Order this document
Anesth Analg 2003 May;96(5):1447-52
Department of Anesthesia and Intensive Care, University of Vienna. Department of Anesthesia, Armed Forces Medical Hospital, Amberg, Germany.
[Medline record in process]
Upper abdominal pain, a frequent symptom of the presence of gallstone disease, is the cause of 6% of the emergency calls of the Austrian emergency system. Pain resulting from cholelithiasis is characteristically severe. Recent data show that active warming during emergency transport of trauma victims is effective in reducing pain. Therefore, we hypothesized that local active warming of the abdomen would be an effective pain treatment for patients with acute cholelithiasis and could be provided by paramedics. Sixty patients (>19 yr) consented to participate in this study. They were divided into two groups: Group 1, who received active warming of the upper abdomen with a carbon-fiber warming blanket (42 degrees C), and Group 2, who received no warming of the abdomen. Neither group received any drug-based pain care. Patients were asked to rate their pain and anxiety by using visual analog scales (VAS). Statistical evaluation was performed with Student's t-test; P < 0.05 was considered significant. In Group 1, a significant (P < 0.01) pain reduction was recorded in all cases on a visual analog scale (VAS), from 86.8 +/- 5.5 mm to 41.2 +/- 16.2 mm. In Group 2, the patients' pain scores remained comparable, from 88.3 +/- 9.9 mm to 88.1 +/- 10.0 mm on a VAS. In comparing Group 1 with Group 2 on arrival at the hospital, pain scores showed a significant difference (P < 0.01). In Group 1, the VAS score changes for anxiety were significantly reduced (P < 0.01), from 82.7 +/- 10.8 mm before treatment to 39.0 +/- 14.0 mm after treatment. In Group 2, a nonsignificant change of this score was noted, from 84.5 +/- 14.6 mm to 83.5 +/- 8.4 mm. Comparing Group 1 with Group 2 on arrival at the hospital showed a significant difference in anxiety scores (P < 0.01). We conclude that local active warming is an effective and easy-to-learn treatment for pain resulting from acute cholelithiasis in emergency care. IMPLICATIONS: Active local warming of the upper abdomen is an effective treatment for patients with cholelithiasis being transported to the hospital by paramedics who are not permitted to provide any drug-based pain care. We observed no negative side effects of this treatment.
PMID: 12707148, UI: 22592007
Other Formats:
Anesth Analg 2003 May;96(5):1413-4
Department of Pediatric Anesthesiology, Children's Memorial Hospital, and. Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Division of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
IMPLICATIONS: Chemotherapy for cancer is associated with pain including cutaneous vasculitis. Magnesium, an N-methyl-D-aspartic acid-receptor antagonist, was used successfully to treat an adolescent with pain caused by cutaneous vasculitis secondary to methotrexate therapy.
PMID: 12707144, UI: 22592003
Anesth Analg 2003 May;96(5):1392-6
Pain Relief Unit, Liver Unit and Department of Medical Imaging, Rambam Medical Center and the B. Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel.
Percutaneous needle liver biopsy is an important procedure for the diagnosis and evaluation of liver disease and is frequently associated with pain. In this prospective study, we investigated the prevalence and characteristics of this pain syndrome. Fifty-four subjects, who underwent liver biopsy under ultrasound guidance, received 5 mg of diazepam orally 1 h before the procedure and local infiltration with 10 mL of 2% lidocaine just before needle insertion. Outcome measures included the visual analog scale for measuring pain intensity over 24 h, pain localization on a body scheme, and the Spielberger questionnaire for measuring anxiety levels. Forty-seven (84%) of the 54 respondents reported pain 30 min after the biopsy (visual analog scale, 4.2 +/- 0.5; mean +/- SEM), and 21 (39%) reported pain at the 24-h time point. Biopsy site pain was reported by 9 subjects, right shoulder pain by 14, and pain at both sites by 24. Higher pain intensities were reported by women and by subjects with higher anxiety levels. This study indicates that liver biopsy is a painful condition in most patients. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia, thus indicating that a more profound analgesic treatment is required for better control of this pain. IMPLICATIONS: Percutaneous liver biopsy is a painful procedure in most patients. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia. A more profound analgesic treatment is required for better control of this pain.
PMID: 12707140, UI: 22591999
Anesth Analg 2003 May;96(5):1386-91
Department of Anesthesiology, The University of Tokyo, Tokyo, Japan.
Epidurally administered midazolam can potentiate analgesia by epidural bupivacaine. However, whether this effect is synergistic or additive is not known. In this study, we investigated the spinally-mediated analgesic interaction between midazolam and bupivacaine by using the tail-flick and formalin tests in rats with chronically implanted catheters. Behavioral effects were also observed. The dose dependency of analgesia and the 50% effective doses of intrathecal midazolam and bupivacaine were determined, and then the interaction of these two drugs was examined with an isobolographic analysis. Both drugs had dose-dependent analgesic effects in both the tail-flick test and the formalin test. The 50% effective dose values of the combination were significantly lower than the calculated additive values in both tests (P = 0.023 in the tail-flick test; P = 0.0025 in Phase 1 and 0.047 in Phase 2 of the formalin test). Behavioral side effects decreased in the combination group compared with each drug alone. In conclusion, intrathecally administered midazolam and bupivacaine had synergistic analgesic effects on acute thermal- or inflammatory-induced pain, with decreased behavioral side effects. IMPLICATIONS: In both acute thermal- and inflammatory-induced pain, intrathecally administered midazolam and bupivacaine produced synergistic analgesia with decreased side effects in intrathecally catheterized rats.
PMID: 12707139, UI: 22591998
Anesth Analg 2003 Apr;96(4):1235; author reply 1235
Publication Types:
PMID: 12651698, UI: 22537633
Anesth Analg 2003 Apr;96(4):1083-8, table of contents
Departments of Anesthesiology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA. brian.sites@hitchcock.org
Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I-III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 microg), 3) morphine (250 microg) with clonidine (25 microg), and 4) morphine (250 microg) with clonidine (75 microg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone. IMPLICATIONS: In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 microg) combined with clonidine (25 or 75 microg) provided superior analgesia compared with intrathecal morphine alone.
PMID: 12651665, UI: 22537600
Anesth Analg 2003 Apr;96(4):1079-82, table of contents
Department of Anesthesia, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, Japan 565-0871. kueta@anes.med.osaka-u.ac.jp
Because individual variation is a likely factor affecting both the incidence and severity of side effects and the analgesic efficacy of epidural opioids, assessment of individual variation could be useful in deciding optimal dosage. By evaluating the response to a small test dose of IV fentanyl, we designed this study to predict the degree of pain relief and the incidence of side effects in patients who would be receiving postoperative epidural fentanyl. Before the induction of anesthesia, 50 micro g of fentanyl was administered IV, and 2 min after fentanyl, the patient response was evaluated. Twenty-three patients, who reported nausea, sleepiness, dizziness, sensation of warmth, and other symptoms, were categorized as responders (Group R); the remaining 20 patients were categorized as nonresponders (Group NR). At the completion of surgery, infusion of epidural fentanyl was administered (0.3 mg/d in 0.25% bupivacaine) for 96 h. At postoperative Hours 6 and 24, Group R had significantly lower visual analog scale scores for postoperative pain intensity and required fewer analgesics than Group NR. The incidence of side effects, however, was 74% for Group R and 10% for Group NR (P < 0.05), and side effects were more serious in Group R. This study demonstrates that preoperative administration of a small dose of fentanyl during the induction of anesthesia enables prediction of the analgesic efficacy of postoperative epidural fentanyl and the incidence and severity of side effects. IMPLICATIONS: Preoperative administration of a small dose of fentanyl during the induction of anesthesia enables prediction of the analgesic efficacy of postoperative epidural fentanyl and the incidence and severity of side effects.
PMID: 12651664, UI: 22537599
Anesth Analg 2003 Apr;96(4):982-6, table of contents
Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue (B2-AN), Seattle, WA 98101, USA. anejmn@vmmc.org
Suprascapular nerve block (SSNB) reportedly improves analgesia and 24-h outcomes after arthroscopic shoulder surgery performed under general anesthesia. In this study, we assessed the analgesic and clinical outcome efficacy of SSNB as an adjunct to interscalene brachial plexus block (ISB) for ambulatory nonarthroscopic shoulder surgery. Fifty patients were randomized to receive either a SSNB or sham injection as part of a standardized ISB-general anesthesia regimen. Time to first significant pain (the primary outcome measure) was significantly delayed in the SSNB group (594 +/- 369 min versus 375 +/- 273 min, respectively; P = 0.02). There were no other differences between groups with regard to postanesthesia recovery unit measures, 24-h assessment of pain, supplemental analgesic use, or quality of life outcomes. We conclude that adjunctive SSNB adds minimal value to a primary ISB anesthetic for nonarthroscopic shoulder surgery. IMPLICATIONS: When used as an adjunct to an interscalene block combined with general anesthesia, suprascapular nerve block with bupivacaine moderately prolongs analgesia without improving other outcome measures after ambulatory nonarthroscopic shoulder surgery.
PMID: 12651646, UI: 22537581
Other Formats: Links:
BMJ 2003 Apr 26;326(7395):920
Department of Emergency Medicine, Vienna General Hospital, Wahringer Gurtel 18-20, A-1093 Vienna, Austria.
PMID: 12714474, UI: 22599460
BMJ 2003 Apr 26;326(7395):911
Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands. ibc.korthals-de_bos.emgo@med.vu.nl
OBJECTIVE: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Primary care. PARTICIPANTS: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). MAIN OUTCOME MEASURES: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. RESULTS: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. CONCLUSIONS: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
PMID: 12714472, UI: 22599458
Cancer 2003 May 1;97(9):2334-2340
Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
[Record supplied by publisher]
BACKGROUND: Pain is mediated centrally by N-methyl-D-aspartate (NMDA) receptors. The antinociceptive effects of preincision dextromethorphan (DM), an NMDA antagonist, have been demonstrated in surgical patients under general or epidural anesthesia. The authors investigated the effects of DM on postoperative pain and other parameters in patients undergoing surgery for bone malignancy under standardized combined general and epidural anesthesia using patient-controlled epidural analgesia (PCEA) postoperatively. METHODS: Patients received placebo or DM 90 mg (30 patients per group) in a double-blind manner preoperatively and on each of the two following days. Postoperative PCEA consisted of 1.6 mg ropivacaine plus 4 &mgr;g/mL fentanyl both continuously and by demand up to 96 hours, starting when subjective pain intensity was greater than or equal to 4/10 (visual analog score). Rescue drugs on demand (paracetamol or dipyrone orally) were also available. RESULTS: The DM patients experienced about 50% (P < 0.01) less pain than their placebo counterparts for more than 2 postoperative days and they rated their overall maximal pain intensity by one-half that estimated by the placebo-treated patients (P < 0.01). The DM group also consumed 30-50% less epidural analgesics than the total amount consumed by the placebo-medicated group (P < 0.01) and demanded significantly (P < 0.05) fewer rescue drugs on the first postoperative day. They were less sedated (40-60%, P < 0.01) and reported 50% fewer overall side effects (P < 0.05). The groups were similar for the need for urinary catheterization, time of first ambulation, and/or discharge home. CONCLUSIONS: A 3-day DM administration is associated with better pain reduction in patients undergoing surgery for bone malignancy under combined general and epidural anesthesia with postoperative PCEA compared with placebo without increasing side effects. Cancer 2003;97:2334-9. Copyright 2003 American Cancer Society.DOI 10.1002/cncr.11330
PMID: 12712491
Eur J Anaesthesiol 2003 Jan;20(1):77-8
PMID: 12553396, UI: 22440428
Eur J Anaesthesiol 2003 Jan;20(1):75-6
PMID: 12553395, UI: 22440427
Eur J Anaesthesiol 2003 Jan;20(1):72-3
PMID: 12553393, UI: 22440425
J Pediatr 2003 Apr;142(4):373-6
Department of Pediatric Hematology/Oncology, Washington University School of Medicine, St Louis, Missouri.
OBJECTIVE: To test the hypothesis that children with terminal cancer and neuropathic pain require rapid increases of opioids and benzodiazepines immediately before death, we compared drug usage in the last 72 hours of life in children with and without neuropathic pain.Patients and methods Through the use of retrospective case analysis, pediatric patients with terminal cancer were divided into two groups: one with and one without neuropathic pain. Opioid and benzodiazepine dosages were recorded during the last 3 days of life. RESULTS: Eighteen patients were identified: 12 with neuropathic pain and 6 without neuropathic pain. In the neuropathic group, the average dose of morphine 72 hours before death was 231 mg/kg per day and increased to 380 mg/kg per day on the day of death (P =.009). The average benzodiazepine dosage 72 hours before death was 6.0 mg/kg per day and increased to 25.0 mg/kg per day on the day of death (P =.018). In the nonneuropathic pain group, the average dose of morphine and benzodiazepine 72 hours before death was 3.0 mg/kg per day and 0.08 mg/kg per day, respectively, and did not increase substantially on the day of death. CONCLUSIONS: Dying children with cancer and neuropathic pain have higher baseline requirements of morphine and benzodiazepines and require rapid increases of both drugs in the last 72 hours of life than dying children without neuropathic pain.
PMID: 12712053, UI: 22597795
J Pediatr 2003 Apr;142(4):361-3
Department of Anesthesiology Perioperative and Pain Medicine and Department of Medicine Children's Hospital Boston, MA.
PMID: 12712049, UI: 22597791
Neurology 2003 Apr 22;60(8):1284-9
Departments of Neurology, Odense (Drs. Sindrup and Madsen) and Aarhus (Drs. Bach and Jensen) University Hospitals, and Clinical Pharmacology (Dr. Gram), University of Southern Denmark, Odense.
BACKGROUND: Tricyclic antidepressants (TCA) are often used in the treatment of painful polyneuropathy. Venlafaxine is a serotonin and weak noradrenaline reuptake inhibitor antidepressant with a different profile of other pharmacologic actions from those of TCA. OBJECTIVE: To test if venlafaxine would relieve painful polyneuropathy and compare its possible efficacy with that of the TCA imipramine. METHODS: The study design was randomized, double blind, and placebo controlled, with a three-way crossover. Forty patients were assigned to one of the treatment sequences, and 29 completed all three study periods. The daily doses were venlafaxine 225 mg and imipramine 150 mg. During the three treatment periods, each of 4 weeks' duration, patients rated pain paroxysms, constant pain, and touch- and pressure-evoked pain by use of 0- to 10-point numeric rating scales. RESULTS: The sum of the individual pain scores during treatment week 4 was lower on venlafaxine (80% of baseline score; p = 0.006) and imipramine (77%; p = 0.001) than on placebo (100%) and did not show any statistical difference between venlafaxine and imipramine (p = 0.44). The individual pain scores for pain paroxysms, constant pain, and pressure-evoked pain showed a similar pattern, whereas touch-evoked pain was uncommon and was not altered by any of the drugs. Numbers needed to treat to obtain one patient with moderate or better pain relief were 5.2 for venlafaxine and 2.7 for imipramine. CONCLUSION: Venlafaxine relieves pain in polyneuropathy and may be as effective as imipramine.
PMID: 12707430, UI: 22593650
Neurology 2003 Apr 8;60(7):1167-71
King's Regional Neuroscience Center, London, UK. eli.silber@kcl.ac.uk
BACKGROUND: Headache is the most common nervous system complication at altitude; however, there have been few attempts to characterize clinical features of high-altitude headaches (HAH). OBJECTIVE: To measure prospectively the incidence of HAH and to determine its risk factors and characteristics. METHODS: Members of an expedition to Kanchenjunga base camp in Nepal (5,100 m) were prospectively studied. Subjects were interviewed prior to the trip and while trekking recorded headaches experienced at >3,000 m using a structured questionnaire incorporating International Headache Society (IHS) and acute mountain sickness (AMS) criteria. In addition, clinical features of headaches in 19 trekkers in other groups above 3,000 m were recorded using the same questionnaire. RESULTS: Eighty-three percent (50/60) reported at least 1 HAH (median 2, range 0 to 10). Those who developed HAH were younger (p = 0.04); women and persons with headaches in daily life were more likely to report severe headaches (p = 0.03 and p = 0.07). One hundred thirty-eight HAH, experienced by 69 persons, are described. The mean altitude at which headaches occurred was 4,723 m. Twenty-six percent of headaches woke subjects at night or occurred upon awakening. HAH reported by migraineurs were accompanied by more phonophobia (p = 0.008). There were no IHS accompanying symptoms in 44% of headaches or symptoms of AMS in 52% of headaches. CONCLUSIONS: Headaches are a frequent complication of ascent to altitude. Older age appears to offer some protection, whereas headaches were more severe in women and persons with headaches in daily life. There is a wide clinical spectrum, with some suggesting intracranial hypertension. There is a need for evidence-based diagnostic criteria for headaches at altitude.
PMID: 12682326, UI: 22569104
Neurology 2003 Apr 8;60(7):1064-70
Department of Neurology, Albert Einstein College of Medicine, Bronx, NY10461, USA. Rlipton@aecom.yu.edu
Management of headache disorders, a leading reason for neurologic outpatient visits, is often difficult. In this article, the authors summarize and categorize the common reasons for treatment failure leading to referral to subspecialty headache centers. They have grouped these treatment failures into five broad categories: 1) the diagnosis is incomplete or incorrect; 2) important exacerbating factors have been missed; 3) pharmacotherapy has been inadequate; 4) nonpharmacologic treatment has been inadequate; 5) other factors, including unrealistic expectations and comorbidity, exist. The authors present an orderly approach to treatment failure to assist neurologists in managing difficult patients. Most refractory headache patients have a biologically determined problem and can be helped by accurate diagnosis or effective treatment. Persistence in treating these patients can be very rewarding. The authors provide a checklist intended to facilitate the management of refractory patients.
PMID: 12682307, UI: 22569085
Pediatrics 2003 Apr;111(4 Pt 2):e497-503
New Hanover Regional Medical Center, Wilmington, North Carolina 28402, USA. debra_mclendon@yahoo.com
OBJECTIVE: Using an evidence-based approach, a Vermont Oxford Network focus group whose goal was to reduce brain injury developed and implemented a number of potentially better practices. Each center approached implementation of the practices differently. Reducing the incidence of intraventricular hemorrhage and periventricular leukomalacia are important for improving long-term outcomes for low birth weight infants. METHODS: Implementation approaches for some but not all of the practices at the various centers are discussed. The practices reviewed include optimal peripartum management, such as resuscitation, avoidance of hypothermia, optimal surfactant delivery, early neonatal management by the most experienced providers, and measures to minimize pain and stress. Additional practices include maintenance of neutral head positioning, fluid volume therapy for hypotension, indomethacin prophylaxis, ventilator management, avoidance of routine suctioning, and limiting the use of sodium bicarbonate and postnatal dexamethasone. RESULTS: Approaches to implementation were center specific, and results vary. Although some practices were easier to implement than others, communication, education, and leadership were critical to the process. CONCLUSIONS: The quality improvement multidisciplinary approach is a useful tool for finding ways to reduce the incidence of intraventricular hemorrhage and periventricular leukomalacia.
PMID: 12671170, UI: 22558450