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1.
Ned Tijdschr Geneeskd ; 1642021 03 18.
Artículo en Neerlandesa | MEDLINE | ID: mdl-33793139

RESUMEN

A 58-year-old female with a history of obesity, smoking and hypertension underwent shoulder arthroscopy. Prior to the arthroscopy, patient received an interscalene brachial plexus block. After the arthroscopy, patient had an oxygen saturation of 85%, caused by an unilateral diaphragm paralysis due to a phrenic nerve block.


Asunto(s)
Artroscopía , Bloqueo del Plexo Braquial/efectos adversos , Hipoxia/inducido químicamente , Parálisis Respiratoria/inducido químicamente , Hombro/cirugía , Diafragma , Femenino , Humanos , Persona de Mediana Edad
2.
Ned Tijdschr Geneeskd ; 150(13): 723-8, 2006 Apr 01.
Artículo en Neerlandesa | MEDLINE | ID: mdl-16623345

RESUMEN

Pancreatic cancer tends to be diagnosed at a relatively late stage of the disease when curative resection is precluded. In view of the poor prognosis and the severe pain, palliative care should be aimed at providing adequate pain relief and optimal quality of life. Pancreatic cancer pain is primarily treated by the combination of NSAIDs, adjuvant analgesic drugs, and oral or transdermal opioids. The neurolytic coeliac plexus block is recommended as adjuvant therapy for the palliative treatment of pancreatic cancer pain. In addition quality of life, especially functional and physical aspects, is significantly improved in patients following a coeliac plexus block. The most common approach to the coeliac plexus is the percutaneous posterior technique. Serious complications that may follow application of this technique include sensory disorders, muscle weakness and paraparesis. More recently, new techniques such as thoracoscopic splanchnicectomy and endoscopic ultrasound-guided coeliac plexus block have emerged as efficient alternatives in terms of pain relief and quality-of-life improvement. The neurolytic coeliac plexus block has become a well-developed method of pain relief in patients with pain resulting from malignancies of the pancreas. To define the role of these new techniques in the palliative treatment of pancreatic cancer pain, comparative studies regarding efficacy, side effects, and complications have to be performed.


Asunto(s)
Bloqueo Nervioso Autónomo/métodos , Plexo Celíaco , Manejo del Dolor , Dolor/etiología , Cuidados Paliativos , Neoplasias Pancreáticas/complicaciones , Analgésicos/uso terapéutico , Plexo Celíaco/efectos de los fármacos , Humanos , Estadificación de Neoplasias , Neoplasias Pancreáticas/diagnóstico , Pronóstico , Calidad de Vida , Resultado del Tratamiento
3.
Pain ; 117(1-2): 231-5, 2005 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-16098665

RESUMEN

Questions have been raised about the potential neurotoxicity of the neuraxial use of ketamine although ketamine and its active enantiomer S(+)-ketamine have been used intrathecally and epidurally (caudally) for the management of perioperative pain and in a variety of chronic pain syndromes. Clinical experience following neuraxial administration of S(+)-ketamine has been documented without reference to local central nervous system toxicity following this approach. In addition, there are no preclinical safety data regarding stability, compatibility, and neurotoxicity on intrathecal use of single S(+)-ketamine or combinations of S(+)-ketamine, morphine, bupivacaine, and clonidine. In the present case, the continuous intrathecal administration of S(+)-ketamine, in combination with morphine, bupivacaine, and clonidine resulted in adequate pain relief in a patient suffering from intractable neuropathic cancer pain. However, postmortem observation of the spinal cord and nerve roots revealed severe histological abnormalities including central chromatolysis, nerve cell shrinkage, neuronophagia, microglial upregulation, and gliosis. Based on our results, neuraxial administration of S (+)-ketamine cannot be recommended for clinical practise before a systematic study of toxicology of neuraxial S(+)-ketamine in animals or humans has been performed.


Asunto(s)
Analgésicos/uso terapéutico , Ketamina/uso terapéutico , Neoplasias/complicaciones , Dolor/tratamiento farmacológico , Femenino , Humanos , Ketamina/efectos adversos , Persona de Mediana Edad , Dolor/etiología , Dolor/patología , Cambios Post Mortem , Médula Espinal/efectos de los fármacos , Médula Espinal/patología
4.
Pain ; 118(1-2): 224-31, 2005 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-16202531

RESUMEN

The efficacy of 50 and 75 mg S(+)-ketamine administered daily by an iontophoresis-assisted transdermal drug delivery system was tested against placebo in a randomized, double-blind design in 33 patients with central neuropathic pain. At baseline and 1 week after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale (VAS), health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Safety assessment included incidence and intensity of adverse events. No significant differences in pain scores (VAS) were observed between the ketamine groups and placebo during the course of the trial. Corrected for baseline levels, daily 50 mg S(+)-ketamine did not improve patient's health status or quality of life compared with placebo treatment. However, daily 75 mg S(+)-ketamine showed significant improvements on the Pain Disability Index, on the EQ-5D, and on the SF-36 except for the role-physical functioning and general health perception. Iontophoretic administration of S(+)-ketamine was well tolerated with a low incidence of adverse events (mild and transient in nature, resolving spontaneously). Iontophoretic administration of S(+)-ketamine was not more effective than placebo treatment in reducing pain scores in patients with severe central neuropathic pain. However, iontophoretic administration of 75 mg S(+)-ketamine improved the health status and the quality of life in these patients.


Asunto(s)
Analgésicos/administración & dosificación , Iontoforesis , Ketamina/administración & dosificación , Neuralgia/tratamiento farmacológico , Dolor Intratable/tratamiento farmacológico , Administración Cutánea , Analgésicos/efectos adversos , Analgésicos/uso terapéutico , Método Doble Ciego , Esquema de Medicación , Femenino , Estado de Salud , Humanos , Iontoforesis/efectos adversos , Iontoforesis/métodos , Ketamina/efectos adversos , Ketamina/uso terapéutico , Masculino , Persona de Mediana Edad , Neuralgia/diagnóstico , Neuralgia/psicología , Dimensión del Dolor , Dolor Intratable/diagnóstico , Dolor Intratable/psicología , Placebos , Calidad de Vida , Índice de Severidad de la Enfermedad , Encuestas y Cuestionarios , Resultado del Tratamiento
5.
Reg Anesth Pain Med ; 26(6): 572-5, 2001.
Artículo en Inglés | MEDLINE | ID: mdl-11707798

RESUMEN

BACKGROUND AND OBJECTIVES: Neuropathic cancer pain due to tumor growth near the brachial plexus is often treated with a combination of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, and oral or transdermal opioids. We propose placement of a catheter along the brachial plexus using a posterior approach for patients not responding to the above-mentioned treatment. CASE REPORT: We describe 2 patients with neuropathic cancer pain in the arm and shoulder despite treatment with dexamethasone, amitriptyline, gabapentin, opioids, and, in 1 patient, oral ketamine. An increase in daily opioid dosage did not relieve the pain but caused unacceptable side effects of nausea, vomiting, and sedation. Continuous administration of local anesthetics via a brachial plexus catheter inserted at the cervical level using a posterior approach resulted in a markedly improved analgesia and decreased opioid requirement. CONCLUSION: Continuous brachial plexus block should be considered in patients with severe neuropathic cancer pain in the arm and shoulder. To achieve sufficient pain relief for prolonged periods of time, a catheter was inserted to block the brachial plexus using a posterior approach. This technique may be a valuable alternative to the interscalene approach because of the improved fixation of the catheter in the muscle sheet of the trapezius, splenius cervicus, and levator scapulae muscles, and the decreased likelihood of catheter dislodgment during neck movements.


Asunto(s)
Plexo Braquial , Neoplasias/complicaciones , Bloqueo Nervioso , Dolor/tratamiento farmacológico , Dolor/etiología , Adulto , Anestésicos Locales , Bupivacaína , Humanos , Masculino , Persona de Mediana Edad , Bloqueo Nervioso/efectos adversos , Radiografía , Columna Vertebral/diagnóstico por imagen
6.
Pain ; 152(2): 267-273, 2011 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-21078545

RESUMEN

The mechanisms underlying central neuropathic pain are poorly understood. Pain inhibitory mechanisms including sertononergic and norepinephrine systems may be dysfunctional. In this randomized, double-blinded, placebo-controlled trial we evaluated the effects of duloxetine on pain relief (spontaneous pain and evoked pain), tolerability, health status, and quality of life in patients with central pain related to cerebrovascular lesions or spinal cord lesions. At baseline and eight weeks following start of treatment subjects were evaluated with standard measures of efficacy: pain intensity (primary efficacy variable), quantitative sensory testing, health status and quality of life (secondary efficacy variables). Forty-eight patients received escalating doses of either duloxetine (60 and 120mg/day) or matching placebo capsules. In both groups, patients started with 1 capsule per day. If pain relief was insufficient, patients were titrated to a higher dose. A trend towards a decrease in mean pain score after eight weeks was observed for duloxetine treatment (p=0.056). Duloxetine alleviated dynamic (p=0.035) and cold allodynia (p<0.001) significantly better than placebo. Tactile pain and pressure pain thresholds did not improve significantly. The duloxetine group showed a significant improvement for the bodily pain domain of the SF36 (p=0.035). No significant differences were observed in the other domains of the SF36, the Pain Disability Index, and the EQ-5D. While this trial showed no significant effect on pain intensity, duloxetine revealed a biologic effect. It would be worthwhile to suspend our judgement and to perform more studies to evaluate the role of duloxetine in modulation of the symptoms of central neuropathic pain.


Asunto(s)
Neuralgia/tratamiento farmacológico , Neuralgia/etiología , Traumatismos de la Médula Espinal/complicaciones , Accidente Cerebrovascular/complicaciones , Tiofenos/farmacología , Adulto , Evaluación de la Discapacidad , Método Doble Ciego , Clorhidrato de Duloxetina , Femenino , Humanos , Hiperalgesia/tratamiento farmacológico , Hiperalgesia/etiología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud/métodos , Dimensión del Dolor/métodos , Umbral del Dolor/efectos de los fármacos , Umbral del Dolor/fisiología , Efecto Placebo , Traumatismos de la Médula Espinal/tratamiento farmacológico , Accidente Cerebrovascular/tratamiento farmacológico , Tiofenos/uso terapéutico , Resultado del Tratamiento
8.
Pain ; 136(1-2): 150-7, 2008 May.
Artículo en Inglés | MEDLINE | ID: mdl-17703885

RESUMEN

The effective treatment of patients suffering from central neuropathic pain remains a clinical challenge, despite a standard pharmacological approach in combination with anticonvulsants and antidepressants. A randomized, double-blinded, placebo-controlled trial evaluated the effects of pregabalin on pain relief, tolerability, health status, and quality of life in patients with central neuropathic pain caused by brain or spinal cord injuries. At baseline and 4 weeks after the start of treatment subjects were evaluated with standard measures of efficacy: pain intensity measured by visual analog scale, health status (Pain Disability Index and EQ-5D) and quality of life (SF-36). Forty patients received escalating doses of either pregabalin (150, 300, and 600mg/day) or matching placebo capsules. In both groups, patients started with 1 capsule per day (either 150mg of pregabalin or placebo). If pain relief was insufficient, patients were titrated to a higher dose. There was a statistically significant decrease in mean pain score at endpoint for pregabalin treatment, compared with placebo (P=0.016). Follow-up observation showed no significant difference in Pain Disability Index scores between the two groups. The pregabalin group, however, showed a statistically significant improvement for the EQ-5D. Pregabalin treatment led to a significant improvement in the bodily pain domain of the SF36. In the other domains, more favorable scores were reported without reaching statistical significance. Pregabalin, in a flexible-dose regime, produced clinically significant reductions in pain, as well as improvements in health status in patients suffering from severe central neuropathic pain.


Asunto(s)
Enfermedades del Sistema Nervioso Central/tratamiento farmacológico , Dimensión del Dolor/efectos de los fármacos , Dolor/tratamiento farmacológico , Ácido gamma-Aminobutírico/análogos & derivados , Enfermedades del Sistema Nervioso Central/patología , Enfermedades del Sistema Nervioso Central/psicología , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dolor/patología , Dolor/psicología , Dimensión del Dolor/métodos , Pregabalina , Calidad de Vida/psicología , Ácido gamma-Aminobutírico/administración & dosificación
9.
Acta Anaesthesiol Scand ; 49(5): 665-70, 2005 May.
Artículo en Inglés | MEDLINE | ID: mdl-15836681

RESUMEN

BACKGROUND: Intrathecal administration of meperidine, an opioid with local anesthetic activity, can induce analgesia in patients with intractable cancer pain. However, continuous intrathecal administration may result in the accumulation of normeperidine, responsible for central nervous system toxicity. METHODS: Ten patients with neuropathic cancer pain, not responding to conventional opioid therapy, were treated with continuous intrathecal administration of meperidine. In all patients, plasma concentrations of meperidine and normeperidine were measured the first days after the start of treatment. Visual analog scale scores were recorded to evaluate pain relief. Quality of life was assessed before and 3 weeks following the start of intrathecal treatment. RESULTS: In three patients the plasma concentrations of meperidine and normeperidine increased rapidly. In one patient the plasma normeperidine concentration was higher than the meperidine concentration. One patient demonstrated transient symptoms suggestive for central nervous system excitation. Three weeks following the start of treatment, seven patients were available for evaluation of their quality of life. Pain relief and overall quality of life improved during the intrathecal treatment. CONCLUSION: We conclude that continuous intrathecal administration of meperidine alone, or in combination with clonidine, can provide significant pain relief in patients with poor pain control despite pharmacological treatment. However, accumulation of meperidine and normeperidine resulting in central nervous system toxicity may occur during this treatment.


Asunto(s)
Analgésicos Opioides/sangre , Analgésicos Opioides/uso terapéutico , Meperidina/análogos & derivados , Meperidina/sangre , Meperidina/uso terapéutico , Neoplasias/complicaciones , Dolor Intratable/tratamiento farmacológico , Anciano , Analgésicos Opioides/efectos adversos , Femenino , Humanos , Inyecciones Espinales , Masculino , Meperidina/efectos adversos , Persona de Mediana Edad , Dolor Intratable/etiología , Calidad de Vida
10.
Acta Anaesthesiol Scand ; 48(2): 249-52, 2004 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-14995949

RESUMEN

The effective treatment of patients suffering from neuropathic cancer pain remains a clinical challenge. When patients experience either insufficient analgesia or problematic side-effects after opioid administration, intrathecal administration of morphine and other medications such as bupivacaine and clonidine may offer significant advantages. Additionally, ketamine, a non-competitive N-methyl-D-Aspartate-receptor antagonist is able to alter pain perception at the spinal level. Because of the potential neurotoxicity after neuraxial use of racemic ketamine, intrathecal administration of the preservative-free active compound, S (+)-ketamine may be a valuable alternative. In this paper, we present a patient with severe neuropathic cancer pain successfully treated by continuous intrathecal infusion of morphine, bupivacaine, clonidine and S (+)-ketamine. Moreover, quality of life measurements before and 3 weeks after the start of spinal treatment revealed an improvement in pain relief and a higher overall quality of life. No clinical signs of neurologic deficit were observed during spinal treatment with S (+)-ketamine. However, the continuous intrathecal administration of S (+)-ketamine should be considered as the last resort because there are no preclinical safety data with relevant concentrations on intrathecal use of S (+)-ketamine.


Asunto(s)
Analgésicos/administración & dosificación , Antagonistas de Aminoácidos Excitadores/administración & dosificación , Ketamina/administración & dosificación , Neoplasias/fisiopatología , Dolor Intratable/tratamiento farmacológico , Anciano , Femenino , Humanos , Estereoisomerismo
11.
Can J Anaesth ; 45(5 Pt 1): 483-7, 1998 May.
Artículo en Inglés | MEDLINE | ID: mdl-9598265

RESUMEN

PURPOSE: In this manikin study a modified Macintosh blade was prospectively compared with its original focussing on the forces exerted on the maxillary incisor teeth and intubation success. The modified blade, a standard Macintosh blade with a reduced proximal flange, was intended to reduce the forces exerted on the maxillary incisors. METHODS: A manikin equipped with two sensors, to measure forces applied to the maxillary incisors in the axial and the transverse direction, was used. Fourteen staff anaesthetists and 16 residents each performed two laryngoscopies with both blades. RESULTS: All laryngoscopies resulted in successful tracheal intubation. The maximal and mean forces exerted on the teeth in the axial direction were 12 N and 5.8 N smaller (P < 0.0005 and P < 0.0005, respectively) when the modified blade was used. CONCLUSION: The use of the modified blade resulted in a reduction of the forces on the maxillary incisors whereas the intubation success rate was the same as with the original. Studies in manikins can be useful in comparative laryngoscope testing.


Asunto(s)
Laringoscopios , Humanos , Estudios Prospectivos
12.
Can J Anaesth ; 43(7): 665-71, 1996 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-8807170

RESUMEN

PURPOSE: In this study the effect of level of experience of the intubator on the forces applied by the Macintosh laryngoscope on the maxillary incisors in both the axial and transverse direction were investigated. METHODS: Five groups of different levels of experience (15 per group), staff anaesthetists, residents, nurse anaesthetists, surgeons and students, performed one laryngoscopy and subsequent intubation on an intubation manikin equipped with sensors to measure these forces. RESULTS: Maximal transverse forces oriented toward the base of the skull (Fmtpmax) were between 0 and 10 N in 46 cases (61%), between 10 and 20 N in 21 (28%) and > or = 20 N (maximum 46.5 N) in eight cases (11%). The maximal values of the transverse forces oriented toward the intubator (Fmtnmax) were between 0 and 10 N in 69 cases (92%), between 10 and 20 N in 3 (4%) and > or = 20 N (maximum 36.4 N) in 3 (4%). Level of experience was related to Fmtpmax (Spearman: P = 0.04, r = 0.24). In addition, Fmtnmax was less in experienced intubators (anaesthetist and residents) than in inexperienced intubators (all other groups) (Student's t test: P = 0.04). CONCLUSION: In contrast to the effect on forces exerted in the axial direction, experience proved to have a beneficial effect on the forces in the transverse direction.


Asunto(s)
Laringoscopía , Humanos , Incisivo , Intubación Intratraqueal , Maxilar , Proyectos Piloto
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