Effectiveness of fentanyl buccal soluble film in cancer patients with inadequate breakthrough pain control.

BACKGROUND: Clinical evidence for the rapidity and effectiveness of fentanyl buccal soluble film (FBSF) in reducing pain intensity of breakthrough cancer pain (BTcP) remains inadequate. This study aimed to evaluate the efficacy of FBSF proportional to the around-the-clock (ATC) opioid regimens in rapidly relieving the intensity of BTcP episodes by determining the percentage of patients requiring further dose titration. METHODS: The study procedure included a dose-finding period followed by a 14-day observation period. Pain intensity was recorded with a Numeric Rating Scale (NRS) at onset and 5, 10, 15, and 30 min after FBSF self-administration. Meaningful pain relief was defined as the final NRS score ≤ 3. Satisfaction survey was conducted for each patient after treatment using the Global Satisfaction Scale. RESULTS: A total of 63 BTcP episodes occurred in 30 cancer patients. Only one patient required rescue medication at first BTcP episode and then achieved meaningful pain relief after titrating FBSF by 200 µg. Most BTcP episodes relieved within 10 min. Of 63 BTcP episodes, 30 (47.6%), 46 (73.0%), and 53 (84.1%) relieved within 5, 10, and 15 min after FBSF administration. Only grade 1/2 adverse events were reported, including somnolence, malaise, and dizziness. Of the 63 BTcP episodes, 82.6% were rated as excellent/good satisfaction with FBSF. CONCLUSION: FBSF can be administrated "on demand" by cancer patients at the onset of BTcP, providing rapid analgesia by achieving meaningful pain relief within 10 min. TRIAL REGISTRATION: This study was retrospectively registered 24 December, 2021 at Clinicaltrial.gov (NCT05209906): https://clinicaltrials.gov/study/NCT05209906 .

[A prospective comparative study on effectiveness of single versus continuous adductor canal block combined with local infiltration anesthesia in unicompartmental knee arthroplasty].

Objective: To compare the early analgesic effects and the impact on knee joint function recovery after unicompartmental knee arthroplasty (UKA) between single adductor canal block (SACB) and continuous adductor canal block (CACB) combined with local infiltration anesthesia (LIA) using a prospective study. Methods: The patients with knee osteoarthritis admitted between April 2022 and December 2023 were enrolled as a subject. Among them, 60 patients met the selection criteria and were enrolled in the study. They were randomly assigned to the SACB group or CACB group in a ratio of 1:1 using a random number table method. There was no significant difference between the two groups ( P>0.05) in terms of age, gender, height, body mass, body mass index, affected side, and preoperative resting visual analogue scale (VAS) score and active VAS score, Oxford knee score (OKS), and American Hospital of Special Surgery (HSS) score. All patients received multimodal analgesia management using LIA combined with SACB or CACB. The operation time, pain related indicators (resting and activity VAS scores, number and timing of breakthrough pain, opioid consumption), joint function related indicators (quadriceps muscle strength, knee range of motion, OKS score, and HSS score), as well as postoperative block complications and adverse events were recorded and compared between the two groups. Results: There was no significant difference in the operation time between the two groups ( P<0.05). All patients in the two groups were followed up with a follow-up time of (9.70±4.93) months in the SACB group and (12.23±5.05) months in the CACB group, and the difference was not significant ( P>0.05). The CACB group had a significant lower resting VAS score at 24 hours after operation compared to the SACB group ( P<0.05). There was no significant difference in resting and active VAS scores between the two groups at other time points ( P>0.05). The CACB group had a significantly lower incidence of breakthrough pain compared to the SACB group [9 cases (30.00%) vs. 17 cases (56.67%); P<0.05). However, there was no significant difference in the timing of breakthrough pain occurrence and opioid consumption between the two groups ( P>0.05). Four cases in the SACB group and 7 cases in the CACB group experienced adverse events, with no significant difference in the incidence of adverse events between the two groups ( P>0.05). The CACB group had significantly better knee joint mobility than the SACB group at 1 and 2 days after operation ( P<0.05). There was no significant difference between the two groups in knee joint mobility on 0 day after operation and quadriceps muscle strength and OKS and HSS scores at different time points ( P>0.05). Conclusion: In UKA, the analgesic effects and knee joint function recovery are similar when compared between LIA combined with SACB and LIA combined with CACB. However, SACB is simpler to perform and can avoid adverse events such as catheter displacement and dislocation. Therefore, SACB may be a better choice.

The influence of ambient environmental factors on breakthrough Cancer pain: insights from remote health home monitoring and a proposed data analytic approach.

BACKGROUND: Breakthrough cancer pain (BTCP) is primarily managed at home and can stem from physical exertion and emotional distress triggers. Beyond these triggers, the impact of ambient environment on pain occurrence and intensity has not been investigated. This study explores the impact of environmental factors on the frequency and severity of breakthrough cancer pain (BTCP) in the home context from the perspective of patients with advanced cancer and their primary family caregiver. METHODS: A health monitoring system was deployed in the homes of patient and family caregiver dyads to collect self-reported pain events and contextual environmental data (light, temperature, humidity, barometric pressure, ambient noise.) Correlation analysis examined the relationship between environmental factors with: 1) individually reported pain episodes and 2) overall pain trends in a 24-hour time window. Machine learning models were developed to explore how environmental factors may predict BTCP episodes. RESULTS: Variability in correlation strength between environmental variables and pain reports among dyads was found. Light and noise show moderate association (r = 0.50-0.70) in 66% of total deployments. The strongest correlation for individual pain events involved barometric pressure (r = 0.90); for pain trends over 24-hours the strongest correlations involved humidity (r = 0.84) and barometric pressure (r = 0.83). Machine learning achieved 70% BTCP prediction accuracy. CONCLUSION: Our study provides insights into the role of ambient environmental factors in BTCP and offers novel opportunities to inform personalized pain management strategies, remotely support patients and their caregivers in self-symptom management. This research provides preliminary evidence of the impact of ambient environmental factors on BTCP in the home setting. We utilized real-world data and correlation analysis to provide an understanding of the relationship between environmental factors and cancer pain which may be helpful to others engaged in similar work.

Subcutaneous Patient-Controlled Analgesia in Home-Based Palliative Care: "It's as Straightforward as Pushing a Button, Right at my Fingertips".

Subcutaneous patient-controlled analgesia (SCPCA) in home-based palliative care is a potentially valuable option for providing effective pain relief to some patients, particularly when conventional analgesic approaches prove ineffective or are refused. Our case report illustrates the use of SPCA for the management of breakthrough pain in a patient receiving palliative care at home with no improvement after multiple previous treatments. SCPCA was found to be safe and successful. Future research is essential to explore its precise role, appropriate indications, prescription guidelines, and safety considerations across various palliative care contexts.

Estudio observacional, prospectivo y multicéntrico sobre el uso de citrato de fentanilo transmucosa en la práctica clínica habitual para el control de las crisis de dolor irruptivo en pacientes oncológicos / Observational, prospective and multicenter study on the use of transmucosal fentanyl citrate in regular clinical practice for the control of breakthrough pain crises in cancer patients

Objetivo: Evaluar el grado de satisfacción de los pacientes y/o cuidadores con el tratamiento de citrato de fentanilo transmucosa en la gestión de las crisis de dolor irruptivo oncológico en términos de facilidad de uso. Métodos: Se realizó un estudio observacional, prospectivo y multicéntrico con 48 pacientes sometidos a tratamiento de mantenimiento con opioides para el dolor crónico basal provocado por el cáncer y que, además, sufrían crisis de dolor irruptivo para las que estaban recibiendo tratamiento con citrato de fentanilo. La variable principal del estudio fue el grado de satisfacción de los pacientes y/o sus cuidadores con el citrato de fentanilo en el manejo de las crisis de dolor irruptivo oncológico, evaluadas mediante cuestionarios Escala Visual Analógica (EVA). Resultados: El 90,6 % de los pacientes/cuidadores muestran un elevado grado de satisfacción con el empleo de citrato de fentanilo en términos de facilidad de uso (valor medio EVA de 8,2). Por su parte, tanto la valoración general por parte de los pacientes/cuidadores como por parte de los sanitarios ha sido muy positiva (valor medio EVA 7,7). Conclusiones: El citrato de fentanilo es una terapia fácil de usar y eficaz para el tratamiento de las crisis de dolor irruptivo oncológico, con amplia aceptación tanto por parte de pacientes y cuidadores como de los profesionales sanitarios.(AU)

Objective: To assess the degree of satisfaction of patients and/or caregivers with transmucosal fentanyl citrate treatment in the management of breakthrough cancer pain crises in terms of ease of use. Methods: An observational, prospective and multicenter study was carried out with 48 patients undergoing maintenance treatment with opioids for baseline chronic cancer pain and who, in addition, suffered breakthrough pain crises for those who were receiving treatment with fentanyl citrate. The main variable of the study was the degree of satisfaction of the patients and/or their caregivers with fentanyl citrate in the management of breakthrough cancer pain crises, evaluatedby means of Visual Analogue Scale (VAS) questionnaires. Results: 90.6 % of patients/caregivers show a high degree of satisfaction with the use of fentanyl citrate in terms of ease of use (mean VAS value of 8.2). For its part, both the general assessment by the patients/caregivers and by the healthcare professionals has been very positive (mean VAS value 7.7). Conclusions: Fentanyl citrate is an easy-to-use and effective therapy for the treatment of breakthrough cancer pain crises, widely accepted by both patients and caregivers as well as health professionals.(AU)

Resiliência: avaliação de pacientes queimados em um hospital de urgência e emergência / Resilience: evaluation of burned patients in an urgency and emergency hospital / Resiliencia: evaluación de pacientes quemados en un hospital de urgencias y emergencias

A recuperação de vítimas de queimaduras é longa e dolorosa e afeta diversas esferas da vida do paciente. A resiliência, que se refere à capacidade humana de enfrentar e se adaptar a eventos adversos, exerce grande importância no processo de recuperação da queimadura. Logo, este trabalho objetiva avaliar a capacidade de resiliência de pacientes queimados, no momento da admissão e da alta hospitalar, em um hospital de emergência e urgência de Goiânia. Trata-se de um estudo descritivo, quantitativo e transversal que utiliza a Escala de Resiliência de Connor-Davidson (CD-RISC) como instrumento de mensuração. Na admissão hospitalar, a média da resiliência foi de 71,35, tendo sido observada uma relação significativa entre o fator Amparo da escala CD-RISC e a presença do(a) companheiro(a). O escore de resiliência encontrado nesta pesquisa é consistente com outros achados da literatura científica internacional e nacional referente à expressão da resiliência em vítimas de queimaduras e outros adoecimentos. A relação entre o fator Amparo e a presença de um(a) companheiro(a) enfatiza a importância da rede de apoio familiar na reabilitação do paciente queimado.(AU)

The recovery of burned patients is long and painful and impacts on different areas of people's lives. Resilience, which refers to the human capacity to face and adapt to adverse events, plays a major role in the process of recovery from burns. Therefore, the present study aims to assess the resilience of burned patients, on admission and hospital discharge, in an emergency and urgency hospital in Goiânia. This is a descriptive, quantitative and cross-sectional study that uses the Connor-Davidson Resilience Scale (CD RISC) as a measuring instrument. At hospital admission, the mean resilience was 71.35, with a significant association between the Support factor on the CD RISC scale and the presence of a partner. The resilience score found in the present study is consistent with other findings in the international and national scientific literature regarding the expression of resilience in victims of burns and other illnesses. The relationship between the Support factor and the presence of a partner emphasizes the importance of the family support network in the rehabilitation of the burned patient.(AU)

La recuperación de los pacientes quemados es larga y dolorosa e impacta en diferentes esferas de la vida de las personas. La resiliencia, que se refiere a la capacidad humana para enfrentar y adaptarse a eventos adversos, juega un papel importante en el proceso de recuperación de las quemaduras. Por tanto, el presente estudio tiene como objetivo evaluar la resiliencia de los pacientes quemados, en el momento del ingreso y el alta, en un hospital de emergencia y urgencia en Goiânia. Se trata de un estudio descriptivo, cuantitativo y transversal que utiliza la Escala de Resiliencia Connor-Davidson (CD RISC) como instrumento de medida. Al ingreso hospitalario, la resiliencia media fue de 71,35, con associación significativa entre el factor Amparo de la escala CD RISC y la presencia de pareja. El puntaje de resiliencia encontrado en el presente estudio es consistente con otros hallazgos en la literatura científica nacional e internacional sobre la expresión de resiliencia en víctimas de quemaduras y otras enfermedades. La relación entre el factor Amparo y la presencia de pareja enfatiza la importancia de la red de apoyo familiar en la rehabilitación del paciente quemado.(AU)

Prevalencia y caracterización del dolor irruptivo oncológico en pacientes hospitalizados en Vigo. Estudio Dolopaho / Prevalence and characterization of breakthough cancer pain in hospitalized patients in Vigo. The Dolopaho study

Introducción: El dolor sigue siendo en la actualidad un problema no resuelto en los pacientes con cáncer. A pesar de los avances en el tratamiento del dolor en los últimos años, persisten lagunas que dificultan un tratamiento global, como es el caso del dolor irruptivo oncológico (DIO). Objetivos: Evaluar la prevalencia de DIO de una muestra de pacientes ingresados en un servicio de oncología médica, analizar si el dolor era el principal motivo de ingreso en estos pacientes, así como determinar si existe un infradiagnóstico y, por tanto, un infratratamiento en los mismos previamente al ingreso. Métodos: Estudio observacional prospectivo. Se reclutaron los pacientes de forma consecutiva, independientemente del motivo de ingreso. Las variables analizadas en relación con el dolor irruptivo fueron las siguientes: presencia de dolor irruptivo según el algoritmo de Davies; semejanza de los episodios de dolor irruptivo entre sí y respecto al dolor basal; número de crisis de dolor a lo largo del día y a lo largo de la semana; escala visual analógica del dolor irruptivo; tiempo desde el inicio del dolor hasta su máxima intensidad medida en los siguientes rangos: < 5 min, 5-30 min, > 30 min; la duración de los episodios: < 5 min, 5-30 min, > 30 min; desencadenantes del dolor irruptivo (incidental, espontáneo); percepción individual de la alteración en la calidad de vida y efectividad de los fármacos utilizados. Resultados: Se incluyeron un total de 115 pacientes. En la muestra analizada el 33,9 % de los pacientes presentaron dolor irruptivo, de ellos el 95 % recibían tratamiento con opioides mayores, pero en solo el 56 % de los casos se asociaron a opioides de liberación ultrarrápida. Conclusión: El manejo de los pacientes con DIO continúa siendo un reto a día de hoy. Cerca de la mitad de los pacientes con dolor irruptivo no habían recibido tratamiento adecuado en nuestro estudio y, por tanto, probablemente no estaban bien caracterizados. (AU)

Background: Pain is often inadequately treated in patients with cancer. Although in recent years there have been major advances in the treatment of pain, there are still gaps for a global treatment, such as breakthrouth cancer pain (BCP). Objectives: The main objective was to evaluate the prevalence of BCP in a sample of patients admitted to a oncology medical department, in order to see whether pain is the main reason for admission in these patients, as well as to determine whether they were correctly treated and diagnosed before admission. Methods: An observational, prospective study. Patients were enrolled consecutively, regardless of reason for admission. The variables analyzed in relation to breakthrough pain were the following: presence of breakthrough pain according to the Davies scale; similarities of breakthrough pain events to each other and to baseline pain; number of irruptive pain events throughout the day and throughout the week; visual analogue scale of breakthrough pain; time between the onset of breakthrough pain and maximum intensity as measured in the following ranges: < 5 minutes, 5-30 minutes, > 30 minutes; duration of the breakthrough pain event (< 5 minutes, 5-30 minutes, > 30 minutes); triggers of breakthrough pain (incidental, spontaneous); perceived quality of life impairment and effectiveness of the drugs used. Results: A total of 115 patients consecutively admitted were analyzed regardless of reason for admission. In the analyzed sample, 33.9 % of patients had breakthrouth pain, and 95 % of the patients with breakthrough pain received treatment with strong opioids, though only in 56.4 % of cases associated with ultra-rapid-release opioids.Conclusions: The management of BCP is still a challenge. About half of patients with breakthrough cancer pain had not received adecuated treatment in our study, and were therefore poorly diagnosed. (AU)

Dolor irruptivo oncológico de mal control secundario a masas suprarrenales bilaterales / Breaktrhough cancer pain bad controlled secondary to bilateral adrenal masses

Presentamos el caso de un paciente varón de 67 años diagnosticado de adenocarcinoma de pulmón en estadio IV con dolor irruptivo oncológico (DIO) de difícil control. Durante el transcurso de la enfermedad el paciente necesitó varios ingresos por complicaciones, siendo la más común el mal control del DIO. Tras varios cambios en la pauta analgésica (rotación de opioides, cambios en tratamientos coadyuvantes y vías de administración), se consiguió buen control del dolor a pesar de progresión de la enfermedad de base. Finalmente, el paciente precisó ingreso hospitalario ante deterioro del estado general y claudicación familiar. Ante mal pronóstico, el equipo de Cuidados Paliativos y los familiares decidieron instaurar tratamiento con medidas de confort. De la relevancia del caso clínico que aportamos se concluye que es necesaria la existencia de equipos multidisciplinares formados y entrenados en este ámbito para un buen manejo terapéutico y una mejor calidad de vida en los pacientes

We present the case of a 67-year-old male with stage IV adenocarcinoma lung cancer who presented difficult control of breakthrough cancer pain. During the course of the disease, the patient had to be hospitalized several times due to complications. The most common complication was breakthrough cancer pain. After many changes in the analgesic treatment (opioid rotation, changes in coadjuvant drugs and routes of administration), good control of analgesic pain was achieved despite the progression of this underlying disease. Finally, the patient required being hospitalized due to deterioration of the general condition and family claudication. Faced with a por prognosis, the Palliative Care and Oncology team decided to establish treatment with comfort measures. We can conclude that the existence of multidisciplinary trained team is necessary for good therapeutic management and a better quality of life in patients

Manejo del dolor irruptivo asociado a la cura de úlceras cutáneas / Management of breakthrough pain associated with the cure of skin ulcers

OBJETIVOS: Valorar el manejo profiláctico del dolor irruptivo asociado a la cura de úlceras cutáneas, teniendo en cuenta los diferentes tratamientos que se usan en la práctica clínica para la prevención y la reducción del dolor. MATERIAL Y MÉTODOS: Estudio multicéntrico, observacional y transversal. El estudio se llevó a cabo en 11 hospitales en España. Se recopilaron datos sobre las características de las úlceras, además de variables demográficas y clínicas de los pacientes. La valoración del dolor, la ansiedad y la satisfacción del paciente se midieron mediante el cuestionario del dolor de McGill, la escala de ansiedad de Hamilton y escalas visuales analógicas. RESULTADOS: La mayoría de los pacientes presentaba niveles bajos de ansiedad (74,2 %, ninguna o leve), mientras que la satisfacción de los pacientes y los profesionales sanitarios era alta (8,3 y 7,7, respectivamente). Se administraron medicamentos opioides al 73,8 % de los pacientes, que experimentaron significativamente (p < 0,0001) menos dolor que aquellos que no recibieron tratamiento o que recibieron medicamentos no opioides. El tipo de tratamiento se relacionó con la edad del paciente, la percepción del dolor durante la cura, los años de experiencia del profesional, el uso de guías clínicas y el servicio o unidad en el que se llevó a cabo la cura. El uso de profilaxis se relacionó significativamente con el tratamiento del dolor irruptivo, con úlceras más graves y con el tratamiento realizado por un profesional con menos de 20 años de experiencia, que siguió las guías clínicas. Otros factores relacionados con el uso de opioides fueron la presencia de ansiedad, la unidad donde se realizaron los cuidados y los años de experiencia del profesional de la salud. CONCLUSIONES: Las diferencias en el manejo del paciente dependieron de numerosos factores. La profilaxis con opioides se asoció con una menor percepción del dolor para el paciente

OBJECTIVE: to assess the prophylactic management of breakthrough pain associated with skin ulcers care procedures, considering the different treatments used in clinical practice for the prevention and minimization of pain. MATERIAL AND METHODS: A multicenter, cross-sectional, observational study. The study was conducted in 11 hospitals distributed throughout Spain. Ulcer features, patient demographics and clinical characteristics were recorded. Pain assessment, and patients' anxiety and satisfaction were measured using McGill Pain Questionnaire, Hamilton Anxiety Rating Scale and visual analogue scales (VAS). RESULT: Low levels of anxiety were registered (74.2%, none or mild) and patient and healthcare professional satisfaction was high (8.3 and 7.7, respectively). Opioid drugs were administered to 73.8% of patients, who experienced significantly less pain than those who did not receive treatment or who received non-opioid drugs (p < 0.0001). Type of management was related to patient age, ulcer characteristics, treatment for background pain, patient anxiety levels, perception of pain during the procedure, years of experience of the healthcare professional, the use of clinical guidelines, and the unit in which it was performed. Factors significantly related to the use of prophylaxis were treatment for background pain, more severe ulcers, and treatment by a professional with <20 years of experience who followed clinical guidelines. Significant factors related to the use of opioids were anxiety, the care unit, and the years of experience of the healthcare professional. CONCLUSIÓN: Differences in patient management depended on numerous factors. Prophylaxis with opioids, mainly fentanyl, resulted in less pain for the patient

Fentanilo transmucoso y dolor irruptivo: la otra cara de la moneda / Transmucosal fentanyl and breakthrough pain: The other side of the coin

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Comparación del consumo intrahospitalario de fentanilo de liberación inmediata en 2014 y 2017: ¿uso o abuso? / Comparison of hospital consumption of immediate-release fentanyl: use or abuse?

OBJETIVO: El fentanilo de liberación inmediata está indicado en el tratamiento del dolor irruptivo en pacientes oncológicos que ya reciben opiáceos como analgesia de base crónica. Según una alerta emitida por la Agencia Española del Medicamento, su consumo en condiciones distintas a las autorizadas ha aumentado de manera alarmante en los últimos años, con mayor riesgo de que se produzca abuso y dependencia. El objetivo principal del estudio fue comparar el uso de fentanilo de liberación inmediata fuera de ficha técnica en pacientes hospitalizados en nuestro centro en 2014 y 2017. MÉTODOS: Se realizó un estudio descriptivo transversal retrospectivo en el que se compararon las prescripciones de fentanilo de liberación inmediata en los pacientes adultos ingresados durante los años 2014 y 2017 en un hospital del grupo 5 (Hospital 12 de Octubre de Madrid). Las variables fueron recogidas mediante la historia clínica electrónica. El estudio de asociación entre las variables cualitativas se calculó mediante el test de la chi-cuadrado, y las cuantitativas mediante la prueba de t-student. RESULTADOS: En 2014 se realizaron 0,43 prescripciones de fentanilo de liberación inmediata por cada 100 ingresos, y en 2017 0,54 por cada 100 ingresos. El 22,1% (n=34) de las prescripciones fueron fuera de ficha técnica en 2014, mientras que en 2017 resultaron el 31,8% (n=76) (p = 0,034). Las indicaciones fuera de ficha técnica más frecuentes fueron la cura de úlceras y heridas, así como el tratamiento del dolor crónico no oncológico. CONCLUSIONES: El uso de fentanilo de liberación inmediata en el ámbito hospitalario sufre un aumento considerable en comparación con el año 2014, así como su uso fuera de las indicaciones autorizadas

OBJECTIVE: Immediate-release fentanyl is indicated in the treatment of breakthrough pain in cancer patients who already receive opioids as background chronic analgesia. According to an alert issued by the Spanish Agency of Medicines, its consumption under non-authorized conditions has alarmingly increased in recent years, with a greater risk of abuse and dependence. The main objective of this study is to compare the off-label use of immediate-release fentanyl in our hospital during 2014 and 2017. METHODS: Retrospective cross-sectional descriptive study in which immediate-release fentanyl prescriptions were compared in adult patients admitted during 2014 and 2017 in a group 5 hospital. Variables were collected by the electronic medical record. The association study between qualitative variables was calculated using the chi-square test, and quantitative variables with the t-student test. RESULTS: In 2014, 0.43 immediate-release fentanyl prescriptions were made in our center for every 100 admissions, and in 2017 0.54/100 admissions. 22.1% (n=34) prescriptions were off-label in 2014, while in 2017 31.8% (n=76) (p = 0.034). Both years, the most frequent off-label indications were healing of ulcers and wounds and non-cancer chronic pain. CONCLUSIONS: The use of immediate-release fentanyl in the hospital setting has considerably increased in comparison to 2014, as well as its off-label use

Amputación por úlcera de pie diabético con dolor incoercible, evitada con sevoflurano tópico / Painful diabetic foot ulcer amputation avoided thanks to topical sevoflurane

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Tratamiento con fentanilo sublingual del dolor irruptivo asociado a reacciones alérgicas durante la infusión de quimioterapia / Sublingual fentanyl for the treatment of breakthrough cancer pain during allergic reactions to chemotherapy infusion

Introducción: Las reacciones de hipersensibilidad a fármacos (RHF) son eventos potencialmente mortales que se producen durante la administración de diversos agentes quimioterápicos. Pueden cursar con un dolor intenso, considerado en algunos casos como dolor irruptivo oncológico (DIO). Actualmente no existen guías para el tratamiento de este tipo específico de dolor. Objetivos: Evaluar, en pacientes oncológicos, la eficacia del citrato de fentanilo sublingual 100 mcg en el tratamiento del DIO asociado a RHF durante la infusión de quimioterapia. Material y métodos: Estudio retrospectivo con pacientes que recibieron quimioterapia en el servicio de Oncología Médica del Hospital de Denia entre 2013 y 2016 y que fueron tratados con fentanilo por DIO asociado a RHF (EVA > 7). Se estableció la gravedad del DIO mediante una escala EVA antes y después de administrar fentanilo. Se utilizó la t de Student para comparar las puntuaciones EVA antes y después del tratamiento. Resultados: En total, se incluyeron 34 pacientes (73,53 % mujeres, edad media 59,68 años). Los tratamientos quimioterápicos asociados a una mayor frecuencia a la aparición de DIO por RHF fueron docetaxel y oxaliplatino (ambos 35,29 %), seguidos de paclitaxel (20,59 %). En promedio, los pacientes tuvieron un valor basal de EVA de 8,55 (DE 0,79) antes de ser tratados con fentanilo. Tras el tratamiento, la intensidad media del dolor fue de 1,48 (DE 1,50), siendo la diferencia significativa (p < 0,001). La duración media del episodio de DIO fue de 5,29 minutos (DE 2,25), y el tiempo medio hasta el inicio del alivio del dolor de 1,52 minutos (DE 0,71). Conclusiones: Fentanilo sublingual es un fármaco efectivo en el manejo del DIO asociado a RHF durante la infusión de taxanos y oxaliplatino, donde permite un alivio rápido y signifi cativo del dolor. Se debe seguir investigando su papel en este contexto mediante ensayos clínicos controlados

Introduction: Drug hypersensitivity reactions (DHR) are events that can occur during the administration of several chemotherapeutic agents and which could potentially be life-threatening. These events may present with intense pain, in some cases known as breakthrough cancer pain (BTCP). There are no currently available treatment guidelines for this specifi c type of pain. Objectives: To assess the effi cacy of sublingual fentanyl citrate 100 mcg in cancer patients in the treatment of DHR-related BTCP during chemotherapy infusion. Material and methods: A retrospective study with patients receiving chemotherapy in the Medical Oncology Department of Hospital de Denia between 2013 and 2016 who were treated with fentanyl due to DHR-related BTCP (VAS [Visual Analogue Scale] > 7). BTCP severity was determined via a VAS before and after fentanyl administration. Student's t-test was used to compare VAS scores before and after the treatment. Results: A total of 34 patients were included (73.53 % women; mean age: 59.68 y/o). The chemotherapy treatments that were most frequently associated with the occurrence of DHR-related BTCP were docetaxel and oxaliplatin (both 35.29 %), followed by paclitaxel (20.59 %). On average, patients had a baseline VAS score of 8.55 (SD 0.79) before being treated with fentanyl. After treatment, the mean pain intensity was 1.48 (SD 1.50), which represented a signifi cant difference (p < 0.001). The mean duration of the BTCP episode was of 5.29 minutes (SD 2.25), and the mean time to achieve pain relief was 1.52 minutes (SD 0.71). Conclusions: Sublingual fentanyl is an effective drug in the management of DHR-related BTCP during the infusion of taxanes and oxaliplatin, as it provides for a rapid and significant pain relief. Its role in this context should be further investigated by means of controlled clinical trials

Deshabituación rápida de opioides / Fast opioid detoxification

Introducción: En estos últimos 15 años, el incremento del uso de analgésicos opioides ha sido progresivo y elevado. La percepción de la existencia de cuadros de dolor mal tratados ha provocado que muchos sistemas de salud incentiven a los profesionales en el uso de opioides, para evitar episodios de sufrimiento inútiles y estériles. Dicha incentivación, el uso de receta electrónica, la facilitación y simpleza de prescripción tras la desaparición de receta de estupefacientes tradicional, supuso una liberalización significativa y uso de opioides progresivo entre todas las especialidades médicas que habitualmente no los prescribían. Además, la aparición de nuevos opioides sintéticos, con aparentemente menores efectos secundarios, fáciles de usar y con buen perfil farmacocinético, quizás ha suscitado una confianza irreal en la inocuidad de dichos fármacos. Estos últimos años han sido años de alta prescripción y de hallazgo de efectos no deseados por los elevados consumos y prescripciones un tanto quizá alejadas de la idoneidad y poco control sobre los pacientes. Nosotros detectamos en nuestro departamento de salud varios casos de pacientes con problemas reales derivados del consumo de opioides, de origen iatrogénico, siempre por prescripción médica legal y con gravísimos efectos secundarios, que conllevaban riesgo vital. Objetivo: Realizar una deshabituación rápida del consumo de opioides, sin poner en riesgo la salud y vida del paciente, de un modo rigurosamente monitorizado y controlado. Material y métodos: Nuestra comunicación científica se basa en la descripción del trabajo realizado sobre un grupo de pacientes afectados por un elevado consumo de opioides. Nuestro método de deshabituación a los opioides consiste en el ingreso de los pacientes en la Unidad de Cuidados Intensivos del Servicio de Anestesiología de nuestro hospital para la retirada absoluta de los mismos. Se realiza en primer lugar una valoración basal clínica, psicológica, social y biológica, y tras solicitar un consentimiento informado, se procede a una retirada de los opioides, con monitorización avanzada e inicio de sedación profunda multimodal, hasta el nivel que sea necesario para cada paciente, incluso con previsión de posible intubación orotraqueal y asistencia ventilatoria. Realizamos mantenimiento vital convencional de cuidados intensivos, con fluidoterapia, profilaxis antitrombótica, protección digestiva, fisioterapia, control de diuresis y control bioquímico, metabólico y nutricional durante 96 horas. Posteriormente, el paciente, tras asegurar su estabilidad y seguridad, pasa a una planta de hospitalización convencional durante unas 48 horas, con tratamiento de perfil psiquiátrico manejado por la Unidad de Conductas Adictivas. Tras ser dado de alta hospitalaria, se continúa tratamiento y control por Unidad de Conductas Adictivas, Unidad de Dolor y Unidad de Rehabilitación Física. Resultados: Describimos los resultados obtenidos con el uso de dos pautas en las que se combinan distintos grupos farmacológicos usados para la deshabituación: midazolam, propofol, ketamina, dexmedetomidina, clonidina y naloxona, en la consecución del mantenimiento del paciente libre de opioides garantizando la estabilidad hemodinámica, respiratoria y la seguridad biológica del paciente. Conclusiones: La desconexión rápida de opioides es un tratamiento eficaz, que recupera al paciente de un infierno vital grave del que difícilmente se puede salir sin una ayuda externa. Lo consideramos un método seguro, ya que no se nos ha presentado ninguna complicación severa, aunque son pacientes que precisan de unos cuidados médicos de vigilancia intensiva. El posterior seguimiento y ayuda es imprescindible, aunque como pacientes de dolor, precisan de un buen entorno social y familiar, para conseguir el apoyo necesario y no volver a recaer. Por todo ello, y en base a los resultados obtenidos en nuestro estudio, consideramos que es un método adecuado y eficaz, aunque caro en recursos

Introduction: For the last 15 years we have witnessed a steady increase in opioid consumption. Being aware of an undertreatment in certain pain situations, many health care providers have encouraged their physicians to prescribe opioids to avoid unnecessary suffering. Such encouragement, also by means of switching from the traditional paper prescription to the current electronic one, has led to a wide spread in opioid prescription even among those medical specialities which never did before. Besides, new synthetic opioids with apparently less side effects, favourable kinetics and easer to take, might have arosen a wrong impression of unreal harmlessness. Therefore, the increased prescription and its obvious consequence of consumption has led to an alarming increase in the number of side effects, proving our patients not to be so well controlled. We have perceived in our Health Department several different patients with opioid consumption abuse derived from medical prescription with potential life threatening side effects, that's why we have conducted a medical path for their detoxification. Aim: To perform a safe fast opioid detoxification (FOD) in our fully monitored patients. Method and materials: To perform our FOD path we previously admit the patients in our ICU unit. After a careful clinical, psychological, social and biological assessment, and having requested their informed consent, we monitor all their vital constants in bed and we start a deep polymodal sedation up to the required level for each patient, getting even ready for oral intubation and mechanical ventilation if needed. Our regular vital maintenance is based on fluids, deep vein thrombosis prophylaxis, digestive prophylaxis, physiotherapy, urine output and blood tests for 96 hours. Having achieved our goal, regarding the patients are stable, they are discharged to the ward for an additional 48 hours period, with psyquiatric treatment and under the care of the Addictive Conducts Unit. The patients are fi nally discharged from hospital with a multimodal supervision and treatment conducted by our Pain Unit, Addictive Conducts Unit and Physical Rehabilitation. Results: We describe the results achieved with two different drug approaches which combine different pharmacological groups frequently used for detoxification: midazolam, propofol, ketamine, clonidine and naloxone, for our aim of succeeding in keeping the patients opioid-free without endangering their haemodynamic, breathe or biology. Conclusions: FOD has proved to be a successful treatment in rescuing the patients from a living hell out of which they would have found it impossible to leave without qualified help. We deem it safe with the right ICU surveillance, since no major complications have occurred, but a thereafter following and help is mandatory, since, like any other patient attended at a Pain Clinic, they require a favouring social and familiar environment to avoid any relapse. Finally, and given our results, we consider this detoxifi cation method right and safe but highly costly in resources

Neuralgia de Arnold en paciente en fase de prueba de SCS por síndrome de espalda fallida / Occipital neuralgia during stimulation trial period of SCS in failed back surgery sindrome

El síndrome de espalda fallida es una de las patologías más frecuentes para estimulación de los cordones posteriores. Aunque es una técnica segura, no está exenta de complicaciones. Presentamos un caso poco habitual de migración en SCS

Failed back surgery syndrome is one of the most common indications for spinal cord stimulation. Although is a safe technique, it has some complications such electrode migration. Here is an unusual migration case of a SCS electrode in a FBSS patient

Dexmedetomidina versus lidocaína endovenosa en el control de dolor irruptivo y la funcionalidad en pacientes con canal lumbar estrecho / Dexmedetomidine versus endovenous lidocaine in breakthrough pain control and functionality in patients with lumbar stenosis

Introducción: El dolor es un motivo de ausentismo laboral, en especial el dolor irruptivo secundario a canal lumbar estrecho. La dexmedetomidina como analgésico actúa inhibiendo la liberación de sustancia P en la vía nociceptiva y bloquea los receptores de aspartato y glutamato. Por otro lado, la lidocaína también previene y alivia el dolor mediante la interrupción de la neuroconducción, uniéndose a su receptor específico dentro de los canales de sodio. Objetivo: Evaluar la eficacia analgésica de la dexmedetomidina versus lidocaína en perfusión endovenosa como tratamiento del dolor irruptivo secundario a canal lumbar estrecho. Material y métodos: Ensayo clínico controlado, aleatorizado, triple ciego, realizado en la clínica del dolor del HGM, se evaluaron dos grupos de pacientes con diagnóstico de dolor irruptivo secundario a canal lumbar estrecho; un grupo tratado con dexmedetomidina (0,3 mcg/kg) y otro grupo tratado con lidocaína (2 mg/kg) en perfusión endovenosa. Se realizó medición de la intensidad del dolor y el estado de sedación antes de iniciar el tratamiento y posteriormente a los 30, 60 y 120 minutos. También se evaluó la funcionalidad de los pacientes a través del índice de discapacidad de Oswestry antes y a los siete días del tratamiento. Se evaluó de forma secundaria el efecto de los tratamientos sobre los signos vitales. Resultados: No hubo diferencia estadísticamente significativa en la reducción de la intensidad del dolor a los 120 minutos entre los pacientes tratados con dexmedetomidina (EVA 1,29 ± 1,63) comparados con los tratados con lidocaína (EVA 1 ± 1,19, p = 0,594). Se observó que al final de la perfusión de los fármacos, la dexmedetomidina produjo mayor sedación a diferencia de la lidocaína (p = 0,003). Ambos tratamientos mejoran la funcionalidad en todos los pacientes sin haber diferencia estadísticamente significativa entre los tratamientos (p = 0,508) no se observaron efectos depresores sobre los signos vitales. Conclusiones: La dexmedetomidina y la lidocaína son igual de eficaces para el tratamiento del dolor irruptivo, con inicio de acción en los primeros 30 minutos de iniciada la perfusión hasta las siguientes 2 horas. No se observaron eventos adversos medicamentosos a las dosis recomendadas

Introduction: The pain is a reason for absenteeism labour, especially breakthrough pain secondary to narrow lumbar canal. Dexmedetomidine is an analgesic, act by inhibiting the release of substance P in the nociceptive pathway and blocks the aspartate and glutamate receptors. On the other hand, lidocaine also prevents and relieves pain by interrupting neuroconduction, binding to its specific receptor within the sodium channels. Objective: To evaluate the analgesic efficacy of dexmedetomidine versus lidocaine in intravenous perfusion as a treatment for breakthrough pain secondary to narrow lumbar canal. Material and methods: Controlled clinical trial, randomized, triple-blind, performed at the HGM pain clinic, two groups of patients with diagnosis of breakthrough pain secondary to narrow lumbar canal were evaluated; group one was treated with dexmedetomidine (0.3 mcg/kg) and the other group was treated with lidocaine (2 mg/kg) in intravenous infusion. Measurement of pain intensity and sedation status was made before starting the treatment and after 30, 60 and 120 minutes. The functionality of the patients was also assessed through the Oswestry disability index before and seven days after treatment. Secondarily evaluated the effect of treatments on vital signs. Results: There was not any statistically significant difference in the reduction of pain intensity at 120 minutes between patients treated with dexmedetomidine (EVA 1.29 ± 1.63) compared with those who were treated with lidocaine (EVA 1 ± 1.19, p = 0.594), it was observed that at the end of drugs perfusion, dexmedetomidine produced greater sedation, unlike lidocaine (p = 0.003), both treatments improved functionality in all patients without having a statistically significant difference between treatments (p = 0.508), they were not observed depressant effects on vital signs. Conclusions: Dexmedetomidine and lidocaine are just as equally effective for the treatment of breakthrough pain, with onset of action in the first 30 minutes after the infusion started until the next 2 hours, no adverse drug events were observed at the recommended doses

Proyecto adapta: adecuación del tratamiento en dolor irruptivo oncológico / Adapta project: adequacy of treatment in breakthrough cancer pain

Introducción: El fentanilo de administración transmucosa tiene características específicas que lo convierten en el fármaco adecuado para el tratamiento del dolor irruptivo oncológico (DIO). Aunque en España existe un amplio consenso sobre la idoneidad de la administración de fentanilo transmucoso para el DIO, es relevante conocer cómo los oncólogos adecuan su prescripción al paciente y cuáles son los factores determinantes de la elección de las diferentes formas farmacéuticas. Objetivos: El objetivo principal de este proyecto fue identificar y priorizar los atributos que los oncólogos médicos españoles tienen en cuenta cuando valoran las opciones de tratamiento con fentanilo transmucoso en pacientes con DIO. Métodos: Un comité científico realizó una tipificación de 14 atributos relevantes en la prescripción de fentanilo transmucoso para el DIO. Posteriormente se generó un dossier de evidencia científica comparando estos 14 atributos entre los distintos fentanilos transmucosos disponibles, que se compartió con el panel de expertos (115 oncólogos médicos). Tras una exhaustiva revisión del documento, los participantes realizaron una votación online de priorización de los atributos. Resultados: De catorce atributos analizados, siete consiguieron un consenso de ≥ 50 % de los participantes: el inicio de la acción analgésica (84 %), la adecuación del efecto del fentanilo al perfil del episodio de DIO (72 %), la facilidad de uso por los pacientes y cuidadores (69 %), la duración del efecto (58 %), la presencia de mucositis (57 %),la facilidad de titulación de la dosis óptima (57 %) y las presentaciones y dosis disponibles (59 %). Conclusiones: Los atributos más valorados fueron los relativos a la rapidez de acción del tratamiento analgésico y su adaptación al perfil del DIO, algo esperable dadas las características clínicas del episodio de DIO. Como atributos menos valorados aparecen el riesgo de abuso o conductas aberrantes y la presencia de rinitis para su administración, lo que indica que la existencia de estos factores no tiene tanta influencia en la elección del tratamiento para el abordaje del DIO. Estos resultados permitirán a los oncólogos médicos conocer qué atributos deben ser tenidos en cuenta a la hora de personalizar los tratamientos del paciente con DIO con el objetivo de mejorar la adecuación de la analgesia de rescate

Introduction: Transmucosal fentanyl has specific properties which make it ideal for the treatment of breakthrough cancer pain (BTCP). Although there is a broad consensus for the administration of transmucosal fentanyl for BTCP in Spain, there is uncertainty as to the way oncologists adjust their prescription to the patient and what are the determinants of the choice of different pharmaceutical forms. Objectives: The main objective of this study was to analyze and prioritize the attributes that Spanish oncologists consider when assessing treatment options with transmucosal fentanyl in patients with BTCP. Methods: A Scientific Committee performed a classification of 14 relevant attributes in the prescription of transmucosal fentanyl for BTCP. Subsequently, a dossier of scientific evidence was generated comparing these 14 attributes among the different available transmucosal fentanyl formulations, which was shared with the panel of experts (115 Medical Oncologists). After a thorough review of the document, the participants carried out an online vote for the prioritization of the attributes. Results: Out of fourteen attributes analyzed, seven achieved a consensus of ≥ 50 % of the participants: the start of the analgesic action (84 %), the adequacy of the effect of fentanyl to the BTCP episode (72 %), the ease of use (58 %), the presence of mucositis (57 %), the ease of titration of the optimal dose (57%), and the variety of presentations and doses available (59 %). Conclusions: The most valued attributes were those related to the speed of action of the analgesic treatment and its adaptation to the BTCP profile, something to be expected given the spontaneous, unpredictable, and transitory nature of BTCP. As less valued attributes appear the risk of abuse or aberrant behavior and the presence of rhinitis for its administration, which indicates that the existence of these factors do not influence the choice of treatment for BTCP. These results will allow medical oncologists to know what attributes should be taken into account when customizing the patient's treatment of BTCP in order to improve the adequacy of rescue analgesia

Programmed intermittent epidural bolus as compared to continuous epidural infusion for the maintenance of labor analgesia: a prospective randomized single-blinded controlled trial / 대한마취과학회지

BACKGROUND: Programmed intermittent epidural bolus (PIEB) techniques are a new area of interest for maintaining labor analgesia due to the potential to decrease motor block and improve labor analgesia. This study compares continuous epidural infusion (CEI) to 2 PIEB regimens for labor analgesia. METHODS: One hundred fifty patients undergoing scheduled induction of labor at term gestation having epidural labor analgesia were randomized to receive an epidural analgesia regimen of bupivacaine 0.125% with fentanyl 2 μg/ml at either PIEB 5 ml every 30 min (Group 5q30), PIEB 10 ml every 60 min (Group 10q60), or 10 ml/h continuous infusion (Group continuous epidural infusion [CEI]). The primary outcome is the pain scores throughout labor. Secondary outcomes include degree of motor block, dermatomal sensory levels, the number of physician-administered boluses, and patient satisfaction. RESULTS: While the average pain scores throughout labor did not differ significantly between groups, fewer patients in group 10q60 received physician-administered boluses for breakthrough pain (34.9% in 10q60 vs. 61.0% in 5q30 and 61.9% in CEI, P = 0.022). Dermatomal sensory levels, degree of motor block, and patient satisfaction did not differ significantly between groups. CONCLUSIONS: Our study suggests that high volume PIEB regimens for labor analgesia decrease breakthrough pain and physician-administered boluses.