What to Do, and What Not to Do, When Diagnosing and Treating Breakthrough Cancer Pain (BTcP): Expert Opinion.

Clinical management of breakthrough cancer pain (BTcP) is still not satisfactory despite the availability of effective pharmacological agents. This is in part linked to the lack of clarity regarding certain essential aspects of BTcP, including terminology, definition, epidemiology and assessment. Other barriers to effective management include a widespread prejudice among doctors and patients concerning the use of opioids, and inadequate assessment of pain severity, resulting in the prescription of ineffective drugs or doses. This review presents an overview of the appropriate and inappropriate actions to take in the diagnosis and treatment of BTcP, as determined by a panel of experts in the field. The ultimate aim is to provide a practical contribution to the unresolved issues in the management of BTcP. Five 'things to do' and five 'things not to do' in the diagnosis and treatment of BTcP are proposed, and evidence supporting said recommendations are described. It is the duty of all healthcare workers involved in managing cancer patients to be mindful of the possibility of BTcP occurrence and not to underestimate its severity. It is vital that all the necessary steps are carried out to establish an accurate and timely diagnosis, principally by establishing effective communication with the patient, the main information source. It is crucial that BTcP is treated with an effective pharmacological regimen and drug(s), dose and administration route prescribed are designed to suit the particular type of pain and importantly the individual needs of the patient.

[Subarachnoid anesthesia with Sprotte 24-G needle in ambulatory surgery]. / Anestesia subaracnoidea con ago di Sprotte 24-G in chirurgia ambulatoriale.

In order to evaluate the possibility of using a selective subarachnoid anesthesia in ambulatory surgery we studied its feasibility with a Sprotte needle 24 G in 103 patients (range 15-67 years) undergoing a knee joint arthroscopy. The subarachnoid anesthesia was achieved with Sprotte needle 24 G with introducer with patient on lateral decubitus. Hyperbaric bupivacaine 1% (0.05 mg/cm height) was used in order to obtain a selective homolateral metameric anesthesia between L1 and S3. The numbers of attempts were 1.29 (range 1-4). We involved the homolateral determatomeres in 94% of our attempts, adding a weak anesthetic action on contralateral ones. In the remaining 6% of the patients the anesthesia was bilateral and extending in an overlying manner. Anesthesia was adequate for the time needed to perform all the surgical procedures. Nevertheless in 3 patients the tourniquet was painful. We registered systemic hypotension only in 2% of the patients (a reduced systolic pressure value > 30%). No cases of postdural puncture headache were registered. Non postural atypical headache was seem in 3.9% of the patients. Urinary retention necessitating catheterization was noted only in 3 cases. A weak backache was revealed in 8.8%. When interviewed after surgery, 98% of our patients fulfilled the technique. In spite of technical difficulties that the use of the Sprotte needle may present, the selective subarachnoid anesthesia may be a safe alternative to the other anesthetic procedures for ambulatory surgery of the legs.