RESUMO
BACKGROUND: Chronic abdominal pain is common in chronic pancreatitis (CP) and may involve altered central pain processing. This study evaluated the relationship between pain processing and pain outcome after pancreatic duct decompression and/or pancreatic resection in patients with CP. METHODS: Patients with CP underwent quantitative sensory testing. Pain processing was measured via electrical pain detection (ePDT) and electrical pain tolerance (ePTT) thresholds in dermatomes C5 and L4. Inhibitory descending pain control mechanisms were assessed using the conditioned pain modulation (CPM) paradigm. Healthy controls and patients with CP were compared, and patients with CP and a poor pain outcome (visual analogue scale (VAS) score greater than 30) were compared with those with a good pain outcome (VAS score 30 or less). RESULTS: Forty-eight patients with CP had lower ePDT, ePTT and CPM responses compared with values in 15 healthy controls (P < 0·030). The sum of ePDT values was lower in patients with a poor pain outcome than in those with a good outcome (median 7·1 versus 11·2 mA; P = 0·008). There was a correlation with the VAS score and the sum of ePDT values (rs = -0·45, P = 0·016) and ePTT values (rs = -0·46, P = 0·011), and CPM response (rs = -0·43, P = 0·006) in patients with CP. CONCLUSION: After pain-relieving pancreatic surgery, patients with CP exhibit altered central pain processing compared with that in healthy controls. Poor pain outcomes are associated with more central sensitization and more pronociceptive descending pain modulation, and this should be considered when managing persistent pain after pain-relieving surgery for CP.
Assuntos
Dor Abdominal/fisiopatologia , Sistema Nervoso Central/fisiologia , Pancreatite Crônica/fisiopatologia , Adulto , Estudos de Casos e Controles , Sensibilização do Sistema Nervoso Central/fisiologia , Dor Crônica/fisiopatologia , Temperatura Baixa , Descompressão Cirúrgica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Limiar da Dor/fisiologia , Pancreatite Crônica/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Itch and pain are common symptoms in skin disease. It has been suggested that negative emotions may play a role in itch and pain. To date, however, the role of emotions has only been studied for pain in experimental studies, not yet for itch. OBJECTIVES: To investigate the effects of negative and positive emotions on the sensitivity to itch and pain. METHODS: Film fragments were used to induce a negative or positive emotional state in healthy women. Itch and pain were induced using the following somatosensory stimuli: electrical stimulation, histamine iontophoresis and the cold pressor test. RESULTS: Results showed that the scores for itch and pain evoked by histamine and the cold pressor test, respectively, were significantly higher in the negative than in the positive emotion condition, whereas tolerance thresholds to electrical stimulation and the cold pressor test, and stimulus unpleasantness scores did not differ between the two conditions. CONCLUSIONS: These findings for the first time indicate in an experimental design that emotions play a role in sensitivity to somatosensory sensations of both itch and pain.
Assuntos
Emoções , Dor/psicologia , Prurido/psicologia , Análise de Variância , Temperatura Baixa , Estimulação Elétrica , Feminino , Histamina/farmacologia , Agonistas dos Receptores Histamínicos/farmacologia , Humanos , Iontoforese , Medição da Dor , Autorrelato , Adulto JovemRESUMO
BACKGROUND: Bilateral thoracoscopic splanchnicectomy (BTS) is a well-known technique to alleviate intractable pain in patients with chronic pancreatitis. BTS not only disrupts afferent fibers from the pancreas that mediate pain but also postganglionic sympathetic fibers, which originate in segments T5-T12 and which innervate the vasculature of the liver, pancreas, and the adrenal gland. The purpose of this study was to assess whether and how BTS affects sympathetic noradrenergic and adrenomedullary function in patients with chronic pancreatitis. METHODS: Sixteen patients with chronic pancreatitis for at least 1 year underwent autonomic function testing before and 6 weeks after BTS for intractable pain. Testing was performed during supine rest and during sympathetic stimulation when standing. RESULTS: Supine and standing systolic and diastolic blood pressure were significantly lower post-BTS compared with pre-BTS (P = 0.001). One patient showed orthostatic hypotension after BTS. Baseline plasma norepinephrine levels and plasma norepinephrine responses to sympathetic activation during standing were not reduced by BTS. In contrast, supine plasma epinephrine levels and responses during standing were significantly reduced (P < 0.001). Parasympathetic activity was unaffected by BTS as shown by unaltered Valsalva ratio, I-E difference, and ΔHRmax. CONCLUSIONS: BTS for pain relief in patients with chronic pancreatitis reduced adrenomedullary function, due to disruption of the efferent sympathetic fibers to the adrenal gland. BTS did not affect noradrenergic sympathetic activity, although blood pressure was lower after the sympathectomy.
Assuntos
Bloqueio Nervoso Autônomo/métodos , Dor Intratável/cirurgia , Pancreatite Crônica/complicações , Nervos Esplâncnicos/cirurgia , Toracoscopia/métodos , Medula Suprarrenal/fisiologia , Adulto , Idoso , Sistema Nervoso Autônomo/fisiologia , Pressão Sanguínea/fisiologia , Epinefrina/metabolismo , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Norepinefrina/metabolismo , Dor Intratável/sangue , Dor Intratável/etiologia , Pancreatite Crônica/sangue , Pancreatite Crônica/fisiopatologia , Postura , Respiração , Manobra de Valsalva/fisiologiaRESUMO
BACKGROUND: Central sensitisation due to visceral pancreatic nociceptive input may play an important role in chronic pancreatitis pain. Using quantitative sensory testing (QST), this first study investigates whether thoracoscopic splanchnic denervation (TSD), performed to reduce nociceptive visceral input, affects central sensitisation in chronic pancreatitis patients. PATIENTS AND METHODS: We studied 19 chronic pancreatitis patients (11 men, 8 women on stable opioid medication) and 18 healthy volunteers as preoperative controls. Preoperatively and 6 weeks after TSD, pain numeric rating scores, opioid medication, and thresholds to electric skin stimulation and pressure pain (measured in dermatomes T10 (pancreas), C5, T4, L1, L4) were documented. Treatment success was defined as cessation of opioids 6 weeks after TSD. RESULTS: Six weeks after TSD, there was a trend towards lower pain scores, only 10 patients were still on opioids (P<0.05 vs. preoperatively) and thresholds overall were significantly higher than preoperatively (pressure pain: +25%, P<0.001; electric: sensation +55%, pain detection +34%, pain tolerance +21%, P<0.05). Gender-specific differences in hypoalgesia patterns were seen. Preoperatively, TSD treatment successes consumed significantly less opioids than failures, without significant differences in preoperative patterns of neuroplasticity. CONCLUSIONS: TSD for chronic pancreatitis pain resulted in fewer patients on opioids and overall increases in pain thresholds. Our results suggest that TSD for reducing visceral nociceptive input may be effective in reducing resulting central sensitisation. Although patients benefiting from TSD consume less opioids preoperatively, we were unable to clearly link treatment success with specific perioperative patterns of neuroplasticity such as the presence or absence of hyperalgesia.
Assuntos
Denervação , Dor/etiologia , Dor/cirurgia , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia , Nervos Esplâncnicos/cirurgia , Toracoscopia , Adulto , Idoso , Estimulação Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nociceptores/fisiologia , Medição da Dor , Limiar da Dor/fisiologia , Pressão , Estudos ProspectivosRESUMO
Pain is the major presenting symptom of chronic pancreatitis. Patients with chronic pancreatitis experience substantial impairments in health-related quality of life. Pain may be considered as the most important factor affecting the quality of life. The pathogenesis of pancreatic pain is poorly understood. The cause of pain in chronic pancreatitis is probably multifactorial. This article discusses the various hypotheses that have been suggested to underlie pain. Special attention is paid to the concept of autonomous central sensitisation and hyperalgesia as a cause of pain. Strict abstinence from alcohol is the first step of chronic pancreatic pain management. As a second step, it is important to exclude treatable complications of chronic pancreatitis, such as pseudocysts. Symptomatic treatment with analgesics is often unavoidable in patients with chronic pancreatitis. Acetaminophen, non-steroidal anti-inflammatory drugs and eventually opioids are suitable. Several trials have been performed with pancreatic enzymes, but a meta-analysis demonstrated no significant benefit in terms of pain relief. The treatment of chronic pancreatic pain requires a multidisciplinary approach that tailors the various therapeutic options to meet the need of the individual patient.
Assuntos
Dor/tratamento farmacológico , Pancreatite Crônica/tratamento farmacológico , Animais , Dieta , Humanos , Estresse Oxidativo , Dor/etiologia , Pancreatite Crônica/complicações , Qualidade de VidaRESUMO
Protocols for testing conditioned pain modulation (CPM) vary between different labs/clinics. In order to promote research and clinical application of this tool, we summarize the recommendations of interested researchers consensus meeting regarding the practice of CPM and report of its results.
Assuntos
Condicionamento Psicológico/fisiologia , Limiar da Dor/fisiologia , Dor/diagnóstico , Humanos , Medição da Dor/métodosRESUMO
Status epilepticus is one of the most frequent neurological emergencies in the intensive care unit. Standard treatment includes intravenous barbiturates, benzodiazepines and phenytoin. However, drug coma is sometimes necessary to control refractory status epilepticus. We report such a case, successfully treated by intravenous propofol coma to EEG burst suppression.
Assuntos
Coma/induzido quimicamente , Propofol/uso terapêutico , Estado Epiléptico/tratamento farmacológico , Clonazepam/uso terapêutico , Quimioterapia Combinada , Eletroencefalografia , Escala de Coma de Glasgow , Humanos , Infusões Intravenosas , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Fenitoína/uso terapêutico , Estado Epiléptico/diagnósticoRESUMO
Chronic pain management by Swiss specialist physicians with the primary hypothesis that pain clinic practitioners conform better to good practice (interdisciplinarity, diagnostic/therapeutic routines, quality control, education) than other specialists treating chronic pain was surveyed. Management of all types of chronic pain by pain clinic practitioners and rheumatologists, oncologists or neurologists was compared via a mailed questionnaire survey (n=125/group). Two hundred and twenty-nine (46%) of 500 mailed questionnaires were returned with similar group return rates. Eighty-six percent of responders find chronic pain therapy very difficult/difficult; they estimate only 45% of these patients achieve good outcomes. Twenty-three per cent of responders belong to an interdisciplinary pain centre, but 72% of chronic pain patients are treated by responders alone. Fifty-nine percent never/only occasionally use therapeutic algorithms, 38% use formal pain diagnostic procedures, 20% have a pain quality control programme. Fifty-one percent lack past pain education, 37% do not attend continuing pain education, 69% agree that pain education is their greatest need. Pain clinic practitioners are more interdisciplinary and use more pain diagnostics than other specialists. They are matched by oncologists in education and success in therapeutic escalation, and bettered by them in algorithm use. Pain clinic practitioners and oncologists bring particular-differing-skills to chronic pain management compared to rheumatologists and neurologists. Chronic pain management diversity may result from differences in malignant and benign pain, and its generally being provided by the speciality treating the underlying cause. This survey identifies targets for improvement in areas fundamental to good chronic pain practice: interdisciplinarity, diagnostic/therapeutic tools, quality management and education.
Assuntos
Medicina/normas , Clínicas de Dor/normas , Manejo da Dor , Garantia da Qualidade dos Cuidados de Saúde/métodos , Especialização , Algoritmos , Analgésicos/uso terapêutico , Doença Crônica , Protocolos Clínicos/normas , Educação Médica Continuada/tendências , Humanos , Relações Interprofissionais , Medicina/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Dor/diagnóstico , Clínicas de Dor/tendências , Medição da Dor/métodos , Garantia da Qualidade dos Cuidados de Saúde/normas , Inquéritos e Questionários , Suíça , Resultado do TratamentoRESUMO
We believe that today balanced TIVA represents the best anesthetic technique for neurological surgery. Freely acknowledging that this point of view is unproven (36) with regard to the hard criterion of patient outcome on leaving the hospital, we submit that the intermediate or surrogate criteria discussed make a convincing case for preferring TIVA to volatile-based anesthetic techniques. Until a study demonstrating hard outcome differences between the two techniques is achieved, we will continue to encourage the use of TIVA in neuroanesthesia, based on its practical (anesthetic depth, neuromonitoring, surgical field) and theoretical (homeostasis, metabolism, antinociception, neuroprotection) advantages.
Assuntos
Anestesia Intravenosa , Encéfalo/cirurgia , Analgésicos/farmacologia , Anestesia por Inalação , Anestésicos Intravenosos/farmacocinética , Anestésicos Intravenosos/farmacologia , Encéfalo/metabolismo , Encéfalo/fisiologia , Isquemia Encefálica/prevenção & controle , Homeostase , Humanos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
We describe a case in which jugular venous bulb oxygen saturation (SjvO2) monitoring proved useful during the surgical resection of an intracranial arteriovenous malformation (AVM). Surgical resection of large intracranial AVMs may be followed by normal perfusion pressure breakthrough with brain swelling, hyperemia, and subsequent problems in achieving hemostasis. SjvO2 monitoring during AVM embolization by interventional radiology has been shown to help in deciding whether embolization is sufficient to avoid such postresection hyperemia, but its use during surgical resection has not been described. In the case discussed, SjvO2 monitoring enabled assessment of the risk of postresection hyperemia preoperatively and permitted the degree and completeness of surgical AVM resection to be followed intraoperatively. During the normal perfusion pressure breakthrough bleeding which followed complete AVM resection, SjvO2 monitoring helped with safe management of the controlled hypotension that finally permitted hemostasis to be achieved.
Assuntos
Malformações Arteriovenosas Intracranianas/cirurgia , Oxigênio/sangue , Adulto , Encéfalo/patologia , Artéria Carótida Interna/diagnóstico por imagem , Embolização Terapêutica , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/diagnóstico , Malformações Arteriovenosas Intracranianas/fisiopatologia , Veias Jugulares , Imageamento por Ressonância Magnética , Masculino , Monitorização Intraoperatória , Radiografia , Fatores de TempoRESUMO
In order to explain the reported shorter clinical duration of action of cumulative ED95 of pipecuronium in infants as compared to children or adults, the pharmacokinetic profiles of pipecuronium were compared in infants (n = 6; mean age 6.8 months; mean weight 7.3 kg) in children (n = 6; mean age 4.6 years; mean weight 19.2 kg) and in adults (n = 7; mean age 42 years; mean weight 58.2 kg). Equipotent doses (2 x ED95) of pipecuronium were injected i.v. as single bolus and arterial blood was sampled for 4-5 h. Pipecuronium was quantified by complex formation with [125I]-labelled rose bengal. Pharmacokinetic parameters were calculated using a two-compartment open model. The median for the distribution half-life of pipecuronium was 2.54 min (interquartile range: 1.0-2.5 min) in infants and 2.04 min (0.26-2.04 min) in children; both were significantly shorter than in adults (5.75 [3.7-9.7] min). The plasma clearance of pipecuronium was significantly decreased in infants (1.50 [0.6-1.5] ml.min-1.kg-1; P < 0.05) as compared to children and adults (2.27 [0.88-2.27] and 2.45 [1.7-3.2] ml.min-1.kg-1, respectively). The total volume of distribution was similar in all three groups. We conclude that the pharmacokinetic features of pipecuronium are age-dependent: differences as compared to adults consisted of a faster distribution in both infants and children and a slower elimination in infants. The pharmacokinetic profile of pipecuronium does not explain the faster recovery from neuromuscular blockade in infants as compared to children. Because of the low total plasma clearance in infants, pipecuronium dosage should be carefully monitored to avoid accumulation and prolonged paralysis.
Assuntos
Fármacos Neuromusculares não Despolarizantes/farmacocinética , Pipecurônio/farmacocinética , Adolescente , Adulto , Fatores Etários , Pré-Escolar , Humanos , Lactente , Fármacos Neuromusculares não Despolarizantes/sangue , Pipecurônio/sangueRESUMO
We studied nociception-associated arousal following laryngoscopy and intubation in patients scheduled for elective open heart surgery, using EEG power spectra and hemodynamics. Either fentanyl (7 micrograms/kg; n = 30) or sufentanil (1 microgram/kg; n = 30) were given in a randomized fashion to induce anesthesia in heavily premedicated patients, followed by pancuronium bromide (100 micrograms/kg). EEG-power spectra (delta, theta, alpha, beta) as well as mean arterial blood pressure (MAP) and heart rate (HF) were measured at the following end-points: before the induction of anesthesia (control), 1 and 10 minutes after laryngoscopy and intubation (L & I). Linear regression analysis was computed to determine which of the EEG power spectra was most sensitive to detect insufficient blockade of nociceptive-related arousal when correlated with haemodynamics. In the fentanyl group the change in HF closely correlated with the decrease of power in the slow delta- and theta-domain (r2 = 0.98 and r2 = 0.89 respectively) of the EEG. The change in MAP also closely correlated with a decrease in the slow delta- and theta-domain (r2 = 0.97 and r2 = 0.99 respectively). There was little correlation in regard to spectral edge frequency (SEF) and HF and MAP changes (r2 = 0.36 and r2 = 0.12 respectively). In the sufentanil group the change in HF correlated closely with an increase of power in the fast alpha and a decrease in the slow theta-domain (r2 = 0.91 and r2 = 0.98 respectively) of the EEG. The changes in MAP closely correlated with an increase in the fast alpha-band a decrease in the slow theta-domain (r2 = 0.98 and r2 = 0.73 respectively). Also there was little correlation of SEF with HF and MAP changes (r2 = 0.09 and r2 = 0.02 respectively). Among the EEG-spectra, reduction of power in the slow delta- and theta-bands are the most sensitive parameters to determine insufficient antinociception of opioids commonly used for the induction in cardiac anesthesia. Increase of power in the alpha-band seems to be closely correlated with cortical reactivation and reduction of hypnosis, while a reduction of power especially in the deltabut more so in the theta-band of the EEG reflects nociception related arousal.
Assuntos
Anestésicos Intravenosos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Eletroencefalografia/efeitos dos fármacos , Fentanila/administração & dosagem , Frequência Cardíaca/efeitos dos fármacos , Intubação Intratraqueal , Laringoscopia , Sufentanil/administração & dosagem , Ritmo alfa/efeitos dos fármacos , Nível de Alerta/efeitos dos fármacos , Ponte de Artéria Coronária , Ritmo Delta/efeitos dos fármacos , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Nociceptores/efeitos dos fármacos , Pancurônio/administração & dosagem , Medicação Pré-Anestésica , Estudos Prospectivos , Ritmo Teta/efeitos dos fármacosRESUMO
Owing to the recent advances of bioelectric signals computerized treatment a real monitoring of anaesthesia is now possible, either by EEG or by classical or event-related evoked potentials methods. Available methods and their indications and difficulties are discussed with the help of some clinical examples.
Assuntos
Anestesia , Monitorização Fisiológica/métodos , Eletroencefalografia , Potenciais Evocados/fisiologia , HumanosRESUMO
BACKGROUND: High-frequency electrical stimulation (HFS) of human skin induces not only an increased pain sensitivity in the conditioning area but also an increased pain sensitivity to mechanical punctate stimuli in the non-conditioned surrounding skin area. The aim of the present study was to investigate whether this heterotopically increased mechanical pain sensitivity can be facilitated through the induction of negative expectations. METHODS: In two independent conditions [a nocebo (n = 15) and control condition (n = 15)], we applied mechanical pain stimuli before, directly after, 10 min and 20 min after HFS in the skin area surrounding the conditioning area, and measured the reported pain intensity [visual analogue scale (VAS)]. All subjects (of both conditions) received a written instruction about the HFS protocol, but only the instruction in the nocebo condition was extended by the following text (in Dutch): 'After the HFS, your skin will become more sensitive to the pinprick stimulation'. RESULTS: Our results clearly show that induced expectations of increased mechanical pain sensitivity after HFS facilitates the reported pain intensity after HFS more than when no information is given. CONCLUSIONS: This study shows for the first time that brain mechanisms, via the induction of negative expectations, can facilitate heterotopic mechanical hyperalgesia after HFS of human skin.
Assuntos
Estimulação Elétrica , Hiperalgesia/psicologia , Enquadramento Psicológico , Adolescente , Adulto , Condicionamento Psicológico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fibras Nervosas Amielínicas/fisiologia , Efeito Nocebo , Medição da Dor , Limiar da Dor/fisiologia , Estimulação Física , Pele , Adulto JovemAssuntos
Colífagos/metabolismo , Escherichia coli/metabolismo , Óperon , Sítios de Ligação , Vírus de DNA/metabolismo , Indução Enzimática , Repressão Enzimática/efeitos dos fármacos , Frequência do Gene , Isoleucina/farmacologia , Mutação , Recombinação Genética , Treonina/metabolismo , Treonina/farmacologia , Transdução Genética , Triptofano Sintase/metabolismoRESUMO
Pain treatment in chronic pancreatitis patients is difficult, with pain frequently relapsing or persisting. Recent studies suggest that altered central nervous system pain processing underlies the chronic pain state in these patients. There is evidence that increased sympathetic activity may also play a role in some chronic pain syndromes. This study assessed sympathetic nervous system activity and its relation to pain processing in patients with severe painful chronic pancreatitis. The authors postulated that chronic pancreatitis patients with more sympathetic activity exhibit more generalized hyperalgesia. In 16 chronic pancreatitis patients, sympathetic activity was measured via venous plasma norepinephrine (NE) levels (supine, standing). Pain processing was quantified via pressure pain tolerance thresholds (PPTs) in dermatomes T10 (pancreatic area), C5, T4, L1. Five patients showed increased supine plasma NE levels (NE ≥ 3.0 nmol/L). PPTs were lower in patients with increased NE levels (INE) compared with patients with normal NE (NNE) (means [95% confidence interval]: INE 402 kPa [286-517] versus NNE 522 kPa [444-600]; P = .042). In severe chronic pancreatitis patients, increased sympathetic activity and hyperalgesia appear associated, suggesting that sympathetic activity may also play a role in these patients' pain.