[Peripheral nerve stimulation in the treatment of various types of headache]. / Estimulación de nervio periférico en el tratamiento de diferentes tipo de cefaleas.

BACKGROUND AND OBJECTIVE: Headache has a great impact on patients' quality of life and in industrialized countries there is economic impact as well. One of the pathophysiologic theories to explain headache is activation of afferent C2-C3 nerve fibers. Afferent peripheral nerve stimulation by occipital nerve provocation at C2-C3 seems to alleviate headache by acting on the trigeminocervical complex, which would largely explain the effectiveness of this modality. The aim of this study was to describe peripheral nerve stimulation as an alternative therapy in patients who do not respond to other headache treatments. MATERIAL AND METHODS: Multicenter retrospective study between April 2005 and May 2009, analyzing cases of patients treated with nerve stimulation for severe chronic headache. In all patients the medical history included type of headache, intensity of pain on a numerical scale, medical treatment used, and number of headache episodes. We recorded the percentage of patients with negative tests. Patients implanted with a generator assessed effectiveness on the numerical scale; we analyzed the percentage of perceived improvement at 1, 3, 6, and 12 months. We also analyzed the extent of coverage provided by the electrodes, patient satisfaction, reduction in the number of episodes and medication, and complications. RESULTS: Of 31 patients, 87% had positive results, with a significant decrease in pain from baseline (P < .001); 85.2% reported sustained improvement of > 50%, and 96.3% reported a decrease of > 2 points on the pain scale. All patients expressed satisfaction during the period of follow-up. Fifty-six percent had no headaches after a year and 47% had stopped taking medication. The most frequent complication was electrode migration.

[Neuromuscular blockade monitoring. Part 1]. / Monitorización del bloqueo neuromuscular. 1a parte.

Many recent studies have underlined the importance of quantitative neuromuscular monitoring and the high incidence of residual block in clinical practice in spite of the use of nondepolarizing neuromuscular blockers of intermediate duration. Neuromuscular monitoring facilitates the tailoring of the muscular paralysis and appropriate patient recovery at the end of surgery. Monitoring also controls or prevents residual block and serves to guide the use of reversing agents. This review describes the physiology of neuromuscular junctions as well as the principles and patterns of nerve stimulation and clinical monitoring. In addition to drawing on their own experience, the authors have reviewed the literature available through evidence-based indexes and other databases up to December 2008. Most references found were case series and reviews. Quantitative monitoring is an evidence-based practice that should be applied in all situations in which a neuromuscular block is established.

[Effect of posture on spinal cord stimulation in patients with chronic pain syndromes: analysis of energy requirements in different patient postures]. / Efecto de la postura en la estimulación medular en pacientes con síndromes de dolor crónico. Análisis del gasto de energía dependiendo de la postura del paciente.

BACKGROUND AND OBJECTIVE: Patients being treated with spinal cord stimulation for chronic pain complain of variable paresthesias, particularly in relation to changes in posture. Such changes affect the great majority of patients with implantable pulse generators, requiring them to use the external programmer for avoidance of painful paresthesias or even to disconnect the generator, leading to loss of pain relief. The aim of this study was to determine the relationship between the pulse charge needed for stimulation and the patient's different postures. MATERIAL AND METHODS: Observational study of 70 patients treated with spinal cord stimulation in the following postures and situations: decubitus position, standing, seated, and walking. With the patients standing, we analyzed the thresholds of perception, pain, and pain relief, as well as the therapeutic range. Studies were performed in all patients. Later, data were analyzed by anatomical positioning of the stimulator (cervical, thoracic, sacral, occipital, or subcutaneous). RESULTS: In the analysis of the therapeutic range in the overall group we identified statistically significant differences between decubitus and standing positions and between decubitus position and walking. At the level of the thoracic spine differences were identified between all positions except between standing and walking and between seated and decubitus positions. At the level of the cervical spine, no significant differences were detected. Analysis of the pulse charge showed a significant difference in the decubitus position, in which less charge was needed to achieve satisfactory stimulation. When electrodes implanted at the cervical and thoracic levels were compared, differences were found between standing and seated positions (P=.04) but none between decubitus position or walking and the other positions. CONCLUSION: Stimulation systems are not currently designed to adapt to changes in distance between the electrodes and nerve fibers. Improvements are required in this respect.

Neuraxial analgesia in a pregnant woman with Fowler's syndrome and sacral neuromodulation.

We report the anesthetic management of a 16-year-old woman with Fowler's syndrome who became pregnant three years after sacral neuromodulation was initiated for treatment of the condition. Multidisciplinary consensus was to switch off the neurostimulator during pregnancy, and attempt vaginal delivery with a neuraxial block. When the patient was admitted for labor, an epidural catheter was placed successfully. The patient had a normal vaginal delivery. Sacral neuromodulation was restarted uneventfully in the early puerperium and the Fowler's syndrome remains well controlled. The baby continues to develop normally three years after delivery.

European Pain Federation position paper on appropriate opioid use in chronic pain management.

Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non-specialist opioid prescribers. There is much confusing and conflicting information available to non-specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi-faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non-specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. SIGNIFICANCE: This position paper provides expert recommendations for primary care physicians and other non- specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi-faceted approach to pain management, in properly selected and supervised patients.

[Assessment of the impact of pain on work productivity: validation of the Spanish WPAI:Pain questionnaire]. / Valoración de la repercusión del dolor sobre la productividad laboral: validación del cuestionario WPAI:Pain.

BACKGROUND: Health measuring instruments are essential in daily clinical practice. However, a validation process is needed in order to certify the validity and reliability of it. The aim of our study is to validate a questionnaire to assess the consequences of pain in work productivity. METHODS: Based on the Work Productivity and Activity Impairment Questionnaire ­ General Health we have created a modified version called WPAI:Pain in order to be able to measure the consequences of pain in work productivity. The study was conducted following the usual guidelines of test validation, omitting face validity as WPAI:Pain is a modification of an existing questionnaire. Validity and reliability were calculated. RESULTS: A total of 577 questionnaires were obtained in 2 spanish university hospitals. The questionnaire's discriminating power was verified by Mann-Whitney test. Reliability tests were realized, Cronbach's alpha was 0.896 and Guttman split-half was 0.921. Stability was evaluated with a test-retest which was significant. Construct validity was established by Pearson correlation comparing the results of the questionnaire with the pain visual analog scale, which was statistically significant for all values. CONCLUSIONS: The WPAI:Pain questionnaire is a valid instrument for measuring the consequences of pain in work productivity.It is currently the only one validated in Spanish.Major studies are needed in order to establish its universal validity.

[Applications of informatics in anesthesiology: anesthesia graphics]. / Aplicaciones de la informática en anestesiología: gráfica anestésica.

Computerization has brought radical changes to anesthesiology. Quality of care, management, cost control, training, research, safety and privacy have all improved. The anesthesiologist has been freed from repetitive clerical tasks and is able to make better use of time. A graphic display of anesthesia is only one of the many computer applications available as a consequence of links created among monitoring, continuous infusion and intelligent alarm systems, automatic data collection, network monitoring and the availability of bibliographic information (through Internet connection). The computer graphic display of anesthesia is more precise, legible, complete and reliable (during critical events, in substitutions of anesthesiologists or for research) than the traditional graph. One of the greatest problems of computer graphing today--besides start-up costs--is that of inserting comments on monitoring artifacts, given that the graph is a legally valid medical document.

[Reversion of atracurium and vecuronium residual nondepolarising neuromuscular blockade with low doses of neostigmine]. / Reversión del bloqueo neuromuscular residual por atracurio y vecuronio con dosis bajas de neostigmina.

OBJECTIVES: To assess the effectiveness of low doses of neostigmine in the reversion of residual non-polarising neuromuscular blockade (RNMB). MATERIAL AND METHODS: The work involved one hundred and nineteen adult patients, ASA I-III, anaesthetised with fentanyl, thiopental, O2-N2O-isoflurane and atracurium (n=62) or vecuronium (n=57). RNMB was monitored with continuous electromyography of adductor pollicis with TOF stimulation. When TOF-Ratio (TR) < 75%, neostigmine 0.035, 0.03, 0.025 or 0.02 mg/kg (and atropine 0.0175, 0.015, 0.0125 or 0.01 mg/kg) were administrated based on the degree of NMB (0-1, 2, 3 or 4) to TOF stimulation respectively, registering the time to achieve TR > 75% and secondary effects. RESULTS: Both groups were homogeneous. Twenty-five point eight percent (25.8%) (group A) and 21.1% (group V) presented TR>75% at the end of surgery, while 11.3% and 19.2% showed TR < 75% with 0-1 responses, 6.5% and 11.5% 2 responses, 4.8% and 7.6% 3 responses, and 51.6% and 50% 4 responses to TOF stimulation in groups A or V respectively. All patients who received neostigmine presented TR > 75% in 10.5+/-7 (group A) and 10.3+/-6.4 min. (group V). A predominance of secondary effects in the atracurium group was observed (p=0.027), basically due to excessive salivation, nausea and vomiting. There were no cases of RNMB. CONCLUSIONS: The reversion of the residual neuromuscular blockade of atracurium or vecuronium with low doses of neostigmine and atropine adjusted to the degree of RNMB is effective even in deep blockades, reducing the risk of secondary effects.

[Negative pressure pulmonary edema: 3 case reports]. / Edema pulmonar por presión negativa: a propósito de 3 casos.

Negative pressure pulmonary edema is a complication, described since 1977, caused by upper airway obstruction in both children and adults. Although its aetiopathogeny is multifactorial, especially outstanding is excessive negative intrathoracic pressure caused by the forced spontaneous inspiration of a patient against a closed glottis, that causes high arteriole and capillary fluid pressures that favor transudation into the alveolar space The resulting pulmonary edema can appear a few minutes after the obstruction of the airway or in a deferred way after several hours. The clinical manifestations are potentially serious, but normally respond well to treatment with supplemental oxygen, positive pressure mechanical ventilation and diuretics. Diagnostic suspicion is important for acting promptly. We report three clinical cases with acute negative pressure pulmonary edema.

Comparative study of intubating conditions at the first minute with suxamethonium, rocuronium and different priming techniques of rocuronium.

BACKGROUND AND OBJECTIVE: To evaluate orotracheal intubation conditions after 1 min. PATIENTS AND METHODS: A prospective randomized study with 376 adult American Society of Anesthesiologists (ASA) Grade I-III patients. Each patient received propofol, fentanyl and either suxamethonium (1 mg kg(-1)) or rocuronium. The intubating dose of rocuronium (2 x ED95) was preceded 4 min earlier by saline, or a 0.1 x ED95 priming dose of rocuronium, atracurium, cis-atracurium, vecuronium or mivacurium. Intubating conditions were graded as excellent, good or poor with respect to laryngoscopy, vocal cord position and movement and reaction to intubation and/or cuff inflation. RESULTS: There were significant differences (P < 0.05) in laryngoscopy between suxamethonium and rocuronium primed with saline, atracurium or cis-atracurium. With respect to vocal cord position and movement during intubation, rocuronium without priming differed significantly from all other groups and for reaction to insertion of tracheal tube and/or cuff inflation. Rocuronium without priming differed significantly from all other groups except for rocuronium primed with itself. The mivacurium group showed more signs of pre-curarization than other groups (P < 0.05). There were significant differences between rocuronium alone and the other groups when final intubating conditions were compared. CONCLUSIONS: Priming rocuronium with 0.1 x ED95 of vecuronium, rocuronium, atracurium or cis-atracurium is a safe technique and did not increase risk of pre-curarization in healthy patients.