Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0344307 (analgesia)
 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A case is reported of a 67-year-old man who underwent major vascular surgery (iliobifemoral bypass with unilateral sympathectomy) under epidural anaesthesia and resulting in permanent neurological damage. Lumbar epidural anaesthesia was carried out using a mixture of bupivacaine, lidocaine with adrenaline, and alfentanil. The surgical course was uneventful, except for a 30 minute period of relative hypotension (90 vs. 110 mmHg preoperatively). Continuous epidural analgesia (12 ml.h-1 of 0.125% bupivacaine without adrenaline) was started after the end of surgery. Twelve hours later, flaccid lower limb paralysis was noted, but thought to be due to the bupivacaine. At the 24th hour, the epidural analgesia was discontinued and the catheter removed. There were a motor paralysis and a partial sensory block, raising to the level of T10 (temperature and pain). A CT scan and myelography of the thoracolumbar spine revealed no anomaly. The sensory loss ended within ten days, but the motor deficit regressed only slightly. Unfortunately, the patient died on the 16th day after an episode of severe chest pain. The probable cause of the neurological damage was an anterior spinal infarct. It was not possible to determine the degree of responsibility of the peripheral vascular disease, the anaesthetic or the surgery.
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PMID:[Paraplegia after epidural anesthesia for vascular surgery]. 175 57

Epidural spinal cord stimulation by means of chronically implanted electrodes was carried out on 121 patients with pain of varied benign organic etiology. In 116 patients, the pain was confined to the back and lower extremities and, of these, 56 exhibited the failed-back syndrome. Most patients were referred by a pain management service because of failure of conventional pain treatment modalities. Electrodes were implanted at varying sites, dictated by the location of pain. A total of 140 epidural implants were used: 76 unipolar, 46 Resume electrodes, 12 bipolar, and six quadripolar. Patients were followed for periods ranging from 6 months to 10 years, with a mean follow-up period of 40 months. Forty-eight patients (40%) were able to control their pain by neurostimulation alone. A further 14 patients (12%), in addition to following a regular stimulation program, needed occasional analgesic supplements to achieve 50% or more relief of the prestimulation pain. Pain secondary to arachnoiditis or perineural fibrosis following multiple intervertebral disc operations, when predominantly confined to one lower extremity, seemed to respond favorably to this treatment. Uniformly good results were also obtained in lower-extremity pain secondary to multiple sclerosis. Pain due to advanced peripheral vascular disease of the lower limbs was well controlled, and amputation below the knee was delayed for up to 2 years in some patients. Pain due to cauda equina injury, paraplegic pain, phantom-limb pain, pure midline back pain without radiculopathy, or pain due to primary bone or joint disease seemed to respond less well. Patients who responded to preliminary transcutaneous electrical nerve stimulation generally did well with electrode implants. Notable complications included wound infection, electrode displacement or fracturing, and fibrosis at the stimulating tip of the electrode. Three patients in this series died due to unrelated causes. Epidural spinal cord stimulation has proven to be an effective and safe means of controlling pain on a long-term basis in selected groups of patients. The mechanism of action of stimulation-produced analgesia remains unclear; further studies to elucidate it might allow spinal cord stimulation to be exploited more effectively in disorders that are currently refractory to this treatment modality.
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PMID:Treatment of chronic pain by epidural spinal cord stimulation: a 10-year experience. 186 42

We report the extradural administration of low-dose morphine in 10 ml of 10% dextrose (2-3 mg) to 98 adult patients with various types of acute and chronic pain. Extradural morphine injections were given either via a Tuohy needle (single or repeat injection) or via an extradural catheter. Pain relief was evaluated by subjective scoring and by the subsequent need for systemic analgesics. In 56% of patients, pain relief was considered good or excellent, in 24% it was fair, and in 20%, poor. The best results were after surgery and trauma and in patients with advanced peripheral vascular disease. The analgesia of each dose of extradural morphine lasted for 8 h (mean range 4-36 h). There was no motor, sensory or sympathetic blockade and no respiratory or haemodynamic complications. Dizziness and vomiting occurred in two patients, and urinary retention for about 12 h in three.
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PMID:Observations on extradural morphine analgesia in various pain conditions. 737 Jan 40

After suffering some setbacks since its introduction in 1967, stimulation of the spinal and peripheral nervous systems has undergone rapid development in the last ten years. Based on principles enunciated in the Gate Control Hypothesis that was published in 1968, stimulation-produced analgesia [SPA] has been subjected to intensive laboratory and clinical investigation. Historically, most new clinical ideas in medicine have tended to follow a three-tiered course. Initial enthusiasm gives way to a reappraisal of the treatment or modality as side-effects or unanticipated problems arise. The last and third phase proceeds at a more measured pace as the treatment is refined by experience. This review is divided into three parts as it traces the progress of spinal cord stimulation [SCS] and peripheral nerve stimulation [PNS]. The review commences with a discussion of the theory of SCS and PNS, and is followed by early reports during which it became apparent that the modality is essentially only effective in the treatment of neuropathic pain. The last section describes the modern experience including efficacy in specific types of pain and concludes with recent accomplishments that dramatize the relief of pain which can be achieved in nonoperable peripheral vascular disease or myocardial ischemia. Over the years, a search for those transmitters that might be influenced by spinal cord stimulation focused on somatostatin, cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), neurotensin and other amines, although only substance "P" was implicated. More recently, in animal studies, evidence that GABA-ergic systems are affected may explain the frequent successful suppression of allodynia that follows spinal cord stimulation. During the past eight years, much attention has been directed to studies that use a chronic neuropathic pain model. While PNS held significant promise as a pain relieving modality, early electrode systems and their surgical implantation yielded variable results due to evolving technical and surgical skills. These results dramatically reduced the continued development of PNS, which then gave way to a preoccupation with SCS. Modern development of SCS with outcome studies, particularly in relation to failed back surgery syndrome [FBSS] and the outcome of peripheral nerve surgery for chronic regional pain syndromes, has earned both modalities a place in the ongoing management of patients with intractable neuropathic pain. The last section, dealing with pain of peripheral vascular and myocardial ischemia, is perhaps one of the more exciting developments in stimulation produced analgesia and as the papers discussed demonstrate, can provide a level of analgesia and efficacy that is unattainable by other treatment modalities. SCS and PNS has an important role to play in the management of conditions that are otherwise refractory to conservative or other conventional management.
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PMID:Stimulation of the central and peripheral nervous system for the control of pain. 901 59

Patients with severe peripheral vascular disease may suffer considerable pain which can be difficult to control with conventional analgesics. We sought to assess the analgesic effect of transdermal nitrate patches in such patients. A prospective trial was performed in 15 patients with ischaemic rest pain due to atherosclerotic peripheral vascular disease. Pain control and oral analgesic requirement were assessed. Fourteen of the 15 had a good or moderate response to the nitrate patches with a subsequent reduction in oral analgesic requirement. The patients with primarily small vessel disease had the greatest improvement in pain control. We conclude that topical nitrates may be used to provide rapid and safe analgesia for patients with ischaemic rest pain.
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PMID:Locally applied transdermal nitrate patches for the treatment of ischaemic rest pain. 948 96

Coronary artery disease (CAD), arterial hypertension, chronic bronchitis and diabetes mellitus are the most frequently encountered diseases complicating the clinical course of the vascular patient. Clinical signs of cardiac or pulmonary disease are often absent in patients with decreased functional capacity due to claudication. For instance, clinical evidence of coronary artery disease was found in 36% of patients scheduled for different vascular surgical procedures, whereas coronary angiography revealed significant stenoses in as many as 53-68%. Patients with chronic hypertensive disease, coronary artery disease and increased impedance to left ventricular ejection due to atherosclerosis frequently develop impairment of left ventricular (LV) function. Even without clinical or radiological evidence, approximately 20-35% of vascular patients have a LV ejection fraction below 50% indicating impaired systolic LV function. The incidence of diabetes mellitus in vascular surgical patients is around 18%. When requiring insulin treatment, diabetes is an independent risk factor for postoperative ischemic events and congestive heart failure. Those with autonomic neuropathy are often asymptomatic as regards coronary artery disease. Coronary artery disease is responsible for over 50% of the immediate, medium- and long-term mortality and morbidity. Unstable myocardial ischemia, acute myocardial infarction which is detected by troponin I and ischemic pulmonary edema are the most common immediate postoperative cardiac complications. A large number of recent studies, using long-term ECG recording techniques, have allowed more accurate estimation of the incidence and time course of perioperative myocardial ischemia in vascular surgical patients. The highest incidence of ischemia when compared to daily life activities has been noted during the first two days after surgery but has been reported to remain elevated even 3-5 days after surgery. Interestingly, the incidence of intraoperative ischemia is lower than that observed during daily life. Knowledge of the etiology of perioperative myocardial infarction is essential if one is to improve cardiac outcome after vascular surgery. Many studies have addressed this important field in patients undergoing vascular surgery. They have documented a relationship between perioperative myocardial ischemia and postoperative myocardial infarction. Although postoperative myocardial infarctions are in most cases limited to endocardium (non Q wave infarction) they significantly reduce life expectancy of the vascular surgical patients. The reduction of cardiac risk following general surgery should focus on methods by which the incidence of myocardial ischemia, particularly during the postoperative period, could be reduced. These methods include intensive intraoperative analgesia or preventive administration of cardiovascular treatment which limit postoperative stress: alpha-2 agonists or betablocking agents. There are, at present, no studies which convincingly confirm an overall decreased mortality if coronary bypass surgery is performed prior to peripheral vascular surgery. Although it has been demonstrated that the mortality of the peripheral procedure is reduced to approximately one half, the mortality of a coronary bypass procedure in vascular surgical patients is five to eight times that recorded in a coronary artery bypass population without peripheral vascular disease. It remains to be shown if the use of coronary angioplasty prior to peripheral vascular surgery can provide a more satisfactory overall outcome. Several non-invasive techniques have been suggested to improve the identification of high-risk patients undergoing vascular surgery. These tests include exercise ECG, ambulatory ECG, dipyridamolethallium scintigraphy and determination of left ventricular ejection fraction by gated radionuclide imaging. (ABSTRACT TRUNCATED)
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PMID:[Physiopathologic introduction to anesthesia and resuscitation of the vascular patient]. 955 51

The molecular basis of cannabinoid activity is better understood since the discovery of the CB(1) receptor in the mammalian brain and the CB(2) receptor in peripheral tissues. Subsequently, an endogenous CB(1) receptor ligand, arachidonylethanolamide (anandamide), was isolated from porcine brain and shown to be metabolized by the enzyme arachidonylethanolamide amidohydrolase or fatty acid amide hydrolase. Recently, we have characterized a reuptake system for the transport of anandamide across the cell membrane, and have shown that selective inhibition of this transporter is associated with analgesia and peripheral vasodilation. The four cannabinoid system proteins, including the CB(1) and CB(2) receptors, fatty acid amide hydrolase, and the anandamide transporter, are excellent targets for the development of novel medications for various conditions, including pain, immunosuppression, peripheral vascular disease, appetite enhancement or suppression, and motor disorders. During the last decade, numerous selective ligands for each of these proteins were designed and synthesized. Many of these agents serve as important molecular probes, providing structural information about their binding sites, as well as pharmacological tools imparting information about the roles of their targets in physiological and disease states. All of the above compounds that modulate the functions of the endocannabinoid system can be collectively described under the term cannabinergics, regardless of chemical classification or type of resultant pharmacological action.
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PMID:From cannabis to cannabinergics: new therapeutic opportunities. 1218 58

The administration of anti-platelet agents to surgical patients with a history of coronary artery disease or peripheral vascular disease represents an everyday challenge to anaesthesiologists when epidural anaesthesia or analgesia is to be considered. Practice guidelines suggest stopping clopidogrel at least 7 days before placing an epidural catheter. Withholding anti-platelet drugs represents a great risk to many of these patients. On the other hand, withholding perioperative epidural analgesia denies the patients its benefits including faster resolution of postoperative ileus, earlier ambulation, decreased risk of thromboembolism and vascular graft thrombosis, and decreased hospital stay. The charts of 306 vascular surgical patients who received epidural analgesia without withholding clopidogrel perioperatively were reviewed for the presence of any postoperative complications related to the continued intake of clopidogrel. No postoperative neurological complications resulting from the use of epidural analgesia were found in any of these patients. The point estimate (95% confidence limits) for the risk of epidural haematoma or other complications for this study is 0 (0-1)%. No neurological complications were found as a result of placing an epidural catheter in patients actively taking clopidogrel. Owing to the small sample size, we cannot recommend the liberal use of epidural analgesia with ongoing clopidogrel administration at this time. Further prospective studies, with larger sample size, are needed in order to substantiate our findings.
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PMID:Epidural analgesia in vascular surgery patients actively taking clopidogrel. 2064 44

We present two cases of severe pain due to critical limb ischemia (CLI) treated with automated intermittent bolus infusion for continuous sciatic nerve blocks. Case 1: A 32-year-old man had severe lower extremity ischemic pain due to Fontaine grade IV peripheral vascular disease. The pain did not respond to systemic analgesics. A popliteal nerve catheter was placed under ultrasound guidance. After confirming the effect of continuous infusion of ropivacaine from the catheter unsatisfactory, automated intermittent with patient-controlled bolus administration was started. His pain was controlled well. Case 2: A 52-year-old man had severe foot pain due to Buerger's disease. Bypass surgery and angioplasty failed to improve his symptoms. Even after the amputation of superficial fibular nerve, deep fibular nerve and tibial nerve, his pain persisted. The continuous popliteal sciatic nerve block was started. As continuous infusion did not relieve his pain, automated intermittent with patient-controlled bolus administration was started. However even with this technique, his pain was not relieved well. In some patients whose severe pain due to CLI could not be managed well, automated intermittent bolus infusion of local anesthetics from peripheral nerve catheter may provide better analgesia than continuous infusion.
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PMID:[Automated intermittent bolus infusion for continuous sciatic nerve block: a case report]. 2180 Jun 74

Vascular bypass is a surgical procedure widely used to treat peripheral vascular disease. The intraoperative anesthetic technique and the most appropriate postoperative analgesia for these high-risk patients remain controversial. We present the case of a patient undergoing femoropopliteal-distal bypass in our service, presenting with relevant comorbidities to the choice of anesthetic technique. This patient had several determining factors of difficult airway, especially thoracic kyphoscoliosis, which prevented him from being properly positioned for airway management, and chronic lung disease. This patient was also taken antiplatelet drugs, which is a contraindication for neuraxial block. So, we chose the anesthetic technique of peripheral nerve block, specifically the blockade of femoral and sciatic nerves.
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PMID:[Anesthesia for lower extremity vascular bypass with peripheral nerve block]. 2681 96


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