Current opinion in anaesthesiology
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Curr Opin Anaesthesiol · Oct 2015
ReviewBreakthrough pain in cancer patients: prevalence, mechanisms and treatment options.
The aim of this article was to examine the definition, the characteristics, and the management of breakthrough cancer pain (BTP) in cancer patients by a critical review of recent literature. ⋯ BTP represents a serious problem reported by many cancer patients despite receiving regular use of opioids. Subgroups of breakthrough pain have been identified. Different modalities of pharmacological interventions are available. Further studies are warranted to assess the net benefit of these drugs to assist decision-making by patients, clinicians, and payers according to individual clinical conditions.
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This review outlines the analgesic role of perineural adjuvants for local anesthetic nerve block injections, and evaluates current knowledge regarding whether adjuvants modulate the neurocytologic properties of local anesthetics. ⋯ Dexmedetomidine added as a peripheral nerve blockade adjuvant improves block duration without neurotoxic properties. The combined adjuvants clonidine, buprenorphine, and dexamethasone do not appear to alter local anesthetic neurotoxicity. Midazolam significantly increases local anesthetic neurotoxicity in vitro, but when combined with clonidine-buprenorphine-dexamethasone (sans local anesthetic) produces no in-vitro or in-vivo neurotoxicity. Further larger-species animal testing and human trials will be required to reinforce the clinical applicability of these findings.
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Ultrasound guidance is frequently utilized for needle placement and observation of local anesthetic spread when performing peripheral nerve blocks. Although there is evidence that ultrasound technology can reduce complications, there are limitations to 2-dimensional (2-D) ultrasound. Three-dimensional (3-D) and especially real-time 3-D (4-D) ultrasound may allow for optimized and well tolerated needle positioning and enhanced observation of local anesthetic spread around the target structure. This article reviewed the current literature regarding the use of 3-D and 4-D ultrasound technology in a regional anesthesia setting. ⋯ At present, there are limited data regarding the use of 3-D ultrasound and a complete lack of randomized controlled clinical trials evaluating the potential benefits of real-time 3-D (4-D) ultrasound. This may be in part due to technical limitations associated with these techniques.
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Increased understanding of the pathophysiology in traumatic brain injury (TBI) has resulted in the development of core physiological targets and therapies to preserve cerebral oxygenation, and in doing so prevent secondary insult. This review addresses the many systemic complications of TBI that make achieving these targets challenging and can influence outcome. ⋯ Effective management of TBI should go beyond formulaic-based pursuit of physiological targets and requires a detailed understanding of the multisystem response of the body.