RESUMEN
Las fracturas costales tienen una elevada prevalencia en nuestra sociedad. Un adecuado y precoz control analgésico resulta fundamental a la hora de evitar complicaciones respiratorias y favorecer una rápida recuperación funcional en los pacientes con fracturas costales. Se han empleado diferentes estrategias para dicho control analgésico, desde fármacos intravenosos hasta técnicas regionales más clásicas como el catéter epidural o el bloqueo paravertebral torácico. El bloqueo ecoguiado del plano profundo del músculo erector de la espina (ESPB) constituye una alternativa eficaz en el manejo del dolor agudo derivado de las fracturas costales, permitiendo una fisioterapia y rehabilitación precoz
Rib fractures have a high prevalence in our society. An adequate and precocious analgesic control is essential to avoid respiratory complications and favor a rapid functional recovery in patients with rib fractures. Different strategies have been used for analgesic control, from intravenous drugs to more classic regional techniques such as epidural catheter or thoracic paravertebral block. Ultrasound-guided blockade of the deep plane of the erector spine muscle (ESPB) is an effective alternative in the management of acute pain derived from rib fractures, allowing physiotherapy and early rehabilitation
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/complicaciones , Dolor Agudo/tratamiento farmacológico , Fracturas de las Costillas/tratamiento farmacológico , Analgésicos/administración & dosificación , Analgesia Controlada por el Paciente/métodos , Bloqueo Nervioso/métodos , Infusión Espinal/métodos , Resultado del Tratamiento , Dimensión del Dolor/métodos , Catéteres de Permanencia , Cateterismo/métodosRESUMEN
There are inconsistent results regarding the efficacy and safety of intermittent epidural bolus (IPB) versus continuous epidural infusions (CPI) for labor analgesia. This study used a meta-analytic approach to assess the safety and treatment efficacy of IPB versus CPI for labor analgesia based on randomized controlled trials (RCTs). Four electronic databases were used to identify eligible RCTs. Pooled effect estimates at 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-two RCTs with 2,573 parturients were selected for final analysis. The findings revealed no significant differences between IPB and CPI for the incidences of cesarean and instrumental delivery. IPB was shown to be associated with shorter total duration of labor [weighted mean difference (WMD): -21.46; 95% CI: -25.07 to -17.85; P < 0.001], duration of the first of stage of labor (WMD: -13.41; 95% CI: -21.01 to -5.81; P = 0.001), and duration of the second stage of labor (WMD: -4.98; 95% CI: -9.32 to -0.63; P = 0.025). Furthermore, IPB significantly reduced the incidences of required anesthetic interventions compared with CPI [relative risk (RR): 0.61; 95% CI: 0.39-0.95; P = 0.030], whereas there was no significant difference between IPB and CPI for the time required in the first anesthetic intervention (WMD: 7.73; 95% CI: -33.68-49.15; P = 0.714). The local anesthetic IPB (bupivacaine equivalents) was associated with lower milligrams per hour of local anesthetic (WMD: -0.89; 95% CI: -1.41 to -0.36; P = 0.001) and better maternal satisfaction (WMD: 8.76; 95% CI: 4.18-13.35; P < 0.001). There were no significant differences between IPB and CPI for the risk of adverse events. This study found that parturients with IPB have short total duration of labor and duration of the first and second stage of labor, reduced requirements for additional anesthetic interventions, and improved maternal satisfaction.
Asunto(s)
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Dolor de Parto/tratamiento farmacológico , Adulto , Analgesia Epidural/efectos adversos , Analgesia Obstétrica/efectos adversos , Analgésicos/administración & dosificación , Bupivacaína/administración & dosificación , Parto Obstétrico/métodos , Esquema de Medicación , Femenino , Humanos , Infusión Espinal/métodos , Inyecciones Espinales/métodos , Embarazo , Ensayos Clínicos Controlados Aleatorios como Asunto , Seguridad , Resultado del TratamientoRESUMEN
INTRODUCCIÓN: Una de las ventajas de utilizar bolos epidurales es que se ejerce mayor presión de inyección y por tanto más difusión produciendo un mayor bloqueo sensitivo. Por tanto si a mayor velocidad de administración del bolo más presión se ejerce cabe esperar que el nivel sensitivo alcanzado sea mayor. OBJETIVO: Nuestro objetivo fue comparar el nivel sensitivo alcanzado con el set de alto flujo y el de flujo estándar a velocidades máximas. MATERIAL Y MÉTODOS: Se incluyeron setenta y tres gestantes primíparas que solicitaron analgesia epidural utilizando bolos epidurales intermitentes programados a 10ml cada 60 min de ropivacaína al 0,1% con fentanilo 2ug/ml más analgesia epidural controlada por la paciente. Dichos bolos se administraron con set de infusión estándar a 250ml/h o de alto flujo a 500ml/h según la práctica clínica habitual de cada anestesiólogo. El objetivo primario fue evaluar el nivel sensitivo alcanzado. Los objetivos secundarios fueron la escala visual analógica, la escala modificada de Bromage y el consumo anestésico en términos de analgesia de rescate (analgesia epidural controlada por la paciente y bolos administrados por el anestesiólogo). RESULTADOS: La mediana del nivel sensitivo máximo fue T9 en el grupo de alto flujo y T7 en el de flujo estándar, siendo dicha diferencia significativa estadísticamente (P=0,0002). No hubo diferencias significativas en la escala visual analógica, Bromage o analgesia de rescate. CONCLUSIÓN: El set de alto flujo no ofrece beneficios en cuanto a los resultados analizados por lo que hay que valorar su uso ya que conlleva un coste adicional
INTRODUCTION: The higher injection pressure obtained with epidural boluses give greater anaesthetic spread, and therefore better sensory block. Therefore, it stands to reason that anaesthetic administered at greater injection pressure and a higher flow rate would spread to a higher sensory level. OBJECTIVE: Our aim was to compare the sensory level reached with the high flow. and standard flow set at maximum rates. MATERIAL AND METHODS: We included 73 primiparous women who requested epidural analgesia for labour using programmed intermittent epidural boluses of 0.1% ropivacaine at a flow rate of 10ml/h and 2 ug/ml fentanyl plus patient-controlled epidural analgesia. The boluses were administered with a standard (250ml/h) or high-flow (500ml/h) infusion set, according to the usual clinical practice of each anaesthesiologist. The primary objective was to evaluate the sensory level reached. Secondary objectives were pain on a visual analogue scale, motor block measured on the modified Bromage scale, and anaesthesia consumption in terms of rescue analgesia (patient-controlled epidural analgesia) and anaesthesiologist-administered boluses. RESULTS: The median maximum sensory level reached was T9 in the high flow group and T7 in the standard flow group; this difference was statistically significant (p=.0002). There were no significant differences in visual analogue scale, Bromage or rescue analgesia between groups. CONCLUSION: Our results show that the high flow set does not offer benefits. The use of such sets need to be evaluated due to their higher cost
Asunto(s)
Humanos , Femenino , Embarazo , Adolescente , Adulto Joven , Adulto , Persona de Mediana Edad , Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Anestésicos Locales , Anestésicos Locales/administración & dosificación , Dolor de Parto/tratamiento farmacológico , Ropivacaína/administración & dosificación , Fentanilo/administración & dosificación , Infusión Espinal/métodos , Escala Visual Analógica , Manejo del Dolor , Estudios ProspectivosRESUMEN
BACKGROUND: Programmed intermittent epidural boluses may improve the spread of local anesthetics compared to continuous epidural infusion, improving labor analgesia and obstetric outcomes. However, there are limited data from studies using commercially available pumps capable of coadministering programmed intermittent epidural boluses or continuous epidural infusion with patient-controlled epidural analgesia. Therefore, we performed this prospective, randomized, double-blind study to compare the impact of programmed intermittent epidural boluses versus continuous epidural infusion on labor analgesia and maternal/neonatal outcomes. We hypothesized that programmed intermittent epidural boluses will result in lower patient-controlled epidural analgesia consumption compared to that with continuous epidural infusion. METHODS: Following standardized initiation of epidural labor analgesia, women were randomized to receive 0.1% ropivacaine with 2 µg/mL fentanyl as 6-mL programmed intermittent epidural boluses every 45 minutes or continuous epidural infusion at 8 mL/h in a double-blind fashion with similar patient-controlled epidural analgesia settings in both groups. The primary outcome was patient-controlled epidural analgesia consumption per hour. Secondary outcomes included a need for physician interventions, patterns of patient-controlled epidural analgesia use, motor blockade, number of patients who developed hypotension, pain scores, duration of second stage of labor, mode of delivery, and maternal satisfaction. RESULTS: We included 120 patients (61 in programmed intermittent epidural boluses group and 59 in continuous epidural infusion group) in the analysis. The median (interquartile range) patient-controlled epidural analgesia volume consumed per hour was not significantly different between the groups: 4.5 mL/h (3.0-8.6 mL/h) for the continuous epidural infusion group and 4.0 mL/h (2.2-7.1 mL/h) for the programmed intermittent epidural boluses group (P = .17). The Hodges-Lehmann location shift estimate of the difference (95% CI) from the continuous epidural infusion to the programmed intermittent epidural boluses group is 0.9 mL/h (-0.4 to 2.2 mL/h). There were also no significant differences between the groups in any of the secondary outcomes except for higher median (interquartile range) patient-controlled epidural analgesia attempts per given ratio per hour in the programmed intermittent epidural bolus group (0.17 [0.10-0.30] vs 0.12 [0.08-0.18]; P = .03) and more motor block in the continuous epidural infusion group (those with Bromage score <5, 27.5% vs 50.0%; P = .03). CONCLUSIONS: Under the conditions of our study, we did not find improved outcomes with programmed intermittent epidural boluses compared to continuous epidural infusion except for less motor block with programmed intermittent epidural boluses. Future studies should assess whether smaller but clinically important differences exist and evaluate different parameters of programmed intermittent epidural boluses to optimize analgesia and outcomes with this mode of analgesia.
Asunto(s)
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Anestésicos Locales/administración & dosificación , Infusión Espinal/métodos , Dolor de Parto/tratamiento farmacológico , Ropivacaína/administración & dosificación , Adulto , Analgesia Epidural/instrumentación , Analgesia Obstétrica/instrumentación , Método Doble Ciego , Femenino , Humanos , Bombas de Infusión Implantables , Infusión Espinal/instrumentación , Dolor de Parto/diagnóstico , Embarazo , Estudios ProspectivosRESUMEN
BACKGROUND: As reported, patients experience less postoperative pain after propofol-based total intravenous anesthesia (TIVA). In the present study, we investigated the postoperative analgesic effects between propofol-based TIVA and desflurane anesthesia after spine surgery. METHODS: Sixty patients were included who received (surgical time >180 minutes) lumbar spine surgery. Patients were randomly assigned to receive either TIVA (with target-controlled infusion) with propofol/fentanyl-based anesthesia (TIVA group) or desflurane/fentanyl-based anesthesia (DES group), titrated to maintain Bispectral Index values between 45 and 55. All patients received patient-controlled analgesia (PCA) with fentanyl for postoperative pain relief. Numeric pain rating scale (NRS) pain scores, postoperative fentanyl consumption, postoperative rescue tramadol use, and fentanyl-related side effects were recorded. RESULTS: The TIVA group patients reported lower NRS pain scores during coughing on postoperative day 1 but not day 2 and 3 (Pâ=â.002, Pâ=â.133, Pâ=â.161, respectively). Less fentanyl consumption was observed on postoperative days 1 and 2, but not on day 3 (375âµg vs 485âµg, Pâ=â.032, 414âµg vs 572âµg, Pâ=â.033, and 421âµg vs 479âµg, Pâ=â.209, respectively), less cumulative fentanyl consumption at postoperative 48âhours (790âµg vs 1057âµg, Pâ=â.004) and 72âhours (1210âµg vs 1536âµg, Pâ=â.004), and total fentanyl consumption (1393âµg vs 1704âµg, Pâ=â.007) when compared with the DES group. No difference was found in rescue tramadol use and fentanyl-related side effects. CONCLUSION: Patients anesthetized with propofol-based TIVA reported less pain during coughing and consumed less daily and total PCA fentanyl after lumbar spine surgery.
Asunto(s)
Anestesia Intravenosa/métodos , Anestésicos Intravenosos/administración & dosificación , Desflurano/administración & dosificación , Vértebras Lumbares/cirugía , Dolor Postoperatorio/tratamiento farmacológico , Propofol/administración & dosificación , Adulto , Anciano , Analgesia Controlada por el Paciente/estadística & datos numéricos , Femenino , Fentanilo/administración & dosificación , Humanos , Infusión Espinal/métodos , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Resultado del Tratamiento , Adulto JovenAsunto(s)
Dolor en Cáncer/terapia , Dolor Crónico/terapia , Neoplasias del Colon/complicaciones , Bombas de Infusión Implantables , Manejo del Dolor/métodos , Bupivacaína/administración & dosificación , Dolor en Cáncer/etiología , Cateterismo , Dolor Crónico/etiología , Neoplasias del Colon/terapia , Fluoroscopía , Humanos , Hidromorfona/administración & dosificación , Infusión Espinal/instrumentación , Infusión Espinal/métodos , Masculino , Persona de Mediana Edad , Manejo del Dolor/instrumentación , Columna Vertebral/diagnóstico por imagen , Resultado del TratamientoRESUMEN
Recombinant adeno-associated viruses (rAAVs) are the leading in vivo gene delivery platform, and have been extensively studied in gene therapy targeting various tissues, including the central nervous system (CNS). A single-bolus rAAV injection to the cerebrospinal fluid (CSF) space has been widely used to target the CNS, but it suffers from several drawbacks, such as leakage to peripheral tissues. Here, a protocol is described using an osmotic pump to infuse rAAV slowly into the mouse CSF space. Compared to the single-bolus injection technique, pump infusion can lead to higher CNS transduction and lower transduction in the peripheral tissues.
Asunto(s)
Dependovirus/genética , Vectores Genéticos/administración & dosificación , Infusión Espinal/métodos , Médula Espinal/cirugía , Transducción Genética/métodos , Animales , Encéfalo/metabolismo , Encéfalo/cirugía , Encéfalo/virología , Catéteres de Permanencia , Líquido Cefalorraquídeo/virología , Dependovirus/metabolismo , Femenino , Terapia Genética/métodos , Humanos , Bombas de Infusión Implantables , Infusiones Intraventriculares , Infusión Espinal/instrumentación , Masculino , Ratones , Ratones Endogámicos C57BL , Presión Osmótica , Médula Espinal/metabolismo , Médula Espinal/virología , Transducción Genética/instrumentación , TransgenesRESUMEN
BACKGROUND: Both general and spinal anaesthesia with short-acting local anaesthetics are suitable and reliable for knee arthroscopy as an ambulatory procedure. Chloroprocaine (CP) 1% seems to be the ideal spinal local anaesthetic for this indication. OBJECTIVE: The aim of this study was to compare spinal anaesthesia using CP 1% with general for outpatient knee arthroscopy with regard to procedure times, occurrence of pain, patient satisfaction and recovery, and also costs. DESIGN: A randomised controlled single-centre trial. SETTING: University Medical Centre Mannheim, Department of Anaesthesiology and Surgical Intensive Care Medicine, Mannheim, Germany. April 2014 to August 2015. PATIENTS: A total of 50 patients (women/men, 18 to 80 years old, ASA I to III) undergoing outpatient knee arthroscopy were included. A contra-indication to an allocated anaesthetic technique or an allergy to medication required in the protocol led to exclusion. INTERVENTIONS: Either general anaesthesia with sufentanil, propofol and a laryngeal mask for airway-management or spinal with 40-mg CP 1% were used. We noted procedure times, patient satisfaction/recovery and conducted a 7-day follow-up. MAIN OUTOMES: Primary outcome was duration of stay in the day-surgery centre. Secondary outcomes were first occurrence of pain, patient satisfaction, quality of recovery and adverse effects. In addition, we analysed treatment costs. RESULTS: Spinal had faster recovery than general anaesthesia with patients reaching discharge criteria significantly earlier [117âmin (66 to 167) versus 142âmin (82 to 228), Pâ=â0.0047]. Pain occurred significantly earlier in the general anaesthesia group (Pâ=â0.0072). Costs were less with spinal anaesthesia (cost ratio spinal: general 0.57). Patients felt significantly more uncomfortable after general anaesthesia (Pâ=â0.0096). CONCLUSION: Spinal anaesthesia with 40-mg CP 1% leads to a significantly earlier discharge and is cheaper compared with general. TRIAL REGISTRATION: German Clinical Trials Register, www.drks.de, identifier: DRKS00005989.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Anestésicos Locales/administración & dosificación , Artroscopía/métodos , Infusión Espinal/métodos , Rodilla/cirugía , Procaína/análogos & derivados , Adulto , Procedimientos Quirúrgicos Ambulatorios/efectos adversos , Anestesia Intravenosa , Artroscopía/efectos adversos , Composición de Medicamentos , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intravenosas , Rodilla/patología , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Satisfacción del Paciente , Procaína/administración & dosificaciónRESUMEN
RATIONALE: Intrathecal therapy, with a low complication rate, has become an alternative to standard pain management for treatment of neuropathic cancer pain. PATIENT CONCERNS: Here, we reported a late-stage cancer patient with intractable neuropathic pain in his right neck, shoulder, and upper limb. DIAGNOSES: The pain started 2 years ago when the patient was diagnosed as squamous cell carcinoma with metastasis to right supraclavicular lymph nodes. INTERVENTIONS: Cervical intrathecal infusion of morphine and bupivacaine with patient control analgesia by external pump was performed. The intrathecal catheter was located at the level of C6 vertebra. The initial concentration of bupivacaine and morphine were both 1âmg/mL with infusion rate of 0.3âmL/h and bolus of 0.3 mL. Subsequently, the concentrations increased to 2âmg/mL (bupivacaine) and 1.33âmg/mL (morphine), with infusion rate to 0.6âmL/h and bolus to 0.5âml. OUTCOMES: The pain intensity decreased from numerical rating scale 6 to 7 to 2 to 3 at rest, and from 10 to 5 to 6 of breakthrough pain. LESSONS: In conclusion, cervical intrathecal infusion requires low concentration but high doses of bupivacaine and morphine, which is safe and effective in cancer patients with refractory pain and short life expectancy.
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Infusión Espinal/métodos , Neuralgia/tratamiento farmacológico , Manejo del Dolor/métodos , Dolor Intratable/tratamiento farmacológico , Cuidados Paliativos/métodos , Anciano , Analgesia Controlada por el Paciente/métodos , Analgésicos Opioides/administración & dosificación , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/secundario , Vértebras Cervicales , Humanos , Masculino , Morfina/administración & dosificación , Neoplasias Primarias Desconocidas/complicaciones , Neuralgia/etiología , Dolor Intratable/etiologíaRESUMEN
Neuromodulation, or the utilization of advanced technology for targeted electrical or chemical neuronal stimulation or inhibition, has been expanding in several neurological subspecialties. In the past decades, immune-modulating therapy has been the main focus of multiple sclerosis (MS) research with little attention to neuromodulation. However, with the recent advances in disease-modifying therapies, it is time to shift the focus of MS research to neuromodulation and restoration of function as with other neurological subspecialties. Preliminary research supports the value of intrathecal baclofen pump and functional electrical stimulation in improving spasticity and motor function in MS patients. Deep brain stimulation can improve MS-related tremor and trigeminal neuralgia. Spinal cord stimulation has been shown to be effective against MS-related pain and bladder dysfunction. Bladder overactivity also responds to sacral neuromodulation and posterior tibial nerve stimulation. Despite limited data in MS, transcranial magnetic stimulation and brain-computer interface are promising neuromodulatory techniques for symptom mitigation and neurorehabilitation of MS patients. In this review, we provide an overview of the available neuromodulatory techniques and the evidence for their use in MS.
Asunto(s)
Interfaces Cerebro-Computador , Estimulación Encefálica Profunda/métodos , Bombas de Infusión Implantables , Infusión Espinal/métodos , Esclerosis Múltiple/rehabilitación , Relajantes Musculares Centrales/administración & dosificación , Estimulación de la Médula Espinal/métodos , Estimulación Magnética Transcraneal/métodos , Estimulación Eléctrica Transcutánea del Nervio/métodos , Humanos , Infusión Espinal/instrumentaciónRESUMEN
BACKGROUND AND OBJECTIVES: Cannabinoid receptors (CB1R/CB2R) are known to play important roles in pain transmission. In this study, we investigated the effects of continuous intrathecal infusion of CB1/2R agonists in the L5/6 spinal nerve ligation pain model. METHODS: Under isoflurane anesthesia, rats received nerve ligation and intrathecal catheter connected to an infusion pump. After surgery, saline (1 µL/h), CB1/2R agonist WIN55,212-2, CB1R agonist ACEA, or CB2R agonist AM1241 (1 µmol/h) was given intrathecally for 7 days. The mechanical and thermal sensitivities of rat hindpaw were determined by von Frey hair and radiant heat tests. The expression of CB1/2R and protein levels of CB1/2R, Iba1, glial fibrillary acidic protein, and tumor necrosis factor α were examined by immunofluorescence study and Western blotting. RESULTS: On postligation day 7, rats that received WIN55,212-2, ACEA or AM1241 had significantly higher mean withdrawal thresholds (6.8, 8.4, and 10.2 g) and latencies (6.3, 7.3, and 9.1 seconds) than did saline-treated rats (1.7 g, 2.2 seconds). Cannabinoid receptors were expressed not only in IB4 (isolectin B4) and CGRP (calcitonin gene-related peptide) dorsal root ganglion neurons, their central terminals, and peripheral axons, but also in neurons, microglia, and astrocytes in spinal cord. Cannabinoid receptor agonists enhanced nerve ligation-induced up-regulation of cannabinoid receptor in spinal cord and dorsal root ganglion. Treatment with WIN55,212-2 or AM1241, but not ACEA, markedly reduced nerve ligation-induced up-regulation of Iba1, glial fibrillary acidic protein, and tumor necrosis factor α in spinal cord. CONCLUSIONS: Continuous intrathecal infusion of CB1/2R agonists elicits antinociception in the pain model. The mechanisms might involve their actions on neurons and glial cells. CB2R, but not CB1R, seems to play an important role in the regulation of nerve injury-induced neuroinflammation.
Asunto(s)
Agonistas de Receptores de Cannabinoides/administración & dosificación , Cannabinoides/administración & dosificación , Infusión Espinal/métodos , Neuralgia/tratamiento farmacológico , Receptor Cannabinoide CB1/agonistas , Receptor Cannabinoide CB2/agonistas , Animales , Benzoxazinas/administración & dosificación , Ligadura , Masculino , Morfolinas/administración & dosificación , Naftalenos/administración & dosificación , Neuralgia/patología , Ratas , Ratas Sprague-Dawley , Nervios Espinales/efectos de los fármacos , Nervios Espinales/patologíaRESUMEN
BACKGROUND: The lumbar infusion test (LIT) and tap test (TT) have previously been described for the diagnosis and selection of appropriate surgical candidates in idiopathic normal pressure hydrocephalus (iNPH). METHODS: We retrospectively reviewed 81 consecutive patients with a clinical diagnosis of iNPH selected for supplementary testing. Clinical evaluation was scored with the Japanese Grading Scale for Normal Pressure Hydrocephalus, the Global Deterioration Score, and the modified Rankin Scale (mRS). The test protocol included a cerebrospinal fluid pressure monitoring (PMi), an LIT, and a TT. Patients were selected for surgery if outflow resistance was ≥14 mm Hg/mL/minute or if a clinical improvement was recorded after TT. RESULTS: Sixty-eight patients were selected for ventriculoperitoneal shunting; 72.8% had a positive PMi or LIT, 74.1% had a positive TT, and 63.0% were positive to both tests. Complications were all transient. Clinical evaluation at 12 months after shunting showed a global improvement in 60 patients (88.2%). Overall, 75.0% of patients had no significant disability (mRS score, 1 and 2), 20.6% had an mRS score of 3 or 4, and 4.4% had severe disability after surgery. The positive predictive value of PMi/LIT, TT, or both combined was similar (89.8, 90.0, and 88.2%); however, 21.7% of patients who improved after surgery were selected with either a positive LIT or TT alone. CONCLUSIONS: LIT and TT are complementary and they can easily be combined in sequence with a low complication rate and high probability of selecting patients with iNPH who may benefit from ventriculoperitoneal shunt surgery.
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Derivaciones del Líquido Cefalorraquídeo/métodos , Hidrocéfalo Normotenso/diagnóstico , Hidrocéfalo Normotenso/terapia , Infusión Espinal/métodos , Manometría/métodos , Punción Espinal/métodos , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Selección de Paciente , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
Baclofen is commonly used to treat spasticity of central etiology. Unfortunately, a potentially lethal withdrawal syndrome can complicate its use. This is especially true when the drug is administered intrathecally. There are very few cases of baclofen withdrawal leading to reversible cardiomyopathy described in the literature. The authors present a patient with a history of chronic intrathecal baclofen use who, in the setting of acute baclofen withdrawal, develops laboratory, electrocardiogram, and echocardiogram abnormalities consistent with cardiomyopathy. Upon reinstitution of intrathecal baclofen, the cardiomyopathy and associated abnormalities quickly resolve. Although rare, it is crucial to be aware of this reversible cardiomyopathy to ensure its prompt diagnosis and treatment.
Asunto(s)
Baclofeno , Cardiomiopatías , Bombas de Infusión Implantables/efectos adversos , Contrapulsador Intraaórtico/métodos , Cuadriplejía/tratamiento farmacológico , Síndrome de Abstinencia a Sustancias , Adulto , Baclofeno/administración & dosificación , Baclofeno/efectos adversos , Cardiomiopatías/inducido químicamente , Cardiomiopatías/diagnóstico , Cardiomiopatías/fisiopatología , Cardiomiopatías/terapia , Cateterismo de Swan-Ganz/métodos , Angiografía Coronaria/métodos , Ecocardiografía/métodos , Falla de Equipo , Humanos , Infusión Espinal/instrumentación , Infusión Espinal/métodos , Masculino , Relajantes Musculares Centrales/administración & dosificación , Relajantes Musculares Centrales/efectos adversos , Síndrome de Abstinencia a Sustancias/diagnóstico , Síndrome de Abstinencia a Sustancias/etiología , Síndrome de Abstinencia a Sustancias/fisiopatología , Síndrome de Abstinencia a Sustancias/terapia , Resultado del TratamientoRESUMEN
INTRODUCTION: Ziconotide is a non-opioid analgesic for intrathecal (IT) administration. The aim of this review is to provide a comprehensive and clinically relevant summary of the literature on dosing and administration with IT ziconotide in the management of refractory chronic pain, and to describe novel dosing strategies intended to improve clinical outcomes. MATERIALS AND METHODS: A Medline search was conducted for "ziconotide," supplemented by manual searching of published bibliographies and abstracts from conferences. RESULTS: Early experience with IT ziconotide in clinical trials combined with improved understanding of drug pharmacokinetics in the cerebrospinal fluid have led to a reappraisal of approaches to trialing and initiation of continuous-infusion therapy in an effort to improve tolerability. The traditional paradigm of trialing by inpatient continuous infusion may be shifting toward outpatient trialing by IT bolus, although definitions of success and specific protocols remain to be agreed upon. Expert consensus on IT continuous infusion with ziconotide suggests a starting dose of 0.5 to 1.2 mcg/day followed by dose titration of ≤0.5 mcg/day on a no more than weekly basis, according to individual patients' pain reductions and regimen tolerability. DISCUSSION: Newer modalities that include patient-controlled analgesia and nocturnal flex dosing have been shown to hold promise of further improvements in ziconotide efficacy and tolerability. CONCLUSIONS: Clinical trials and experience confirm the feasibility and usefulness of IT ziconotide in the management of refractory chronic pain. Emerging evidence suggests that additional IT delivery options may further expand the usefulness and benefits of ziconotide.
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Analgésicos no Narcóticos/administración & dosificación , Dolor Crónico/tratamiento farmacológico , Infusión Espinal/métodos , Dolor Intratable/tratamiento farmacológico , omega-Conotoxinas/administración & dosificación , Bases de Datos Bibliográficas/estadística & datos numéricos , Relación Dosis-Respuesta a Droga , Humanos , Resultado del TratamientoRESUMEN
OBJECTIVE: To describe the successful treatment of refractory corneal neuropathic pain with neuromodulation techniques. DESIGN: Single case report. SETTING: Academic tertiary care center in the United States of America. SUBJECT AND METHODS: A 30-year-old woman presented with a 7-year history of refractory bilateral keratoneuralgia following laser-assisted in-situ keratomileusis (LASIK) procedure on both eyes. Having failed all conservative measures, the patient initially underwent trigeminal nerve stimulation and subsequently was implanted with an intrathecal drug delivery system (IDDS) with the catheter placed at the level C1. RESULTS: Following an initial favorable response to the trigeminal nerve stimulator, the pain became refractory to neurostimulation after a few months and the system was explanted. The patient was successfully trialed with an intrathecal catheter placed at the level of C1 delivering a combination of bupivacaine and low dose fentanyl. The patient was then implanted with an IDDS equipped with a patient-activated bolus system. The patient was very satisfied with the treatment and has had greater than 50% pain relief for over a year. CONCLUSIONS: Intrathecal delivery of bupivacaine and low dose fentanyl in the upper cervical spine can be effective in controlling refractory eye pain in properly selected patients and treatment centers.
Asunto(s)
Bombas de Infusión Implantables , Queratomileusis por Láser In Situ/efectos adversos , Neuralgia/tratamiento farmacológico , Manejo del Dolor/métodos , Adulto , Analgésicos/administración & dosificación , Bupivacaína/administración & dosificación , Vértebras Cervicales , Córnea/inervación , Femenino , Fentanilo/administración & dosificación , Humanos , Infusión Espinal/métodos , Neuralgia/etiología , Dolor Intratable/tratamiento farmacológicoRESUMEN
When systemic analgesics or antispasmodics fail to control chronic pain or cause intolerable adverse effects, an intrathecal drug delivery system may be the best bet.
Asunto(s)
Analgesia , Analgésicos/administración & dosificación , Dolor Crónico , Bombas de Infusión Implantables , Infusión Espinal , Parasimpatolíticos/administración & dosificación , Analgesia/efectos adversos , Analgesia/métodos , Dolor Crónico/diagnóstico , Dolor Crónico/tratamiento farmacológico , Dolor Crónico/etiología , Relación Dosis-Respuesta a Droga , Resistencia a Medicamentos , Tolerancia a Medicamentos , Humanos , Infusión Espinal/efectos adversos , Infusión Espinal/métodos , Manejo del Dolor/métodos , Dimensión del Dolor , Selección de Paciente , Resultado del TratamientoRESUMEN
BACKGROUND: Infiltration procedures are a common treatment of lumbar radiculopathy. There is a wide variety of infiltration techniques without an established gold standard. Therefore, we compared the effectiveness of CT-guided transforaminal infiltrations versus anatomical landmark-guided transforaminal infiltrations at the lower lumbar spine in case of acute sciatica at L3-L5. METHODS: A retrospective chart review was conducted of 107 outpatients treated between 2009 and 2011. All patients were diagnosed with lumbar radiculopathic pain secondary to disc herniation in L3-L5. A total of 52 patients received CT-guided transforaminal infiltrations; 55 patients received non-imaging-guided nerve root infiltrations. The therapeutic success was evaluated regarding number of physician contacts, duration of treatment, type of analgesics used and loss of work days. Defined endpoint was surgery at the lower lumbar spine. RESULTS: In the CT group, patients needed significantly less oral analgesics (p < 0.001). Overall treatment duration and physician contacts were significantly lower in the CT group (p < 0.001 and 0.002) either. In the CT group, patients lost significant fewer work days due to incapacity (p < 0.001). Surgery had to be performed in 18.2 % of the non-imaging group patients (CT group: 1.9 %; p = 0.008). CONCLUSION: This study shows that CT-guided periradicular infiltration in lumbosciatica caused by intervertebral disc herniation is significantly superior to non-imaging, anatomical landmark-guided infiltration, regarding the parameters investigated. The high number of treatment failures in the non-imaging group underlines the inferiority of this treatment concept.
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Dolor de la Región Lumbar/tratamiento farmacológico , Radiculopatía/tratamiento farmacológico , Radiología Intervencionista , Reinserción al Trabajo , Ciática/tratamiento farmacológico , Adulto , Analgésicos/uso terapéutico , Puntos Anatómicos de Referencia , Anestésicos Locales/administración & dosificación , Antiinflamatorios/administración & dosificación , Bupivacaína/administración & dosificación , Femenino , Humanos , Infusión Espinal/métodos , Degeneración del Disco Intervertebral/complicaciones , Degeneración del Disco Intervertebral/diagnóstico por imagen , Dolor de la Región Lumbar/etiología , Vértebras Lumbares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Prednisolona/administración & dosificación , Radiculopatía/etiología , Estudios Retrospectivos , Ciática/etiología , Factores de Tiempo , Tomografía Computarizada por Rayos X , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
Intrathecal drug delivery represents an advanced modality for refractory chronic pain patients as well as intractable spasticity. This article reviews the advantages and indications for intrathecal therapy, as well as recommendations for proper patient selection using a multidisciplinary team to provide a global assessment of the impact of chronic pain on the patient's well-being. The goals and expectations of trialing are discussed alongside advantages and disadvantages of several trialing techniques. A discussion of outcomes is presented for patients with chronic pain due to both malignant and nonmalignant causes.
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Bombas de Infusión Implantables , Infusión Espinal/métodos , Dolor/tratamiento farmacológico , Dolor/cirugía , Selección de Paciente , Médula Espinal/cirugía , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Dolor Crónico/tratamiento farmacológico , Humanos , Morfina/uso terapéutico , Neuralgia/tratamiento farmacológico , Dolor Nociceptivo/tratamiento farmacológico , Resultado del Tratamiento , omega-Conotoxinas/uso terapéuticoRESUMEN
OBJECTIVE: To review all pharmacological and physiological data available on intrathecal baclofen (ITB) therapy and to evaluate its use in clinical practice and future research. DATA SOURCES: PubMed was searched for relevant anatomic, physiological, and pharmacological data available on ITB. STUDY SELECTION: All currently available data on ITB pharmacokinetics (PKs) and pharmacodynamics (PDs) in both human and animal studies were reviewed and combined with the anatomy and physiology of the intrathecal space and cerebrospinal fluid flow. DATA EXTRACTION: Only 4 studies reported PK data on ITB in humans. More studies reported PD data on ITB; however, none were combined with PK data. More detailed data on PK could be gathered from studies using an animal model. DATA SYNTHESIS: ITB does not spread equally over the intrathecal space after injection, but it diffuses according to a concentration gradient. ITB distribution can be influenced by the location of the catheter tip and by changing the infusion mode. CONCLUSIONS: The pharmacological and physiological data on ITB can be used to support decisions in clinical practice concerning drug concentration, infusion regimens, localization of the catheter tip, and management of tolerance; however, some strategies have little evidence in humans.
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Baclofeno/farmacocinética , Agonistas de Receptores GABA-B/farmacocinética , Infusión Espinal/métodos , Espasticidad Muscular/metabolismo , Animales , Baclofeno/farmacología , Tolerancia a Medicamentos , Agonistas de Receptores GABA-B/farmacología , Humanos , Espasticidad Muscular/tratamiento farmacológico , Músculo Esquelético/efectos de los fármacos , Músculo Esquelético/metabolismoRESUMEN
Plantar incision in rat generates spontaneous pain behaviour. The opioid drug, morphine used to treat postsurgical pain produces tolerance after long-term administration. Loperamide, a potent mu-opioid agonist, has documented analgesic action in various pain conditions. However, loperamide analgesia and associated tolerance following continuous spinal administration in postsurgical pain has not been reported. Chronic spinal infusion of drugs was achieved using intrathecal catheters connected to osmotic minipump. Coinciding with the onset of spinal infusion of loperamide or morphine, rats were subjected to plantar incision. Pain-related behaviour was assessed by Hargreaves apparatus (thermal hyperalgesia) and von Frey filaments (mechanical allodynia). Morphine and loperamide (0.5, 1 and 2 microL/h) induced analgesia was observed until 7th day post-plantar incision in Sprague-Dawley rats. Morphine and loperamide produced dose-dependent analgesia. Loperamide, in the highest dose, produced analgesia till 7th day. However, the highest dose of morphine produced inhibition of thermal hyperalgesia till 5th day and mechanical allodynia only till 3rd day post-plantar incision. Morphine and loperamide produced analgesia in postsurgical pain, which may be mediated through different mechanisms. Longer duration of analgesia with loperamide could probably be due sustained blockade of calcium channels.