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Biomedical subjects

M J Lema

Publications and source records attributed to M J Lema.

At least 19 recordsLinked to original sources
PubMed2001

Invasive analgesia techniques for advanced cancer pain.

Because most cancer pain involves multiple anatomic sites, invasive techniques are intended to be analgesic adjuvants and not serve as the definitive treatment. These procedures often allow patients to reduce their dosages in their current drug regimens or to derive greater pain relief from their present doses in order to improve their quality of life. Medical care of the suffering pain patient requires a multimodality, multispecialty approach combining psychotherapy, social support, and pain management to provide the best possible quality of life or quality of dying.

Analgesia↗
PubMed2000

NCCN Practice Guidelines for Cancer Pain.

The overall approach to pain management encompassed in these guidelines is comprehensive. It is based on objective pain assessments, utilizes both pharmacologic and nonpharmacologic interventions, and requires continual reevaluation of the patient. The NCCN Cancer Pain Practice Guidelines Panel believes that cancer pain can be well controlled in the vast majority of patients if the algorithms presented are systematically applied, carefully monitored, and tailored to the needs of the individual patient.

Acetaminophen↗
PubMed1998

The relationship between depression and pain language in cancer and chronic non-cancer pain patients.

The present study investigated the relationship between depression and pain description among cancer and chronic non-cancer pain patients in a large outpatient sample. Participants consisted of 312 patients (158 men and 154 women) attending a pain management clinic at a comprehensive cancer institute. Sixty-one percent of the patients (190/312) were experiencing pain related to cancer and 39% (122/312) were experiencing chronic nonmalignant pain. Multivariate analyses of covariance were used to assess differences in the sensory and affective indices of the McGill Pain Questionnaire (MPQ) associated with depression and type of pain. Current pain intensity was the covariate. The results indicated that the MPQ affective and sensory intensity scales did not significantly differ among patients with cancer and chronic non-cancer pain. There were also no significant differences in the percentage of affective and sensory pain descriptors chosen by these patients. However, depression significantly influenced MPQ pain description. Depressed patients with pain scored higher on the affective pain intensity dimension of the MPQ than non-depressed patients with pain (P < 0.001). Depressed patients also chose more affective pain descriptors than non-depressed patients (P < 0.001). Chi-square analyses revealed that depressed and non-depressed pain patients made significantly different choices on four of the five MPQ affective adjective lists. There were no differences in the sensory pain index or the percentage of sensory pain descriptors based on depression. These findings are discussed in terms of their clinical implications and their relationship to the existing literature.

Adolescent↗
PubMed1997

Asystole as a neurologic sign.

The authors present a case of asystole occurring during dural closure following craniotomy with the patient in the supine position. This 22-year-old woman had a left parietal lobe tumor resected with bipolar cautery. Standard intraoperative monitoring with a left radial arterial line and a right internal jugular central venous catheter was used during the surgery. The anesthetic course was complicated by intraoperative bleeding that responded to three units of fresh frozen plasma. Prior to closure, the operative site appeared dry and intact. After closure, asystole occurred suddenly and resolved with evacuation of 500 ml of blood. It is speculated that the asystole was preceded by an acute increase in intracranial pressure and a subsequent secondary brainstem compression.

Adult↗
PubMed1996

Bowel function recovery after radical hysterectomies: thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: a pilot study.

STUDY OBJECTIVE: To determine if the use of continuous epidural bupivacaine-morphine in the perioperative period is associated with a significant decrease in the recovery time of postoperative ileus when compared with parenteral morphine administration. DESIGN: Prospective (quality of analgesia) and retrospective (bowel function recovery), nonrandomized study. SETTING: Inpatient gynecology-oncology patients at a university-affiliated tertiary cancer center hospital. PATIENTS: 68 women who experienced uncomplicated radical hysterectomies for cancer. INTERVENTIONS: Intraoperative epidural-general anesthesia or general anesthesia only was administered. Postoperative continuous epidural analgesia with bupivacaine-morphine and intravenous (IV) morphine via patient-controlled analgesia (PCA). Both forms of therapy were titrated to provide patients with a dynamic visual analog pain score of 5 or less on a 10-point scale throughout the study period. Patients were weaned from infusions when pain scores remained at less than 5 for 12 hours and no breakthrough medication was used. MEASUREMENTS AND MAIN RESULTS: Rest and dynamic pain scores, time of first flatus, length of nasogastric therapy, time to solid food intake, daily and total morphine requirements and length of hospitalization were recorded. The epidural group required fewer days of nasogastric therapy (4 +/- 3 versus 8 +/- 2 days, p = 0,0001), tolerated solid foods sooner (6 +/- 2 versus 11 +/- 3 days, p < 0.0001), and had a shorter hospitalization time (10 +/- 3 versus 14 +/- 4 days, p = 0.0001) when compared with the PCA group. CONCLUSIONS: The use of thoracic epidural bupivacaine-morphine results in a decrease in the duration of postoperative ileus, which was associated with earlier hospital discharge.

Aged↗
PubMed1996

Postoperative epidural opioid analgesia: what are the choices?

The administration of hydrophilic opioids via a continuous infusion results in selective spinal analgesia with a low incidence of side effects. Lipophilic opioids may also be associated with spinal effects. However, the doses required to produce postoperative analgesia also produce plasma concentrations within the MEAC. Thus, in clinical practice it may not be possible to limit epidural doses of lipophilic opioids to those associated with spinal analgesia. Regardless of the mechanism of action, epidural administration of lipophilic opioids may offer no clinical advantages over the IV route. Notwithstanding, epidural administration of small doses of lipophilic opioids in combination with local anesthetics may offer significant clinical advantages over systemic administration of opioids alone. Dose-ranging studies will be necessary to determine the ideal concentrations of opioids and local anesthetics, as well as the ratios of the two drugs to obtain optimal analgesia with minimal incidence of side effects.

Analgesia, Epidural↗
PubMed1995

The influence of preoperative concentrations of beta-endorphin and met-enkephalin on the duration of analgesia after transurethral resection of prostate.

beta-Endorphin (beta-EP) and methionine-enkephalin (M-EK) are endogenous peptides that play a role in the modification of pain perception and analgesia threshold. In order to understand more about pathophysiology of pain in association with neuroaxial blocks, we evaluated cerebrospinal fluid (CSF) concentrations of beta-EP and M-EK prior to spinal anesthesia (SA) in patients undergoing transurethral resection of prostate (TURP) to determine the correlation between preanesthesia concentrations and the duration of postoperative analgesia and opioid requirements. Twenty-five healthy patients undergoing TURP under SA were enrolled. beta-EP and M-EK were measured with a competitive radioimmunoassay. Mean preoperative beta-EP and M-EK concentrations were 153 +/- 44 and 38 +/- 5 pg/mL, respectively. Those with beta-EP concentrations > 153 pg/mL had significantly longer analgesia (P < 0.01), and lower utilization of morphine in the first postoperative day (P < 0.01). Moreover, patients with milder postoperative pain (visual analog scale score < 4/10) had significantly higher beta-EP concentrations (P < 0.01). A similar correlation was not found with M-EK values. These data suggest that preoperative CSF beta-EP, but not M-EK, concentrations correlate with the duration and quality of postoperative analgesia, as well as opioid requirements after spinal anesthesia.

Aged↗
PubMed1995

Perforation and partial obstruction of an armored endotracheal tube.

Armored endotracheal tubes are often used during cases in which there is a risk of compromise of a polyvinylchloride tube with positioning of a patient's head. The authors describe a case in which partial airway obstruction and perforation of such a tube occurred as a result of biting by a patient. Ways to avoid this complication are discussed.

Adult↗
PubMed1994

Epidural bupivacaine/sufentanil therapy for postoperative pain control in patients tolerant to opioid and unresponsive to epidural bupivacaine/morphine.

BACKGROUND: Opioids are thought to have equal analgesic effects when equivalent doses are used. However, sufentanil may achieve maximum effect while occupying fewer spinal opioid receptors (higher intrinsic efficacy). Therefore, sufentanil may be more effective than morphine when administered intraspinally in opioid-tolerant patients. METHODS: This study evaluated 20 chronic cancer pain patients who underwent abdominal surgery for tumor resection. All patients used large doses of morphine (> 250 mg/day-1) preoperatively for 3 months or longer. Intraoperatively, patients received combined general-epidural anesthesia with 0.5% bupivacaine and 0.02% morphine at 8 ml/h-1. Postoperative continuous epidural analgesia with 0.1% bupivacaine and 0.02% morphine at 5 ml/h-1 plus intravenous patient-controlled analgesia morphine (3 mg every 6 min) was given. Epidural infusions were increased every 30 min by 1 ml/h-1 to achieve a dynamic (during coughing) visual analog pain score (VAPS) of less than 5/10. If the desired VAPS was not achieved after 6 h or the epidural morphine infusion was increased to 2 mg/h-1, 50 micrograms of sufentanil in 10 ml of normal saline was given as an epidural bolus dose. The epidural infusion then was switched to 0.0002% sufentanil (2 micrograms/ml-1) and 0.1% bupivacaine (1 mg/ml-1) at 7 ml/h-1. Further titration to maintain a dynamic VAPS of less than 5/10 occurred every 4 h. RESULTS: Mean preoperative daily oral morphine use was 380 +/- 97 mg (range 290-490) for 4 +/- 1 months. Before the switch to sufentanil, patients had received a mean maximum morphine dose of 8.8 +/- 0.2 mg intraoperatively plus 9.0 +/- 1.2 mg during 4.2 +/- 0.3 h postoperatively (1.8 +/- 0.4 mg/h-1), at which point VAPS ranged between 7-10/10. All patients experienced adequate analgesia within 1 h of starting sufentanil therapy. The mean sufentanil dose during the first 4 h of treatment was 17 +/- 0.2 micrograms/h-1. At this time, VAPS ranged from 0-3/10. Satisfactory analgesia was achieved with sufentanil at a lower than a calculated equally potent dose of morphine (23 micrograms/h-1 vs. 17 micrograms/h-1, P < 0.01). Intravenous patient-controlled analgesia morphine requirements were also lower (7.8 mg/h-1 vs. 2.0 mg/h-1, P < 0.01). Length of morphine and sufentanil therapies were 5 +/- 3 h and 10 +/- 2 days, respectively. No patient experienced signs or symptoms of opioid withdrawal. CONCLUSIONS: These results suggest that sufentanil can be used successfully in opioid-tolerant patients who do not experience adequate pain control in the early postoperative period despite a large dose of epidural morphine. Moreover, sufentanil should be considered an effective alternative therapy for postoperative pain control in chronic opioid users using high doses of oral opioids before surgical intervention.

Abdomen↗
PubMed1994

Postoperative epidural bupivacaine-morphine therapy. Experience with 4,227 surgical cancer patients.

BACKGROUND: We prospectively studied surgical cancer patients who received epidural bupivacaine-morphine to determine perioperative morphine use, side effects, and complications. METHODS: All study patients received general-epidural anesthesia followed by epidural analgesia with 0.05% or 0.1% bupivacaine and 0.01% morphine at a rate of 5-10 ml.h-1 to keep the dynamic pain score at less than 5 (of 10). Patients were evaluated daily for pain relief, side effects, catheter migration, accidental removal, hypotension, respiratory rate, mental status changes, nausea and vomiting, and pruritus. RESULTS: Over 4 yr, 4,227 patients (61% women, aged 68 +/- 24 yr) were studied. Lumbar epidural catheters (n = 2,248 or 53.18%) were used more frequently than thoracic catheters (n = 1,979 or 46.82%) (P < 0.00001). Most of the patients were discharged to the surgical wards after the procedures (n = 3,001, 71%). Those patients (n = 1,226, 29%) admitted to the surgical intensive care unit, spent 1.2 +/- 0.8 days. Epidural catheter failure occurred in 283 (6.3%) patients. Length of epidural analgesia therapy was 6.3 +/- 2.6 days. There were three cases (0.07%) of respiratory depression which were treated with oxygen, intravenous naloxone, and by stopping the epidural infusion for 6 h. Hypotension occurred in 126 patients (3%). There were no apparent cases of catheter migration to either the subdural or subarachnoid space. Nausea or vomiting occurred in 929 patients (22%). Pruritus occurred in 930 patients (22%). CONCLUSIONS: Continuous epidural analgesia with 0.05-0.1% bupivacaine and 0.01% morphine is an effective method of postoperative analgesia with a low incidence of side effects, that can be safely administered on the surgical wards with no special monitoring equipment.

Adult↗
PubMed1994

The efficiency of an autotransfusion system for tumor cell removal from blood salvaged during cancer surgery.

The efficiency of a gravity-dependent autotransfusion system (ATS) for filtering tumor cells from blood was examined under laboratory and clinical conditions. In laboratory studies, reconstituted whole blood was seeded with known numbers of cultured A431 human vulva carcinoma cells then filtered through the ATS. Cancer cells were recovered from blood samples taken before and after filtration using a density gradient centrifugation procedure, and identified by immunocytochemical techniques, based upon their cytoskeletal intermediate filament proteins. It was estimated that 55%-76% of the A431 cells were retained by the ATS filters, and of those cancer cells that passed through the ATS, 62% suffered lethal trauma and the remainder showed morphologic damage. In clinical studies, blood was harvested from the surgical site during resection of primary cancers from three patients. In agreement with the laboratory studies, 50%-68% of tumor cells were filtered by the ATS from blood harvested during surgery. These results are discussed in terms of metastatic inefficiency and the potential for use of autotransfused blood salvaged during cancer surgery.

Blood Transfusion, Autologous↗
PubMed1993

Interpleural analgesia for the treatment of severe cancer pain in terminally ill patients.

Interpleural analgesia was used to alleviate acute, severe exacerbations of chronic pain unrelieved by pharmacologic therapy in ten terminally ill cancer patients. Pain from metastatic disease to the neck, arms, chest, brachial plexus, thorax, or abdomen was effectively eliminated between 7 hr and 40 days in nine patients, who died with minimal or no pain. The technique was performed primarily using bupivacaine. No side effects were detected. Interpleural analgesia appears to be effective in rapidly controlling acute exacerbations of cancer pain in terminally ill patients. Moreover, it may also be a suitable therapy for moribund patients when used as a continuous-infusion technique.

Adult↗