Best practice & research. Clinical anaesthesiology
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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.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewImplantable devices for pain control: spinal cord stimulation and intrathecal therapies.
Untreated chronic pain is costly to society and to the individual suffering from it. The treatment of chronic pain, a multidimensional disease, should rely on the expertise of varying health care providers and should focus not only on the neurobiological mechanisms of the process but also on the psychosocial aspects of the disease. ⋯ Intrathecal therapies with opioids such as morphine, fentanyl, sufentanil or meperidine--or non-opioids such as clonidine or bupivacaine--provide analgesia in patients with nociceptive or neuropathic pain syndromes. Baclofen, intrathecally, provides profound relief of muscle spasticity due to multiple sclerosis, spinal cord injuries, brain injuries or cerebral palsy.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewFrom pain research to pain treatment: the role of human experimental pain models.
There is no objective measure of a complete pain perception; we can, however, measure different aspects of nociceptive processing and pain perception. Earlier, experimental pain models often only involved induction of cutaneous pain using a single stimulus modality. Recently new experimental models have been developed eliciting various modalities of deep and visceral pain which more closely resemble clinical pain conditions. ⋯ However, in spite of our immense knowledge, we still do not know how to prevent and treat this hyperexcitability efficiently. Our understanding of nociceptive mechanisms involved in acute and chronic pain and the effects of anaesthetic drugs or combinations of drugs on these mechanisms in humans may also be expanded using human experimental models. This mechanism-based approach may help us to develop and test therapeutic regimes in patients with acute and chronic pain.
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Best Pract Res Clin Anaesthesiol · Jun 2002
ReviewSpinal anaesthesia: local anaesthetics and adjuncts in the ambulatory setting.
Intrathecal lidocaine remains a popular choice for ambulatory spinal anaesthesia due to its reliability, rapid onset and predictable rapid recovery profile. However, concerns with transient neurological symptoms (TNS) and their significant association with lidocaine have generated interest in alternative local anaesthetic agents to provide adequate spinal anaesthesia with the briefest possible recovery period. ⋯ Controversies regarding the possible lower risk of TNS with newer spinal anaesthetic techniques and new discharge criteria are reviewed. The final section provides technical pearls to optimize ambulatory spinal anaesthetic outcomes.