Order this document
BMJ 2003 Feb 1;326(7383):252-3
Department of Social Medicine, University of Bristol, Bristol BS8 2PR. rona.campbell@bris.ac.uk
Publication Types:
PMID: 12560274, UI: 22446344
Other Formats:
Br J Anaesth 2003 Mar;90(3):377-379
Department of Anesthesiology and Pain Medicine, 3B2.32 Walter C. Mackenzie Health Sciences Centre, University of Alberta Hospitals, 8440-112 Street, Edmonton, Alberta, Canada T6G 2B7. Faculty of Pharmacy and Pharmaceutical Science, 3118 Dentistry-Pharmacy Centre, University of Alberta, Edmonton, Alberta, Canada T6G 2N8.
[Record supplied by publisher]
BACKGROUND: I.V. rocuronium produces intense discomfort at the site of injection in conscious patients. Four strategies to reduce or prevent this discomfort were studied. METHODS: Two hundred and fifty adult patients, ASA I-III, were randomized into five groups of 50 patients in a blinded, prospective study. The control group received rocuronium 10 mg alone. For the remaining four groups, rocuronium 10 mg was mixed with sodium bicarbonate 8.4% 2 ml, fentanyl 100 micro g, lidocaine 2% or normal saline. The pH and osmolality of all mixtures were measured. Patient data were analysed using ordinal logistic regression. Osmolality and pH data were analysed using the Kruskal-Wallis test with Dunn's multiple comparison test. RESULTS: When compared with rocuronium alone, only the addition of saline failed to significantly reduce the pain reported by patients. The addition of fentanyl reduced the complaint of pain by 1.9 times (P<0.049) and the addition of lidocaine 2% reduced it by 3.6 times (P<0.0001). Sodium bicarbonate 8.4% reduced the reporting of pain by 18.4 times (P<0.0001). CONCLUSIONS: Sodium bicarbonate 8.4%, when added to rocuronium, markedly reduces the experience of pain during the i.v. administration of a small dose of rocuronium. Br J Anaesth 2003; 90: 377-9
PMID: 12594153
Br J Anaesth 2003 Mar;90(3):296-9
Department of Anaesthesia and Intensive Care Medicine, Department of Neurology, Department of Paediatrics, Department of Biostatistics and Documentation, University of Innsbruck, A-6020 Innsbruck, Anichstrasse 35, Austria.
[Medline record in process]
BACKGROUND: Cerebral blood flow is affected by painful stimuli, and analgesic agents may alter the response of cerebral blood flow to pain. We set out to quantify the effects of remifentanil and nitrous oxide on blood flow changes caused by experimental pain. METHODS: We simulated surgical pain in 10 conscious volunteers using increasing mechanical pressure to the tibia. We measured changes in cerebral blood flow velocity in the middle cerebral artery (CBFV(MCA)) caused by the pain, using transcranial Doppler sonography. We gave increasing doses of remifentanil (0.025, 0.05 and 0.1 micro g kg(-1) min(-1)) or nitrous oxide [20%, 35% and 50% end-tidal concentration (FE'(N(2)O))] and compared these effects on blood flow changes. RESULTS: Nitrous oxide increased CBFV(MCA) only when given at 50% FE'(N(2)O). Remifentanil did not affect CBFV(MCA). Pain increased CBFV(MCA). Both agents attenuated this pain-induced change in CBFV(MCA) with the exception of nitrous oxide at 20% FE'(N(2)O). CONCLUSIONS: Inhalation of nitrous oxide or adminstration of remifentanil attenuated pain-induced changes in CBFV(MCA). Br J Anaesth 2003: 90: 296-9
PMID: 12594139, UI: 22482053
Eur J Anaesthesiol 2002 Nov;19(11):834-6
PMID: 12442936, UI: 22330100
Eur J Anaesthesiol 2002 Nov;19(11):803-7
Leicester Royal Infirmary, University Department of Anaesthesia, Critical Care & Pain Management, UK. anae@le.ac.uk
BACKGROUND AND OBJECTIVE: A critical factor that delays patient discharge following day-surgery is severe postoperative pain and the requirement for strong analgesics. Laparoscopic sterilization is a day case procedure and is associated with additional postoperative pain compared with diagnostic laparoscopy. This pain, associated with application of Filshie clips, may be ischaemic or spasmodic in aetiology. Papaverine relaxes smooth muscle, and the aim of the study was to investigate if papaverine would be effective in improving postoperative pain if administered directly to the Fallopian tubes. Bupivacaine is used commonly in day-surgery and so we compared the effect of this local anaesthetic with saline placebo. METHODS: Sixty-six ASA I-II females undergoing laparoscopic sterilization were entered into the prospective, randomized, double-blind, placebo-controlled clinical trial. They received intrauterine papaverine (30 mg) or bupivacaine (0.375% 30 mL) or normal saline (30 mL) via the transcervical route before application of Filshie clips. RESULTS: There were no significant differences in the postoperative period between the three groups in the number of patients needing analgesia in the first 60 min postoperatively, the time to first analgesia, the rescue analgesic or antiemetic consumption, the incidence of postoperative nausea and vomiting, and the sedation and visual analogue pain scores. CONCLUSIONS: From the data presented, we would not recommend routine transcervical administration of papaverine or bupivacaine for pain following laparoscopic sterilization.
PMID: 12442929, UI: 22330093
Eur J Anaesthesiol 2002 Nov;19(11):780-8
claude.lentschener@cch.ap-hop-paris.fr
Improvement in surgical techniques, technology and perioperative assessment has dramatically simplified the anaesthetic care for elective liver resection. Patients with a non-tumorous healthy liver should only need the usual preoperative assessment. Patients with pre-existing parenchymal liver disease should be specifically assessed for gas exchange impairment, alcoholic or nutritional-associated cardiomyopathy, infection, cirrhosis decompensation, acute alcoholic hepatitis, and kidney impairment. The type of anaesthetic management does not influence the intra- and postoperative courses. Intermittent clamping of the portal vascular triad is better tolerated than prolonged continuous periods of ischaemia--especially in patients with abnormal liver parenchyma. Intraoperative antibiotic prophylaxis must be administered to prevent translocation of intestinal enterobacteria to the systemic circulation in patients with both healthy and diseased livers. Blood-salvage techniques have limited indications in liver resection. Systematic invasive haemodynamic monitoring is no longer warranted. An arterial cannula should only be considered in procedures of long duration and in selected situations likely to cause anticipated circulatory impairment: total liver vascular occlusion, repeat surgery, combined organ resection, and surgery conducted on tumours >10 cm in size or in connection with the vena cava. In a recent large series of liver resections, 60% of patients did not need a blood transfusion, only 2% of transfused patients received >10 units of blood and cirrhosis was not predictive of increased intraoperative bleeding. Postoperative ascites, which always develops at the expense of circulating fluid, is a frequent occurrence in patients with healthy or diseased livers. Intra- and postoperative fluid limitation does not prevent postoperative ascites. Volume expansion, diuretics and vasopressor therapy should be initiated early to prevent kidney failure.
PMID: 12442926, UI: 22330090
J Pain Symptom Manage 2003 Feb;25(2):179-84
Departments of Palliative Medicine, University Hospital of Wales, Cardiff, Wales, United Kingdom
For a small number of cancer patients, good pain control remains difficult to achieve despite adequate assessment and medical management. In nine cases, effective control of intractable pain from malignant pelvic disease was achieved by open thoracic cordotomy. The technique was well tolerated, with no major complications. Eight of the nine patients decreased their median daily oral morphine requirement from 560 mg (range 360-2600 mg) to 160 mg (range 40-1000 mg). Maximal survival time post-cordotomy was 830 days, with a median of 107 days. No patient experienced recurrent pain in the initially painful site. For patients with intractable pain associated with advanced pelvic malignancy, the use of an open cordotomy should be considered when satisfactory pain control is not achieved by medical or minimally invasive methods.
PMID: 12590033, UI: 22478184
J Pain Symptom Manage 2003 Feb;25(2):169-78
Cancer Center, Hammersmith Hospital, London, United Kingdom
While morphine is historically the gold standard for the management of severe cancer pain, some patients either do not achieve adequate analgesia, or suffer intolerable side effects from this drug. For these patients, alternatives such as hydromorphone are recommended. This review explores the evidence for the efficacy of hydromorphone in the management of pain. A systematic search, from 1966 to 2000, of published and unpublished randomized trials that involved the administration of hydromorphone for both acute and chronic pain conditions in adults and children, was conducted. Forty-three studies were included in the review; 11 involved chronic cancer pain and 32 acute pain. Approximately half the studies received a low quality score. In addition, the heterogeneity of the studies precluded combination of data and results. Overall, hydromorphone appears to be a potent analgesic. The limited number of studies available suggests that there is little difference between hydromorphone and other opioids in terms of analgesic efficacy, adverse effect profile and patient preference. However, most studies involved small numbers of patients and wide ranges in equianalgesic dose ratios, making it difficult to determine real differences between interventions.
PMID: 12590032, UI: 22478183
J Pain Symptom Manage 2003 Feb;25(2):101-3
Department of Obstetrics and Gynecology Brigham and Women's Hospital, Boston, MA, USA
PMID: 12590024, UI: 22478175
J Pain Symptom Manage 2003 Feb;25(2):99-101
Pain and Palliative Care Service Department of Neurology Memorial Sloan-Kettering Cancer Center, New York, NY, USA
PMID: 12590023, UI: 22478174
Spine 2003 Feb 15;28(4):395-401
*Derbyshire Royal Infirmary, Derby.
STUDY DESIGN A cross section of Web sites accessible to the general public was surveyed.OBJECTIVE To evaluate the quality of information on low back pain and its treatment that a "typical" patient user might access on the Internet.SUMMARY OF BACKGROUND DATA Individuals with back pain have a desire to learn about their condition, what to expect, and what they can do about it. Web sites play a potentially useful role in providing information to help people learn about their low back pain and select the most appropriate methods of management.METHODS A general search using popular search engines located 60 Web sites about back pain for review. A list of criteria for evaluating and scoring back pain Web sites was established using available literature and current clinical guidelines for the management of acute low back pain. The total quality score (maximum score, 38) was composed of two separate scores: one for general quality of the site (maximum score, 14) and one for site content specific to low back pain (maximum score, 24). Statistical tests, as appropriate, were used to investigate the relation between general indicators of Web site quality and total scores obtained.RESULTS The quality of the Web sites surveyed was poor, most of them (n = 58, 97%) scoring less than half the maximum available score. The mean total score was 7.4 (range, 2-25). The mean score was 4.9 (range, 1-12) for general Web site quality and 2.4 (range, 1-13) for content specific to low back pain. Web sites providing references, sites created more recently, and sites not created for advertising purposes tended to be of better quality.CONCLUSIONS This study highlighted the poor quality of information, particularly information about low back pain, available to "typical" patient users on the Internet. Health care professionals must have a role in evaluating existing information and in developing good-quality evidence-based Web sites. Patients with back pain should be discouraged from using the Internet as a source of information unless the Web sites they access have been evaluated and found to provide evidence-based messages.
PMID: 12590218, UI: 22478422
Spine 2003 Feb 15;28(4):390-4
STUDY DESIGN Four strata of randomly selected health care providers in North Carolina (primary care MDs, Doctors of Chiropractic, orthopedic surgeons, and group model HMO primary care providers) enrolled 1633 consecutive patients with low back pain into a cohort study.OBJECTIVE To determine whether race had an independent effect on rate of recovery from low back pain, and whether there was any racial disparity in the treatments provided to patients with low back pain.SUMMARY OF BACKGROUND DATA Little research to date has examined the relation between patient race and recovery from an episode of acute low back pain.METHODS Consecutive patients were enrolled in the provider's office and contacted by telephone at baseline, at 2, 4, 8, 12, and 24 weeks, and at 22 months.RESULTS Blacks (n = 238) at baseline had higher pain scores on a 10-point scale (5.92 5.25; < 0.01) and worse functional disability (12.1 11; = 0.04), as assessed by the 23-point Roland-Morris scale, yet were considered by their health provider as having less severe pain and less likely to have disc disease than white patients ( < 0.05 for all comparisons). Blacks had worse functional disability at most follow-up interviews. Blacks were shown to be less likely to receive radiographs (49% 40%) or advanced imaging studies (10% 6%), even after controlling for income, education, baseline severity of low back pain, and insurance status ( < 0.05). Doctors of Chiropractic had different practice approaches than MDs, and there was an interaction with patient race.CONCLUSIONS The relation of patient race to outcomes from and care for low back pain is complex. Blacks have slightly worse functional status than whites on presentation and at follow-up assessment. Blacks receive less intense diagnostic and treatment approaches from MDs, although the severity of their impairment is at least as great.
PMID: 12590217, UI: 22478421
Spine 2003 Feb 15;28(4):385-9
STUDY DESIGN A cross-sectional population-based study was conducted.OBJECTIVE To investigate the influence of pregnancy on any gender differences in sickness absence related to back pain diagnoses in the group 16 to 44 years of age.SUMMARY OF BACKGROUND DATA Back pain diagnoses are a major reason for sickness absence, especially among pregnant women. There is, however, little knowledge on the extent to which back pain during pregnancy may account for any differences in sickness absence when compared with men and nonpregnant women.METHODS Data on sick leave periods certified by a physician were combined from two research databases: one including all insured persons (n = 50,167) and one including pregnant women (n = 1342) for the duration of 1 year.RESULTS When pregnant women were subtracted from "all women," nonpregnant women had the same cumulative incidence of sickness absence related to back pain diagnoses as men. Among "all women" sick-listed with back pain diagnoses, 37% were pregnant, a finding not evident from official statistics. Sickness absence increased with age among nonpregnant women and men, but decreased among pregnant women.CONCLUSIONS The proportion of sickness absence related to back pain diagnoses did not differ between nonpregnant women and men ages 16 to 44 years. The importance of back pain diagnosis as a reason for sickness absence may thus be overrated among nonpregnant women.
PMID: 12590216, UI: 22478420
Spine 2003 Feb 15;28(4):380-4
*Faculty of Applied Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.
STUDY DESIGN A clinical convenience sample of workers with low back problems was tested once for a variety of parameters.OBJECTIVES To quantify the links between lumbar range of motion and scores obtained from functional evaluation tests.SUMMARY OF BACKGROUND DATA Although lumbar range of motion traditionally has been the standard used to determine disability for the purposes of compensation, a concern arises from the fact that a discrete physical impairment associated with low back pain and diminished range of motion often is never found.METHODS This study involved 18 workers with chronic low back pain referred to a rehabilitation center for determination of compensation and fitness for return to work. Lumbar range of motion was precisely and accurately measured with a three-dimensional lumbar motion instrument. In addition, typical functional tests were performed for each patient. Comparisons were made between all the lumbar range of motion values and each of the functional ability scores.RESULTS The most notable finding was the lack of significant correlation between most of the lumbar range of motion values and the functional test scores. Only 9 of a possible 144 correlations were significant.CONCLUSIONS The relation between lumbar range of motion measures and functional ability is weak or nonexistent. This has implications for clinical practice as it relates to disability determination for patients with chronic low back pain, and perhaps for the current impairment guidelines of the American Medical Association.
PMID: 12590215, UI: 22478419
Spine 2003 Feb 15;28(4):358-63
STUDY DESIGN A case series of adults with surgical treatment for adult idiopathic thoracolumbar and/or lumbar scoliosis, low back pain, and spinal stenosis was studied.OBJECTIVE To assess pain relief, curve correction, and complications after combined procedures consisting of decompression, spine fusion, and stabilization.SUMMARY OF BACKGROUND DATA Only one publication has focused specifically at this group, and this was before the advent of modern segmental instrumentation. This is the first report of long-term follow-up evaluation in such a patient population.METHODS This study included 16 patients who underwent elective anterior and posterior surgical reconstruction for adult idiopathic thoracolumbar and/or lumbar scoliosis, spinal stenosis, and low back pain with a minimum follow-up period of 2 years. Radiographic findings, clinical results, and long-term outcome data were obtained using the Modified Scoliosis Research Society outcome instrument and the Oswestry Disability Back Pain Questionnaire.RESULTS Restoration of coronal and sagittal balance, or improvement thereof, was achieved in all the patients with balance problems. There was significant improvement in all outcome domains. Overall, 94% of the patients were satisfied with the surgery. Ten major complications occurred in 10 patients, 8 of whom required additional surgery. There were two minor complications.CONCLUSIONS Combined symptoms of back pain and spinal stenosis require complex reconstructive surgery in adults with idiopathic thoracolumbar and/or lumbar scoliosis. Significant pain relief, functional restoration, and satisfaction can be achieved and maintained over the long term in the properly selected patient.
PMID: 12590210, UI: 22478414
Spine 2003 Feb 15;28(4):341-6
Department of *Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu.
STUDY DESIGN This study evaluated the effect of gabapentin on neuropathic pain in patients with spinal cord injury.OBJECTIVE To compare the effect of gabapentin on neuropathic pain refractory to conventional analgesics in patients with spinal cord injury and different durations of symptoms.SUMMARY OF BACKGROUND DATA Neuropathic pain in patients with spinal cord injury severely compromises their quality of life. Gabapentin is a new antiepileptic drug that may additionally have a role in the treatment of neuropathic pain. So far, there has been little prospective research investigating the effect of gabapentin on neuropathic pain in patients after spinal cord injury or comparing gabapentin-treated patients with varying durations of symptoms after spinal cord injury.METHODS The study included 31 patients who had experienced neuropathic pain associated with spinal cord injury or cauda equina syndrome. These subjects were divided into two groups. Group 1 (n = 13) was composed of patients whose duration of pain was less than 6 months, and Group 2 (n = 18) comprised patients whose symptoms of neuropathic pain had lasted more than 6 months. Although these patients had been treated with conventional analgesics such as antidepressants, anticonvulsants, membrane stabilizer, and neuroleptics, they reported that their condition did not improve after a medication trial of at least 2 weeks duration. In this study, conventional analgesics were continued at a therapeutic level, and gabapentin was administrated for an 18-day titration period followed by a 5-week maintenance period at a dosage of 1800 mg/day or the maximum tolerable dosage. The efficacy of gabapentin administration was gauged by a pain score and a sleep interference score using a 100-mm visual analogue scale (VAS) every 2 weeks. The scores of the two groups were compared every 2 weeks over the course of the 8-week study.RESULTS The mean pain score and the mean sleep interference score for Group 1 decreased more than that of Group 2 during the interval between 2 to 8 weeks ( < 0.05). The mean pain score for Group 1 decreased from 7.3 +/- 0.5 initially to 3 +/- 0.6 after 8 weeks of treatment, whereas the corresponding score for Group 2 decreased from 7.6 +/- 0.4 to 5.1 +/- 0.6 ( < 0.05). The mean sleep interference score for Group 1 decreased from 5.7 +/- 0.9 initially to 1.8 +/- 0.8 after 8 weeks of treatment, whereas the corresponding score for Group 2 decreased from 5.9 +/- 0.8 to 4.2 +/- 0.7 ( < 0.05). As compared with the onset of this study, a decrease in pain score of 2 or more was reported at the completion of this study for 11 patients (100%) in Group 1 and 10 (71%) of 14 patients in Group 2. A decrease of 2 or more in sleep interference scores was reported for 8 (89%) of 9 patients with sleep interference in Group 1 and for 8 (62%) of 13 patients with sleep interference in Group 2. Some adverse effects such as somnolence were noted, but they were mild or moderate in intensity.CONCLUSIONS Gabapentin may be effective in decreasing neuropathic pain refractory to conventional analgesics in some patients with spinal cord injury whose duration of symptoms is less than 6 months, although those with duration of symptoms longer than 6 months showed a significant decrease as well. The drug is unlikely to cause serious adverse effects that limit its use in patients with spinal cord injury.
PMID: 12590206, UI: 22478410