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BACKGROUND: Patient-controlled analgesia (PCA) is one of the most popular and effective methods for managing postoperative pain. Various types of continuous infusion pumps are available for the safe and accurate administration of analgesic drugs. Here we report the causes and clinical outcomes of device-related errors in PCA. METHODS: Clinical records from January 1, 2011 to December 31, 2014 were collected by acute pain service team nurses in a 2715-bed tertiary hospital. Devices for all types of PCA, including intravenous PCA, epidural PCA, and nerve block PCA, were included for analysis. The following 4 types of infusion pumps were used during the study period: elastomeric balloon infusers, carbon dioxide-driven infusers, semielectronic disposable pumps, and electronic programmable pumps. We categorized PCA device-related errors based on the error mechanism and clinical features. RESULTS: Among 82,698 surgical patients using PCA, 610 cases (0.74%) were reported as human error, and 155 cases (0.19%) of device-related errors were noted during the 4-year study period. The most common type of device-related error was underflow, which was observed in 47 cases (30.3%). The electronic programmable pump exhibited the high incidence of errors in PCA (70 of 15,052 patients; 0.47%; 95% confidence interval, 0.36-0.59) among the 4 types of devices, and 96 of 152 (63%) patients experienced some type of adverse outcome, ranging from minor symptoms to respiratory arrest. CONCLUSIONS: The incidence of PCA device-related errors was <0.2% and significantly differed according to the infusion pump type. A total of 63% of patients with PCA device-related errors suffered from adverse clinical outcomes, with no mortality. Recent technological advances may contribute to reducing the incidence and severity of PCA errors. Nonetheless, the results of this study can be used to improve patient safety and ensure quality care.
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Analgesia Controlada pelo Paciente/efeitos adversos , Analgésicos Opioides/efeitos adversos , Falha de Equipamento , Erros de Medicação/efeitos adversos , Centros de Atenção Terciária , Analgesia Controlada pelo Paciente/tendências , Feminino , Humanos , Bombas de Infusão/efeitos adversos , Bombas de Infusão/tendências , Masculino , Erros de Medicação/tendências , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária/tendênciasRESUMO
Objective: A cervical epidural steroid injection is one of the most commonly performed interventions to manage chronic neck pain and cervical radiculopathy. Despite its many severe complications, cervical transforaminal epidural steroid injection (CTFESI) is a clinically necessary modality for managing neck pain and cervical radiculopathy. We aimed in this study to find a safer optimal needle entry angle to decrease the chance of an accidental vertebral artery (VA) puncture even with a proper needle entry angle and to visualize the target of the needle tip. Methods: This retrospective study included 312 patients with neck pain or cervical radiculopathy who had undergone magnetic resonance imaging scans for diagnosis and treatment. The first line was drawn from the midpoint of the two articular pillars and passed through the exact midline of the spinous process. The second line was drawn parallel to the ventral lamina line (conventional transforaminal approach line, CTAL). The third line was drawn parallel to the ventral margin at the midpoint of the superior articular process's ventral border (new transforaminal approach line, NTAL). The angle of intersection between the midline and CTAL versus with NTAL were measured from both sides (right and left) at C5-6, C6-7, and C7-T1 levels. Also, the distance of CTAL and NTAL from VA were measured from both sides at each level. We examined whether the CTAL and NTAL would penetrate the ipsilateral VA, internal carotid artery (ICA), and internal jugular vein (IJV). Results: There were significant differences between CTAL and NTAL angles at all levels (P < 0.001). There were significant differences between the distance of CTAL and NTAL from VA at all levels (P < 0.001). There were also significant differences between the observed frequency of CTAL and NTAL that would penetrate the major ipsilateral vessel (VA, ICA, and IJV) on all levels and sides (P < 0.001~0.030). Conclusion: The angle of NTAL (approximately 70°) is safer than the angle of CTAL (approximately 50°) when considering vascular injuries to vessels, such as the VA, ICA, and IJV.
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Injeções Epidurais/métodos , Cervicalgia/tratamento farmacológico , Radiculopatia/tratamento farmacológico , Esteroides/administração & dosagem , Adulto , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/fisiopatologia , Feminino , Humanos , Injeções Epidurais/efeitos adversos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Cervicalgia/complicações , Cervicalgia/diagnóstico por imagem , Agulhas/efeitos adversos , Manejo da Dor/métodos , Radiculopatia/complicações , Radiculopatia/diagnóstico por imagem , Esteroides/efeitos adversos , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/lesões , Artéria Vertebral/fisiopatologiaRESUMO
OBJECTIVES: The objective of this study was to determine the effects of combining pulsed radiofrequency (PRF) treatment and transforaminal epidural injection (TFEI) to treat patients with chronic refractory lumbar radicular pain caused by lumbar spinal stenosis. STUDY DESIGN: Randomized control trial. SETTINGS: Interventional pain management practice. METHOD: Sixty-two patients were assigned to the study groups (PRF group = 31; control group = 31). Under fluoroscopic guidance, the RF needle was positioned close to the lumbar dorsal root ganglion. The PRF group received 3 cycles of PRF treatment, and sensory stimulation without RF lesioning was applied to the control group. After PRF or sham lesioning, a local anesthetic with steroid was injected. The primary outcome of a successful response was defined as: 1) ≥50% or 4-point pain reduction in the numerical rating scale (NRS) without an increase in the Oswestry disability index (ODI) or medication quantification scale (MQS), or mean score <4 in the global perceived effect (GPE) scale; or 2) ≥30% or 2-point pain reduction in NRS with a simultaneous decrease in ODI, MQS, or ≥6 points in the GPE scale. RESULT: The number of patients with successful treatment results was higher in the PRF group at 2 months (P = 0.032) and 3 months (P = 0.018). No significant differences were observed in terms of the secondary outcome variables between the 2 groups. CONCLUSION: The TFEI provided significant short-term pain relief and PRF can be applied in conjunction with TFEI to achieve higher treatment efficacy compared with TFEI alone.
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Anestésicos Locais/administração & dosagem , Dor Lombar/terapia , Manejo da Dor/métodos , Tratamento por Radiofrequência Pulsada/métodos , Radiculopatia/terapia , Idoso , Terapia Combinada/métodos , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Injeções Epidurais , Dor Lombar/diagnóstico , Região Lombossacral , Masculino , Pessoa de Meia-Idade , Medição da Dor/efeitos dos fármacos , Medição da Dor/métodos , Radiculopatia/diagnóstico , Resultado do TratamentoRESUMO
PURPOSE: This study aimed to investigate the association between the clinical symptoms of central lumbar spinal stenosis (CLSS) and morphological parameters using magnetic resonance imaging (MRI) data. METHODS: We retrospectively reviewed 117 patients who visited our pain clinic from 2009 to 2013 and were diagnosed as CLSS. All patients underwent MRI of the L-spine and we measured the dural sac cross-sectional area (DSA), spinal canal cross-sectional area (SCA), ligamentum flavum cross-sectional area (LFA) and ligamentum flavum thickness (LFT) at the most stenotic intervertebral level on MRI. Clinical outcomes were investigated using the patient-assessed quantitative measurement of visual analog scale (VAS) and subjective disability was assessed by the Oswestry Disability Index (ODI). Additionally, subjective walking distance (SWD) was also collected from electronic medical records. RESULTS: There were no statistically significant correlations found between the VAS score and the DSA, SCA, LFA, and LFT. A statistically significant linear association existed between the DSA and SCA and the subjective walking distance (r=0.201, P=0.045 and r=0.198, P=0.049, respectively) indicating that the larger the DSA or SCA, the longer the SWD before the occurrence of claudication. The LFA and LFT were significantly correlated with the ODI score (r=0.249, P=0.007 and r=0.250, P=0.007, respectively). CONCLUSION: Larger LFA and LFT values are associated with higher ODI values. A larger DSA and SCA are associated with a longer SWD before claudication occurs. To evaluate CLSS patients, clinicians should more carefully inspect the integral morphological parameters than the individual morphological parameters.
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Vértebras Lombares , Imageamento por Ressonância Magnética , Estenose Espinal , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Vértebras Lombares/patologia , Vértebras Lombares/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estenose Espinal/diagnóstico , Estenose Espinal/epidemiologia , Estenose Espinal/patologia , Estenose Espinal/fisiopatologiaRESUMO
OBJECTIVE: Monitoring of cardiac output is required during anesthesia for off-pump coronary artery bypass (OPCAB) surgery. Recently, FloTrac, a new device for arterial pressure waveform analysis for cardiac output (APCO) monitoring without external calibration, was developed. The authors have compared APCO with STAT-mode continuous cardiac output (SCCO) in patients undergoing OPCAB surgery. DESIGN: A clinical study. SETTING: A university hospital (single institution). PARTICIPANTS: Thirty consecutive patients undergoing elective OPCAB surgery. INTERVENTIONS: Arterial pressure measurement with FloTrac, pulmonary arterial catheter insertion. MEASUREMENTS AND MAIN RESULTS: APCO and SCCO measurements were recorded after pulmonary artery catheter insertion (T1), after sternotomy (T2), after heart positioning for left anterior descending artery anastomosis (T3, T4), after heart positioning for obtuse marginal artery anastomosis (T5, T6), after heart positioning for posterior descending artery anastomosis (T7, T8), and after sternal closure (T9). APCO and SCCO were compared using the Bland-Altman method and the percentage error by Critchley's criteria. SCCO and APCO ranged from 2.1 to 6.9 L/min and 1.2 to 7.4 L/min, respectively, and showed low correlation (r = 0.29). The overall bias by the Bland-Altman method between SCCO and APCO was -0.23 L/min, with a precision of -1.4 to 0.9 L/min, and the overall limits of agreement were -2.5 to 2.0 L/min. The overall mean CO was 4.0 ± 0.95 L/min. The overall percentage error between SCCO and APCO measurements was 57%. CONCLUSIONS: Uncalibrated APCO values do not agree with thermodilution SCCO and significantly overestimated the SCCO in patients undergoing OPCAB surgery. Further evaluation is required to verify the clinical acceptance of FloTrac APCO in OPCAB surgery.
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Monitores de Pressão Arterial/normas , Pressão Sanguínea/fisiologia , Débito Cardíaco/fisiologia , Ponte de Artéria Coronária sem Circulação Extracorpórea/normas , Procedimentos Cirúrgicos Eletivos/normas , Monitorização Intraoperatória/normas , Idoso , Calibragem/normas , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Estudos Prospectivos , Termodiluição/métodos , Termodiluição/normasRESUMO
Although endoscopic ultrasound-guided celiac neurolysis (EUS-CN) and percutaneous celiac neurolysis (PCN) are utilized to manage intractable pain in pancreatic cancer patients, no direct comparison has been made between the two methods. We compared the efficacy and safety of EUS-CN and PCN in managing intractable pain in such patients. Sixty pancreatic cancer patients with intractable pain were randomly assigned to EUS-CN (n = 30) or PCN (n = 30). The primary outcomes were pain reduction in numerical rating scale (NRS) and opioid requirement reduction. Secondary outcomes were: successful pain response (NRS decrease ≥50% or ≥3-point reduction from baseline); quality of life; patient satisfaction; adverse events; and survival rate at 3 months postintervention. Both groups reported sustained decreases in pain scores up to 3 months postintervention (mean reductions in abdominal pain: 0.9 (95% confidence interval (CI): -0.8 to 4.2) and 1.7 (95% CI: -0.3 to 2.1); back pain: 1.3 (95% CI: -0.9 to 3.4) and 2.5 (95% CI: -0.2 to 5.2) in EUS-CN, and PCN groups, respectively). The differences in mean pain scores between the two groups at baseline and 3 months were -0.5 (p = 0.46) and -1.4 (p = 0.11) for abdominal pain and 0.1 (p = 0.85) and -0.9 (p = 0.31) for back pain in favor of PCN. No significant differences were noted in opioid requirement reduction and other outcomes. EUS-CN and PCN were similarly effective and safe in managing intractable pain in pancreatic cancer patients. Either methods may be used depending on the resources and expertise of each institution.
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PURPOSE: This study compared the efficacy and safety of controlled-release pregabalin (GLA5PR GLARS-NF1 tablets) with those of an immediate-release pregabalin capsule after 12 weeks' administration to patients with peripheral neuropathic pain. METHODS: In this multicenter, randomized, double-blind, active-controlled, parallel-group, Phase III study, the primary outcome was to confirm that a single treatment with the study drug (after the evening meal) is clinically noninferior to the control drug (BID regimen) at improving the mean Daily Pain Rating Scale score for treating peripheral neuropathic pain. Secondary outcomes were the Daily Sleep Interference Scale, Medical Outcomes Study Sleep Scale, Hospital Anxiety and Depression scale, and frequency of rescue medication use. The safety and tolerability of GLA5PR GLARS-NF1 tablets were also evaluated. The total daily dose of pregabalin is 150-600 mg. FINDINGS: Of the 352 randomized subjects, 261 (n = 130, study group; n = 131, control group) were analyzed. The difference in adjusted mean Daily Pain Rating Scale scores between the groups was -0.11 (95% confidence interval, -0.05 to 0.30), indicating that the study group is noninferior to the control group. There was no statistically significant difference in Daily Sleep Interference Scale, Medical Outcomes Study Sleep Scale, and Hospital Anxiety and Depression scale scores between the groups at treatment termination. Logistic regression analysis revealed no significant difference in the use of rescue medication between the groups (P = 0.217). The overall adverse event profile of the groups was similar, and no serious adverse drug reactions were observed. IMPLICATIONS: GLA5PR GLARS-NF1 tablets can be effectively and safely administered to patients with peripheral neuropathic pain. Furthermore, we found that sleep, anxiety, and depression were improved with pain control. Owing to the once-daily administration, treatment effects can be maximized by improved treatment compliance. ClinicalTrials.gov identifier: NCT03221907.
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Analgésicos/administração & dosagem , Neuralgia/tratamento farmacológico , Pregabalina/administração & dosagem , Idoso , Analgésicos/efeitos adversos , Preparações de Ação Retardada/administração & dosagem , Preparações de Ação Retardada/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pregabalina/efeitos adversos , Método Simples-Cego , Comprimidos , Resultado do TratamentoRESUMO
The aim of this study was to determine the association between radiologic spinal pathology and the response to medial branches block (MBB). This retrospective observational study compared 165 patients. A successful response was defined as ≥30% or a 2-point reduction in the numeric rating scale (NRS) compared with the baseline at the 1-month follow-up. The facet angle, facet angle difference, facet joint degeneration, disc height and spondylolisthesis grade were analyzed from an MRI at the L3 to S1 levels. Univariate and multivariate logistic regression analyses were used to evaluate independent factors associated with a successful response of MBB. In the univariate analysis, the disc height at L5-S1 and facet angle difference at L3-4 were lower in the positive responders (p = 0.022 and p = 0.087, respectively). In the multivariate analysis, the facet angle difference at L3-4 and disc height at L5-S1 were independent factors associated with a successful response (odds ratio = 0.948; p = 0.038 and odds ratio = 0.864; p = 0.038, respectively). In patients with a degenerative disc at L5-S1, MBB can lead to a good response for at least one month. In patients with facet tropism at L3-4 level, the response to MBB after one month is likely to be poor.
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Objective To investigate the change in pulse transit time (PTT)-time between the electrocardiographic R wave and the highest point of the corresponding plethysmographic wave-after lumbar sympathetic ganglion block (LSGB) and evaluate PTT as an indicator of successful LSGB. Methods Sixteen cases of sympathetically mediated lower extremity neuropathic pain treated with LSGB were studied. Correlations between the changes in PTT and temperature were used to identify the cutoff point indicating successful LSGB. Results PTT rate of change at 5 min relative to the baseline PTT (dPTT5/PTT0) significantly correlated positively with the temperature change at 20 min (correlation coefficient 0.734). The dPTT5/PTT0 ratios of the Success and Failure groups were 6.46 ± 2.81% and 2.77 ± 1.72%, respectively. The dPTT5/PTT0 cutoff indicating successful LSGB, based on receiver operating characteristic curve analysis, was 4.23%. Conclusion PTT measurement 5 min after local anesthetic injection was an early, objective indicator of successful or failed LSGB.
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Anestésicos Locais , Bloqueio Nervoso Autônomo , Gânglios Simpáticos/diagnóstico por imagem , Neuralgia/terapia , Análise de Onda de Pulso/métodos , Adulto , Idoso , Eletrocardiografia , Feminino , Gânglios Simpáticos/fisiopatologia , Humanos , Extremidade Inferior/diagnóstico por imagem , Extremidade Inferior/inervação , Extremidade Inferior/fisiopatologia , Região Lombossacral/inervação , Masculino , Pessoa de Meia-Idade , Neuralgia/diagnóstico por imagem , Neuralgia/fisiopatologia , Oximetria , Pletismografia , Análise de Onda de Pulso/instrumentação , Curva ROC , Estudos Retrospectivos , Temperatura , Resultado do TratamentoRESUMO
BACKGROUND: Chronic neck and upper extremity pain associated with cervical origin is common, and cervical interlaminar epidural steroid injections (CILESIs) are frequently used to manage the symptoms of cervical spinal disorders. However, CILESIs are associated with risks such as dural puncture and cord injury. OBJECTIVES: We aimed to determine the optimal needle tip visualization, in order to minimize CILESIs-induced complications. STUDY DESIGN: Retrospective observational study. SETTING: The single center study in Seoul, Republic of Korea. METHODS: Participants were 312 adults with neck or upper extremity pain caused by cervical lesion such as cervical herniated nucleus pulposus (HNPs). They underwent magnetic resonance imaging (MRI). Patients with severe cervical spinal stenosis, prior posterior cervical spine surgery, or other anatomical abnormalities of the vertebral laminae were excluded from the study. By using axial T2-weighted spin-echo MRI, we defined the area between the spinous processes as the anterior posterior zone 1 (APZ1), and the area lateral to the spinous processes as the anterior posterior zone 2 (APZ2). Line 1 was drawn along the ventral margin of lamina that confined APZ1, and line 2 was similarly drawn in order to define APZ2. The angles between the midsagittal line and lines 1 and 2 were defined as angle 1 and angle 2, respectively. Angles were measured at the C5-6, C6-7, and C7-T1 levels, on both right and left sides at each level. RESULTS: Angle 1 values (in degrees) at right C5-6, left C5-6, right C6-7, left C6-7, right C7-T1, and left C7-T1 were 62.54 ± 10.52, 64.34 ± 9.86, 62.03 ± 10.27, 62.87 ± 10.64, 61.64 ± 11.0, and 62.58 ± 10.83, respectively. Angle 2 values at right C5-6, left C5-6, right C6-7, left C6-7, right C7-T1, and left C7-T1 were 50.44 ± 6.84, 50.77 ± 7.00, 49.15 ± 6.07, 49.89 ± 6.45, 50.84 ± 6.68, and 50.24 ± 6.60, respectively. There were significant differences between angles 1 and 2 at each level. LIMITATIONS: This study is a retrospective review and did not employ controls, blinding, or randomization. Additionally, the optimal CLO angles for CILESIs and cervicothoracic interlaminar epidural steroid injections (CTILESIs) have not been assessed in clinical studies. Another limitation is that we divided lamina into only APZ1 and APZ2. CONCLUSIONS: During CILESIs, a contralateral oblique (CLO) view at 60 degrees is superior to other angles for visualizing the epidural space when the needle tip is placed in the interlaminar space and within the spinous processes margin. When the needle tip is placed in the interlaminar space and lateral to the spinous processes, a CLO view at 50 degrees is most appropriate.Institutional Review Board (IRB) approval number: S2016-0390-0001Key words: Chronic neck pain, chronic upper extremity pain, cervical epidural injections, cervical interlaminar steroid injections, steroid, needle tip position, needle tip visualization, fluoroscopy, complication, contralateral oblique view.
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Injeções Epidurais , Agulhas , Vértebras Cervicais , Espaço Epidural , Humanos , Modalidades de Fisioterapia , Estudos RetrospectivosRESUMO
BACKGROUND: Hypertrophy of the ligamentum flavum (LF) has been considered as a major cause of lumbar central spinal stenosis (LCSS). Previous studies have found that ligamentum flavum thickness (LFT) is correlated with aging, disc degeneration, and lumbar spinal stenosis. However, hypertrophy is different from thickness. Thus, to evaluate hypertrophy of the whole LF, we devised a new morphological parameter, called the ligamentum flavum area (LFA). OBJECTIVES: We hypothesized that the LFA is a key morphologic parameter in the diagnosis of LCSS. STUDY DESIGN: Retrospective observational study. SETTING: The single center study in Seoul, Republic of Korea. METHODS: LF samples were collected from 166 patients with LCSS, and from 167 controls who underwent lumbar magnetic resonance imaging (MRI) as part of a routine medical examination. T1-weighted axial MR imageswere acquired at the facet joint level from individual patients. We measured the LFA and LFT at the L4-L5 intervertebral level on MRI using a picture archiving and communications system. The LFA was measured as the cross-sectional area of the whole LF at the L4-L5 stenotic level. The LFT was measured by drawing a line along the side of the ligament facing the spinal canal and along the laminar side of the ligament curve and then measuring the thickest point at the L4-L5 level. RESULTS: The average LFA was 96.56 ± 30.74 mm2 in the control group and 132.69 ± 32.68 mm2 in the LCSS group. The average LFT was 3.61 ± 0.72 mm in the control group and 4.24 ± 0.97 mm in the LCSS group. LCSS patients had significantly higher LFA (P < 0.001) and LFT (P < 0.001). Regarding the validity of both LFA and LFT as predictors of LCSS, Receiver Operator Characteristics (ROC) curve analysis showed that the best cut-off point for the LFA was 105.90 mm2, with 80.1% sensitivity, 76.0% specificity, and area under the curve (AUC) of 0.83 (95% CI, 0.78 - 0.87). The best cut off-point of the LFT was 3.74 mm, with 70.5% sensitivity, 66.5% specificity, and AUC of 0.72 (95% CI, 0.66 - 0.77). LIMITATIONS: The principal methodological limitation was the retrospective observational nature. Anatomically, degenerative lumbar spinal stenosis can involve the central canal, foramina, and lateral recess. However, we focused on LCSS only. CONCLUSIONS: Although the LFT and LFA were both significantly associated with LCSS, the LFA was a more sensitive measurement parameter. Thus, to evaluate LCSS patients, the treating doctor should more carefully analyze the LFA than LFT.Institutional Review Board (IRB) approval number: S2015-1328-0001Key words: Ligamentum flavum, ligamentum flavum area, ligamentum flavum thickness, lumbar central spinal stenosis, hypertrophy of the ligamentum flavum, morphological parameter, cross-sectional area, optimal cut-off point.
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Ligamento Amarelo/patologia , Estenose Espinal/diagnóstico , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Hipertrofia/fisiopatologia , Masculino , Pessoa de Meia-Idade , República da Coreia , Estudos RetrospectivosRESUMO
Spontaneous intracranial hypotension (SIH) is characterized by postural headache because of low cerebrospinal fluid (CSF) pressure. Brain magnetic resonance imaging (MRI) and radioisotope (RI) cisternography can be used to identify the site of a CSF leakage. Although autologous epidural blood patch (EBP) is a very effective treatment modality, some patients require a repeat autologous EBP. We investigated whether autologous EBP responses correlate with surrogate markers of quantitative findings.All cases of autologous EBP for SIH from January 2006 to December 2014 were enrolled. The demographic variables, number of EBPs, pain scores, RI cisternography (early visualization of bladder activity), and MRI findings (subdural fluid collections, pachymeningeal enhancement, engorgement of venous structures, pituitary hyperemia, and sagging of the brain) were reviewed.Patients with early bladder activity on RI cisternography had a tendency to need a higher number of autologous EBPs. Only sagging of the brain and no other variables showed a statistically significant negative correlation with the number of autologous EBPs.The response to autologous EBP may be related to the radiologic findings of early bladder activity on RI cisternography and sagging of the brain on MRI.
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Placa de Sangue Epidural , Hipotensão Intracraniana/diagnóstico por imagem , Hipotensão Intracraniana/terapia , Adulto , Idoso , Feminino , Cefaleia/etiologia , Humanos , Hipotensão Intracraniana/complicações , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Medição da Dor , Cintilografia , Estudos Retrospectivos , Resultado do Tratamento , Bexiga Urinária/diagnóstico por imagem , Adulto JovemRESUMO
OBJECTIVE: There is no well-defined predictor of satisfactory pain relief after celiac plexus block (CPB) at the early stage of treatment. This study evaluated whether measurement of the electrocardiographic R-wave and the arrival time of the pulses at the toe pulse transit time (E-T PTT) can be an early predictor of pain response and success of CPB in patients with chronic intractable visceral pain. METHODS: Twelve patients aged between 20 and 80 years who underwent CPB for treatment of chronic intractable cancer-related abdominal pain were included. A successful CPB was determined as a >50% decrease on the numerical rating scale measured 24 hours after the procedure. The E-T PTT at baseline and at 5, 10, 20, and 30 minutes after the injection of local anesthetic was measured as the time between the R-wave on the electrocardiogram and the peak point of the corresponding plethysmogram wave from the ipsilateral great toe. The change in the E-T PTT that was predictive of a successful CPB was analyzed using receiver operating characteristic curve analysis. RESULTS: A CPB was successful in 9 of 12 cases; the dE-T PTT5/E-T PTT0 of the success group was 6.84%±5.04% versus 0.72%±0.78% in the failure group (P=0.021). The mean E-T PTTx differed significantly between timepoints (F=9.313, P=0.014) and between the success and failure groups (P<0.01). The best value of dE-T PTT5/E-T PTT0 indicating a successful CPB, estimated by receiver operating characteristic curve analysis, was 2.30% (sensitivity 88.9%, specificity 100%). The area under the curve was 96% (95% confidence interval, 85.7%-100%). CONCLUSIONS: Prolongation of E-T PTT at 5 minutes after CPB correlates closely with a significant analgesic effect.
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Dor Abdominal/terapia , Plexo Celíaco/fisiologia , Bloqueio Nervoso/métodos , Análise de Onda de Pulso , Dor Abdominal/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Eletrocardiografia , Feminino , Lateralidade Funcional , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/complicações , Medição da Dor , Valor Preditivo dos Testes , Curva ROC , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: No studies to date have compared bone mineral density (BMD) changes after epidural steroid injection (ESI) between postmenopausal patients taking antiosteoporotic medication and those who are not. OBJECTIVE: The aim of the present study was to analyze the relationship between ESI and BMD changes in postmenopausal patients according to antiosteoporotic medication use. STUDY DESIGN: Retrospective analysis. SETTING: Department of Anesthesiology and Pain Medicine at Asan Medical Center, Korea. METHODS: We retrospectively analyzed postmenopausal women who underwent ESI using dexamethasone. All women had received a diagnosis of lumbar spinal stenosis and their BMD had been measured before and after treatment. BMD was evaluated by dual-energy x-ray absorptiometry at the lumbar spine, femoral neck, femoral trochanter, and total femur, and was recorded as absolute g/cm2 and T-scores. A total of 126 patients were included in the final analysis. ESI patients were grouped as follows: group 1 (n = 74) ESI patients who took antiosteoporotic medication; group 2 (n = 52) ESI patients who did not take antiosteoporotic medication. RESULTS: In group 1, there were no significant differences between baseline and post-treatment BMD absolute values (g/cm2) in the lumbar spine, femoral neck, femoral trochanter, and total femur. In group 2, significant changes in the post-treatment BMD absolute values (g/cm2) from baseline were observed in the femoral neck (-1.48 ± 3.84%), femoral trochanter (-2.80 ± 7.50%), and total femur (-2.23 ± 4.52%), but not in the lumbar spine (-2.23 ± 4.52%). LIMITATIONS: This study contained a small sample size, no control group, and no long-term follow-up of the BMD changes after ESI. CONCLUSIONS: Our data provide new evidence indicating that ESI causes BMD changes in postmenopausal women who do not take antiosteoporotic medication. Thus, we recommend that prophylactic antiosteoporotic treatment be considered for postmenopausal women who require ESI treatment.
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Densidade Óssea , Osteoporose Pós-Menopausa/tratamento farmacológico , Idoso , Conservadores da Densidade Óssea/uso terapêutico , Feminino , Humanos , Vértebras Lombares , Pessoa de Meia-Idade , Pós-Menopausa , Estudos RetrospectivosRESUMO
Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.
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Analgesia Epidural/métodos , Injeções Epidurais/métodos , Dor/tratamento farmacológico , Parestesia/tratamento farmacológico , Adulto , Idoso , Reações Falso-Positivas , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Agulhas , Dor/complicações , Dor/diagnóstico por imagem , Parestesia/complicações , Parestesia/diagnóstico por imagem , Estudos RetrospectivosRESUMO
BACKGROUND/AIMS: Viral suppression of the hepatitis B virus (HBV) can be induced by lamivudine, but the relapse seen in many patients after cessation of lamivudine therapy is troublesome. We thought that the host immune response is important to prevent viral relapse. We compared the frequency of HBV-specific CD8+ T cells in the peripheral blood and their expansion capacity after exposure to viral antigen between the patients showing sustained HBeAg seroconversion after use of lamivudine and those patients without sustained response. METHODS: We analyzed HBV-specific CD8+ T cells that were isolated from the blood of 14 patients with HLA-A2 who showed lamivudine induced HBeAg seroconversion (HBV DNA < 0.5 pg/mL, and the cells were negative for HBeAg) at the end of lamivudine therapy. The purified T cells were directly stained ex vivo, after they had been stimulate with synthetic peptide, using the HBV core 18-27-specific HLA tetramer (Tc 18-27) and monoclonal antibody to CD8. The HBV viral load was quantified by the Amplicor HBV Monitor assay. RESULTS: In patients with a sustained HBeAg response (the sustained group) for a duration of 15.5 months of follow-up, the median number of Tc 18-27 cells out of the 5 X 10(4) CD8+ T cells was 49.5 (15-135). On the contrary, in patients who experienced relapse (the relapsed group) during a median of 7.5 months of follow-up, the median number of Tc 18-27 cells out of the 5 X 10(4) CD8+ T cells was 13.5 (0-95). Especially, among patients with a viral load of HBV DNA < 1 X 10(3) copies at the end of treatment, the median number of Tc 18-27 cells out of 5 X 10(4) CD8+ T cells was 87 (45-135) in sustained group compared to 12 (6-50) in the relapsed group. All patients in the sustained group demonstrated a vigorous expansion of the core 18-27-specific CD8+ T cells after stimulation with viral peptide, in contrast to only 3 out of 8 patients in the relapsed group. CONCLUSIONS: This study demonstrates that the frequency and functional responsiveness of the circulating HBV-specific CD8+ T cells may be important for obtaining a sustained HBeAg response to lamivudine.
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Antivirais/uso terapêutico , Linfócitos T CD8-Positivos/imunologia , Antígenos E da Hepatite B/sangue , Vírus da Hepatite B/imunologia , Hepatite B/imunologia , Lamivudina/uso terapêutico , Adulto , Feminino , Hepatite B/tratamento farmacológico , Hepatite B/virologia , Humanos , Masculino , Recidiva , Carga ViralRESUMO
BACKGROUND: An objective marker of successful stellate ganglion block (SGB) does not exist. Horner syndrome, which is currently used to determine the effect of SGB, is sometimes ambiguous. OBJECTIVE: To investigate the change in pulse transit time (PTT) after SGB, and to evaluate the utility of PTT as an objective measure of successful SGB. METHODS: Eight patients (34 to 62 years of age) underwent SGB for diagnosis or treatment of sympathetically mediated pain of the upper extremities. The success of the SGB was determined according to the presence of Horner syndrome. Electrocardiography, noninvasive blood pressure measurements and pulse oximetry were used to monitor all patients. PTT was measured using data saved on the WinDaq waveform browser. RESULTS: PTT was measured at baseline and 3 min, 5 min and 10 min after the injection of a local anesthetic. At 3 min after SGB, the mean (± SD) PTT was 624.6±20.5 ms. At 5 min after injection, the mean PTT was 630.8±17.5 ms. Prolonged PTT at 5 min was found to return to the baseline value at 10 min (613.6±14.7 ms). According to the Friedman test, the differences from baseline values were significant (P=0.008). CONCLUSION: Measurement of PTT at 5 min after local anesthetic injection can help to objectively determine the success of SGB.
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Bloqueio Nervoso Autônomo/métodos , Dor/cirurgia , Gânglio Estrelado/fisiologia , Adulto , Pressão Sanguínea/fisiologia , Eletrocardiografia , Feminino , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Análise de Onda de Pulso , Fatores de TempoRESUMO
BACKGROUND AND OBJECTIVES: Spontaneous intracranial hypotension (SIH) is characterized by a severe and disabling headache that is usually orthostatic in nature. Cisternography is a useful diagnostic test for evaluating the presence and location of cerebrospinal fluid (CSF) leakage, and a targeted epidural blood patch (EBP) based on the cisternography findings is a very effective treatment modality for SIH. However, the effects of EBPs are not predictable, making repeat EBPs essential in some cases. The aim of the present study was to find the relationship between the EBP response and cisternographic findings, hypothesizing that the number of required EBPs would increase with an increased number of CSF leakage levels as determined by radionuclide cisternography. METHODS: All patients who underwent an EBP and had been discharged with significant improvements in symptoms of SIH during 2006 to 2011 were enrolled. Patients who had no radionuclide cisternographic results were excluded. The demographic variables, number of EBPs, cisternographic findings (location, bilaterality, and number of leakage sites), and preprocedural and postprocedural pain scores were reviewed. RESULTS: There was no correlation found between the cisternographic findings and the number of EBPs. Only the preprocedural pain scores showed a statistically significant correlation with the number of EBPs. CONCLUSIONS: Our study suggests that the response to the EBP is related to the severity of symptoms but not to the number and locations of cisternographic CSF leakages.
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Placa de Sangue Epidural/estatística & dados numéricos , Hipotensão Intracraniana/diagnóstico , Hipotensão Intracraniana/terapia , Adulto , Idoso , Placa de Sangue Epidural/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
AIM: The generation of oxygen free radicals has been implicated in the pathogenesis of experimental pancreatitis. The aim of this study was to determine the role of oxygen free radicals in patients with acute pancreatitis. METHODS: The plasma levels of C-reactive protein (CRP), lipid peroxide (LPO), myeloperoxidase (MPO) and superoxide dismutase (SOD) were measured in 13 patients with acute pancreatitis and 14 healthy volunteers. RESULTS: Among the patients with acute pancreatitis, there were higher plasma levels of LPO and MPO and lower SOD activity in patients with severe pancreatitis than in those with mild pancreatitis. However, there was no significant difference in the serum marker of oxidative stress no matter what the etiology was. The LPO level was especially correlated with the concentration of serum CRP and CT severity index. CONCLUSION: The oxygen free radicals may be closely associated with inflammatory process and the severity of acute pancreatitis. Especially, the concentration of plasma LPO is a meaningful index for determining the severity of the disease.
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Peróxidos Lipídicos/sangue , Estresse Oxidativo , Pancreatite/metabolismo , Índice de Gravidade de Doença , Doença Aguda , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/etiologia , Peroxidase/sangue , Valor Preditivo dos Testes , Prognóstico , Espécies Reativas de Oxigênio/metabolismo , Superóxido Dismutase/sangueRESUMO
BACKGROUND/AIMS: It has been unclear whether immediate antiviral therapy or observation under the expectation of spontaneous inactivation of hepatitis B virus (HBV), is more appropriate for the treatment of chronic hepatitis B (CHB) with acute exacerbation. We intended to analyze the short-term natural course of CHB with acute exacerbation and evaluate the efficacy of lamivudine. METHODS: We analyzed 35 CHB patients with acute exacerbation (positive HBV DNA or HBeAg and ALT>400 IU/L) between March 2000 and May 2003. We regularly checked serum HBV DNA, HBeAg and liver function tests including ALT every 1 to 3 months. If ALT was above 100 IU/L during the follow-up period, patients were treated with 100 mg lamivudine orally once a day. We compared the efficacy of lamivudine use between this group and the group provided with immediate lamivudine trial at their first visit. RESULTS: 27 CHB patients with acute exacerbation were observed without immediate lamivudine trial. In 5 of these patients normal ALT, negative HBeAg and HBV DNA were maintained during 19 months (group 1a). Slightly elevated or normal ALT was maintained without HBeAg seroconversion in 3 patients (group 1b). However, serum ALT flared up above 100 IU/L in 19 patients within 5 months. So, lamivudine was tried on these patients (group 2). The serum HBV DNA was extremely low, being 6.5 pg/mL in group 1a compared to 518.1 pg/mL in group 2. Spontaneous inactivation of HBV was observed in 71.4% (5/7) of patients with HBV DNA less than 20 pg/ mL at the first visit. ALT was lower and HBV DNA was higher in group 2 than the 8 patients who received immediate lamivudine trial at the first visit (group 3). The response rate of lamivudine was similar between group 2, 56.3% (9/16) and group 3, 62.5% (5/8). CONCLUSIONS: Spontaneous inactivation of HBV was expected in CHB with acute exacerbation and extremely low level of HBV DNA (less than 20 pg/mL) in a short term follow-up period. Immediate lamivudine therapy might be more appropriate in most CHB patients with acute exacerbation.