Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0030193 (pain)
 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Many agents are available for sedation of agitated, delirious patients. In general, they should be administered intravenously to achieve a painless, more rapid, and more reliable onset of action. Proper selection of an agent requires understanding the basic principles discussed in this article, including the T-1/2 alpha and T-1/2 beta and the side-effect profile associated with each class of drugs, as well as for each agent. As a group, BNZs tend to be the safest and most predictable, and can be titrated easily when administered intravenously. Neuroleptic agents such as haloperidol may act synergistically with BNZs, resulting in control of agitation without significantly depressing the patient's level of consciousness or respiratory drive. Barbiturates, highly effective sedatives, more profoundly depress the respiratory and cardiovascular systems, and probably should be reserved for the severely agitated patient who cannot be controlled otherwise. Etomidate and propofol, useful for short-term procedures, probably should be avoided for long-term use in the agitated patient because of potentially serious side effects. Opioids should be used to provide adequate pain relief and to supplement other sedatives. Inadequate doses or dosing regimens should be avoided. Once sedation has been achieved, control usually can be maintained with continuous intravenous infusions of BNZs, perhaps in combination with a continuous infusion of an opioid or intermittent administration of a neuroleptic agent. With goal-oriented titration of the pharmacologic therapy, patients can be maintained safely in a sedate, calm state; intermittent periods of agitation, alternating with periods of severely depressed level of consciousness, can be avoided. Finally, when pharmacologic suppression of agitation and delirium is needed, the patient must be evaluated fully to determine the underlying cause of the confusional state.
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PMID:Pharmacology of intravenous sedatives and opioids in critically ill patients. 800 Sep 23

Cancer patients occasionally experience periods of rapidly escalating pain--"crescendo" pain--that may present a challenge in assessment and management. Although these episodes are often associated with progressive neoplasm, any of a variety of other processes may be involved. Delirium is a potentially treatable and frequently unrecognized factor. We present three patients who illustrate this relationship between delirium and a crescendo pattern of cancer pain.
J Pain Symptom Manage 1994 Jan
PMID:Delirium as a contributing factor to "crescendo" pain: three case reports. 816 61

We reported two cases of acute alcoholic myopathy associated with rhabdomyolysis. The first case was 62 year-old man, who had been drinking every day for 40 years. Following diarrhea, he had psychic symptoms, and was admitted to our hospital. He was in a state of delirium. Tremor in extremities, dysarthria and weakness of lower extremities were observed. Neither swelling nor grasping pain were seen in any muscles. Laboratory data showed severe hypokalemia and high levels of serum muscle enzymes and myoglobin. An increase of lactate and pyruvate was not seen in ischemic exercise test performed at the acute or the recovery phase. It was suggested that glycolysis in muscles was suppressed in this case. The second case was 43 year-old man, who had been drinking every day for 27 years. Rapidly progressive weakness of both lower extremities was seen, and he was admitted to our hospital. Grasping pain of both legs and proximal muscle weakness of extremities were observed. Laboratory date showed normokalemia and high levels of serum muscle enzymes and myoglobin. Muscle biopsy showed no abnormal findings in histology and electron microscopy. Although the pathogenesis of acute alcoholic myopathy is unknown, suppression of muscle glycolysis enzyme caused by ethanol may play an important role in the first case.
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PMID:[Two cases of acute alcoholic myopathy associated with rhabdomyolysis]. 829 65

A 36-year-old man was stung by a wasp OD. He became delirious and had dyspnea, ocular pain, and severely decreased visual acuity OD. A broken stinger was found in the central deep cornea. Additional ocular findings were keratitis, iritis, cataract, secondary glaucoma, and unrecordable electroretinographic responses.
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PMID:Wasp sting-induced retinal damage. 848 60

Pain is an understudied problem in frail elderly patients, especially those with cognitive impairment, delirium, or dementia. The focus of this study was to describe the pain experienced by patients in skilled nursing homes, which have a high prevalence of cognitive impairment. A random sample of 325 subjects was selected from ten community skilled nursing homes. Subjects underwent a cross-sectional interview and chart review for the prevalence of pain complaints, etiology, and pain management strategies. Pain was assessed using the McGill Pain Questionnaire and four unidimensional scales previously utilized in younger adults. Thirty-three percent (33%) of subjects were excluded because they were either comatose (21%), non-English speaking (3.7%), temporarily away (sick in hospital) (4.3%), or refused to participate (3.7%). Of 217 subjects in the final analysis, the mean age was 84.9 years, 85% were women, and most were dependent in all activities of daily living. Subjects demonstrated substantial cognitive impairment (mean Folstein Mini-Mental State exam score was 12.1 +/- 7.9), typically having deficits in memory, orientation, and visual spatial skills. Sixty-two percent reported pain complaints, mostly related to musculoskeletal and neuropathic causes. Pain was not consistently documented in records, and pain management strategies appeared to be limited in scope and only partially successful in controlling pain. None of the four unidimensional pain-intensity scales studied in this investigation had a higher completion rate than the Present Pain Intensity Scale of the McGill Pain Questionnaire (65% completion rate). However, 83% of subjects who had pain could complete at least one of the scales. We conclude that cognitive impairment among elderly nursing home residents present a substantial barrier to pain assessment and management. Nonetheless, most patients with mild to moderate cognitive impairment can be assessed using at least one of the available bedside assessment scales.
J Pain Symptom Manage 1995 Nov
PMID:Pain in cognitively impaired nursing home patients. 859 19

In advanced cancer patients close to death, delirium, multifocal myoclonus, and restlessness may occur. Multi-organ failure and related metabolic changes are mostly responsible for these symptoms. A pharmacologic approach to manage the delirium is necessary in the majority of cases. Benzodiazepines, neuroleptics, and barbiturates are the most common drugs used. In the case reported, propofol administered at very low doses provided good control of neuropsychiatric symptoms. After a loading dose of 20 mg, an infusion of 50-70 mg per hr was started. The patient died peacefully after 8 hr of propofol infusion, without requiring opioids. Propofol seems to be a promising drug in treating the terminal agitated state that can be associated with the dying process.
J Pain Symptom Manage 1995 Nov
PMID:Propofol in terminal care. 859 25

Occasionally, terminal ill patients with severe agitated delirium are extremely difficult to sedate, either becoming too deeply sedated when undisturbed or severely agitated when disturbed. This situation occurs even with the short-acting benzodiazepines such as midazolam. This paper describes the use of a low-dose infusion of the anesthetic agent propofol (Diprivan, Zenica), which has a very short length of action and allows the depth of sedation to be easily controlled from minute to minute.
J Pain Symptom Manage 1995 Nov
PMID:The use of propofol in palliative medicine. 859 26

Meperidine is widely used for pain control in the hospital setting. It is also known for its propensity to cause mental status changes in renally and hepatically impaired patients. A case is reported of a 37-year-old man with chronic renal failure maintained on peritoneal dialysis in whom delirium developed when he was treated with meperidine not only on one occasion but also on two subsequent admissions. The pharmacology of meperidine is reviewed and the implications of using the medication in patients with renal impairment are discussed.
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PMID:Meperidine associated mental status changes in a patient with chronic renal failure. 866 67

We reviewed the circumstances surrounding the use of sedation for symptom control in a Japanese hospice. Of 143 inpatients, 69 (48.3%) received sedation and died an average 3.9 days after sedation was begun. Symptoms requiring sedation included dyspnea, pain, general malaise, agitation, and nausea. In 83% of cases, those symptoms were escalating as death approached. In about one-half of the cases, sedation was carried out intermittently until the patient died. Sedation was gained by such sedatives as midazolam, morphine, and haloperidol. Side effects included suppression of the respiratory and/or circulatory system in nine cases (in four cases it caused death), and delirium in one case; tolerance and dependence were also observed in two cases. We also examined the explanation to and understanding of the patients and their family members about sedation. This experience suggested the type of communication methods that are likely to be useful in Japan. It stresses the importance of intermittent use of sedation and communication with family members. We propose criteria for sedation to improve symptom control that would be acceptable in Japan.
J Pain Symptom Manage 1996 Jul
PMID:Sedation for symptom control in Japan: the importance of intermittent use and communication with family members. 871 14

We have observed among patients of the Southern Community Hospice Programme that up to 25% experience acute delirium when treated with morphine and improve when the opioid is changed to oxycodone or fentanyl. This study aimed to confirm by a prospective trial that oxycodone produces less delirium than morphine in such patients. Oxycodone was administered by a continuous subcutaneous infusion, as this allowed more flexible and reliable dosing, and patients were monitored for any adverse reactions to the drug. Thirteen patients completed the study. Statistically significant improvements in mental state and nausea and vomiting occurred following a change from morphine to oxycodone. Pain scores improved but did not reach a level of statistical significance. The phenotype status of the patients was tested to establish their capacity to metabolize oxycodone. One patient who did not achieve adequate pain control proved to be a poor metabolizer. These results show that oxycodone administered by the subcutaneous route can provide effective analgesia without significant side effects in patients with morphine-induced delirium. This treatment allows patients to remain more comfortable and lucid in their final days. A small proportion of patients who do not metabolize oxycodone effectively may not receive this benefit.
J Pain Symptom Manage 1996 Sep
PMID:Attenuation of morphine-induced delirium in palliative care by substitution with infusion of oxycodone. 880 81


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