receptor and its associated ion channels, it can prevent central sensitization caused by peripheral nociceptive stimulation. However, transport of magnesium from blood to cerebrospinal fluid (CSF) across the blood-brain barrier is limited in normal humans. The current study was designed to evaluate whether perioperative intravenous magnesium sulfate infusion affects postoperative pain. METHODS: Sixty patients undergoing abdominal hysterectomy received 50 mg/kg intravenous magnesium sulfate as a bolus dose followed by a continuous infusion of 15 mg x kg(-1) x h(-1) for 6 h (magnesium group) or the same volume of isotonic saline (control group). At the end of surgery, serum and CSF magnesium concentration were measured in both groups. The cumulative postoperative analgesic consumption was measured to assess the analgesic effect using a patient-controlled epidural analgesia device. Pain intensities at rest and during forced expiration were evaluated at 6, 24, 48, and 72 h postoperatively. RESULTS: At the end of surgery, patients in the magnesium group had significantly greater postoperative serum magnesium concentrations compared with both preoperative and control group values (P < 0.001). Despite significantly higher serum magnesium concentrations in the magnesium group, there was no significant difference in magnesium concentration measured in postoperative CSF. Cumulative postoperative analgesic doses were similar in both groups. However, there was observed an inverse relation between cumulative postoperative analgesic consumption and the CSF magnesium concentration in both groups. Visual analog pain scores at rest and during forced expiration were similar and less than 4 in both groups. CONCLUSIONS: Perioperative intravenous administration of magnesium sulfate did not increase CSF magnesium concentration and had no effects on postoperative pain. However, an inverse relation between cumulative postoperative analgesic consumption and the CSF magnesium concentration was observed. These results suggest that perioperative intravenous magnesium infusion may not be useful for preventing postoperative pain.
PMID: 11575536, UI: 21459357
Br J Anaesth 2001 Apr;86(4):572-5
Department of Surgery and Anaesthesia, Central Hospital of Seinajoki, Finland.
We studied the analgesic efficacy of tramadol 2 mg kg(-1) for post-operative analgesia after day-case adenoidectomy in children aged 1-3 yr. Eighty children were allocated randomly to receive tramadol 2 mg kg(-1) i.v. or placebo immediately after induction of anaesthesia. Anaesthesia was induced with alfentanil 10 microg kg(-1) and propofol 4 mg kg(-1) followed by mivacurium 0.2 mg kg(-1) for tracheal intubation. Anaesthesia was continued with sevoflurane in nitrous oxide and oxygen. All children were given ibuprofen rectally at approximately 10 mg kg(-1) before the start of surgery. Post-operative pain and recovery assessments were performed by a nurse blinded to the analgesic treatment using the Aldrete recovery score, the pain/discomfort scale and measurement of recovery times. Rescue medication (pethidine in increments of 5 mg i.v.) was administered according to the pain scores. A post-operative questionnaire was used to evaluate the need for analgesia at home up to 24 h after operation. Rescue analgesic at home was rectal or oral ibuprofen 125 mg. Children in the tramadol group required fewer pethidine doses than those in the placebo group (P = 0.014). Forty-five per cent of children receiving tramadol did not require post-operative analgesia at all compared with 15% of children receiving placebo (P = 0.003). Recovery times and the incidence of adverse effects were similar in the two groups in the recovery room and at home. The requirement for rectal ibuprofen at home did not differ between groups.
PMID: 11573636, UI: 21457539
Br J Anaesth 2001 Apr;86(4):528-34
Department of Anaesthesia, Monash University, Monash Medical Centre, Clayton, Victoria, Australia.
Fourteen patients scheduled for orthopaedic knee reconstruction surgery were enrolled in a prospective, double-blind, randomized study in which they received alphadolone (25-500 mg, n = 9) or placebo (lactose, n = 5) given orally 1 h after operation. All the subjects received a standardized general anaesthetic and the same type of surgery followed by physiotherapy using a continuous passive movement machine. Morphine was administered intravenously after operation by patient-controlled analgesia. Verbal rating and visual analogue scores assessed pain experiences for 6 h. Orally administered alphadolone up to 500 mg caused no increase in sedation, respiratory depression, nausea or vomiting. The experiences of these side-effects were all rated as none, mild or moderate. Orally administered alphadolone caused statistically significant reductions in morphine use and simultaneous highly significant reductions in pain scores. We conclude that alphadolone is a useful analgesic in humans when given by the oral route.
PMID: 11573627, UI: 21457530
Br J Anaesth 2001 Jun;86(6):893-5
Department of Neurosurgery, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India.
Intracranial subdural haematoma is an exceptionally rare complication of spinal anaesthesia. A 20-yr-old male underwent appendicectomy under partial spinal and subsequent general anaesthesia. A week later, he presented with severe headache and vomiting not responding to bed rest and analgesia. Magnetic resonance imaging showed a small acute subdural haematoma in the right temporo-occipital region. The patient improved without surgical decompression. The pathogenesis of headache and subdural haematoma formation after dural puncture is discussed and the literature briefly reviewed. Severe and prolonged post-dural puncture headache should be regarded as a warning sign of an intracranial complication.
PMID: 11573605, UI: 21457508
Br J Anaesth 2001 Jun;86(6):763-8
Klinik fur Anaesthesiologie und Intensivmedizin, Universitatskliniken des Saarlandes, Homburg, Germany.
We investigated the analgesic effect and the neurological recovery time after administration of remifentanil in mechanically ventilated patients in an intensive care unit. Twenty patients, after trauma or major surgery with no intracranial pathology, were randomized to receive either remifentanil/propofol (n=10) or sufentanil/propofol (n=10). A sedation score and a simplified pain score were used to assess adequate sedation and analgesia. Medication was temporarily stopped after 24 h. Immediately before and 10 and 30 min after, the degree of sedation and pain score were evaluated. Adequate analgesia and sedation was achieved with remifentanil 10.6 microg kg(-1) h(-1) and propofol 2.1 mg kg(-1) h(-1), or sufentanil 0.5 microg kg(-1) h(-1) and propofol 1.3 mg kg(-1) h(-1). The difference in propofol dose between groups was significant. Ten minutes after terminating the medication, the degree of sedation decreased significantly after remifentanil and all patients could follow simple commands. During the following 20 min, all patients with remifentanil emerged from sedation and complained of considerable pain. By contrast, in the sufentanil group, only six (7) responded to commands after 10 (30) min and their pain score remained essentially unchanged during the 30-min observation period. We conclude that, in contrast to sufentanil, remifentanil facilitates rapid emergence from analgesia and sedation, allowing a clinical neurological examination within 10-30 min in mechanically ventilated patients with no intracranial pathology.
PMID: 11573581, UI: 21457484
Br J Anaesth 2001 Mar;86(3):413-21
Portex Department of Anaesthesia, Institute of Child Health, London, UK.
PMID: 11573533, UI: 21457436
Br J Anaesth 2001 Mar;86(3):377-81
Department of Otorhinolaryngology, Kuopio University Hospital, Finland.
We have evaluated the safety and efficacy of ketoprofen during tonsillectomy in 106 adults receiving standardized anaesthesia. Forty-one patients received ketoprofen 0.5 mg kg(-1) at induction ('pre' ketoprofen group) and 40 patients after surgery ('post' ketoprofen group), in both cases followed by a continuous ketoprofen infusion of 3 mg kg(-1) over 24 h; 25 patients received normal saline (placebo group). Oxycodone was used for rescue analgesia. Patients in the ketoprofen groups experienced less pain than those in the placebo group. There was no difference between the study groups in the proportion of patients who were given oxycodone during the first 4 h after surgery. However, during the next 20 h, significantly more patients in the placebo group (96%) received oxycodone compared with patients in the 'pre' ketoprofen group (66%) and the 'post' ketoprofen group (55%) (P=0.002). Patients in the placebo group received significantly more oxycodone doses than patients in the two ketoprofen groups (P=0.001). Two patients (5%) in the 'pre' ketoprofen group and one (3%) in the 'post' ketoprofen group had post-operative bleeding between 4 and 14 h. All three patients required electrocautery.
PMID: 11573528, UI: 21457431
Br J Anaesth 2001 Mar;86(3):329-31
PMID: 11573519, UI: 21457422
Br J Anaesth 2001 Sep;87(3):390-9
Department of Anaesthesiology and Paediatric Surgery, Sophia Children's Hospital, University Hospital Rotterdam, Dr Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.
Children aged 0-3 yr were stratified for age and randomized to receive either continuous morphine (CM, 10 microg x kg(-1) x h(-1)) with three-hourly placebo boluses or intermittent morphine (IM, 30 microg x kg(-1) every 3 h) with a placebo infusion for postoperative analgesia. Plasma concentrations of epinephrine, norepinephrine, insulin, glucose and lactate were measured before and at the end of surgery and 6, 12 and 24 h after surgery. Pain was assessed with validated pain scales [the COMFORT scale and a visual analogue scale (VAS)] with the availability of additional morphine doses. Minor differences occurred between the randomized treatment groups, the oldest IM group (aged 1-3 yr) having a higher blood glucose concentration (P=0.003), mean arterial pressure (P=0.02) and COMFORT score (P=0.02) than the CM group. In the neonates, preoperative plasma concentrations of norepinephrine (P=0.01) and lactate (P<0.001) were significantly higher, while the postoperative plasma concentrations of epinephrine were significantly lower (P<0.001) and plasma concentrations of insulin significantly higher (P<0.005) than in the older age groups. Postoperative pain scores (P<0.003) and morphine consumption (P<0.001) were significantly lower in the neonates than in the older age groups. Our results show that continuous infusion of morphine does not provide any major advantages over intermittent morphine boluses for postoperative analgesia in neonates and infants.
PMID: 11517122, UI: 21407604
Br J Anaesth 2001 Sep;87(3):385-9
Department of Anaesthesia and Intensive Care, Hospital Bichat, 46 rue Henri Huchard, F-75018 Paris, France.
Use of morphine by titration in the post-anaesthesia care unit (PACU) is often the first step in postoperative pain management. This approach provides rapid analgesia but shows a wide inter-individual variability in morphine requirements and may prolong patient stay in the PACU. The aim of this study was to identify the patient characteristics, surgical, anaesthetic, and postoperative factors predictive of early morphine requirements. The study included 149 patients undergoing various non-cardiac surgical procedures under general anaesthesia. In the multiple regression analysis of nine variables, only ethnicity (Caucasian), emergency surgery, major surgery, surgery exceeding 100 min, and pain score on arrival in PACU were predictive factors of morphine requirements. This observational study identifies for the first time independent predictive factors of morphine requirements in the early postoperative period. Future studies are warranted to evaluate the impact of intervention on these factors and any resulting improvement in postoperative pain treatment.
PMID: 11517121, UI: 21407603
Cephalalgia 2001 Sep;21(7):765-9
Department of Neurology and Danish Pain Research Center, Aarhus University Hospital, Aarhus, Denmark.
Within the last 2 decades there has been an explosion in new information on mechanisms underlying pain. Unfortunately this information has not resulted in a similar improvement of our handling of patients with chronic pain including chronic musculoskeletal pain. Neuronal hyperexcitability, which apparently is a key phenomenon in many (if not all) types of chronic pain results in changes in the nervous system from the level of the peripheral nociceptor to the highest cortical centers in the brain. The neuronal plastic changes in chronic pain conditions makes the nociceptive system amenable for treatment with several traditional as well as untraditional types of interventions. Two treatment areas that seem worth exploring within chronic pain including headache concerns preventive measures and endogenous pain modulation.
PMID: 11595009, UI: 21479138
Cephalalgia 2001 Sep;21(7):718-26
Department of Neurology, University of Padua, Padua and Institute of Neurology, University of Parma, Parma, Italy.
We investigated the use of self-administered pain-relieving manoeuvres on a sample of 400 patients with primary headaches-represented by an even distribution of migraine without aura (MO), migraine with aura (MA), episodic tension-type headache (TH), and cluster headache (CH)-consecutively seen at Padua and Parma Headache Centres. Manoeuvres on various regions of the head were used by 258 patients (65% of the cases). The most applied procedures were: compression (114 out of 382 manoeuvres; 30%), application of cold (27%), massage (25%) and application of heat (8%). A significant (P < 0.001) relationship was found between headache diagnoses and type of manoeuvre. In MO patients the application of cold (38% of the manoeuvres) and compression (36%), used mainly on the forehead and temples, prevailed; compression, mainly on the temples, was the most frequent procedure (44%) in MA patients. Massage on the temples and nape was the predominant manoeuvre (43%) in TH patients, whereas in the CH group, which more often required heterogeneous procedures, none of the above-mentioned manoeuvres was prevalent. Compression, as a diagnostic criterion for MO, had a sensitivity of 33% and a specificity of 86%; for the application of cold the figures were 36% and 84%, respectively. Massage had a sensitivity of 33% and a specificity of 80% for TH. The efficacy of the self-administered manoeuvres in reducing pain was scarce. Only 8% of the manoeuvres, in fact, resulted in a good or excellent pain control. Moreover, the efficacy of the manoeuvre was often momentary, wearing off when the manoeuvre stopped. In spite of this, 46% of the subjects used the manoeuvres constantly, at each attack.
PMID: 11594999, UI: 21479128
Eur J Anaesthesiol 2001 Sep;18(9):605-14
Department of Anaesthesia, Derriford Hospital, Plymouth, PL6 8DH, Devon, UK. rsneyd@pms.ac.uk
BACKGROUND: and objective This open, multicentre study compared the efficacy and safety of remifentanil with fentanyl during balanced anaesthesia with 0.8% isoflurane (end-tidal concentration) for major abdominal and gynaecological surgery, and the efficacy and safety of remifentanil for pain management in the immediate postoperative period. METHODS: Two-hundred and eighty-six patients were randomized to receive remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min-1 (n=98), remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) (n=91) or fentanyl 3 microg kg(-1) (n=97) at induction. Thereafter, the study opioids and isoflurane were titrated to effect during the operation. RESULTS: Compared with fentanyl, remifentanil 2 microg kg(-1) followed by 0.4 microg kg(-1) min(-1) reduced the incidence of response to tracheal intubation (30% vs. 13%, P < 0.01), skin incision (33% vs. 4%, P < 0.001) and skin closure (11% vs. 3%, P < 0.05), respectively. Patients receiving remifentanil 1 microg kg(-1) followed by 0.2 microg kg(-1) min(-1) had fewer responses to skin incision than the fentanyl group (12% vs. 33%, P < 0.001), but the incidences of response to tracheal intubation and skin closure were similar. Significantly fewer patients in both remifentanil groups had > or = 1 responses to surgical stress intraoperatively compared with fentanyl (68% and 48% vs. 87%, P < 0.003). The mean isoflurane concentrations required were less in both remifentanil groups compared with the fentanyl group (0.1%, P=0.05). In remifentanil-treated patients, continuation of the infusion at 0.1 microg kg(-1) min(-1) with titration increments of +/- 0.025 microg kg(-1) min(-1) was effective for the management of immediate postoperative pain prior to transfer to morphine analgesia. However, a high proportion of patients experienced at least moderate pain whilst the titration took place. CONCLUSIONS: Anaesthesia combining isoflurane with a continuous infusion of remifentanil was significantly more effective than fentanyl at blunting responses to surgical stimuli. Significantly fewer patients responded to tracheal intubation with remifentanil at 0.4 microg kg(-1) min(-1), supporting the use of a higher initial infusion rate before intubation. Both remifentanil and fentanyl were well-tolerated, with reported adverse events typical of mu-opioid agonists.
PMID: 11553256, UI: 21437525
Lancet 2001 Sep 29;358(9287):1101-2
PMID: 11594328, UI: 21477513
Neurology 2001 Oct 9;57(7):1296-303
School of Psychology (Drs. Drummond and Blockey, and S. Skipworth), Murdoch University, Perth.
OBJECTIVE: To investigate the effect of sympathetic arousal on pain and vasomotor responses in healthy control subjects and patients with complex regional pain syndrome (CRPS), and to determine whether pain increases in patients with particular symptoms. METHODS: In experiments 1 and 2, capsaicin was applied to the forearm of 24 healthy subjects to induce thermal hyperalgesia. Vascular responses were monitored and subjects rated thermal hyperalgesia before and after being startled (experiment 1), and before, during, and after mental arithmetic, breath holding, forehead cooling, the Valsalva maneuver, and a cold pressor test in experiment 2. In a third experiment, sensitivity to heat, cold, and mechanical stimulation was investigated in 61 patients with CRPS. Pain ratings and vascular and electrodermal responses were recorded after patients were startled and during forehead cooling. RESULTS: In experiment 1, thermal hyperalgesia decreased in healthy control subjects after they were startled, and digital blood vessels constricted symmetrically. In experiment 2, thermal hyperalgesia decreased during and after other forms of sympathetic arousal. However, in experiment 3, ratings of clinical pain increased during forehead cooling or after being startled in over 70% of patients with CRPS. Pain increased most consistently during forehead cooling in patients with cold allodynia or punctate allodynia. Digital blood vessels constricted more intensely on the symptomatic than the nonsymptomatic side in patients with CRPS during sympathetic arousal. CONCLUSIONS: Normal inhibitory influences on pain during sympathetic arousal are compromised in the majority of patients with CRPS. The augmented vasoconstrictor response in the symptomatic limb during sympathetic arousal is consistent with adrenergic supersensitivity. An adrenergic sensitivity in nociceptive afferents might contribute to pain and hyperalgesia during sympathetic arousal in certain patients with CRPS.
PMID: 11591852, UI: 21476005
Spine 2001 Oct 15;26(20):2271-7
Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, and the Clinic for Orthopedics, Johannes Gutenberg University, Mainz, Germany.
STUDY DESIGN: For this study, a prospective cohort of 109 patients was recruited consecutively at an orthopedic inpatient unit of a university hospital. Three self-report instruments were administered to patients with sciatica believed to be caused by a herniated lumbar disc to examine their quality of life and psychic stress at baseline and at the 1-year follow-up visit. OBJECTIVES: To investigate whether patients who have undergone a previous discectomy experience greater psychic stress than patients with no surgery, and to determine whether the groups differed regarding their health-related quality of life at the follow-up visit. SUMMARY OF BACKGROUND DATA: Previous studies have described psychic abnormalities in patients with long-term back pain, particularly patients with severe chronicity (i.e., history of surgeries and persistent problems) or those who underwent a previous discectomy. Additionally, a series of studies has shown that psychic and psychosocial parameters exert a significantly greater influence on the success of treatment than do clinical and imaging findings or the extent of disc abnormality. METHODS: The Short Form Health Survey 36, the Symptom Checklist 90, and Screening for Somatoform Disorders were administered to 109 patients consecutively treated in the authors' orthopedic university clinic, at baseline and at the 1-year follow-up visit. RESULTS: In all the patients examined, the physical and mental quality of life improved regardless of their group classification. The psychological distress, according to the Symptom Checklist 90, was clearly reduced in both groups at the follow-up visit, with the exception of somatization, as indicated by Symptom Checklist 90 and Screening for Somatoform Disorders. Whereas the patients who had undergone surgery remained nearly unchanged with regard to their somatization, the patients with no previous surgery improved significantly, as indicated by Screening for Somatoform Disorders and Symptom Checklist 90. Somatization, particularly that surveyed by the comprehensive Screening for Somatoform Disorders, proved to be quite a stabile factor over time in both groups. The extent of the physical impairment before treatment was nearly the same in both groups, as indicated by Short Form Health Survey 36. Despite a markedly higher chronicity of reported problems, patients who had undergone surgery were hardly more greatly impaired in terms of their mental quality of life and psychological distress, as indicated by Symptom Checklist 90, than those without a history of surgery. At the follow-up visit, the differences tended to be minimal as well. As compared with those who had no previous surgeries, the patients who had undergone surgery were significantly more heavily impaired in their physical quality of life despite significant improvements. CONCLUSIONS: Patients with sciatica demonstrated less abnormality in terms of the psychopathologic markers investigated than described in previous studies. Nevertheless, the predisposition to somatize influences health-related quality of life to a high degree.
PMID: 11598519, UI: 21482835
Support Care Cancer 2001 May;9(3):205-6
Pain Relief and Palliative Care Unit, La Maddalena Cancer Centre, Palermo, Italy. mercadsa@tin.it
Chronic opioid medication has been found to cause myoclonus in patients taking it for cancer pain. Gabapentin seemed a likely candidate for the treatment of this myoclonus and has indeed proved useful, as illustrated in this paper by two case histories.
PMID: 11401105, UI: 21293952
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