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Query: UMLS:C0344307 (analgesia)
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Pain is one of the most important considerations in the care of thoracic surgical patients. Failure in pain management is associated with increased mortality and morbidity. Acute pain management aspires to stop the painful stimuli before it is transferred to the CNS. The authors recommend (1) a thorough explanation of the operation and the expected outcome to the patient, (2) preoperative pulmonary rehabilitation for those with marginal lung function, (3) choosing the least painful surgical approach with acceptable exposure, (4) minimizing tissue trauma during surgery, (5) preemptive analgesia, and (6) early ambulation as prophylactic measures that should be employed during hospitalization. Good acute pain control should reduce the incidence of chronic pain. Mediansternotomy and VATS seem to be less acutely painful approaches than thoracotomy for most thoracic surgery. One should rule out recurrent malignancy as the etiology for chronic or recurrent pain. Opioids and NSAIDs are sufficient to produce optimal pain control in patients who undergo VATS and sternotomv. TEA is typically reserved for patients who have a thoracotomy. Opioid PCA can be used instead of-or after the discontinuation of-the epidural catheter. Chronic pain can be treated in many ways, and input from a pain clinic might be beneficial. The single best approach to chronic pain is to prevent it. This can be achieved by selecting the right incisional approach, instituting early physical therapy, and achieving optimal postoperative pain control.
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PMID:Acute and chronic pain syndromes after thoracic surgery. 1247 33

Amniotic fluid embolism is an unpredictable but dramatical complication of pregnancy that occurs when amniotic fluid enter into the maternal circulation. The classical clinical feature is acute respiratory distress, circulatory distress, seizures and coagulopathy. However there is no routine laboratory diagnosis, so that is a diagnosis of exclusion. We report here the case of a patient, on labor with an epidural analgesia who suddenly suffered from seizures, circulatory arrest, and haemorrhage. A symptomatic management was instituted and a caesarean section was performed. An haemostatic hysterectomy was required. The patient survived without any sequelae. Neurological outcome of the child is still reserved.
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PMID:[Amniotic fluid embolism during labor]. 1274 96

Laparoscopic cholecystectomy is clearly the gold standard for symptomatic cholelithiasis. Open cholecystectomy is now reserved for difficult and problematic cases. The purpose of this paper is to propose that mini-laparotomy cholecystectomy (minicholecystectomy) can be as effective as laparoscopic cholecystectomy. This paper compares the two techniques in well-matched patients. In addition mastery of this technique is practical and rewarding and should be part of the repertoire of the general surgeon. We conducted a retrospective review of the experience of a single surgeon at a community-based teaching hospital over a 2-year period for minicholecystectomy and laparoscopic cholecystectomy. Sixty-six patients were matched for age, sex, body surface area, and Acute Physiology and Chronic Health Evaluation II score. The absolute cost was lower for the minicholecystectomy group than for the laparoscopic cholecystectomy group. The operating room times were not significantly different in the two groups (P value 0.79). The average length of stay and the average amount of intramuscular analgesia required for the two groups were also not significantly different (P values 0.69 and 0.35, respectively). Although subjective postoperative satisfaction was equal for both groups the minicholecystectomy group had no complications whereas the laparoscopic group had two (myocardial infarction and cystic duct stump leak) complications. We conclude that minicholecystectomy can be used as a viable alternative to laparoscopic cholecystectomy especially in patients who cannot tolerate laparoscopic procedures and in areas where cost containment is critical.
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PMID:Mini-laparotomy cholecystectomy in the era of laparoscopic cholecystectomy: a community-based hospital perspective. 1288 25

Continuous femoral "3-in-1" nerve blocks are commonly used for analgesia after total knee arthroplasty (TKA). There are conflicting data as to whether additional sciatic blockade is needed. Our routine use of both continuous femoral (CFI) and sciatic (CSI) peripheral nerve blocks was changed because of concerns that sciatic blockade, and its motor consequences in particular, might obscure diagnosis of perioperative sciatic nerve injury. The revised protocol includes placing single-shot blocks and perineural catheters at both sites, but infusing local anesthetic postoperatively only in the CFI. CSI is reserved for patients having poorly controlled posterior knee or calf pain. A sample group of 12 patients treated with this protocol was followed. Ten of 12 patients required use of the CSI. Within 1 h of a 5-10 mL CSI bolus of 0.2% ropivacaine and beginning an infusion of the same drug at 5 mL/h, patients' median pain by verbal analog scale decreased from 7.5 to 2.0 (mean scores from 7.3 to 2.4). It was possible to maintain this level of analgesia until the third postoperative day when catheters were discontinued. Our experience suggests that, in most patients, adequate analgesia after TKA cannot be achieved with CFI alone and that the addition of CSI renders a significant improvement in analgesia.
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PMID:Analgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade? 1533 47

Contemporary standard pharmacological care for the treatment of noncancer pain includes the use of opioid medications. The responsiveness of neuropathic pain to opioids has long been an area of controversy. Evidence from multiple randomized controlled trials indicates that opioids can relieve pain in a variety of neuropathic pain syndromes. Opioids are typically reserved for moderate to severe pain that cannot be relieved by the nonsteroidal anti-inflammatory drugs (NSAIDs). Opioids are often used in combination with other adjuvants or other analgesic agents. The advantage of opioids is the lack of a ceiling effect of the pure mu opioid agonists. The disadvantages of these drugs are a series of mechanism-based opioids-related side effects (e.g., nausea, drowsiness, constipation) and the potential issue of their abuse and misuse. Each patient needs to undergo a comprehensive evaluation and receive education on the treatment. The physician must be well conversant with the differential diagnosis and definitions of physical dependence, tolerance, pseudotolerance, aberrant behaviors, addiction, and pseudoaddiction. No specific opioid drug is intrinsically ''better'' than the others. Opioid rotation refers to the switch from one opioid to another when the degree of analgesia obtained is limited by the persistence of adverse effects or the occurrence of clinically relevant tolerance. This approach is based on the observation that a patient's response varies from opioid to opioid. At present, after 1) appropriate selection of patients and 2) longitudinal patient care with routine assessment of degree of analgesia, functional daily activities, adverse events and aberrant behaviors is carried out, opioid therapy can be the safest and most effective treatment measure for quality of life improvement in the chronic pain patient.
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PMID:Opioid therapy for chronic noncancer pain: practice guidelines for initiation and maintenance of therapy. 1601 15

Labour and delivery result in severe pain for most women. Attention to comfort and analgesia for women in labour is important for physiological reasons and out of compassion. A review of common methods of pain relief of labour was done. Inhalation method as well as intravenous administration of opioids for pain relief in labour is fast giving way to lumbar epidural analgesia. The use of local anaesthetic in labour offers superior pain relief, is effective and safe. The inhalation and parenteral routes seem reserved for patients with contraindication to insertion of epidural. The administration of high volume dilute concentration of local anaesthetic plus lipid soluble opioids, with some level of patient's control, appears to be the current trend in the management of labour pains. There is a body of evidence indicating that Nigerian women may want pain relief in labour. However, there is no organised labour analgesia service in Nigeria. An organised obstetric analgesia service can be developed within the limits of available manpower and technology in an emerging country like Nigeria. This article therefore, focuses on trends in obstetric analgesia and its implications on the development of organised obstetric analgesia services in Nigeria. Key words: obstetric analgesia, obstetric analgesia service, Nigeria.
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PMID:Trends in pain relief in labour: implications for obstetric analgesia service in Nigeria. 1616 Jul 22

Patients who experience a poor response to different systemic opioid trials (oral and intravenous) are candidates for spinal treatment. Breakthrough pain occurring in this group of patients is challenging for physicians. This phenomenon has never been described in this context and the treatment is quite difficult, as patients already demonstrated a poor response to systemic opioids. We report a preliminary experience of alternative methods, including the intrathecal injection of local anesthetic boluses as needed, or alternatively, the use of sublingual ketamine. Twelve consecutive patients with advanced cancer and pain were selected for intrathecal treatment after receiving different trials with systemic opioids. During intrathecal therapy, pain flares not responding to high doses of intravenous morphine were treated with intrathecal boluses of local anesthetics titrated to achieve the best balance between analgesia and adverse effects, or with sublingual ketamine (25 mg), according to their preference. Pain and symptoms were recorded for each episode of breakthrough pain during hospital admission. Effective pain control was achieved in all the episodes treated within 10 minutes with either method, without relevant complications. A mean volume of 0.6 mL of levobupivacaine (LB) 0.25% (1.5 mg) was effective within a few minutes and was well tolerated in patients receiving a continuous intrathecal infusion of a combination of morphine and LB in different doses. Similarly, ketamine in doses of 25 mg sublingually was effective and relatively well tolerated. Despite the difficult clinical situation of these patients, these approaches controlled almost all breakthrough pain events previously unresponsive to relatively high doses of intravenous opioids. These intensive treatments should be reserved for a very selected population and initiated in an appropriate setting with frequent monitoring facilities and skilled nursing.
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PMID:Alternative treatments of breakthrough pain in patients receiving spinal analgesics for cancer pain. 1631 Jun 22

Epidural analgesia for labour has been associated with an increased rate of motor blockade, and instrumental and Caesarean deliveries. In recent years, these risks were significantly reduced with modern concepts of epidural analgesia, including the use of lower doses of local anaesthetics in combination with opioids. With combinations of 0.0625-0.125 % of bupivacaine plus sufentanil or fentanyl, the incidence of maternal motor blockade approximates 10 % and most parturients are nowadays able to ambulate during labour. Methods of epidural drug administration consist of intermittent boluses, patient-controlled epidural analgesia (PCEA) or continuous infusions. While intermittent top-ups and PCEA do not differ in the amount of local anaesthetics used, continuous infusions have been associated with increases in drug consumption and motor blockade in addition to a higher workload (e. g. frequent adjustments of infusion rates). They therefore do not appear to confer significant benefits during labour analgesia. The most common type of anaesthesia for Caesarean delivery is spinal anaesthesia due to its simplicity, cost-effectiveness and speed of onset. It is suitable for cases of an urgent or emergent Caesarean delivery. General anaesthesia still leads to a higher maternal mortality and should be reserved for absolute emergencies and cases where neuraxial blockade is contraindicated.
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PMID:[Current concepts in neuraxial anaesthesia for labour and delivery]. 1634 78

Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The '3-D's' principle--diagnosis, dental treatment and drugs--should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti-inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly-used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.
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PMID:Drugs for pain management in dentistry. 1641 13

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.
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PMID:Percutaneous-guided pain control: exploiting the neural basis of pain sensation. 1653 Jan 19


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