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In vitro effects of local anaesthetics on the thromboelastographic profile of parturients.
Siau C, Ng HP, Tan GM, Ho BS, Pua HL.
Department of Anaesthesia, National University Hospital 5, Lower Kent Ridge,Singapore 119074, Singapore.
BACKGROUND: Post-dural puncture headache can be an incapacitating complication of obstetric epidural analgesia/anaesthesia and early or prophylactic epidural blood patch (EBP) is one of the treatment options. Although local anaesthetic (LA) agents have been shown to have anticoagulation effects in vitro, peri-partum women are known to be hypercoagulable. We postulated that the presence of residual LA might not result in impaired haemostasis of the EBP in parturients. METHODS: Blood samples from 10 healthy term parturients were subjected to thromboelastography after the addition of four different LA (lidocaine, bupivacaine, levobupivacaine, and ropivacaine) preparations. RESULTS: There was a significant reduction in reaction (R) and coagulation (K) time (P<0.001, P<0.05) and an increase in alpha degrees angle (P<0.01) when comparing undiluted blood with the saline control group. Maximum amplitude (MA) and clot lysis (Ly30) did not change significantly despite the 50% dilution. The thromboelastographic parameters of all four LA-treated groups were no different from their saline controls and from each other. CONCLUSION: At clinical dosages, LA did not cause any hypocoagulable changes on the thromboelastographic profile of healthy parturients.
PMID: 15516349 [PubMed - indexed for MEDLINE]
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Effect of obesity and thoracic epidural analgesia on perioperative spirometry.
von Ungern-Sternberg BS, Regli A, Reber A, Schneider MC.
Department of Anaesthesia, University of Basel/Kantonsspital, CH-4031 Basel, Switzerland. bvonungern@uhbs.ch
BACKGROUND: Lung volumes in obese patients are reduced significantly in the postoperative period. As the effect of different analgesic regimes on perioperative spirometric tests in obese patients has not yet been studied, we investigated the effect of thoracic epidural analgesia and conventional opioid-based analgesia on perioperative lung volumes measured by spirometry. METHODS: Eighty-four patients having midline laparotomy for gynaecological procedures successfully completed the study. Premedication, anaesthesia and analgesia were standardized. The patients were given a free choice between epidural analgesia (EDA) (n=42) or opioids (n=42) for postoperative analgesia. We performed spirometry to measure vital capacity (VC), forced vital capacity, peak expiratory flow, mid-expiratory flow and forced expiratory volume in 1 s at preoperative assessment, 30-60 min after premedication and 20 min, 1 h, 3 h and 6 h after extubation. RESULTS: Baseline values were all within the normal range. All perioperative spirometric values decreased significantly with increasing body mass index (BMI). The greatest reduction in VC occurred directly after extubation, but was less in the EDA group than in the opioid group: mean of -23(sd 8)% versus -30(12)% (P<0.001). In obese patients (BMI>30) the difference in VC was significantly more pronounced than in patients of normal weight (BMI<25): -45(10)% versus -33(4)% (P<0.001). Recovery of spirometric values was significantly quicker in patients receiving EDA, particularly in obese patients. CONCLUSION: We conclude that EDA should be considered in obese patients undergoing midline laparotomy to improve postoperative spirometry.
Publication Types:
- Clinical Trial
- Controlled Clinical Trial
PMID: 15486001 [PubMed - indexed for MEDLINE]
Prognosis of multifactorial outcome in lumbar discectomy: a prospective longitudinal study investigating patients with disc prolapse.
Kohlboeck G, Greimel KV, Piotrowski WP, Leibetseder M, Krombholz-Reindl M, Neuhofer R, Schmid A, Klinger R.
University of Munich, Research Unit on Psychiatric Epidemiology and Evaluation, Munich, Germany. gkohlboe@helios.med.uni-muenchen.de
OBJECTIVES: Although previous research has shown that certain medical data and psychosocial factors predict postoperative pain, it remains unclear whether they also contribute to a more distinct outcome measure that is based on classification of self-reported outcome criteria. To assess the prognostic power of somatic, psychologic, and social predictors when evident outcome criteria of surgical treatment are investigated, this study used a prospective longitudinal design examining preoperative factors associated with outcome six months after lumbar discectomy. METHODS: Forty-eight out of 58 consecutive patients were included (60% male, 40% female, mean age 47 years). Preoperative data comprised of Lasegue sign (straight leg raising test), pain duration, paresis and radicular distribution, depression, pain disability, pain coping strategies, and qualitative descriptions of pain. Additionally, sociodemographic and occupational characteristics were observed. Six months' postoperative classification of outcome included pain intensity, pain locations, functional capacity, return to work, and health-related quality of life. RESULTS: From a surgical point of view, lumbar discectomy was successfully carried out on all patients. But, when subjective criteria of outcome were investigated, 56% of patients benefited from lumbar discectomy, whereas 44% of patients had poor results. Lasegue sign, depression, and sensory pain descriptions proved to be significant predictors, whereas pain cognition and pain coping strategies had no significant influence on evident outcome classification. DISCUSSION: Classification of patients regarding their individual outcome profiles showed that patients responded differently to lumbar disc-surgery. High risk factors for poor outcome of surgery are Laseque-sign and depression.
Publication Types:
PMID: 15502690 [PubMed - indexed for MEDLINE]
Efficacy, safety, and steady-state pharmacokinetics of once-a-day controlled-release morphine (MS Contin XL(R)) in cancer pain.
Hagen NA, Thirlwell M, Eisenhoffer J, Quigley P, Harsanyi Z, Darke A.
Departments of Oncology, Medicine, and Clinical Neurosciences (N.A.H.), University of Calgary, and Tom Baker Cancer Center (N.A.H.), Calgary, Alberta; Division of Medical Oncology (M.T.), Montreal General Hospital, Montreal, Quebec; and Department of Scientific Affairs (J.E., P.Q., Z.H., A.D.), Purdue Pharma Canada, Pickering, Ontario, Canada.
The efficacy, safety, and pharmacokinetics of a novel once-daily morphine formulation (OAD morphine) and a 12-hourly formulation (twice-daily CR morphine) were compared in a double-blind, multi-centered crossover study. Chronic cancer pain patients (n=25) were randomized to OAD morphine (mean 238 +/- 319 mg q24h) or twice-daily CR morphine (mean 119 +/- 159 mg q12h) for one week. They then crossed over to the alternate drug, which also was taken for one week. There was no difference between treatments for evaluations of overall pain intensity, analgesic efficacy, or adverse events. However, whereas pain scores increased during the day on twice-daily CR morphine (P=0.0108), they remained stable on OAD morphine. Most patients (68%) chose once-daily dosing for continuing pain management (P=0.015). The AUC ratio was 100.3%, indicating equivalent absorption. Fluctuation indices were 93.5 +/- 28.8% and 179.3 +/- 41.3% (P=0.0001) for OAD morphine and twice-daily CR morphine, respectively. OAD morphine provides analgesia similar to twice-daily CR morphine with reduced fluctuation in plasma morphine concentration and more stable pain control.
PMID: 15652441 [PubMed - as supplied by publisher]
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The ladder and the clock: cancer pain and public policy at the end of the twentieth century.
Meldrum M.
Department of History, University of California at Los Angeles, Los Angeles, California, USA.
The origins of the WHO Cancer Pain Relief Program (the Analgesic Ladder) and its research basis in two very different research traditions, one at Memorial Sloan-Kettering Cancer Center in New York, the other at St. Christopher's Hospice in London, are discussed. The Sloan-Kettering group emphasized precise relative differences in analgesic effects of various drugs, whereas Twycross at St. Christopher's used patient well-being as the crucial benchmark. Despite these differences, both traditions presented evidence of the safe and effective use of strong opioids for cancer pain relief, in a setting of individualized attention and close physician monitoring. The success and limitations of the Ladder as a global health policy are briefly addressed.
PMID: 15652438 [PubMed - in process]
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Stories of cancer pain: a historical perspective.
Winslow M, Seymour J, Clark D.
International Observatory on End-of-Life Care (M.W., D.C.), Institute for Health Research, Lancaster University, Lancaster; and Palliative and End-of-Life Care Research Group (J.S.), School of Nursing and Midwifery, University of Sheffield, Sheffield, United Kingdom.
This article considers published accounts by people with personal experience of cancer, and cancer pain, from 1945 to the present. These firsthand stories communicate deeply personal truths and understandings-and this is their value. Narratives of cancer can inform and support others with the disease and contribute meaningful knowledge to health professionals about the subjective experience of living with cancer and cancer pain. They also highlight where improvements can be made in health care and serve as a platform from which patients may criticize, expose, petition, support, share, challenge, and call for autonomy. A cancer diagnosis can rupture the life of the person who receives it, but as this article illustrates, inscribing the words of a narrative and revealing experiences to a public audience can bring meaning to a life event which might otherwise be viewed as meaningless.
PMID: 15652436 [PubMed - as supplied by publisher]
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The measurement of pain, 1945-2000.
Noble B, Clark D, Meldrum M, Ten Have H, Seymour J, Winslow M, Paz S.
Academic Palliative Medicine Unit (B.N., S.P.), University of Sheffield, Sheffield, United Kingdom; International Observatory on End-of-Life Care (D.C., M.W.), Institute for Health Research, Lancaster University, Lancaster, United Kingdom; Department of History (M.M.), University of California at Los Angeles, Los Angeles, California, USA; Department of Ethics, Philosophy and History of Medicine (H.t.H.), University of Nijmegen, Nijmegen, The Netherlands; and School of Nursing and Midwifery (J.S.), University of Sheffield, Sheffield, United Kingdom.
Three strands of activity can be identified in the history of pain measurement. The first, psychophysics, dates back to the nineteenth century and measures the effect of analgesia by quantifying the noxious stimulation required to elicit pain, as well as the maximum stimulation tolerated. The second uses standardized questionnaires for patients, developed to categorize pain according to its emotional impact, distribution, character, and other dimensions. The third asks patients to report on pain intensity using rating scales, and is used in clinical trials where analgesics are evaluated and results can be combined to influence clinical guidelines and protocols. Although all three strands have found a place in modern clinical practice or drug development, it is the reporting of pain by patients undergoing treatment using simple scales of intensity which has emerged as the crucial method by which analgesic therapies can now be evaluated and compared.
PMID: 15652435 [PubMed - as supplied by publisher]
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Pain and palliative care: the emergence of new specialties.
Seymour J, Clark D, Winslow M.
Palliative and End-of-Life Care Research Group (J.S.), School of Nursing and Midwifery, The University of Sheffield, Sheffield; and International Observatory on End-of-Life Care (D.C., M.W.), Institute for Health Research, Lancaster University, Lancaster, United Kingdom.
In the second half of the twentieth century, the clinical management of patients suffering pain from advanced cancer was transformed. This paper describes cancer pain management during this period, identifying three key elements that promoted innovation: First, the development of a patient-centered approach to analgesic evaluation, which resulted from the search for an alternative analgesic to morphine in studies led by Raymond Houde. Second, the re-introduction by John Bonica of the idea that pain is what the individual feels and thinks it is. Third, the work of Cicely Saunders in establishing the foundations of the modern hospice and palliative care movement. The work of these three clinicians must be set in the context of a time when new hopes emerged that cancer could be cured and, at the same time, the cancer patient began to be remolded from a passive participant in treatment and care to an active collaborator.
PMID: 15652434 [PubMed - as supplied by publisher]
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The history of cancer pain relief.
Clark D.
International Observatory on End-of-Life Care, Institute for Health Research, Lancaster University, Lancaster, United Kingdom.
PMID: 15652433 [PubMed - in process]
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