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Query: UMLS:C0344307 (analgesia)
 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Pain management, nutritional support, and psychosocial support are fundamental services that enhance patients' ability to cope with their cancer and its therapy. The common goal of symptom prevention mandates that each of these supportive services be provided to all patients throughout their cancer experience. Comprehensive cancer pain management begins with identifying the origin of all of the patient's pains and treating each one specifically. Pain prevention can be achieved through around-the-clock opioid administration with as-needed supplements for breakthrough pain and dose titration. Common narcotic side effects such as constipation and nausea also must be prevented. Successful opioid analgesia requires that patient and family concerns regarding addiction and tolerance be dispelled at the outset. Cancer pain prevention can be further optimized with the use of appropriate coanalgesics in response to the pathophysiology of the patient's pains. Cognitive and behavioral therapies may also be useful adjuncts to reduce both pain and suffering. Procedure-oriented pain control should be considered when systemic pharmacologic therapy does not provide adequate pain relief or is associated with intolerable side effects. The only absolute contraindications for pain-relieving procedures are untreatable coagulopathy and a decrease in mental status not related to medical pain management. Useful neurodestructive techniques include radiofrequency lesioning, cryoanalgesia, and chemical neurolysis with agents such as phenol, alcohol, and hypertonic saline. The most beneficial pain-relieving procedures and percutaneous cordotomy, spinal narcotics, celiac and hypogastric plexus ablation, spinal neurolysis, and epidural injection of steroids and hypertonic saline. Procedure selection depends on the cause of the pain and the patient's prognosis. Common indications for pain-relieving procedures include unilateral pain below the shoulder, upper abdominal visceral pains, pelvic visceral pain, perineal pain, vertebral body metastasis, discogenic pain, and spinal stenosis. As results of well-conducted scientific trials begin to appear in the literature, the indications for these procedures will be better understood, resulting in their more appropriate use. Principles of nutritional support in patients with cancer include an awareness of the problem of malnutrition and its impact on performance status, quality of life, prognosis, and treatment; identification of those patients at risk; prophylactic versus therapeutic intervention; and analysis and management of the specific impediment(s) to adequate nutrient intake and absorption. The primary goals for nutritional support in cancer patients are prevention of weight loss and maintenance of adequate protein status. Appreciation of practical issues of nutritional support will enable the practicing physician to achieve these goals using primarily oral nutrition options.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Supportive care in oncology. 128 50

Transdermal fentanyl offers the advantage of providing continuous administration of a potent opioid in the absence of needles and expensive drug-infusion pumps for the treatment of cancer pain. When transdermal fentanyl is initiated, it may be necessary to change the dose every 24-48 hr until an appropriate dose is titrated to the needs of the patient. This should be done by providing short-acting opioids as rescue analgesics for breakthrough pain. Well-accepted principles established for chronic opioid use in cancer pain management should apply to the administration of transdermal fentanyl as well. These include dose titration, the coadministration of adjuvant drugs to counteract opioid side effects and enhance analgesia, and the need to reassess the patient continuously for recurrent tumor and other new sources of pain. Further clinically relevant studies are needed and include 1) the determination of the relative potency of transdermal fentanyl, especially in comparison with oral and parenteral morphine; 2) a prospective study of the side-effect profile of transdermal fentanyl in relationship to oral morphine; and 3) the role of oral transmucosal administration of fentanyl in selection of starting doses of transdermal fentanyl and as a means to provide rescue doses for breakthrough pain.
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PMID:Transdermal fentanyl: suggested recommendations for clinical use. 151 31

Patient-controlled analgesia (PCA) represents a drug-delivery system in which patients self-administer predetermined doses of opiate analgesics. We have taken advantage of recent advances in pump technology and developed a system in which patients with severe pain received a continuous narcotic infusion, along with the capability of PCA bolus for breakthrough pain. All patients were experiencing chronic pain related to cancer and were unable to obtain adequate pain control with either intermittent parenteral, oral, or rectal narcotics. Sixty-nine percent of patients were treated in the home setting, and the majority received morphine sulfate subcutaneously (SQ). Admixture stability studies using high-pressure liquid chromatography (HPLC) showed that dexamethasone, metoclopramide, and haloperidol could be added to the morphine solutions and remain stable for 1 week at room temperature. Of 117 patients entered, 95% received excellent pain control, and side effects were rare, consisting of subcutaneous needle site infection and respiratory depression. Progressive pain due to either advancing disease or development of drug tolerance could be controlled by increasing opiate infusion rates. We conclude that (1) continuous infusion opiate with PCA bolus capability can be initiated and administered safely in the home setting; (2) patients with pain related to malignancy can be managed well with this system; and (3) pain control programs can be designed, implemented, and evaluated in the private practice setting.
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PMID:Patient-controlled analgesia for chronic cancer pain in the ambulatory setting: a report of 117 patients. 247 20

Fifty-one cancer pain patients with limited opioid exposure participated in a randomized, double-blind, repeated-dose, parallel-group comparison of two dosage strengths of the controlled-release morphine preparation, MS Contin tablets (The Purdue Frederick Company, Norwalk, CT). The patients were first stabilized on immediate-release oral morphine 30 mg every 4 hours, with 15 mg available every 2 hours as needed for breakthrough pain ("rescue" dose). Each patient then received either one 100 mg MS Contin tablet or three 30-mg MS Contin tablets every 12 hours, with rescue medication as needed, for 3 days. Analysis of study power revealed sufficient sensitivity to detect clinically relevant differences in pain intensity and use of rescue medication. The two tablet strengths yielded similar pain relief, use of rescue medication, and frequency of side effects. In addition, pain and use of rescue medication did not change from the beginning to the end of the 12-hour dosing intervals in either group. In the study population as a whole, pain intensity was lower and total morphine intake higher during the period on controlled-release morphine. These data establish comparable analgesic efficacy and side effect potential of these two dosage strengths and confirm a 12-hour duration of effect for both. The improved analgesia on the controlled-release morphine may be attributable to increased consumption of drug resulting from improved compliance.
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PMID:Oral controlled-release morphine sulfate. Analgesic efficacy and side effects of a 100-mg tablet in cancer pain patients. 272 May 77

One hundred thirty-eight consecutive, nonrandomized patients, with equivalent demographic and preoperative physiologic parameters, underwent either a video-assisted thoracic surgical (VATS) approach (n = 81) or a limited lateral thoracotomy (LLT) approach (n = 57) to accomplish pulmonary resection for peripheral lung lesions (< or = 3 cm in diameter). Wedge resection was done in 74 VATS patients and 19 LLT patients. Seven patients underwent VATS lobectomy and 38 patients had lobectomy performed through an LLT. Pain was quantitated by postoperative narcotic requirements, the need for intercostal/epidural analgesia, and patient perception of pain index scoring. Shoulder and pulmonary function (forced expiratory volume in 1 second) were measured preoperatively, 3 days postoperatively, and at 3 weeks of follow-up. Patients undergoing VATS experienced significantly less postoperative pain. No patients undergoing VATS required intercostal block/epidural analgesia; 31 LLT patients (54%) required this treatment for breakthrough pain (p = 0.001). Narcotic requirements were less (p = 0.05) among VATS patients, which correlated with lower perception of pain index after operation for VATS patients. Shoulder girdle strength was equally impaired at day 3, but function was more improved in VATS patients at 3 weeks (p = 0.01). Patients undergoing wedge resection alone by LLT had greater impairment in early (day 3) pulmonary function (forced expiratory volume in 1 second) (p = 0.002); this difference from VATS was not sustained at 3 weeks. Video-assisted thoracic surgery is associated with reduced pain, shoulder dysfunction, and early pulmonary impairment compared with LLT for select patients requiring pulmonary resection.
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PMID:Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. 826 26

Laparoscopic colectomy has been associated with a shorter postoperative ileus when compared to open colectomy, although the mechanism is unclear. This study is designed to evaluate gastric emptying following open colectomies (OC) versus laparoscopic-aided colectomies (LAC) using serial serum acetaminophen levels (ACE), which correlate with gastric emptying. The study groups were limited to patients undergoing either right or left colectomy who received general anesthetic. Patients with diabetes mellitus or other colon resections were excluded. Postoperative analgesia was provided with intramuscular ketorolac and opioids for breakthrough pain. Patients received 500 mg ACE at 24 and 48 hours postoperatively, and ACE levels were measured 5, 10, 20, 30, 45, 60, 90, and 120 minutes following ingestion. The OC and LAC groups were matched in terms of operation performed. There were multiple carcinomas in the OC group, and none in the LAC group. Normal control values were also obtained for ACE absorption curves. Of all the time intervals tested at both 24 and 48 hours, there was only a single time interval (30 minutes at the 48-hour testing interval) in which there was a significant difference between the OC and LAC groups. In both the OC and LAC groups, there were multiple time intervals when the ACE levels were significantly different when compared to controls. The results indicate no significant difference in gastric emptying as measured by acetaminophen absorption in postoperative colectomy patients. Therefore, although laparoscopic patients have a clinically shorter postoperative ileus, the mechanism for this reduction appears unrelated to gastric emptying.
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PMID:Prospective comparison of gastric emptying after laparoscopic-aided colectomy versus open colectomy. 865 58

This prospective, randomized double-blind study was conducted to examine the effect of intraoperative opioid (fentanyl) supplementation on postoperative analgesia, emesis, and recovery in ambulatory patients receiving propofol-nitrous oxide anesthesia. Eighty patients undergoing ambulatory gynecologic laparoscopy participated. Confounding variables that could influence the incidence of postoperative emesis were controlled. Patients received either fentanyl 100 micrograms (Group I) or ketorolac 60 mg (Group II) intravenously (IV) at the time of anesthetic induction. No further analgesic supplements were given intraoperatively. Anesthesia was induced with propofol and maintained with propofol-nitrous oxide. Atracurium was used for muscle relaxation and reversed with neostigmine and glycopyrrolate. Postoperative pain during early recovery was treated with IV fentanyl 25-50 micrograms (Group I) or IV ketorolac 15-30 mg (Group II). Subsequent breakthrough pain in both groups was treated with IV fentanyl 25 micrograms increments as needed (rescue analgesia). Eighty-four percent of patients in Group I required analgesics during early recovery versus 56% of patients in Group II (P < 0.05). Maintenance dose of propofol was significantly lower in Group I (129 +/- 35 micrograms.kg-1.min-1 than in Group II (170 +/- 63 micrograms.kg-1.min-1. Immediate recovery (emergence) in the two groups was comparable, despite different propofol requirements. Although the incidence of emetic sequelae in the postanesthesia care unit was not significantly different between the two treatment groups, a significantly larger number of patients in Group I (fentanyl group) had emetic sequelae that required therapeutic intervention (Group I 29% versus Group II 10%). Patients in Group I also took a significantly longer time to ambulate and meet criteria for home discharge. These results indicate that, in patients undergoing ambulatory gynecologic laparoscopy, the practice of administering a small dose of fentanyl at the time of anesthetic induction reduces maintenance propofol requirement, but fails to provide effective postoperative analgesia. Fentanyl administration at anesthetic induction increased the need for rescue antiemetics. The relative severity of emetic sequelae could have contributed to delay in ambulation and discharge.
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PMID:Recovery after propofol with and without intraoperative fentanyl in patients undergoing ambulatory gynecologic laparoscopy. 889 71

The safety of epidural infusion for postoperative analgesia in pediatric spine surgery continues to be established. A continuous epidural infusion of morphine sulfate and bupivacaine was used for postoperative analgesia in 12 pediatric patients undergoing spinal surgery. The epidural was placed intraoperatively by the operating surgeon, while continuous infusion was managed postoperatively by a pediatric anesthesiology pain service team. In addition to the continuous infusion, 2 of the 12 also were provided on-demand patient-controlled boluses via epidural catheter for breakthrough pain. Patients experienced analgesia as documented by a comprehensive pain scale form. No catheters failed, while side effects were minimal and easily managed. These results provide confirmation of the safety and efficacy of continuous epidural infusion for postoperative analgesia following pediatric spine surgery and evidence that patient-controlled epidural analgesia is an option.
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PMID:Postoperative epidural analgesia for pediatric spine surgery. 960 93

"Breakthrough pain" is a common clinical term that has not been conclusively defined or described. Breakthrough pain is a transitory flare of pain experienced when baseline pain has been reduced to a mild or moderate level. Breakthrough pain may be characterized by its relationship to a fixed around-the-clock (ATC) opioid dose, rapid onset and short duration, precipitating events, predictability, pathophysiology (with nociceptive pain being most easily controlled), and etiology. The only prospective study of breakthrough pain conducted to date found a 63% prevalence of breakthrough pain in cancer patients referred to a pain service. Although prevalence figures from other studies vary widely, partly due to the populations chosen, all of the studies verify that breakthrough pain is a serious problem in cancer patients. In fact, several studies have listed incident pain, a subset of breakthrough pain, as a predictor of poor response to analgesic therapy. Breakthrough pain is currently managed with oral or parenteral breakthrough pain medications given in addition to the ATC analgesic regimen. The ATC dosage may also be increased until limited by side effects. Newer agents with a more rapid onset of analgesia and shorter duration of effect may help in the management of breakthrough pain.
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PMID:Breakthrough pain in cancer patients: characteristics, prevalence, and treatment. 968 77

Current guidelines on the treatment of moderate to severe cancer pain recommend the use of scheduled doses of opioids for persistent pain combined with "as needed" doses of similar agents for breakthrough pain. Oral drugs given on an "as needed" basis can be problematic for patients with difficulty in swallowing or for those who suffer from nausea and vomiting. Further, breakthrough pain can become excruciating in a relatively short time, a drawback for analgesics that require gastrointestinal (GI) absorption before pain relief can begin. Hence, there is considerable interest in the development of novel drug administration routes to provide rapid relief of breakthrough pain, particularly through a route that bypasses the GI system. Sublingually administered morphine has sometimes been used in the treatment of breakthrough pain because some believe it provides effective analgesia via an appropriate alternate route. Available pharmacological data, however, do not consistently support the rapid absorption of morphine through the sublingual mucosa, and clinical data concerning the efficacy of sublingual morphine for the treatment of cancer pain are limited, not well-controlled, and inconclusive. While there seems to be a need for provision of rapid, effective analgesia to cancer patients by an alternative route, sublingual morphine may not satisfy this requirement. Newer formulations of analgesics should be tested in the treatment of breakthrough pain due to cancer.
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PMID:Sublingual morphine: efficacy reviewed. 976 21


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