SIAARTI recommendations for chronic noncancer pain.
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Analgesics↗
Biomedical subjects
E Polati
Publications and source records attributed to E Polati.
SIAARTI recommendations on the assessment and treatment of chronic cancer pain.
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Adult↗
Radiofrequency treatment of cancer pain.
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Journal Article↗
Baroreflex and oscillation of heart period at 0.1 Hz studied by alpha-blockade and cross-spectral analysis in healthy humans.
1. Parameters derived from frequency-domain analysis of heart period and blood pressure variability are gaining increasing importance in clinical practice. However, the underlying physiological mechanisms in human subjects are not fully understood. Here we address the question as to whether the low frequency variability (approximately 0.1 Hz) of the heart period may depend on a baroreflex-mediated response to blood pressure oscillations, induced by the alpha-sympathetic drive on the peripheral resistance. 2. Heart period (ECG), finger arterial pressure (Finapres) and respiratory airflow were recorded in eight healthy volunteers in the supine position with metronome respiration at 0.25 Hz. We inhibited the vascular response to the sympathetic vasomotor activity with a peripheral alpha-blocker (urapidil) and maintained mean blood pressure at control levels with angiotensin II. 3. We performed spectral and cross-spectral analysis of heart period (RR) and systolic pressure to quantify the power of low- and high-frequency oscillations, phase shift, coherence and transfer function gain. 4. In control conditions, spectral analysis yielded typical results. In the low-frequency range, cross-spectral analysis showed high coherence (> 0.5) and a negative phase shift (-65.1 +/- 18 deg) between RR and systolic pressure, which indicates a 1-2 s lag in heart period changes in relation to pressure. In the high-frequency region, the phase shift was close to zero, indicating simultaneous fluctuations of RR and systolic pressure. During urapidil + angiotensin II infusion the low-frequency oscillations of both blood pressure and heart period were abolished in five cases. In the remaining three cases they were substantially reduced and lost their typical cross-spectral characteristics. 5. We conclude that in supine rest conditions, the oscillation of RR at low frequency is almost entirely accounted for by a baroreflex mechanism, since it is not produced in the absence of a 0.1 Hz pressure oscillation. 6. The results provide physiological support for the use of non-invasive estimates of the closed-loop baroreflex gain from cross-spectral analysis of blood pressure and heart period variability in the 0.1 Hz range.
Adrenergic alpha-Antagonists↗
Both right and left cervical cordotomies depress sympathetic indexes derived from heart rate variability in humans.
Unilateral percutaneous cervical cordotomy, performed in humans to relieve intractable cancer pain, elicits signs of ipsilateral sympathetic block. In patients undergoing right or left percutaneous cervical cordotomy (9 per group), changes in sympathovagal balance were evaluated by spectral analysis of heart rate to confirm the sympatholytic effect of this surgical procedure and to investigate the lateralization of sympathetic cardiac control. For these purposes, heart rate variability was recorded 1 hour before cordotomy and 24 hours later. Cordotomy significantly depressed the low frequency peak (LF) of heart rate variability and increased the high frequency component (HF), when measured as a percentage of total power. As a consequence, the LF/HF ratio decreased significantly (P =.001), particularly during standing. The effects of right or left cordotomies were not significantly different. In conclusion, in humans unilateral percutaneous cervical cordotomy depresses some sympathetic indexes (LF/total power ratio and LF/HF ratio) derived from heart rate variability, irrespective of side.
Adult↗
Celiac block for the treatment of pancreatic pain.
Neurolytic celiac plexus block (NCPB) is commonly performed to relieve pancreatic cancer pain. Since Kappis described the percutaneous NCPB, a number of variations of this technique have been proposed to improve analgesic results and minimize complications. In this article, we review and discuss techniques, results, and complications of NCPB.
Celiac Plexus↗
Postoperative pain management and recovery after remifentanil-based anaesthesia with isoflurane or propofol for major abdominal surgery. Remifentanil Study Group.
We have assessed if recovery times after morphine or fentanyl, given before terminating remifentanil anaesthesia with isoflurane or propofol, are compromised. We studied patients undergoing elective, major abdominal surgery, allocated randomly to receive remifentanil and isoflurane (n = 277) or remifentanil and propofol (n = 274) anaesthesia. Twenty-five minutes before the end of surgery, patients received fentanyl 0.15 mg or morphine 15 mg in a randomized, double-blind manner followed by a second dose (fentanyl 0.05 mg, morphine 7 mg) for moderate or severe pain in recovery. Recovery was rapid and at an Aldrete score > or = 9 (median 12-15 min), 42-51% of patients reported none or mild pain. However, 26-35% of patients reported severe pain and > 90% required a second dose of opioid within 21-27 min after anaesthesia.
Abdomen↗
Prospective randomized double-blind trial of neurolytic coeliac plexus block in patients with pancreatic cancer.
BACKGROUND: In a randomized double-blind study the efficacy of neurolytic coeliac plexus block (NCPB) was compared with pharmacological therapy in the treatment of pain from pancreatic cancer. METHODS: Twenty-four patients were divided into two groups: 12 patients underwent NCPB (group 1) and 12 were treated with pharmacological therapy (group 2). Immediate and long-term efficacy, mean analgesic consumption, mortality and morbidity were evaluated at follow-up. Statistical analysis was performed with the unpaired t test, Mann-Whitney U test and Fisher's exact test. RESULTS: Immediately after the block, patients in group 1 reported significant pain relief compared with those in group 2 (P < 0.05), but long-term results did not differ between the groups. Mean analgesic consumption was lower in group 1. There were no deaths. Complications related to NCPB were transient diarrhoea and hypotension (P not significant between groups). Drug-related adverse effects were constipation (five of 12 patients in group 1 versus 12 of 12 in group 2), nausea and/or vomiting (four of 12 patients in group 1 versus 12 of 12 in group 2) (P < 0.05), one gastric ulcer and one gluteal abscess in group 2. CONCLUSION: NCPB was associated with a reduction in analgesic drug administration and drug-related adverse effects, representing an effective tool in the treatment of pancreatic cancer pain.
Adult↗
[Management of postoperative pain in stomatology with ibuprofen L-arginine and naproxen].
BACKGROUND: The aim of this prospective, randomized study is to compare the efficacy and safety of ibuprofen L-arginine and naproxen in the treatment of postoperative dental pain. METHODS: Seventy patients undergoing removal of impacted third molars were randomly allocated to receive 4 hours after surgery a single oral dose of either ibuprofen L-arginine 400 mg or naproxen 550 mg. Ten patients dropped out from the study because they took the study drug before the allowed time. Using a self-rating record, patients rated their pain and its relief for 1 hour after the drug administration. Remedication, if needed, and mean time of remedication were also recorded. RESULTS: A statistically significant reduction in pain scores with respect to the baseline values was recorded 5 minutes and 15 minutes after the drug administration in the ibuprofen L-arginine and in the naproxen-treated group, respectively. The summed pain intensity difference (SPID) over 60 minutes resulted significantly higher in the ibuprofen L-arginine than in the naproxen-treated group. A complete abolition of pain 60 minutes after medication was obtained in 12/28 patients (42.9%) in the ibuprofen L-arginine and in 5/32 patients (15.6%) in the naproxen-treated group, respectively (p = 0.04). Number of patients requiring remedication, mean time of remedication and drug related adverse effects did not significantly differ in the two treatment group. CONCLUSIONS: Global evaluation of the drugs by the patients showed ibuprofen more effective drug than naproxen.
Adolescent↗
Ondansetron versus metoclopramide in the treatment of postoperative nausea and vomiting.
In this prospective, randomized, double-blind study, we compared the efficacy and safety of ondansetron and metoclopramide in the treatment of postoperative nausea and vomiting (PONV). One hundred seventy-five patients with PONV during recovery from anesthesia for gynecological laparoscopy were treated intravenously with either ondansetron 4 mg (58 patients), metoclopramide 10 mg (57 patients), or placebo (60 patients). Early antiemetic efficacy (abolition of vomiting within 10 min and of nausea within 30 min from the administration of the study drugs with no further vomiting or nausea episodes during the first hour) was obtained in 54 of 58 patients (93.1%) in the ondansetron group, in 38 of 57 patients (66.7%) in the metoclopramide group, and in 21 of 60 patients (35%) in the placebo group (P < 0.001). This difference was still significant when controlling for age, body weight, history of motion sickness, previous PONV episodes, duration of anesthesia, and intraoperative fentanyl consumption using a logistic model. Early antiemetic efficacy was inversely related to the amount of fentanyl administered during anesthesia, regardless of treatment. According to the Kaplan-Meier method, the probability of remaining PONV-free for 48 h after a successful treatment was 0.59 (95% confidence interval 0.45-0.71) in the ondansetron group, 0.45 (0.29-0.60) in the metoclopramide group, and 0.33 (0.15-0.53) in the placebo group (P = 0.003). In conclusion, ondansetron 4 mg is more effective than metoclopramide 10 mg and placebo in the treatment of established PONV.
Adolescent↗
[Balanced spinal analgesia in the treatment of oncologic pain. Review of the literature].
Certain types of cancer pain fail to respond well either to systemic drug therapy or to spinal opioids because of the occurrence of intolerable adverse effects. In addition to spinal opioids other drugs may produce an antinociceptive effect when administered by the spinal route, such as local anesthetics, NSAID, alpha 2-agonists, calcium-channel blockers, NMDA antagonists, cholinergic drugs, peptides such as somatostatin, octreotide or calcitonin, adenosine agonists, benzodiazepines, neurokinin and cholecystokinin antagonists, nitric oxide synthase inhibitors, corticosteroids, and enkephalinase inhibitors. All these drugs may be administered in combination between them, realising the so called balanced spinal analgesia. The aim of this study is to analyse: the available methods for the evaluation of pharmacological interactions, the types of interaction between different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of cancer pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of opioid refractory cancer pain. Furthermore, the use of cholinergic drugs combined with opioids and alpha 2-agonists may be promising. Finally, even if the synergism between NSAID or NMDA antagonists with opioids or alpha 2-agonists have been proved, at the moment their use in man by the spinal route is not advisable because of the absence of adequate studies on their neurotoxicity and adverse effects.
Adrenergic alpha-Agonists↗
[Prevention of postoperative nausea and vomiting with ondansetron: a prospective, randomized, double-blind study in 90 patients].
Postoperative nausea and vomiting (PONV) are among the most common complications in surgical patients. In this prospective, double blind, parallel group study we compare the prophylactic antiemetic efficacy of ondansetron versus placebo in 90 patients undergoing general balanced anaesthesia. The patients were stratified according to the kind of surgery and randomly allocated to three treatment groups: 30 patients (Group A) received ondansetron 4 mg i.v. 1 hour before the induction of anaesthesia and placebo 1 hour before the end of surgery; 30 patients (Group B) received placebo 1 hour before the end of anaesthesia and ondansetron 4 mg i.v. 1 hour before the end of surgery; 30 patients (Group C-control group) received placebo in both the administrations. Data were analyzed by Student t test and chi 2 test; significance was taken at p < 0.05. The three groups proved comparable with respect to demographic characteristics, duration of anaesthesia and fentanyl consumption. Analysis of the results showed that PONV had a significantly lower incidence in treated patients (Groups A and B) than in the control group patients (Group C): postoperative nausea occurred in 13%, 30% and 67% of patients in Group A, B and C respectively and it was associated with vomiting in 3%, 7% and 57% of patients in Group A, B and C respectively. Although the patients in Group A showed a lower incidence of PONV in comparison to the patients in Group B, such differences proved to be not statistically significant. No adverse effects in relation to drug administration were observed. We conclude that ondansetron 4 mg i.v. is safe and effective in preventing PONV in the surgical patients, particularly when administered before the induction of anaesthesia.
Adult↗
[Hemodynamic and metabolic impairment during hepatectomy: effect of continuous dobutamine infusion].
Following surgical liver resection haemodynamic and metabolic impairment, potentially responsible for post-operative hepatic failure may occur. In this prospective, randomized study such impairments and the effect on them of continuous peri-operative infusion of dobutamine were examined. Twelve patients, scheduled for hepatectomy, were divided in two groups: Group I was treated with an infusion of dobutamine 6 micrograms/kg/min from 10 minutes before the induction of anaesthesia till the fifth postoperative hour; Group II was considered as the control group. The main haemodynamic parameters, gastric pHi and serum lactate level were examined. No significant differences were detected in heart rate, parameters of pressure and SvO2. In both groups, during portal clamp, SVR increased while Cl and DO2 decreased with respect to basal and the other intra- and postoperative values. Gastric pHi decreased in both groups after portal clamp. These alterations were significantly lower in the group treated with dobutamine when compared with the control group. Serum lactate level increased in both groups. This increase was lower in Group I. Differences between groups were not statistically significant. In conclusion, during hepatectomy important haemodynamic and metabolic impairments occur. Dobutamine, by reducing such impairments, can be usefully employed in this kind of surgery.
Adrenergic beta-Agonists↗
[The pre-emptive analgesia in the treatment of postoperative pain].
The term "pre-emptive analgesia" implies the hypothesis that an analgesic treatment, given before nociceptive stimuli reach the Central Nervous System, could prevent or reduce the subsequent pain. The rational basis of this phenomenon, giving rise to much interest in the last years, comes from the finding that noxious stimuli cause wind-up and receptive fields expansion phenomena in the dorsal horn neurons of the spinal cord leading to hyperalgesia. Recently, many clinical trials to verify the existence of a pre-emptive effect regarding the management of postoperative pain by the administration of non steroidal antiinflammatory drugs (NSAIDs), local anesthetics and opioids have been conducted. As regards NSAIDs to date no study demonstrated a pre-emptive effect. Conflicting results emerged from trials employing local anesthetics, opioids or associations of the three classes of drugs. Thus, the "pre-emptive analgesia" represents a very important phenomenon for the basic research, but further trials must investigate its clinical impact.
Analgesia↗
[Intravenous patient-controlled analgesia (PCA) in the treatment of postoperative pain: rationale and clinical application].
The clinical use of the patient-controlled analgesia (PCA) represents a further improvement in the treatment of post-operative pain. In this way in success due to inadequate protocols, unpredictability of the drug absorption and variability of the response to one drug or to the same pain patterns between patients can be avoided. This technique allows the patient himself to control the pain without depending upon nurses or physicians for the administration of analgesic drugs. Although the PCA is in use since several years, there are still some unresolved problems which are considered in this paper.
Analgesia, Patient-Controlled↗
[The neuroendocrine and metabolic response to surgical stress].
Surgical stress and post-operative pain evoke complex neuroendocrine and tissue responses aiming at defence from injury and recovery of body integrity. Such a reaction appears to be a real "hormonal storm" which is mainly induced by Sympathetic Nervous System and sympatho-adrenomedullary and hypothalamic-pituitary-adrenal systems activation and, in the periphery, by the release of inflammatory mediators at the site of injury. These substances by means of complex regulatory mechanisms and reciprocal interactions induce significant cardiovascular, metabolic, inflammatory and immunologic changes. However, this response may became excessive and contribute to an increase in postoperative morbidity and mortality. Since pain is a major factor in neuroendocrine response triggered by surgical injury every effort must be made to achieve effective intra and post-operative pain control.
Animals↗
[Treatment of postoperative pain by balanced spinal analgesia].
Postoperative pain relief has the aim to provide patient subjective comfort, to inhibit neuroendocrine and metabolic responses to surgical injury and to enhance restoration of function by allowing the patient to breathe, cough, move more easily and to begin enteral nutrition. Opioid analgesics, independently from the route of administration, are unable to provide all this. In addition to spinal opioids other drugs, such as local anesthetics, alpha 2-agonists and cholinergic drugs, may produce an antinociceptive effect when administered by spinal route. All these drugs may be administered in combination between them, realising the so called "balanced spinal analgesia". The aim of this study is to analyse the available methods for the evaluation of pharmacological interactions, the types of interaction among different spinal antinociceptive drugs and the role of balanced spinal analgesia in the treatment of postoperative pain. Analysis of the presented data shows that the spinal synergism between opioids-local anesthetics and opioids-alpha 2-agonists can be useful in the treatment of postoperative pain, because these drug combinations are able to provide a satisfactory pain control at low doses with a reduction of the adverse effects. Furthermore, the combined use of opioids-local anesthetics proved to be effective also in abolishing postoperative incident pain and in inhibiting neuroendocrine and metabolic responses to surgical injury. Especially in high risk patients this is related to a better outcome. Finally, even if the synergism between cholinergic drugs with opioids or a2-agonists have been proved, at the moment their use in man by spinal route in the treatment of postoperative pain is not advisable.
Adrenergic alpha-Agonists↗
[Postoperative pain in pediatric patients].
Surgery is an unpleasant experience which is always related to a period of pain. In the pediatric patient this results in an important effective and metabolic-neuroendocrine manifestation. After a short review of the methods recently used to evaluate pain-qualitatively as well as quantitatively, we focused on the different techniques and drugs which can be used by the anesthesiologist to achieve an adequate control of the pain symptoms. The aim is to provide devices which can be used for different groups of age in order to guarantee the maximum efficacy in pain control with the least side effect and invasiveness.
Adolescent↗