[Current strategies in the treatment of tumor pain].
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Acupuncture Therapy↗
Biomedical subjects
D Zech
Publications and source records attributed to D Zech.
A computerized documentation system for cancer pain management units.
A cancer pain management unit can benefit markedly from a well-planned documentation system for administrative and scientific purposes. This article presents the principles of such a computerized system based on relational data base programs. The described system has been used by the authors for the last seven years. The successful documentation of more than 1400 patients over treatment periods of up to 2 years has provided detailed administrative and scientific information.
Algorithms↗
Comment on Banning, Sjögren and Henriksen, PAIN, 47 (1991) 129-134.
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Humans↗
Transdermal fentanyl: clinical pharmacology.
The transdermal therapeutic system (TTS) fentanyl has been designed for rate-controlled drug delivery. It provides a convenient regimen for the use of a drug previously limited by a short duration of action and a noninvasive parenteral route for a drug that is unsuitable for oral administration. TTS fentanyl has been developed to provide continuous controlled systemic delivery of fentanyl base for 72 hr. It is a rectangular, transparent unit composed of a protective peel strip and four functional layers. The amount of fentanyl released from each system (25 micrograms/hr per 10 cm2) is proportional to the surface area. So far, four patch sizes are available (10-40 cm2). When the system is applied, a fentanyl depot concentrates in the upper skin layers. Fentanyl plasma concentrations are not measurable until 2 hr after application, and it takes 8-16 hr latency until full clinical fentanyl effects are observed. Steady-state serum concentrations are obtained after several sequential 72-hr applications, and these are maintained for as long as a system is applied. Following removal, serum fentanyl concentrations decline gradually and fall about 50% in approximately 16 hr. This prolonged apparent elimination half-life occurs because fentanyl continues to be absorbed from the skin. Transdermal fentanyl transport is essentially the same between the chest, abdomen, and thigh. The skin-permeability constant is about 0.0125 mL/hr/cm2, much lower than the regional blood supply to a chest-skin area. Because of potential permeability variations among individuals, a special rate-controlling membrane in the system provides additional control of drug release.(ABSTRACT TRUNCATED AT 250 WORDS)
Administration, Cutaneous↗
A long-term survey of morphine in cancer pain patients.
We surveyed 550 cancer patients who experienced pain and were treated with morphine for a total of 22,525 treatment days. Sufficient pain relief was achieved during more than 80% of this time using an average oral morphine dose of 82.4 mg--significantly lower than other studies. The use of this low dose, which was possible due to the concomitant administration of nonopioids and specific coanalgesics in most patients, resulted in a low incidence of side effects. Constipation and nausea/vomiting were the most common of these side effects. Physical dependence posed no practical problem in discontinuation of morphine treatment. Long-term opioid intake and development of tolerance did not appear to be linked; an increase in morphine dosage was most often explained by progression of the terminal disease. Addiction was a negligible problem, with only one observed case.
Analgesics↗
[Therapy for symptomatic pain in advanced breast cancer].
From 1983-1989, 106 patients with breast cancer were treated in our pain management unit on 6767 treatment days. Pain was caused by bone metastasis in 73% of patients. Neuropathic pain was reported by 32% of the patients. In all but four of these patients, new tumour growth was diagnosed. Patients were treated according to WHO analgesic guidelines with non-opioids on 16% of the days, non-opioids in combination with weak opioids on 36% and with strong opioids on 38% (orally 90%, parenterally 4% of the days). Due to the prevalence of bone pain non-steroidal antiinflammatory drugs were given on 56% of the days. The high incidence of neuropathic pain led to frequent use of co-analgesics (antidepressants 17%, anticonvulsants 12%, steroids 12% of the days). Adjuvant therapy for symptoms other than pain was given on 86% of the days. Whilst 92% of patients reported more than moderate pain on admission, 45% obtained complete pain relief beginning from the first days of treatment. On 92% of the days, patients described their pain as moderate or less. Side effects were treated symptomatically and played a minor role in a reason to change therapy.
Adult↗
Whitacre 22-gauge pencil-point needle for spinal anaesthesia. A controlled trial in 300 young orthopaedic patients.
In a prospective study of 300 young orthopaedic in-patients (less than 40 years) given spinal anaesthesia through a 22-gauge Whitacre (n = 150) or a 25-gauge Quincke spinal needle (n = 150), we found a 5.3% and a 9.3% incidence of post-spinal headache (PSH) respectively. Females (10.6%) had a higher overall incidence of post-spinal headache than males (5.6%) with more than twice as many females being affected in the 25 than in the 22-gauge group (14.5% vs 6.1%). The average duration of post-spinal headache was less in the 22-gauge group (36 h vs 42.4 h) as was the incidence of severe headache. It is concluded that the Whitacre 22-gauge needle is more suited for spinal analgesia in young female patients due to its ease of handling and its lower incidence of post-spinal headache.
Adolescent↗
Pharmacological management of cancer pain.
Cancer pain remains a major cause of suffering. Improvements in its management have made unrelieved cancer pain unacceptable. While pharmacotherapy is the mainstay of cancer pain treatment, other options such as radiotherapy, nerve blocks, etc., have to be considered as well. A comprehensive approach must also address psychosocial issues. A successful pharmacotherapy programme for cancer pain requires careful assessment of the origin and cause of the pain. The selection of analgesics has to be rationalised using a sequential approach such as the WHO stepladder. Oral application by the block in an individually titrated dosage is recommended. Although morphine remains the most useful opioid, it should be used in combination with nonopioids. Co-analgesics, which contribute to analgesia without being classical analgesics, should be used to treat pain of specific origin. Here membrane-stabilizers, antidepressants and steroids play an often underestimated role in the treatment of neurogenic pain. Anxiolytics and major tranquillisers should be avoided because they cause sedation without improving quality of analgesia. Calcitonin, diphosphonates and spasmolytics are of minor importance in this regard. Finally, concomitant medication to treat side effects of the therapy may be necessary in formulating a comprehensive treatment plan.
Analgesics↗
[Development of continuous monitoring of spontaneous respiration in the postoperative phase. 2. Cutaneous oxygen and carbon dioxide partial pressures following i.v. bolus application of fentanyl, buprenorphine, naloxone and amiphenazole in healthy adult subjects].
METHODS: In an attempt to develop a noninvasive monitoring technique for patients in the early postoperative period, cutaneous O2 and CO2 pressures (pctO2, pctCO2) were monitored in ten healthy adult volunteers of both sexes (5 male, 5 female, age 29 +/- 5 years, weight 68 +/- 11 kg) who received, in several sessions after a 60-min equilibration period, i.v. bolus doses of fentanyl (3 micrograms/kg and, 60 min later, another 1.5 micrograms/kg), buprenorphine (3 and 1.5 micrograms/kg), naloxone (1.8 and 0.9 micrograms/kg), and the respiratory analeptic amiphenazole (2 and 1 mg/kg) as well as combinations of fentanyl/amiphenazole or buprenorphine/naloxone in the aforementioned dosages. Data were collected and stored by a personal computer using the TCM3 system with a combination electrode for simultaneous measuring of pctO2 and pctCO2 (TINA, Radiometer) at 30-s intervals. The overall observation period was 240 min. Means, standard deviations, and ranges were calculated for individual data and data pooled for 15-min intervals. Groups were compared by means of Student's t-test and analysis of variance. RESULTS: Following i.v. fentanyl 3 micrograms/kg, pctO2 decreased and pctCO2 increased rapidly and statistically significantly. The changes were of similar intensity after the first and second doses (1.5 micrograms/kg) and normalized about 60 min after each injection. In contrast, following i.v. buprenorphine (3 and 1.5 micrograms/kg) the cutaneous partial pressures changed continuously and progressively during the observation period and did not reach the control values after 240 min. Naloxone and amiphenazole injections had no obvious influence on the time course of the blood gas tensions. If opiates and antagonists were combined, neither the fentanyl/amiphenazole group nor the buprenorphine/naloxone group differed significantly from the respective opiate groups. DISCUSSION AND CONCLUSION: As was discussed in detail in a previous communication, monitoring of opiate-induced respiratory depression must be nonstimulant and, preferably, noninvasive. Whereas the precision and/or limitations of monitoring partial oxygen saturations by pulse oximetry is well documented in the literature, knowledge of the value of cutaneous partial pressure monitoring is still limited and controversial for the adult patient population. The present study was performed to define the usefulness of cutaneous blood gas analysis in healthy volunteers receiving opiate dosages well known in recovery room patients. It is concluded that continuous monitoring of pctO2 and pctCO2 can indeed detect opiate-induced respiratory depression in adults. The well-known difference in respiratory pattern for fentanyl and buprenorphine could easily be determined. It was confirmed that naloxone and amiphenazole in the dosage range studied do not influence spontaneous respiration in healthy adults. Thus, the authors are convinced that continuous monitoring of cutaneous partial pressures of oxygen and carbon dioxide is sensitive enough to be used, in combination with pulse oximetry, in a monitoring concept for patients recovering from surgery and anaesthesia. Results in patients undergoing conventional pain management or patient-controlled analgesia with relatively high opiate dosages will be presented in following papers. Concerning the controversy about clinically relevant interactions between fentanyl and amiphenazole or buprenorphine and naloxone, the present study did not confirm any useful antagonism. Whether this is due to limitations of cutaneous monitoring, the difference between volunteers and patients, or pharmacological reasons must be evaluated in further investigations.
Adult↗
[Perineal pain and rectal cancer--prevalence in local recurrence].
Between 1983 and 1989, 85 patients with either carcinoma of the rectum or a recurrence of a previously diagnosed rectal tumour (47 women and 38 men aged 20 to 87 years) were treated in our pain clinic. In 50 patients, the reason for referral was perineal pain which had been present for one week to two years (median six months, 25%-percentile six weeks, 75%-percentile six months). In some patients this was considered to be due to scar tissue formation by the referring doctors. The pain was classified somatic, visceral and neuropathic in approximately equal numbers of patients, and about half of them described more than one type of pain. The other 35 patients were suffering from pain at other sites. In 40 out of 50 patients with perineal pain, local tumour recurrence was diagnosed. In 29 patients, pain symptoms began with a median of 5.5 months before the tumour recurrence was diagnosed. In a further seven patients, other types of tumour dissemination in the pelvis were considered to be the cause of the perineal pain. In only three patients no evidence of tumour was found in the pelvis. A non-neoplastic cause of perineal pain could be definitely confirmed in only one patient on post-mortem examination. 35 patients reported no perineal pain on admission, although in 19 cases a local cancer recurrence was found. 13 of these patients suffered from pain in the area of sensory innervation of the lumbosacral plexus. From 16 patients without a diagnosis of local recurrence, only four reported pain in this area.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Validation of World Health Organization guidelines for cancer pain relief during the last days and hours of life.
The efficacy of the World Health Organization's guidelines for cancer pain relief was examined in 401 dying patients. At the time of death, only 3% of the patients experienced severe or very severe pain; whereas 52% had no pain at all, 24% experienced only mild or moderate pain, and 20% were unable to rate their pain intensity. Analgesic drugs were the mainstay of therapy during the last 24 hr of life, being administered by mouth in 47% and parenterally in 44% of the patients. Only 9% of the patients required no systemic analgesics. Nonopioid analgesics alone were effective in 5% and a combination of nonopioids and "weak" opioids were effective in 16% of the patients. In the remaining 70% of the patients "strong" opioids alone or in combination with nonopioid analgesics were necessary to achieve adequate pain reduction. Additional adjuvant drugs to treat special types of pain or other symptoms were prescribed in 90% of the patients. Nonpharmacological measures, such as radiotherapy, nerve blocks or neurosurgery played only a very minor role at this stage of the disease. This study shows that cancer pain can be treated satisfactorily until death.
Adolescent↗
Postoperative patient-controlled analgesia with sufentanil: analgesic efficacy and minimum effective concentrations.
Sufentanil has so far seldom been used for intravenous postoperative patient-controlled analgesia (PCA), and the resulting serum concentrations have not yet been determined. Forty ASA I-III patients recovering from major gynecological operations were investigated to evaluate analgesic efficacy, side effects, patient acceptance and threshold concentrations of sufentanil in serum during the early postoperative period, using the On-Demand Analgesia Computer (ODAC). Following an individualized intravenous loading dose of 19.1 +/- 35.7 micrograms (mean +/- 1 s.d.), sufentanil demand doses were 6 micrograms with a concurrent infusion of 1.15 micrograms/h and a maximum hourly dose of 40 micrograms/h; the lockout time was set to 1 min. The duration of PCA was 17.3 +/- 2.1 h. During this time 16 +/- 11 demands per patient were recorded, resulting in an average sufentanil consumption of 131.1 +/- 69.4 micrograms or 7.5 +/- 3.7 micrograms/h (including loading dose). analgesia was mostly judged good. Side effects were only of minor intensity. Sufentanil proved to be about 2.2 to 3.8 times as potent an analgesic as fentanyl when both analgesic effect and duration were considered. Minimum effective sufentanil serum concentration (MEC) as determined by radioimmunoassay varied greatly and could be best described by a log-normal distribution (range less than 0.01-0.56 ng/ml, median 0.024 ng/ml). Intraindividual MEC variability was slightly lower than intersubject variability (76.0 vs. 84.8%). It is concluded that sufentanil is suitable for postoperative PCA. To get into the therapeutic window for analgesia, a serum sufentanil concentration of more than 0.03 ng/ml seems to be necessary.
Adult↗
[Surgical treatment of salivary incontinence in cerebral palsy].
Swallowing dysfunction is the main cause of drooling in cerebral palsy. Medical treatment is inefficient. Surgical treatment involves neurectomy, translocation of the salivary duct or salivary gland resection. Following this, reeducation is advisable. Indications are based on the degree of drooling and on the degree of histories mental retardation. The authors present 2 case histories of drooling in patients with cerebral palsy treated by submandibular gland resection and parotid duct ligation.
Adolescent↗
The importance of non-opioid analgesics for cancer pain relief according to the guidelines of the World Health Organization.
In a retrospective study of 1070 cancer patients being treated according to guidelines of the World Health Organization during a period of 55,285 days, the importance, efficacy and side-effects of non-opioid analgesics were evaluated. The non-opioids were given alone on 6917 days and in combination with weak opioids on 15,253 days, with strong opioids on 24,246 days and with spinal opioids on 1008 days. In evaluating efficacy and safety, it was not possible to differentiate adequately between the effects of non-opioids, opioids and adjuvant drugs, but it was demonstrated that an adequate combination of these drugs was effective and safe in the treatment of cancer pain.
Aged↗
Cancer pain management according to WHO analgesic guidelines.
On admission to a pain management unit, 92.5% of 174 cancer patients suffered from more than moderate pain despite prior treatment. This inefficacy was mainly due to underdosage of drugs, inadequate intake schedule, and hesitation to use strong opioids. Following introduction of an oral drug therapy based on World Health Organization (WHO) guidelines, more than 80% of all patients described their pain as ranging between "none" and "moderate" on a six-step verbal rating scale at all times. To obtain these results, it was necessary to adapt the therapy to increasing pain in the course of terminal disease. Step III (strong opioids) gained more and more importance with time, and step I (nonopioids) was finally useful only in a minority of patients. Side effects played a minor role as a reason to change therapy. Oral drug therapy following these guidelines led to sufficient pain control in most patients over the whole study period (7,400 days); only 11% of the patients required other methods of pain management.
Adolescent↗
Spondylitis without epidural abscess formation following short-term use of an epidural catheter.
A 42-year-old patient had undergone total hip replacement for aseptic femoral head necrosis 9 years previously. He now presented with loosening of the prosthesis and pseudoarthrosis sustained following a femoral shaft fracture 7 months earlier. A total hip replacement was carried out in general anaesthesia combined with an epidural catheter. The epidural catheter was removed on the third postoperative day, after which the patient complained of persistent lumbar pain which was associated with meningismus, fever, leucocytosis and a raised erythrocyte sedimentation rate. In spite of intensive laboratory and radiological investigation, 15 weeks elapsed before a radiological diagnosis of spondylitis of L1 and L2 could be made. Aspiration biopsy of the L1/L2 disc space yielded a growth of Pseudomonas aeruginosa. Antibiotic therapy was begun immediately but could not prevent spread of infection to the adjacent disc-space T12/L1 and the vertebral body T12. The patient made a slow recovery and was discharged in a satisfactory condition wearing a lumbar brace some 9 months after the operation. No evidence of epidural abscess formation was found at any stage and no direct connection between the use of the epidural catheter and spondylitis could be established.
Abscess↗
[Pain-relieving therapy for 57 patients with malignancies in the head and neck area].
From 1983 to 1988 57 patients with far advanced carcinomas of head and neck received pharmacological treatment of severe cancer pain according to the scheme recommended by the WHO. The evaluation of the collected data revealed that satisfactory pain control could be achieved by administration of oral analgetics. Total relief of pain was achieved in more than 35% of the days, significant relief in more than 50%. Side effects observed during therapy and co-medications are discussed.
Anti-Inflammatory Agents↗
[Occlusion of an implanted peridural catheter by a plug of epidermis].
A patient suffering from intensive perianal pain due to recurrent rectal cancer, not controllable by systemic analgesics, was treated by continuous epidural morphine for a period of 8 months. Satisfactory pain relief was achieved although sometimes problems arose with the permeability of the epidural catheter. As a reason for increased resistance, the literature mentions nonspecific foreign-body reactions next to the catheter. In our patient, tumour infiltration into both the lumbosacral plexus and the epidural space leading to compression of the catheter could not positively be excluded. At autopsy an unexpected obstruction of the catheter by epidermis was observed. It could be demonstrated that pieces of epidermis may enter the catheter, bypassing the bacterial filter of the port, and can then clog the tip of the catheter.
Analgesia, Epidural↗