Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report

Abstract Introduction: Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients. Case report: Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient's death. Discussion: This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients.

Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report

Abstract Introduction: Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients. Case report: Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient's death. Discussion: This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients.

Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report.

INTRODUCTION: Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients. CASE REPORT: Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient's death. DISCUSSION: This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients.

Intraoperative Methadone Reduces Pain and Opioid Consumption in Acute Postoperative Pain: A Systematic Review and Meta-analysis.

BACKGROUND: Methadone is a potent opioid exerting an analgesic effect through N-methyl-D-aspartate receptor antagonism and the inhibition of serotonin and noradrenaline reuptake. It has also been used in several procedures to reduce postoperative pain and opioid use. This meta-analysis aimed to determine whether the intraoperative use of methadone lowers postoperative pain scores and opioid consumption in comparison to other opioids. METHODS: Double-blinded, controlled trials without language restrictions were included from MEDLINE, Embase, LILACS, The Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL via EBSCOhost. The included studies tracked total opioid consumption, postoperative pain scores, opioid-related side effects, and patient satisfaction until 72 hours postoperatively. Mean difference (MD) was used for effect size. RESULTS: In total, 476 articles were identified and 13 were considered eligible for inclusion in the meta-analysis. In 486 patients (7 trials), pain at rest (MD, 1.09; 95% confidence interval (CI), 1.47-0.72; P < .00001) and at movement (MD, 2.48; 95% CI, 3.04-1.92; P = .00001) favored methadone 24 hours after surgery. In 374 patients (6 trials), pain at rest (MD, 1.47; 95% CI, 3.04-1.02; P < .00001) and at movement (MD, 2.03; 95% CI, 3.04-1.02; P < .00001) favored methadone 48 hours after surgery. In 320 patients (4 trials), pain at rest (MD, 1.02; 95% CI, 1.65-0.39; P = .001) and at movement (MD, 1.34; 95% CI, 1.82-0.87; P < .00001) favored methadone 72 hours after surgery. A Trial Sequential Analysis was performed and the Z-cumulative curve for methadone crossed the monitoring boundary at all evaluations, additionally crossing Required Information Size at 24 and 48 hours at rest. Methadone group also showed lower postoperative opioid consumption in morphine equivalent dosage (mg) at 24 hours (MD, 8.42; 95% CI, 12.99-3.84 lower; P < .00001), 24-48 hours (MD, 14.33; 95% CI, 26.96-1.91 lower; P < .00001), 48-72 hours (MD, 3.59; 95% CI, 6.18-1.0 lower; P = .007) postoperatively. CONCLUSIONS: Intraoperative use of methadone reduced postoperative pain scores compared to other opioids, and Trial Sequential Analysis suggested that no more trials are required to confirm pain reduction at rest until 48 hours after surgery. Methadone also reduced postoperative opioid consumption and led to better patient satisfaction scores through 72 hours postoperatively compared to other opioids.

Resilience, depression, and quality of life in elderly individuals with chronic pain followed up in an outpatient clinic in the city of São Paulo, Brazil.

PURPOSE: In this study, we assessed resilience, depression, and quality of life in a group of elderly individuals with or without chronic pain. PATIENTS AND METHODS: A cross-sectional study assessing elderly individuals followed up at a geriatrics outpatient clinic and divided into two groups: 54 elderly patients with chronic pain and 54 elderly with no chronic pain. RESULTS: The sample comprised mainly women (67.6%), with mean age 79.9 years. The mean resilience index in the group with pain was 69.4 and, in the group with no pain, 80.1 (P<0.001). Depression was observed in 35.2% of patients with chronic pain; there was no case of depression in those without chronic pain. Quality of life of the elderly with chronic pain was worse in all the domains assessed: physical, mental, emotional, social, vitality, and pain. CONCLUSION: In the study sample, resilience was lower, depression was more frequent, and quality of life was worse in the group of elderly with chronic pain.

Clonidine Effect on Pain After Cesarean Delivery: A Randomized Controlled Trial of Different Routes of Administration.

BACKGROUND: Intrathecal clonidine prolongs spinal anesthesia. We evaluated the effects of the addition of intrathecal or intravenous clonidine (75 µg) to standard cesarean delivery spinal anesthesia on postoperative pain and neonatal outcomes. METHODS: In a randomized, placebo-controlled, double-blind trial, 64 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated and compared among 3 groups: intrathecal clonidine 75 µg, intravenous clonidine 75 µg, and placebo. The primary outcome was acute postoperative pain. A sample size of 26 individuals per group (N = 78) was planned. RESULTS: From April 2015 to April 2016, 64 women were analyzed (14 excluded). No differences in postoperative pain scores were found (Numerical Verbal Scale for pain at movement at 24 hours of postcesarean delivery: 4.53 ± 3.0 vs 4.45 ± 2.73 vs 3.93 ± 3.07 for control, intrathecal, and intravenous, respectively, P = .771). Intrathecal and intravenous clonidine led to more sedation, in comparison to the control group, during the intraoperative period (Richmond Agitation and Sedation Scale: -0.3 ± 0.47 vs -1 ± 0.53 vs -0.73 ± 0.45 for control, intrathecal, and intravenous, respectively, overall P < .001; Dunn correction: P < .001 for intrathecal versus control; P = .021 for intravenous versus control; and P = .208 for intrathecal versus intravenous). CONCLUSIONS: Intrathecal or intravenous clonidine had no effect on postoperative pain after cesarean delivery. Both intrathecal and intravenous clonidine caused more sedation.

Duloxetine as an Analgesic Reduces Opioid Consumption After Spine Surgery: A Randomized, Double-Blind, Controlled Study.

OBJECTIVES: Multimodal analgesia is widely advocated for the control of perioperative pain in an effort to reduce the use of opioid. Duloxetine is a selective inhibitor of serotonin and norepinephrine reuptake with efficacy for chronic pain conditions. The primary objective of this study was to evaluate the efficacy of two 60 mg oral doses of duloxetine in terms of fentanyl consumption during the postoperative period in patients undergoing elective spine surgery. MATERIALS AND METHODS: This study was prospective, double-blind, randomized, and placebo controlled. Patients received either 60 mg duloxetine or an identical placebo 1 hour before surgery and again the following morning. The study participants were allocated into 2 groups: Group C (control) participants received the placebo and Group D (duloxetine) participants received 60 mg duloxetine. The total consumption of fentanyl 48 hours after surgery was measured. Secondary end points were pain scores and the presence or absence of adverse effects, such as headache, nausea, vomiting, itching, dizziness, and drowsiness. RESULTS: Demographic characteristics did not differ between groups. There was a significant difference in fentanyl consumption in the first 24 hours between Groups C and D (mean difference, 223.11±39.32 µg; P<0.001). Fentanyl consumption also differed between Groups C and D after 48 hours (mean difference, 179.35±32.55 µg; P<0.000). The pain scores over 48 hours did not significantly differ between groups. The incidence of side-effects was similar in both groups. DISCUSSION: Duloxetine was effective as an adjunct for postoperative analgesia and reduced opioid consumption.

Magnesium sulfate improves postoperative analgesia in laparoscopic gynecologic surgeries: a double-blind randomized controlled trial.

STUDY OBJECTIVE: The aim of this study is to compare the analgesic effect of intravenous infusion of magnesium sulfate to ketorolac during laparoscopic surgeries. DESIGN: Double-blind randomized controlled trial. SETTING: University-affiliated teaching hospital. PATIENTS: Sixty women submitted to laparoscopic gynecologic oncology surgeries. INTERVENTIONS: Intravenous ketorolac 30 mg in bolus followed by saline infusion (group K), intravenous magnesium sulfate 20 mg/kg in bolus followed by magnesium 2 mg kg(-1) h(-1) (group M) or intravenous saline solution 20 mL in bolus followed by saline infusion during the entire procedure (group S). MEASUREMENTS: Postoperative pain, nausea, vomiting, sedation, opioid consumption, time to first dose of analgesic. MAIN RESULTS: Magnesium sulfate reduced opioid consumption compared with placebo in the postoperative, but not in the intraoperative, period. Nausea, not vomiting, was reduced in ketorolac but not in the magnesium group. Pain intensity was higher in placebo than in the other 2 groups during all periods of observation. In the first 60 minutes, pain intensity was lower in the magnesium than in the ketorolac or the placebo group. CONCLUSION: Intraoperative magnesium sulfate improves postoperative pain control, acting as an opioid-sparing adjuvant, and is similar to ketorolac 30 mg administered in the beginning of surgery.

Safety profile of intravenous patient-controlled analgesia for breakthrough pain in cancer patients: a case series study.

PURPOSE: The WHO analgesic ladder supports medication choice according to pain intensity. The use of the analgesic ladder in an inverse way, has the advantage of using the same principles of the original ladder to treat crisis of pain in cancer patients. The purpose of this study is to describe the use of intravenous patient-controlled analgesia (IV-PCA) technique in patients admitted to an oncological Hospital. METHODS: This is a case series study. Patients assigned to receive IV-PCA between March 2011 and May 2012 were selected for the study. Medical records were reviewed, patients stratified according to the Karnofsky Performance Score (KPS). The primary outcome was to verify if different IV-PCA opioid solutions could be equally effective providing pain relief. Secondary outcomes were the incidence of clinical side effects that can be associated to IV-PCA infusions. RESULTS: A total of 95 medical records were reviewed. Most patients used IV-PCA with morphine (42.1 %), fentanyl (42.1 %) or methadone (15.7 %) to treat exacerbation periods of cancer pain. IV-PCA used as supplementary therapy successfully improved pain control in 78.9 % of the patients, without any difference related to opioid solution. KPS <40 was related to higher rate of pain relief, without any difference in side effects in this group of patients. The most common side effects were sedation (10.5 %) followed by constipation (9.4 %) and nausea (4.2 %). Morphine presented a higher risk than fentanyl for sedation. Analgesia-related delirium or respiratory depression were not reported in this case series study. CONCLUSIONS: IV-PCA provided timely, safe and useful analgesia for patients with severe breakthrough pain and may be useful to help titration of opioids, weaning to oral analgesia and to decide for interventional procedures.

Opioides, sexo e gênero / Opioids, sex and gender

JUSTIFICATIVA E OBJETIVOS: Sexo é um fator importante na modulação da experiência dolorosa. Evidências significativas têm demonstrado que a experiência à dor difere entre homens e mulheres, bem como na resposta à ativação do sistema opioide e seus efeitos analgésicos.Há evidências que as mulheres têm menor limiar que os homens para alguns estímulos álgicos. Os neurotransmissores opioides e seus receptores estão centralmente envolvidos na resposta ao estresse, na supressão à dor ena ação dos analgésicos opioides. O objetivo deste estudofoi analisar a relação entre sexo, gênero e sistema opioide e discutir a relevância de um dos aspectos mais intrigantes da fisiologia da dor: a presença da diferença entre sexo e gênero, sistema opioide e as respostas da analgesia por opioides. CONTEÚDO: Uma revisão da literatura sobre opioides,sexo e gênero, cujo objetivo foi mostrar dados atuais sobre a experiência dolorosa entre homens e mulheres,a ativação opioide central e a resposta aos analgésicos opioides.CONCLUSÃO: Os dados disponíveis na literatura, e os trabalhos em andamento indicam que o sexo provavelmente seja responsável pelas diferenças à analgesia opioide em homens e mulheres, mas a direção e a magnitude destas diferenças dependem de variáveis que se interagem.Como fatores importantes que interagem na percepção dolorosa e na resposta analgésica opioide, devem ser levados em consideração os fatores socioculturais ebiológicos, incluindo as variações hormonais em mulheres e a presença do hormônio masculino nos homens.

BACKGROUND AND OBJECTIVES: Sex is a major factor for pain modulation. Significant evidences haves hown that pain experience is different between men and women, as well as the response to opioid system activation and its analgesic effects. There are evidences that women have lower pain threshold compared to men. Opioid neurotransmitters and their receptors are centrally involved with stress response, pain suppressionand opioids analgesic action. This study aimed to illustrate the relationship between sex, gender and the opioid system and to discuss the relevance of one of the most intriguing aspects of pain physiology: differences between sex and gender, opioid system and opioids analgesic response.CONTENTS: A literature review on opioids, sex and gender, aiming to show current data on pain experience between men and women, central opioid activation andresponse to opioids. CONCLUSION: Data in the literature and ongoing studies indicate that sex is probably responsible for differences in opioid analgesia between men and women, butthe direction and magnitude of such differences depend on interacting variables. Socio-cultural and biological factors, including hormonal variations in women and the presence of male hormone in men are important factors interacting with pain perception and opioid analgesic response.

Influence of naloxone and methysergide on the analgesic effects of low-level laser in an experimental pain model.

BACKGROUND AND OBJECTIVES: Although the mechanism of action of laser phototherapy (LPT) is not known, it is a promising analgesic method. The aim of this study was to evaluate whether the action of LPT depends on the activation of peripheral opioid or serotonergic receptors. METHOD: Inflammatory pain was induced through the injection of carrageenin in the left posterior paw of male Wistar rats. The InGaAIP visible laser diode (660 nm) with fluency of 2.5 J*cm(-2) was used. Von Frey filaments were used to analyze mechanical hyperalgesia. Animals were separated into five groups: Carrageenin; Laser (LPT); Non-coherent light; LPT + Naloxone; and LPT + Methysergide. RESULTS: Low-Level Laser phototherapy proved to be an effective analgesic method, while non-coherent light did not show a similar effect. The use of naloxone blocked the analgesic effect of LPT, while methysergide did not affect LPT-induced analgesia. CONCLUSIONS: According to the parameter used in this study, LPT produced analgesia. Analgesia induced by laser phototherapy is mediated by peripheral opioid receptors. Laser phototherapy does not seem to interact with peripheral serotonergic receptors.

Influência da naloxona e metisergida sobre o efeito analgésico do laser em baixa intensidade em modelo experimental de dor / Influence of naloxone and methysergide on the analgesic effects of low-level laser in an experimental pain model

JUSTIFICATIVA E OBJETIVOS: A fototerapia com laser (LPT) é um método analgésico promissor, embora seu mecanismo de ação não seja totalmente conhecido. O objetivo deste estudo foi avaliar se a ação da LPT é dependente da ativação de receptores opioides ou serotoninérgicos periféricos. MÉTODO: Foram utilizados ratos Wistar machos. A dor produzida foi de caráter inflamatório, através da injeção de carragenina na pata posterior esquerda dos ratos. O laser utilizado foi o Photon Lase III em meio ativo InGaAIP (660 nm), fluência de 2,5 J.cm-2. Analisou-se a hiperalgesia mecânica utilizando filamentos de von Frey. Os animais foram separados em cinco grupos: Carragenina; Laser (LPT); Luz não coerente; LPT + Naloxona e LPT + Metisergida. RESULTADOS: A fototerapia com laser em baixa intensidade mostrou-se um método analgésico eficaz, enquanto o emprego de fonte de luz não coerente não mostrou ter efeito analgésico. O uso de naloxona bloqueou o efeito analgésico do LPT; já o uso de metisergida não afetou a analgesia do LPT. CONCLUSÕES: A LPT nos parâmetros utilizados apresentou efeito analgésico. A analgesia da LPT é mediada por receptores opioides periféricos. A LPT parece não interagir com receptores serotoninérgicos periféricos.

BACKGROUND AND OBJECTIVES: Although the mechanism of action of laser phototherapy (LPT) is not known, it is a promising analgesic method. The aim of this study was to evaluate whether the action of LPT depends on the activation of peripheral opioid or serotonergic receptors. METHOD: Inflammatory pain was induced through the injection of carrageenin in the left posterior paw of male Wistar rats. The InGaAIP visible laser diode (660 nm) with fluency of 2.5 J.cm-2 was used. Von Frey filaments were used to analyze mechanical hyperalgesia. Animals were separated into five groups: Carrageenin; Laser (LPT); Non-coherent light; LPT + Naloxone; and LPT + Methysergide. RESULTS: Low-Level Laser phototherapy proved to be an effective analgesic method, while non-coherent light did not show a similar effect. The use of naloxone blocked the analgesic effect of LPT, while methysergide did not affect LPT-induced analgesia. CONCLUSIONS: According to the parameter used in this study, LPT produced analgesia. Analgesia induced by laser phototherapy is mediated by peripheral opioid receptors. Laser phototherapy does not seem to interact with peripheral serotonergic receptors.

JUSTIFICATIVA Y OBJETIVOS: La fototerapia con láser (LPT) es un método analgésico promisorio, aunque su mecanismo de acción no se conozca en su totalidad. El objetivo de este estudio fue evaluar si la acción de la LPT es dependiente de la activación de receptores opioides o serotoninérgicos periféricos. MÉTODO: Se usaron ratones Wistar machos. El dolor generado fue de carácter inflamatorio, a través de la inyección de carragenina en la pata posterior izquierda de los ratones. El láser utilizado fue el GaIAsAl (660 nm), fluencia de 2,5 J.cm-2. Se analizó la hiperalgesia mecánica utilizando filamentos de von Frey. Los animales se dividieron en cinco grupos: Carragenina; Láser (LPT); Luz no coherente; LPT + Naloxona y LPT + Metisergida. RESULTADOS: La fototerapia con láser en baja intensidad demostró ser un método analgésico eficaz, mientras que el uso de la fuente de luz no coherente no demostró poseer ningún efecto analgésico. El uso de naloxona bloqueó el efecto analgésico del LPT, mientras que el uso de metisergida no afectó la analgesia del LPT. CONCLUSIONES: La LPT en los parámetros utilizados tuvo un efecto analgésico. La analgesia de la LPT es mediada por receptores opióides periféricos. La LPT parece que no interactúa con los receptores serotoninérgicos periféricos.