Management of neuropathic pain induced by surgery: Review of the literature by a group of experts specialized in pain management, anesthesia and surgery.

Chronic postsurgical neuropathic pain (CPSNP) is frequent. While prevalence varies considerably according to type of operation and means of evaluation, it can reach 37% following breast surgery. Identification of risk factors related to the procedure and to the patient and taking into account the development of new, minimally invasive surgical techniques is increasingly nerve-sparing and reduces the likelihood of injury. CPSNP diagnosis in daily practice is facilitated by simple and quickly usable tools such as the NP4 4-question test. Management is based on pharmacological (analgesics, antiepileptics, antidepressants, local anesthetics) and non-pharmacological (kinesitherapy, neurostimulation, psychotherapy) approaches. In light of the present review of the literature, the authors, who constitute an expert group specialized in pain management, anesthesia and surgery, express their support for topical treatments (lidocaine, capsaicin) in treatment of localized postsurgical neuropathic pain in adults.

Parecoxib, propacetamol, and their combination for analgesia after total hip arthroplasty: a randomized non-inferiority trial.

BACKGROUND: This study assessed non-inferiority of parecoxib vs. combination parecoxib+propacetamol and compared the opioid-sparing effects of parecoxib, propacetamol, and parecoxib+propacetamol vs. placebo after total hip arthroplasty. METHODS: In this randomized, placebo-controlled, parallel-group, non-inferiority study, patients received one of four IV treatments after surgery: parecoxib 40 mg bid (n = 72); propacetamol 2 g qid (n = 71); parecoxib 40 mg bid plus propacetamol 2 g qid (n = 72); or placebo (n = 38) with supplemental IV patient-controlled analgesia (morphine). Patients and investigators were blinded to treatment. Pain intensity at rest and with movement was assessed regularly, together with functional recovery (modified Brief Pain Inventory-Short Form) and opioid-related side effects (Opioid-Related Symptom Distress Scale) questionnaires up to 48 h. RESULTS: After 24 h, cumulative morphine consumption was reduced by 59.8% (P < 0.001), 38.9% (P < 0.001), and 26.8% (P = 0.005) in the parecoxib+propacetamol, parecoxib, and propacetamol groups, respectively, compared with placebo. Parecoxib did not meet criteria for non-inferiority to parecoxib+propacetamol. Parecoxib+propacetamol and parecoxib significantly reduced least-squares mean pain intensity scores at rest and with movement compared with propacetamol (P < 0.05). One day after surgery, parecoxib+propacetamol significantly reduced opioid-related symptom distress and decreased pain interference with function compared with propacetamol or placebo. CONCLUSION: Parecoxib and parecoxib+propacetamol provided significant opioid-sparing efficacy compared with placebo; non-inferiority of parecoxib to parecoxib+propacetamol was not demonstrated. Opioid-sparing efficacy was accompanied by significant reductions in pain intensity on movement, improved functional outcome, and less opioid-related symptom distress. Study medications were well tolerated.

Efficiency of auricular acupuncture in climacteric symptoms after cancer treatments.

OBJECTIVES: This paper aims to highlight the efficiency of auriculotherapy in the treatment of hot flushes, especially in cancer-related menopausal transition. METHODS: We used systematically collected data from patients in 2014 in a medical oncology practice. The treatment was made according to the guidelines of The Inter-University Diploma and the cartography of the World Health Organization; data on satisfaction were collected orally. RESULTS: In 2014, 49 patients, among whom 41 had cancer, were treated for hot flushes. Although it is not recommended to treat several symptoms during the same session, we dealt with 1.7 symptoms per session on average. Sixty-nine percent of the patients were satisfied. We lacked data for nine patients, who did not come to the minimal recommended number of treatments (three). Only one patient among those who did not observe any improvement received three treatments. CONCLUSIONS: Auricular acupuncture is a safe and cheap method to treat hot flushes. It has been effective in numerous and various cases, among which were patients who presented cancer-related menopausal symptoms. It may be applied for a large variety of other symptoms.

Effort myocardial ischemia during chemotherapy with 5-fluorouracil: an underestimated risk.

BACKGROUND: Effort-induced myocardial ischemia (EMI) has been seldom described. Aims of our study were (A) to evaluate the prevalence of EMI during long-lasting 5-FU infusion; (B) to identify possible risk factors of EMI during 5-FU infusion. PATIENTS AND METHODS: For the purpose (A), we prospectively evaluated a group of patients undergoing in-hospital continuous infusion (c.i.) of 5-FU. Patients with rest ischemia were excluded. Among 358 consecutive patients, 21 (5.9%) had rest ischemia; 109 could not perform a stress test. The remaining 228 patients underwent a treadmill stress test (TST) after >46 h of 5-FU infusion. For the purpose (B), we compared the characteristics of patients with EMI (including 3 previously described in a 2001 paper) with those without EMI. RESULTS: Among 228 patients, 16 (6.9%) had EMI. These 16 had a second TST after stopping 5-FU: in 14, it was negative, 2 patients with coronary artery disease had milder ischemia. The whole group of 231 (including 3 described in a previous paper) patients undergoing TST included 148 males and 83 females, with mean age of 57.5. Cardiovascular risk factors were present in 178 of them. Eight patients had ischemic heart disease. Among 19 patients with EMI, 7 had angina, 12 silent ischemia. ST segment at ECG was elevated in 10 patients, depressed in 9. Comparing the group with toxicity and the one without, the only significant difference was the complaint of atypical symptoms at rest before the TST. No difference was observed as regards: chemotherapy schedule (chronic c.i. in 49, 5 days in 178, FOLFOX type in 12), coronary risk factors or heart disease. CONCLUSIONS: EMI is as frequent as rest ischemia during 5-FU infusion. Patients undergoing 5-FU continuous infusions should be adviced to avoid unusual efforts, to refer any cardiac symptom, and should be investigated for EMI.

[Prehospital analgesia with femoral nerve block following lower extremity injury. A 107 cases survey]. / Bloc fémoral en analgésie préhospitalière pour traumatisme du membre inférieur. Enquête de pratique observationnelle sur 107 cas.

OBJECTIVE: Femoral Nerve Block (FNB) has been proposed for femoral fracture analgesia in a prehospital setting. METHODS: Descriptive case-series survey. All suspected femoral fractures that were managed by our extrahospital service and had a femoral block were prospectively included. The physician was free to choose any block technique (paravascular femoral block [BFPV], nerve stimulation femoral block [BFNS], or fascia iliaca block [BFI]), as well as local anesthetic mixture and volume. Pain was assessed using a simplified verbal scale (0-4) before (T0), 10minutes after block (T1), and at hospital arrival (T2). Demographic values, actual trauma diagnosis, the technique used, the local anesthetic mixture and volume, incidents and complications were recorded. RESULTS: One hundred and seven blocks were included. Eighty-six percent of the blocks were performed by an anesthesiologist, although they represent 50% of the prehospital physician staff. Pain on the simplified verbal scale (EVS) decreased from T0 to both T1 and T2 for the whole population and also in each technique subgroup (eight BFPV, 36 BFNS, and 63 BFI). Two BFI blocks required a re-injection to be successful. Ten blocks failed (eight BFI, and two BFNS). Among those 10 failed blocks, two were first wrongly quoted as successful and two successful BFNS blocks appeared inadequate with regard to the trauma location outside the femoral dermatoma. No complication was observed. CONCLUSION: Prehospital FNB appeared to be efficacious in routine practice. Teaching FNB to non-anesthesiologist physicians is challenging.

Immunogenicity and safety of the influenza A H1N1v 2009 vaccine in cancer patients treated with cytotoxic chemotherapy and/or targeted therapy: the VACANCE study.

BACKGROUND: Influenza vaccination is recommended to cancer patients undergoing chemotherapy, but vaccine coverage remains low. During the 2009 influenza pandemic, French recommendations were to vaccinate immunocompromised patients with two doses of adjuvanted vaccine. This study aimed to evaluate vaccine immunogenicity in cancer patients receiving chemotherapy. PATIENTS AND METHODS: VACANCE is a prospective open-label study that evaluated the immunogenicity and safety of two doses of AS03A-adjuvanted H1N1v vaccine in cancer patients receiving cytotoxic and/or targeted therapies. Serum haemagglutination-inhibited antibody titres against influenza A H1N1v were measured at days 1, 21, and 42, to estimate the proportion of participants with antibody titres ≥ 1 : 40 [seroprotection rate (SPR)], the efficacy of seroconversion, and factors that increased the geometric mean titre. RESULTS: Sixty-five patients were included. At baseline, 5% of patients had vaccine strain titres of specific haemagglutination inhibition antibodies that were ≥ 1 : 40. After one and two doses of vaccine, SPRs were 48% and 73%, respectively, and seroconversion rates were 44% and 73%, respectively. Vaccine-related adverse events were mild to moderate. CONCLUSIONS: A single dose of AS03-adjuvanted A/H1N1 vaccine triggered a low immune response in cancer patients on chemotherapy depending on their treatment type and frequency. Two doses are needed for these cancer patients.

[PATHOS study on postoperative pain management in Europe: French data]. / Enquête européenne sur la prise en charge de la douleur et de l'analgésie postopératoires (PATHOS) : les résultats français.

INTRODUCTION: Relief of postoperative pain is a major topic of public health and has been repeatedly shown to be inadequate. STUDY DESIGN: A questionnaire survey performed in seven European countries (postoperative analgesic therapy observational survey) in 746 health structures--which perform more than 80% of the total number of surgical procedures of each country--has demonstrated significant improvement when compared with previous surveys, particularly regarding increased use of multimodal analgesia and regular administration of analgesic drugs. The present study describes specific results for the 178 French health care institutions surveyed and 345 questionnaires collected. Preoperative patient information is given on a regular basis for 84% of respondents. RESULTS: Multimodal analgesia is used after major surgery in 87% of cases and prescribed on a regular basis for 84% of respondents. Written protocols are available in 36% of responding institutions. Pain scores are measured several times a day in 65% of institutions. An acute pain service (or any other structure with a similar aim) is found in 52% of institutions. Regular on-site training courses on pain control are delivered to 30% of anaesthesiologists, to 6% of surgeons, to 57% of recovery-room nurses and to 63% of ward nurses. Overall, the study suggests an improvement of current practices but also highlights remaining insufficiencies. CONCLUSION: Important efforts remain to be done, particularly in the field of initial and continuous education of all healthcare categories as this is believed to be the only real way to obtain long-term results.

[Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]. / Analgésie postopératoire par cathéter fémoral après fracture du col du fémur chez la personne âgée: étude prospective randomisée.

INTRODUCTION: The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture. PATIENTS AND METHODS: Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality. RESULTS: Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference. CONCLUSION: Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost.

[Peripheral neurolytic blocks and spasticity]. / Spasticité: intérêt du testing par anesthésie locorégionale et blocs thérapeutiques.

Peripheral nerve blockade is one of the therapeutic possibilities to treat spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents from having efficient rehabilitation. Test-blocks as well as neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occurred and minor side effects are transient painful phenomena during injection. These approaches proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures should be done as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neuron.

[Morphine overdose due to cumulative errors leading to ACP pump dysfunction]. / Surdosage en morphine par cumul d'erreurs provoquant un dysfonctionnement d'une pompe d'analgésie.

We report the case of a 67-year-female patient treated with a postoperative patient controlled analgesia using an Abbott Gemstar pump for after nephrectomy. In the postanaesthesia care unit, fifteen minutes after connecting with of the pump (which bag contained 100 mg of morphine) to the patient, respiratory arrest occurred. A morphine overdose was caused by uncontrolled delivery of the entire bag contents by free flowing due only to gravity. The patient was resuscitated immediately, and had uneventful recovery. This incident was the result of multiple misuse: one misconnection of the tubing between morphine bag and the patient thus shunting the antisiphon valve, and two an improper secured PCA cassette in an open position not detected by the pump. The tubing of these pumps and the software were subsequently modified by Abbott, which should reduce the risk of recurring incident. This accident points out that vigilance must remain rigorous in spite of widespread routine use of PCA.

[Alcohol neurolytic blocks for pain and muscle spasticity]. / Les traitements locaux de la spasticité: blocs périphériques des membres pour alcoolisation ou phénolisation neurolytique.

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

Left atrial invasion by lung carcinoma through a pulmonary vein.

We describe a rare case of small-cell lung carcinoma invading the left atrium through a pulmonary vein. Echocardiography was particularly useful in this case in assessing the intracavitary extension of the tumor and the outcome of therapy. Echocardiography is a low-cost, easy imaging tool, complementary to radiological techniques and useful in evaluating thoracic tumors involving the cardiovascular structures.

Clinical application of ropivacaine for the lower extremity.

Ropivacaine is a new amide local anaesthetic, which is the first commercially available in its category as a pure S-(-) enantiomer. In most recent studies, ropivacaine exhibited a very close pharmacodynamic profile to equipotent doses of bupivacaine. Concentrations of 0.5%, 0.75% and 1% (5, 7.5 and 10 mg/mL, respectively) ropivacaine are used for intraoperative anaesthesia, while the concentration of 0.2% (2 mg/mL) is preferred for postoperative analgesia, either alone or in combination with opioids and/or clonidine. Ropivacaine is responsible for excellent postoperative analgesia following epidural and peripheral perineural injections, using single-shot injections and continuous infusions. Differential sensory/motor block is only apparent at low concentrations (0.2% and less). A significant amount of recent literature focuses on its use for peripheral blocks of the lower limbs, i.e. sciatic and femoral nerve blocks. The primary benefit of ropivacaine is its lower toxicity, mainly lower cardiotoxicity, following accidental intravascular injection. This higher therapeutic index leads to an improved safety profile as compared with potent local anaesthetics such as racemic bupivacaine. For that reason, ropivacaine is a good choice for both intraoperative and postoperative regional anaesthesia and analgesia.