Best practice & research. Clinical anaesthesiology
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To implement a successful acute pain service the following factors are the most important for success: anaesthesiologist-supervised pain nurses and an ongoing educational programme for patients and all health personnel involved in the care of surgical patients. The benefits in increased patient satisfaction and improved outcome after surgery will far outweigh the costs of running an acute pain service that raises standards of pain management throughout the hospital. Optimal use of basic pharmacological analgesia will improve relief of post-operative pain for most surgical patients. ⋯ Chronic pain is common after surgery. Better acute pain relief may reduce this distressing long-term complication of surgery. Research into the long-term effects of optimal neuraxial analgesia and drugs that dampen glutamatergic hyperphenomena (hyperalgesia/allodynia) are urgently needed to verify whether these approaches can reduce the problem of intractable chronic post-operative pain.
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Radiofrequency current is simply a tool used for creating discrete thermal lesions in neural pathways in order to interrupt transmission. In pain medicine, radiofrequency lesions have been used to interrupt nociceptive pathways at various sites. ⋯ Nevertheless, there is evidence that radiofrequency neurotomy has an important role in the management of trigeminal neuralgia, nerve root avulsion and spinal pain. In this chapter the evidence for efficacy and safety is reviewed and interrogated with special emphasis on the available randomized controlled trails and systematic review.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewUnderstanding the physiology and pharmacology of epidural and intrathecal opioids.
Epidural and intrathecal opioid administration has become an important part of contemporary medical practice in a variety of clinical settings. It has been widely assumed that any opioid placed in the epidural or intrathecal spaces will produce highly selective spinally mediated analgesia that is superior to that produced by other analgesic techniques. ⋯ In fact, multiple opioids are currently employed for spinal use despite the fact that clinical evidence has shown that spinal administration does not produce analgesia with a selective spinal mechanism or that the analgesia produced is not superior to that produced by intravenous administration. This chapter presents the basic science and clinical data available to assist clinicians in identifying which opioids are appropriate for spinal use and which are not.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewCellular mechanisms of opioid tolerance and the clinical approach to the opioid tolerant patient in the post-operative period.
The high prevalence of opioid use for recreational purposes in the USA and the European Union, as well as the use of opioids for the treatment of chronic non-malignant pain, has resulted in an increase in the number of patients with opioid tolerance who undergo surgery and require post-operative pain management. The approach to post-operative pain control in these patients is significantly different to the strategies used in opioid naïve patients. Fortunately, better understanding of the cellular mechanisms of opioid tolerance in animals has resulted in the transfer of concepts from the 'bench' to the clinical arena. This chapter describes the new developments in opioid tolerance and how this knowledge can be applied to clinical practice.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewEpidural and intrathecal analgesia for cancer pain.
The three-step analgesic ladder approach developed by the World Health Organization works well in treating the vast majority (70-90%) of patients suffering from pain related to cancer. In those patients who do not get pain relief by this three-step approach, intraspinal agents can be a fourth step in managing pain of malignant origin. ⋯ Many non-opioid agents have also been used intraspinally either alone or in combination with opioids in the treatment of intractable cancer pain. This chapter summarizes the clinical use of these agents with some practical points.