Asenapine versus olanzapine for the treatment of nausea and vomiting in patients with cancer: A retrospective study.

AIM: Patients with cancer often experience nausea and vomiting (N/V), but may have difficulty using olanzapine (OLZ), a common antiemetic. Asenapine (ASE) is a multi-acting receptor-targeted antipsychotic like OLZ, although there is little evidence that ASE serves as an antiemetic. The aim of this study was to evaluate the efficacy and tolerability of ASE compared to those of OLZ for the treatment of N/V in patients with cancer. METHODS: This retrospective study involved patients who received 5 mg ASE, 5 mg OLZ, or 2.5 mg OLZ for 2 days. Daily worst N/V was rated on a scale of 0 (none) to 3 (very much). The primary endpoint was the proportion of patients who had a response, defined as any reduction in N/V score. A complete response (CR) was defined as a score reduction to 0. Secondary endpoints included the proportion of patients with CR and adverse events. RESULTS: Between April 2017 and March 2023, 212 patients were enrolled to receive treatment: 5 mg ASE (n = 34), 5 mg OLZ (n = 102), or 2.5 mg OLZ (n = 76). No significant differences in response rates (52.9% vs. 58.8% vs. 52.6%, p = 0.671) or secondary endpoints were observed between the groups. Patients receiving ASE were more likely to experience oral hypoesthesia (p = 0.004). CONCLUSION: This preliminary study suggests that ASE may be effective for N/V. Further studies are required to confirm these findings.

Case Reports of Transdermal Fentanyl Patch Administration Difficulties in Cancer Patients with Excess Sweating.

(Case 1) A 45-year-old male was diagnosed with prostate cancer. Treatment was administered using bicalutamide and leuprorelin acetate, while a transdermal fentanyl (TDF) was applied for pain relief. However, TDF continued to peel off owing to excessive sweating, even when reinforced by a protective layer. As such, TDF was discontinued and pain control was initiated using other medicines. Sweating occurred irregularly because of hot flashes, approximately four to five times per day. (Case 2) A 37-year-old male was diagnosed with a malignant thymoma and sacral metastasis. For analgesic control, etodolac tablets, carbamazepine tablets, and TDF were administered. Subsequently, the dose of the TDF was gradually increased, but the analgesic effect was low; thus, fentanyl blood concentration was measured. The measurements showed that even higher TDF doses did not increase fentanyl blood levels. During this period, full body sweating began to occur to a large extent due to unknown causes, and it was thought that the absorption of fentanyl decreased. When using a TDF, it is necessary to monitor patients for any sweating during treatment, while also considering changes in medication in some cases. This should promote the maintenance and improvement of the quality of life of the affected patients.

Pharmacokinetic Analysis, Analgesic Effects, and Adverse Effects of Tapentadol in Cancer Patients with Pain.

In this study, we conducted a pharmacokinetic analysis of tapentadol (TP) in Japanese patients with cancer pain and identified covariates influencing pharmacokinetic parameters. In addition, the analgesic effects and adverse effects of TP were investigated. Data were collected from in-patients with cancer pain who had been administered TP as an extended-release formula. The median (range) estimated clearance (CL/F) and distribution volume (Vd/F) of TP were 86.7 (31.3-213.7) L/h and 1288 (189-6736) L, respectively. There was a strong negative correlation between CL/F and age, Child-Pugh score, and albumin-bilirubin (ALBI) score. The subjects were further divided into two groups according to the factors highly correlated with CL/F. The CL/F of patients in the Child-Pugh B group was 0.46-times that of patients in the Child-Pugh A group. In addition, the CL/F of patients with an ALBI score > -2.40 was 0.56-times that of patients with ALBI scores ≤-2.40, and both differences were statistically significant (p < 0.05). The mean intensity of pain over 24 h was investigated daily from before starting TP for the first 7 d of the treatment. TP reduced pain in six of nine patients; the mean pain visual analogue scale score decreased significantly from 59.2 mm before administration to 42.5 mm at days 5-7. Overall, the Child-Pugh and ALBI scores significantly affected the clearance of TP, which was reduced in patients with impaired liver function. These results suggest that TP is an opioid with a sufficient analgesic effect for cancer patients.

[Clinical Effects of Opioid Switching to Tapentadol - Retrospective Analysis of Efficacy and Adverse Effects].

The objective of our study was to evaluate the efficacy and adverse effects of opioid switching to tapentadol(TP). It was a retrospective survey carried out at the Kitasato University Hospital outpatient clinic between September 2014 and May 2016. We evaluated pain intensity using the visual analogue scale and the occurrence of adverse effects before switching, at the first evaluation after switching, and during the steady state of TP administration. We included 10 patients; of these, 3 patients discontinued TP owing to uncontrolled pain. The conversion ratio of the previously administered opioids to TP was 1.17 at the time of the first evaluation after switching and 1.42 during the steady state. The mean(±SD)pain intensity was 4.2±2.2 before opioid switching and 4.6±2.2 at the time of the first evaluation after switching. The mean(±SD)pain intensity in the 7 patients excluding the 3 patients who discontinued TP was 4.3±2.0 before opioid switching and 2.7±1.9 during the steady state. Somnolence improved in 5 patients and constipation improved in 2 patients when a stable dose was achieved. Opioid switching to TP was appropriately accomplished using the conversion ratio. Furthermore, pain, sleepiness, and constipation improved following successful titration. These data suggest that TP can be useful in the treatment of cancer pain, in addition to the currently used opioid preparations.

[Xenon light therapy].

The xenon light, generated by high-intensity electrical stimulation of xenon gas, is used to sterilize wounds, aid tissue repair, and relieve pain as a low-level light therapy. The light produced consists of non-coherent beams of multiple wavelengths in the ultraviolet to infrared spectrum. This broad-band light can be emitted in a continuous wave or pulsed mode, with the wave band chosen and the energy distribution controlled for the purpose. Specifically, wavelengths in the 500-700 nm range are suitable for treating superficial tissue, and wavelengths between 800 and 1,000 nm are suitable for deeper-seated tissues, due to longer optical penetration distances through tissue. One of the most common benefits in the xenon light therapy is considered to be the wide and deep irradiation of optimal rays to living tissue. Research into the use of xenon light for tissue repair and pain reduction is restricted within open-label studies and case reports. The present review expounded the effects of xenon light therapy on the basis of the available evidence in vitro and in vivo studies using a laser beam of single wavelength.

The analgesic effect of a metered-dose 8% lidocaine pump spray in posttraumatic peripheral neuropathy: a pilot study.

BACKGROUND: A topical lidocaine patch is effective in the treatment of posttraumatic peripheral neuropathy (PTPN), but it is not suited for breakthrough pain because of difficulty with an additional application. Here, we examined the effect of 8% lidocaine pump spray (Xylocaine pump spray, XPS) on peripheral neuropathic pain caused by surgery or injury. METHODS: Thirty-one patients with PTPN were randomized to receive either XPS or saline placebo pump spray applied to painful skin areas. The optimal dose of up to 30 sprays (0.1 mL/single spray, 30 times) was individually determined as the dose which completely covered the painful site. After a 7-day period, the patients were crossed over to receive the optimal dose of the alternative spray. Pain was assessed with a visual analog scale. RESULTS: XPS, but not placebo pump spray, significantly decreased the visual analog scale for continuing pain and tactile allodynia. The effect persisted for a median of 5 h (range, 2-60 h) after application. Mild side effects were reported in three patients with XPS consisting of local irritation (n = 3) and local flare (n = 1). All adverse events disappeared without medication within a few hours. CONCLUSIONS: The present study suggests that XPS provides a significant improvement in PTPN due to its prompt analgesia, lack of systemic side effects and convenience.

Comparison of analgesia induced by continuous epidural infusion of plain 1% lidocaine and 1% lidocaine prepared by dilution of 2% lidocaine with the same volume of saline.

STUDY OBJECTIVE: To compare the extent of sensory block induced by continuous epidural infusion of plain 1% lidocaine and 2% lidocaine diluted with saline to 1% lidocaine. DESIGN: Prospective, randomized, blinded study. SETTING: University hospital. PATIENTS: 40 ASA physical status I inpatients scheduled for lower extremity orthopedic surgery. INTERVENTIONS: After surgery with lumbar epidural anesthesia with 0.75% ropivacaine, patients were randomized to two postoperative epidural infusion groups to receive plain 1% lidocaine (plain group) or 2% lidocaine diluted with the same volume of normal saline (dilution group). Continuous epidural infusion was started at a rate of 6 mL/h. MEASUREMENTS AND MAIN RESULTS: Regression of sensory block was significantly prolonged in the plain group, resulting in a significant difference in the spread of sensory block between the two agents from 4 to 6 h postoperatively. There also was a significant difference from the two groups in the level of motor block (modified Bromage scale) between 3 and 5 h postoperatively. CONCLUSIONS: Two percent lidocaine diluted with the same volume of saline is a less potent than the plain 1% lidocaine. The effect of saline as a diluent on epidurally administrated local anesthetics may be of clinical importance.

Regression of sensory and motor blockade, and analgesia during continuous epidural infusion of ropivacaine and fentanyl in comparison with other local anesthetics.

OBJECTIVE: To compare the regression of sensory and motor blockade, and the analgesia during continuous epidural infusion between ropivacaine and other local anesthetics. DESIGN: Two studies were conducted. Study 1: Eighty patients were scheduled for orthopedic procedures of the lower extremity under lumbar epidural anesthesia. Following the operation, continuous infusion of a randomized solution (0.2% ropivacaine, 0.125% bupivacaine, 0.5% lidocaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl) was commenced at a rate of 6 mL/h. The regression of sensory and motor blockade were compared among the groups. Study 2: After gynecologic abdominal surgery, 39 patients were randomized to one of the three epidural infusion groups: 0.2% ropivacaine, 0.125% bupivacaine, or 0.2% ropivacaine with 2.5 microg/mL fentanyl at a rate of 6 mL/h with an additional bolus injection of 3 mL, which can be used when patients have pain. Visual analog scale (VAS) was compared among the groups. RESULTS: Study 1: The level of sensory blockade in all the groups appeared to decrease progressively. However, the regression of sensory blockade was significantly prolonged in patients treated with ropivacaine. The addition of fentanyl to ropivacaine augmented this prolonged analgesic effect. Study 2: VAS after the bolus in the ropivacaine and the ropivacaine + fentanyl groups were significantly lower than that in the bupivacaine group. Patients in the ropivacaine + fentanyl group required significantly fewer supplemental bolus injections. CONCLUSIONS: Continuous epidural infusion of ropivacaine may induce a slower regression of sensory blockade compared with bupivacaine and lidocaine. The addition of fentanyl to ropivacaine can enhance this prolonged analgesic effect with little effect on motor blockade. Epidural infusion of ropivacaine with fentanyl provides effective pain relief, possibly because of the maintenance of sensory blockade by ropivacaine and fentanyl.

A comparison of epidural blockade produced by plain 1% lidocaine and 1% lidocaine prepared by dilution of 2% lidocaine with the same volume of saline.

Local anesthetics are commonly diluted with saline, but the influence of the dilution on the epidural anesthesia remains unclear. We randomized 40 patients scheduled for gynecological abdominal surgery under epidural anesthesia to one of two groups; those in group P received plain commercially prepared 1% lidocaine and those in group D received 1% lidocaine derived from 2% lidocaine and the same volume of saline was infused epidurally with an epidural catheter at L1-2. The pH and sodium and chloride ion concentrations of the solutions were measured. Sensory and motor blockade, foot skin temperature, arterial blood pressure, and heart rate were assessed at 5, 10, and 15 min after the epidural infusion. The spread of sensory blockade was significantly wider in group P at all assessment times than in group D. The increase of foot temperature and decrease of mean arterial blood pressure were significantly faster in group P than in group D. Although the mean pH values of the two solutions were similar, sodium and chloride ion concentrations of the diluted solution were significantly larger than those of the plain solution. We conclude that 2% lidocaine diluted with the same volume of saline produces less potent epidural blockade than commercially prepared plain 1% lidocaine.

[Cranial subdural hematoma after inadvertent dural puncture at epidural anesthesia].

Intracranial subdural haematoma has been reported to be an exceptionally rare complication of accidental dural puncture. An accidental lumbar dural puncture occurred in a 36-yr-old male undergoing orthopedic knee surgery. On the morning after the operation, the patient complained of severe occipital headache, although this was relieved with loxoprofen and rest. This was assumed to be a postdural puncture headache (PDPH) because it had a postural component (it was worse on sitting up). On the third day after the operation, the patient developed a severe diffuse headache together with nausea, which did not subside with analgesia and bed rest. Magnetic resonance imaging of the head showed a small acute subdural hematoma in the bilateral temporooccipital region with no mass effect. The patient was conscious and oriented. There was no focal neurological deficit. The patient was managed conservatively with bed rest and intravenous fluids. His condition improved without surgical decompression and was discharged on the 40 th day after the operation. Severe and prolonged PDPH shoud be considered as a warning sign of an intracranial complication.

Rapid injection of epidural mepivacaine speeds the onset of nerve blockade.

PURPOSE: When used intraoperatively, mepivacaine can produce a satisfactory sensory block. However, insufficient information is available concerning the factors that affect the speed of nerve blockade with epidural analgesia. The optimal rate of injection of mepivacaine has not been determined. We examined whether the speed of epidural infusion of mepivacaine affects the speed of nerve blockade. METHODS: Forty patients, physical status ASA I-II, scheduled for gynecological abdominal surgery, were enrolled in this double blind randomized trial. A catheter was inserted 4 cm in the epidural space in the midline at L1-L2. Three minutes after a test dose of 2 mL plain 1% mepivacaine over four seconds, 8 mL were injected epidurally at a rate of 1 mL.sec(-1) (fast group) or 0.05 mL.sec(-1) (slow group). Sensory and motor blockade, blood pressure, and heart rate were assessed at five, ten, and 15 min after the epidural injection. RESULTS: There was a significant difference in the spread of sensory blockade at five minutes after the epidural injection between the two groups, but not at ten and 15 min. Blood pressure decreased at five and ten minutes, recovered at 15 min in the fast group, and remained stable in the slow group. CONCLUSION: Rapid injection of mepivacaine in the epidural space produced a more rapid onset of epidural block than slow injection, but there was no difference in the final extent of the block.

[Effectiveness of ropivacaine and fentanyl for postoperative epidural analgesia following thoracic surgery].

BACKGROUND: Epidural ropivacaine is now a common drug used for postoperative analgesia. However, little information is available concerning regression of sensory blockade and analgesia following prolonged epidural infusion of ropivacaine. We investigated the efficacy of ropivacaine and fentanyl for postoperative analgesia after thoracic surgery. METHODS: Thirty patients undergoing thoracic surgery were enrolled. After surgery with general and thoracic epidural anesthesia, continuous epidural infusion of 0.2% ropivacaine+fentanyl (1.67 microg x ml(-1)) was started at a rate of 6 ml x h(-1) for patients whose height was more than 155 cm and 4 ml x h(-1) for those below 155 cm with possibility of an additional bolus injection of 3 ml at least every 60 min. RESULTS: An additional epidural injection of 3 ml produced a decrease in VAS without significant changes of vital signs. The greatest VAS was 10+/-25 mm in the incision site and 36+/-38 mm in the ipsilateral shoulder. Sensory blockade was sustained until the morning after the day of surgery. Also blood pressure and heart rate were stable throughout the observation period. There were no adverse effects except for slight nausea in three patients. CONCLUSIONS: A bolus of 3 ml with continuous 4-6 ml x h(-1) epidural injection of ropivacaine plus a small dose of fentanyl would decrease postoperative pain with stable vital signs in patients after thoracic surgery.

[Advantage of ropivacaine for postoperative epidural analgesia following leg orthopedic surgery].

BACKGROUND: Epidural administration of local anesthetics may lead to effective pain relief. However, tachyphylaxis or other problems following prolonged epidural anesthesia may develop and in many cases difficulties exist in the maintenance of the similar degree of sensory blockade. The present study was therefore performed to investigate the analgesic effect of continuous postoperative epidural infusion of ropivacaine with fentanyl in comparison with that of bupivacaine or ropivacaine alone. METHODS: After leg orthopedic surgery with lumbar combined spinal-epidural anesthesia, thirty-six patients were randomized to one of the three postoperative epidural infusion groups: bupivacaine 0.125%, ropivacaine 0.2%, or ropivacaine 0.2% with 2.2 microg x ml(-1) (400 microg x 180 ml(-1)) of fentanyl. Continuous epidural infusion was started at a rate of 6 ml x h(-1) with possibility of an additional bolus injection of 3 ml at least every 60 min. Pain was assessed using a 10-cm visual analog scale (VAS) just before and 15 min after epidural bolus injections, and 15-20 h after the start of continuous epidural infusion as the severe at pain through the observation. The spread of analgesia (loss of sharpness in pinprick perception) and motor block (Bromage scale) were evaluated bilaterally. Systolic and diastolic blood pressure and heart rate were also measured. RESULTS: The epidural bolus infusion was associated with a significant decrease of VAS (P < 0.001) and stable blood pressure and heart rate in all groups. The maximal VAS in patients receiving 0.2% ropivacaine+fentanyl was significantly less compared to that in the other two groups. The regression of sensory blockade was significantly prolonged in patients treated with ropivacaine+fentanyl. There was no significant difference in the spread of sensory analgesia between 20 min and 15-20 h after the continuous epidural anesthesia in this group. None of the patients developed adverse effects such as respiratory depression, nausea, and pruritus. CONCLUSIONS: Epidural injection of ropivacaine with fentanyl decreased postoperative pain with stable vital signs in patients undergoing leg orthopedic surgery, as compared to bupivacaine or ropivacaine alone, possibly because of the maintenance of sensory blockade by ropivacaine and enhancement of this sensory blockade by fentanyl.

[Masseter muscle rigidity after suxamethonium during induction and postoperative abortive malignant hyperthermia in a patient with esophageal achalasia].

A 38-year-old man diagnosed as esophageal achalasia developed masseter muscle rigidity after intravenous suxamethonium during anesthetic induction. Anesthesia was maintained with intravenous agents and epidural blockade, while the masseter muscle rigidity continued. After the surgery, his body temperature increased to 38.8 degrees C concomitantly with the appearance of myoglobinuria suggesting the occurrence of abortive malignant hyperthermia. These symptoms were dissolved by dantrolene administration. He was later proved to be negative with CICR test.

[Postoperative analgesia using continuous lumbar epidural infusion of ropivacaine in comparison with bupivacaine].

BACKGROUND: Epidural bupivacaine infusion is a commonly used technique for postoperative analgesia because of its motor-sparing properties. Recently a new long acting local anesthetic, ropivacaine, has become available. The aim of this study was to investigate the efficacy of ropivacaine and bupivacaine with regard to postoperative analgesia when administered continuously into the lumbar epidural space. METHODS: All patients were ASA I II and undergoing ipsi-lateral leg orthopedic surgery with epidural or combined spinal-epidural anesthesia. Patients were randomly assigned to following three groups: 0.1% ropivacaine (0.1 R); 0.2% ropivacaine (0.2 R); 0.125% bupivacaine (0.125 B). At the end of surgery, continuous infusion was begun at a rate of 6 ml.hr 1 after a bolus epidural administration of 5 ml of 0.2% ropivacaine in R groups and 0.25% bupivacaine in B group. Sensory and motor block, blood pressure, pulse rate, verbal pain score (VPS), analgesic consumption were assessed at 20 min, 1, 3, 10-20 hrs following the beginning of continuous infusion. RESULTS: Vital signs were stable at every measuring point in all groups. In 0.1 R group (n = 20), the spread of sensory block at 3 hrs after infusion was lower than 0.2 R group (n = 19), and VPS during the study was higher than 0.125 B group (n = 17). Bromage scale after 3 hrs was higher in 0.2 R group compared with 0.125 B group. The degree of sensory and motor block gradually decreased, resulting in little difference between the groups. When epidural anesthesia was spread over the surgical area throughout the study, 0.2 R or 0.125 B was sufficiently relieved from postoperative pain. CONCLUSIONS: After leg orthopedic surgery, 6 ml.hr-1 of 0.2 R or 0.125 B provided enough postoperative analgesia when the spread of anesthesia covered the operated area. 0.2 R would be better compared to 0.125 B in continuous epidural infusion for postoperative analgesia due to less systemic toxicity, even though it accompanies a little more intense motor block.