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Acute pain is a frequent entity in the hospital setting and the complexity of its management results in the necessity for practice guidelines to assist health care personnel in decision making for treatment of pain. In Mexico, as in other countries, different task forces have provided recommendations in order to achieve this goal. The present report presents the results obtained by a multidisciplinary group who explored the actual state of acute pain in the country using a questionnaire. Meanwhile, they also analyzed the scientific evidence contained in the literature. The results of these efforts are contained in the practice guidelines proposed by this task force.
Clinical diagnosis in acute abdominal pain is still a major problem. Computer-aided diagnosis offers some help; however, existing systems still produce high error rates. We therefore tested machine learning techniques in order to improve standard statistical systems. The investigation was based on a prospective clinical database with 1254 cases, 46 diagnostic parameters and 15 diagnoses. Independence Bayes and the automatic rule induction techniques ID3, NewId, PRISM, CN2, C4.5 and ITRULE were trained with 839 cases and separately tested on 415 cases. No major differences in overall accuracy were observed (43-48%), except for NewId, which was below the average. Between the different techniques some similarities were found, but also considerable differences with respect to specific diagnoses. Machine learning techniques did not improve the results of the standard model Independence Bayes. Problem dimensionality, sample size and model complexity are major factors influencing diagnostic accuracy in computer-aided diagnosis of acute abdominal pain.
The Canadian Collaborative Acute Pain Initiative, established in 2002, is a voluntary, multidisciplinary consortium of acute pain health professionals from across Canada whose goal is to improve acute pain management through discussion and consensus. The group met in January 2002 to define strategic areas related to the treatment of acute pain. The areas identified were: the definition of pain; the epidemiology of pain; the concept of an 'ideal' acute pain management service; education; therapeutic options; symptom management; and research and safety. In November 2002, a second meeting was held to develop objectives and recommendations for the management of acute pain based on the defined areas. The outcome of these discussions is summarized in this paper.
UNLABELLED: Although previous research suggests that preamputation pain is a risk factor for pain after amputation, little is known about the association between acute postsurgical pain and chronic amputation-related pain. The current prospective study examined the associations of preamputation pain and acute postamputation pain with chronic amputation-related pain. The sample consisted of patients with lower limb amputation (N = 57) who provided both preamputation and postamputation data during a 2-year study period. Preamputation pain intensity and duration were assessed before amputation; acute phantom limb pain (PLP) and residual limb pain (RLP) intensity were assessed on postsurgical days 4 and 5. Acute PLP intensity was the only significant independent predictor of chronic PLP intensity at 6 and 12 months after amputation, whereas preamputation pain intensity was the only significant predictor of chronic PLP intensity at 24 months. Similarly, acute RLP was found to be the best overall predictor of chronic RLP. Other variables (age, gender, level and etiology of amputation, amount of postsurgical pain medication, and duration of preamputation pain) were not associated with chronic pain. These results suggest that higher levels of pain either before or soon after amputation might help to identify individuals at greatest risk for chronic pain problems and most in need of early, intensive pain interventions. PERSPECTIVE: This study suggests that both preamputation pain and acute pain soon after amputation might be associated with bothersome chronic pain. The results support further research on acute pain mechanisms and the effectiveness of early interventions aimed at preventing or managing amputation-related pain.
The effect of the presence of either chronic or acute clinical pain on pain threshold and on the nociceptive flexion reflex (RIII) threshold was studied. The experimental pain sensation and the flexion reflex were evoked by trains of short electrical pulses. It was hypothesized that both kinds of clinical pain would be able to induce 'diffuse noxious inhibitory controls' (DNIC) and thereby raise the 2 experimental thresholds. Patients with chronic low back pain, patients with postoperative pain from oral surgery, and pain-free subjects were tested in 3 conditions: during baseline, after i.v. administration of a placebo, and after i.v. administration of naloxone. In comparison with 2 pain-free control groups, the 2 pain groups had a significantly higher pain threshold in all conditions. However, the RIII threshold was not significantly elevated in chronic or acute pain patients compared to controls. Naloxone had no effect on the RIII or pain threshold in any of the groups. It is concluded that the increased pain threshold which is frequently found in chronic pain patients, and which could be confirmed in the present study, does not result from a DNIC effect. The adaptation level theory offers an alternative explanation. Also, the acute postoperative pain in this study did not seem to induce DNIC. Because other forms of acute pain have been found to be effective in activating DNIC, future research should establish which pains are and which pains are not effective.
This article reports a case of a diabetic patient who suffered from acute painful diabetic neuropathy, following an intensive insulin treatment after a poor glycaemic control period of 8 yr. On the 15th day of the insulin treatment, which enabled rapid successful glycaemic control, the patient began complaining of pain and a burning sensation in the lower extremities, especially during the night. Venlafaxine HCL was initiated and the patient was completely free of pain on the third day of the treatment. As insulin neuritis is infrequent among diabetic patients we consider it is worth reporting the dramatic effect of the venlafaxine HCL treatment.
OBJECTIVE: To measure acute pain in sheep, based on a human pain model, and examined changes in both electroencephalogram frequency spectrum and behavioural responses to increased electrical stimulation in sheep. DESIGN: Analysis of variance (treatment and animal effects) for stimulus intensity where each animal received each electric shock treatment given in the order 0, 5, 10 and 20 mA. PROCEDURE: Eight sheep with electrodes implanted over the surface of the brain were examined for escape-avoidance and electroencephalogram responses to four levels of electrical stimulation from 0-20 mA. RESULTS: With increasing stimulus intensity at the time of feeding, the sheep were more hesitant to return to the feeder or remain near the feeder following stimulation. There was little difference between the 0 and 5 mA stimuli for any of the behaviour variables (P > 0.05). However, there were marked increases in the time taken to re-approach the feeder after receiving an electric shock of 5 mA and of 20 mA (P < 0.05; mean values 3 and 119 s, respectively) and remaining near the feeder for 5 s (P < 0.001; mean values 10 and 167 s, respectively). Following the stimulus, there was an overall increase in the electroencephalogram power spectrum in the first four seconds, which then rapidly returned to normal. In particular, the 20 mA stimulus resulted in higher absolute power values than in the control (0 mA) treatment for delta 2 (P < 0.001), theta 1 (P < 0.05), theta 2 (P < 0.05), alpha 1 (P < 0.001), alpha 2 (P < 0.001) and beta 1 (P < 0.01), bandwidths. Similarly, for the 10 mA stimulus, the absolute power values were greater than the control treatment for delta 2 (P < 0.05), alpha 1 (P < 0.01), alpha 2 (P < 0.001) and beta 1 (P < 0.01) bandwidths. CONCLUSION: The experiment suggests that a human acute pain model is applicable to sheep and that these electroencephalogram changes may provide a good measure of acute pain in sheep
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A survey of postoperative pain management practices was mailed to the 56 Canadian university-affiliated teaching hospitals in December 1991. The aims of the survey were (1) to determine the prevalence, structure, and function of Acute Pain Services and (2) to determine the use and management of patient-controlled analgesia (PCA) and epidural opiate analgesia (EOA) in teaching hospitals. Responses were received from 47 hospitals, representing a return rate of 84%. Twenty-five hospitals (53%) operated an Acute Pain Service and an additional 17 (35%) were attempting to organize one. "Time commitment" was given as the primary reason why hospitals were unable to offer an Acute Pain Service. Most commonly used methods of pain relief were EOA and PCA. Most services were multidisciplinary, with 60% having a nurse and 29% a pharmacist. Irrespective of the presence of an Acute Pain Service, PCA was used at 32 (68%) hospitals, and EOA was used at 41 (87%); however, only 15 provided EOA on general wards. Complications have occurred with both PCA and EOA, with 14 of 32 hospitals indicating that they have had a major or serious complication. The data suggest an estimated incidence of severe respiratory depression of 0.03% with PCA and 0.13% with EOA. No deaths were reported at the time of the survey. Epidural opioid-local anaesthetic EOA-LA combinations were used at 26 (63%) hospitals; however, only six administered these combinations on general words. We conclude that a multidisciplinary team approach to manage postoperative pain is viable in university teaching hospitals of all sizes.(ABSTRACT TRUNCATED AT 250 WORDS)
Previous studies of the Fear-Avoidance Model of Exaggerated Pain Perception have commonly included patients with chronic low back pain, making it difficult to determine which psychological factors led to the development of an "exaggerated pain perception". This study investigated the validity of the Fear-Avoidance Model of Exaggerated Pain Perception by considering the influence of fear of pain and pain catastrophizing on acute pain perception, after considering sex and anxiety. Thirty-two males and 34 females completed the State-Trait Anxiety Inventory, the Fear of Pain Questionnaire, and the Coping Strategies Questionnaire. Subjects underwent a cold pressor procedure and tolerance, pain intensity, and blood pressure reactivity were measured. Sex, anxiety, fear of pain, and pain catastrophizing were simultaneously entered into separate multiple regression models to predict different components of pain perception. Tolerance was not predicted by fear of pain, pain catastrophizing, or anxiety. Pain intensity at threshold and tolerance were significantly predicted by fear of pain, only. Blood pressure reactivity to pain was significantly predicted by anxiety, only. These results suggest that fear of pain may have a stronger influence on acute pain intensity when compared to pain catastrophizing, while neither of the factors predicted tolerance or blood pressure reactivity.
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Twenty-one chronic low back pain (CLBP) patients and 20 control subjects participated in 8 successive cold pressor tests (CPT). The hypotheses were that: (1) CLBP patients would demonstrate poorer acute pain tolerance and report higher acute pain, and (2) CLBP patients would become sensitized during 8 successive CPT trials, while control subjects would habituate, resulting in increasing differences in test behavior between both groups. The results show that the first hypothesis was confirmed. The second hypothesis requires modification, as the control group both habituated and became sensitized, while within the CLBP group no learning or training effect was found. These findings lead one to conclude that the deviant acute pain behavior of CLBP patient may be regarded either as a consequence of CLBP or as an important risk factor in the development of CLBP. Patients with relatively high CLBP levels performed poorly on the CPT as compared with patients with relatively low CLBP levels.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for the management of acute pain. Cyclooxygenase (COX) enzyme is of particular interest because it is the major target of NSAIDs. Although NSAIDs are remarkably effective in the management of pain and inflammation, their use is limited by several adverse effects including gastrointestinal bleeding and ulceration, impaired renal function, and inhibition of platelet aggregation. Discovery of a second cyclooxygenase, COX-2, led to the hypothesis that NSAID side effects could be decreased, as the inhibition of COX-2 is more directly implicated in ameliorating inflammation while the inhibition of COX-1 is related to adverse effects in the GI tract. This stimulated the development of selective COX-2 inhibitors (coxibs) that are better tolerated than nonselective NSAIDs but comparable in analgesic efficacy. This article provides an overview on the therapeutic use of selective COX-2 inhibitors for relief of acute pain, largely based on clinical trials in patients undergoing the surgical removal of impacted third molars, with focus on analgesic efficacy and the potential safety associated with their use compared to dual COX-1/COX-2 inhibitors.
The test behavior of 24 chronic low back pain patients was compared with the behavior of 24 healthy control Ss., matched for age and sex, in an experimental, acute pain situation (cold pressor-test). Chronic low back pain patients showed poorer persistence behavior and reported more pain. Thus, elements of typical chronic low back pain behavior were also present in an acute pain situation. These findings are discussed within the framework of stimulus-generalization theory. In addition, the effect of different coping strategies on pain tolerance was reconfirmed. The chronic low back pain group and the control group did not cope differently.
While there are increasing demands for improved post-operative analgesia and the implementation of Acute Pain Services (APS), the safety of such an approach remains under discussion. This paper analyses the safety outcome of 3016 consecutive post-operative patients treated under the care of a formalised Acute Pain Service. No serious complication resulting in morbidity or mortality occurred. Potentially severe complications without sequelae were discovered in 16 patients (0.53%); this incidence was similar for techniques of systemic opioid administration and continuous regional analgesia. Patient-controlled analgesia (PCA) alone had a significantly lower rate of respiratory depression than PCA with a background infusion or continuous morphine infusion. In 1069 patients receiving continuous regional analgesia (epidural, interpleural, peripheral) no trauma to nervous structures, no infection and no local anaesthetic toxicity occurred. In conclusion, an anaesthesiology-based APS can provide postoperative pain relief using a wide range of relatively invasive techniques without endangering patient safety.
Cold induced acute pain is associated with many autonomic responses of the cardiovascular system, skin conductance and pupil size. However, there are few reports suggesting changes in pulmonary function. Hence present study reports preliminary data on this. Acute pain was induced in 30 non-smoker males, 30-50 yrs of age by immersing hand in cold water and their respiratory rate (RR), tidal volume (TV), inspiratory and expiratory reserve volumes (IRV, ERV) and respective capacities, vital capacity (VC), force vital capacity (FVC), FEV1%, peak flow and flow rates at 75%, 50% and 25% of expired volume (V75,50,25) were measured. Acute pain parameters like pain threshold, tolerance and sensitivity were also recorded. Besides these, heart rate, blood pressure (systolic and diastolic), skin temperature of forehead and opposite palm were also measured. Comparisons were made between values recorded before, during and after cold induced pain. An increase in RR, RV, IC, EC, FVC, FVC%, FEV1 was observed during cold induced pain reflecting an acute state of sympathetic dominance. Positive correlations between heart rate and respiratory rate, and other respiratory with pain parameters were seen during period of induction of acute pain. Hence the study indicates that alterations in pulmonary profile form a part of multidimensional responses observed during cold induced acute pain.
Acute pain tests using mechanical stimuli typically do not involve objects important in the evolutionary history of the subjects, and may fail to evaluate the contribution of biobehavioral defensive reactions to the total pain response. Spines are common structural defenses that protect plants and animals against predation. The present studies examined the reaction to contact with such natural, mechanical pain stimuli in the laboratory rat, utilizing a floor board with protruding pins located in the middle of a novel alley (the "fakir" test). Behavioral responses were characterized in 10-min tests (Experiment 1). Subjects showed voluntary contact with the pins followed by patterns of avoidance and risk assessment (stretch attend and stretch approach). Few subjects crossed the array of pins. The amygdala has been implicated in the perception of pain, particularly in stressful or fearful contexts. In Experiment 2, the fakir test was used to examine, concurrently, the effects of amygdala lesions on analgesiometric (frequency and duration of pin crossings) and anxiometric (risk assessment) measures. Large, bilateral, lesions of the amygdala significantly increased both the number of pin crossings and time spent on the pins without affecting the risk assessment measures. These findings suggest a possible dissociation between anxiety and pain perception with an important (nonaffective) role for the amygdala in the latter.