Sobre el concepto de dolor total / On the concept of total pain

RESUMEN El dolor de los pacientes de cáncer ha sido descrito como dolor total. Tanto en la literatura científica, los libros de texto, así como en informes y directrices de la Organización Mundial de la Salud, el concepto de dolor total ha servido de trasfondo para promover la atención multidisciplinaria de pacientes cuyo dolor involucra también aspectos psicológicos, emocionales, espirituales y sociales. El objetivo de este artículo es proponer una caracterización del concepto de dolor total de manera tal que continúe jugando un papel central en la promoción de la atención multidisciplinaria propia de los cuidados paliativos. Primero, se presenta un bosquejo del concepto y de los diferentes usos en la literatura. Segundo, se hace un contraste con la definición del dolor de la Asociación Internacional para el Estudio del Dolor (IASP) para establecer la naturaleza y referente del concepto de dolor total. Tercero, se muestra cómo esta caracterización del concepto disuelve algunas tensiones en la literatura respecto a su uso adecuado. Se plantea que el concepto de dolor total hace referencia a aquellas relaciones causales entre el dolor y los estados psicológicos, emocionales, espirituales y sociales que han sido Identificadas como susceptibles de ser intervenidas por el modelo de atención paliativa multidisciplinar. Como conclusión, se recomienda no vincular el concepto de dolor total con el padecimiento de una enfermedad en particular, ni con qué tan limitante para la vida es la enfermedad; tampoco para referirse a la "experiencia global" del paciente, ni como un punto muy alto de una escala.(AU)

ABSTRACT The pain suffering in cancer patients has been described as "total pain". The concept of "total pain" plays a key role in the promotion of the multidisciplinary nature of palliative care. In palliative attention, suffering is conceptualized as an addition of physical, psychological, emotional, spiritual and social aspects. In this paper, I offer a characterization of the concept of "total pain", one which preserves its key role in palliative care promotion. First, I sketch the concept and some different usages found in the literature. Second, I establish the nature and referent of the "total pain" concept by means of showing the contrast between it and the pain definition provided by the International Association for the Study of Pain (IASP). Third, I propose that the concept of "total pain" refers to the relevant causal chains identified by the palliative care research as elements susceptible of intervention for the purpose of alleviating patient's suffering. These causal chains feature and link physical, psychological, emotional, spiritual and social aspects of the patient's suffering. As conclusion, I add the recommendation to not associate the concept of "total pain" with any particular diagnostic or disease or any particular prognosis, neither to the global experience of the patient, nor treat it as a high point on a scale.(AU)

Clinical Study on Acupoint Application withChan Wu Gel Cream plus Five Notes Therapy in Relieving Cancer Pain / 上海针灸杂志

Objective To observe the clinical efficacy of acupoint application withChan Wu gel cream plus five notes therapy in treating cancer pain.Method Eighty patients with cancer pain were randomized into a treatment group and a control group, 40 cases in each group. The treatment group received acupoint application withChanWu gel cream at the corresponding acupoints of the affected organ in association with the five notes therapy; the control group was intervened by the three-step analgesic ladder recommended by World Health Organization (WHO). The quality of life and pain intensity were scored before and after the intervention.Result The quality of life and pain degree were significantly changed after the treatment in the two groups (P<0.01). The quality of life and pain intensity of the treatment group were significantly different from that of the control group (P<0.05).Conclusion Acupoint application withChan Wu gel cream plus five notes therapy is effective in mitigating cancer pain and improving the quality of life.

Clinical observation of Oxycodone Controlled-release Tablets in docetaxel second-line treatment of advanced lung cancer / 上海预防医学

[Objective] To evaluate the efficacy and safety of oxycodone controlled-release tablets in patients with advanced non-small cell lung cancer ( NSCLC ) who suffered from cancer pain and needed the treatment of docetaxel as second-line drug. [Methods] Data from 40 patients with NSCLC who suf-fered from moderate and severe cancer pain and were treated with oxycodone controlled -release tablets and docetaxel 75mg/m2 on d1 every 3 weeks from Feb 2007 to July 2011.The analgesic effects, karnofsky per-formance status scales ( KPS) and adverse effects were observed . [ Results] A group of 40 patients were available for evaluation, of whom the response rate was 27.5%,the disease control rate 60%,and the medi-an survival of all 9.35 months, with one-year survival rate being 37.5%.Compared with the condition be-fore treatment, pain in patients was greatly relieved , and the total pain relief rate was 97.5%,with the NRS score decreased significantly , and KPS score significantly raised , whose differences were statistically signifi-cant (P<0.05).The main side effect was hematologic toxicity and constipation , which could be solved af-ter treatment. [ Conclusion] Oxycodone combined with Docetaxel has satisfactory efficacy for the pa-tients with moderate to severe pain in NSCLC , thus markedly improving the quality of life of the patients .

The Effects of Opioid Sparing and Treatment of Opoid Bowel Syndrome of Intravenous Ketorolac in Terminal Cancer Pain Management / 대한마취과학회지

BACKGROUND: Pain management in the terminal stage of advanced cancer is often complicated by opioid-related bowel syndrome and other problems. This study was conducted to investigate the safety and efficacy of ketorolac as an adjunctive analgesic in cancer pain management. METHODS: 10 acutely ill cancer patients suffering from pain, complications of advanced disease, and opioid side effects were included. Except one acute leukemia, all of the patients had metastatic solid tumors. Pain complaints consisted of visceral, somatic and opioid bowel syndrome. They were treated with intravenous morphine patient-controlled analgesia infused with a repeated ketorolac bolus dosing. Demographic data, cancer diagnosis, change of pre- and post-treatment morphine infusion rates, and days until pain control or relief of opioid bowel syndrome were evaluated. RESULTS: Excellent pain relief with improvement of opioid bowel syndrome was achieved in a majority of cases. Ketorolac showed good morphine sparing effects. None of the patients reported gastrointestinal side effects. CONCLUSION: Ketorolac appeared to be well-tolerated in the clinical dose range and for short-term use in acutely-ill terminal cancer pain patients. It also seems to be very effective in relieving opioid-related bowel syndromes.

Adequate Dosage of Butorphanol Combined with Epidural Morphine for Cancer Pain Patients / 대한마취과학회지

BACKGROUND: Continuous epidural morphine administration (CEM) is a common method to treat the pain of terminal cancer patients, but this could produce many side effects/ such as pruritus, nausea, vomiting, constipation and urinary retention. The purpose of this study was to determine the optimal epidural butorphanol dosage to prevent side effects of CEM in terminal cancer patients. METHODS: Thirty terminal cancer patients were randomly assigned to one of three groups. After insertion of epidural catheter, morphine 2 mg and butorphanol 1 mg were injected epidurally for a loading dose and a 2 Day Infusor (2 ml/hr)(Home Pump(R) , I-Flow, Lake Forest, USA) containing morphine 8 mg with butorphanol 2 mg (B2 group, n = 10), 4 mg (B4 group, n = 10) or 6 mg (B6 group, n = 10) mixed with 5% D/W (total 100 ml) was connected. Severity of pain, nausea and vomiting, and pruritus were evaluated using VAS score at 1, 6, 12, 24, 36 and 48 hr after epidural infusion. RESULTS: Severity of pain, nausea and vomiting, and pruritus were significantly decreased in the B6 group as comparable to the other two groups (p < 0.05). CONCLUSIONS: The addition of butorphanol 3 mg to morphine 4 mg in CEM in terminal cancer patients reduced nausea, vomiting and pruritus and improved the pain control effect.

The Pain Alterations in Terminal Cancer Patients Who Received Pain Control / 대한마취과학회지

BACKGROUND: The prevalence of cancer pain was 64% in advanced or terminal cancer patients. In the world, about 25% of all cancer patients had been died without pain control despite of severe pain. We relieved cancer pain with the three methods of treatment such as continuous epidural morphine infusion, alcohol sympathetic block and continuous epidural morphine infusion with alcohol block in the patients requested from other departments. The change of pain was investigated retrospectively. METHODS: The alteration of cancer pain in 26 terminal cancer patients were recorded in visual analogue scale from June 1996 to May 1998 retrospectively. RESULTS: Patients lived average 38.5 days from beginning of pain control. All patients complained severe pain at the point of time requested to pain clinic. But 2 days after pain control, most patients were comfortable or tolerable to pain. At 1 week before death, pain were aggravated and sometimes uncontrolled. CONCLUSIONS: At first time, cancer pain was controlled but it becomes uncontrollable and aggravated in the patients time was drawing near.

A Clinical Study of Splanchnic Nerve Block / 대한마취과학회지

BACKGROUND: It is difficult to manage intractable pain from advanced carcinoma of the upper abdomen. One method used to control pain associated with these malignancies is to block the splanchnic nerve. We investigated that VAS (visual analogue scale) difference before and after splanchnic nerve block (SNB) and pain relief day. Also we studied relationship between VAS before SNB and pain relief day. METHODS: A rewiew of 70 patients who took splanchnic nerve block (SNB) from September 1994 to February 1998 was carried out to assess age, sex, primary diseases, pain sites, VAS before and after SNB, date of diagnosis, date of SNB, date of death and pain relief day, etc. RESULTS: Of 70 patients, 44 were males and the remaining 26 were females. The causes of pain were stomach cancer 28 (40%), pancreatic cancer 18 (25%), gall bladder cancer 7 (10%), hepatoma 6 (8.6%) respcectively. Average day from diagnosis to SNB was 272 and average day from diagnosis to death was 341. So, patients died on the average 69 days after they took the splanchnic nerve block in pain clinic. VAS average before SNB was 8.01 and VAS average after SNB was 3.64. Patients felt pain relief during 35 days after SNB. Pain relief day of patients who had lower VAS before SNB was longer than that of patients who had higher VAS before SNB. CONCLUSION: Early application of splanchnic nerve block will make the patients endure the cancer pain more easily.

Percutaneous Cordotomy Using Thermocouple Electrodes / 대한마취과학회지

Effective noninvasive modalities such as radiotherapy and pharmacologic treatments have become highly developed in the treatment of intractable cancer pain. Although epidural narcotics have been considered particularly useful, limitations still remain in their effectiveness for some patients. Surgical therapy can be a useful alternative to these treatments. Cordotomy is one of the most effective surgical treatments. The first percutaneous cordotomy was attempted by Mullan and his associates in 1963. Rosomoff and his associates modified the procedure using radiofrequency two years later. Cordotomy was widely used by the late 1960's but due to its limited effectiveness and serious complications it was abandoned until 1980 when a new electrode was developed by Levin. A thermocouple cordotomy electrode such as the Levin electrode allows monitoring of impedance and tissue temperature. A radiofrequency lesion can be made by increasing the current directly to the desired temperature rather than by gradual heating with the usual incremental increases in lesion current and time. With the use of this electrode, consistent clinical effects are assured and operating time is reduced. The chances of boiling or charring are also minimized. Since this electrode was developed, cordotomy has received renewed attention virtually everywhere except in Korea. Five terminal cancer patients in whom conservative treatments had failed were treated by cordotomy using the three types of thermocouple electrodes: the levin cordotomy electrode; the TCE thermocouple electrode, and the Kanpolat CT electrode. Due to the small number of patients, a comparison of the effectiveness of these three types could not be made. Although complete pain relief was not achieved in every case, dosages of narcotics could be reduced as a result of this procedure. There were no serious complications except a transient paralysis of the ipsilateral arm in one case and headaches in four cases.

A Modification of Transaortic Celiac Plexus Neurolysis; One Needle, Periaortic Block: A case report / 대한마취과학회지

Celiac plexus neurolysis is performed to relieve intractable upper abdominal pain. Since Kappis had performed splanchnic nerve block in 1919, many methods and its modifications of celiac plexus block have been introduced. In 1983, Ischia and in 1990, Lieberman has introduced the transaortic technique of celiac plexus block. We employed a transaortic approach with some modification of the original method in 12 patients, in which a single needle was advanced from a left posterior paramedian approach through the aorta to deposit the drug directly onto the celiac plexus. After needle has punctured anterior wall of aorta, 50% alcohol 20ml was injected and after retracting the needle to the posterior wall of aorta, also 50% alcohol 20ml was injected. 11 patients experienced marked pain relief and no major complication was encountered. The authors think that our method has some theoretical benefits in effectiveness than the original transaortic method.

The Effectiveness of Transdermal Fentanyl Patch in Cancer Pain Patients / 대한마취과학회지

BACKGROUND: The aim of this study was to investigate the suitability of a dose conversion table from oral morphine to transdermal fentanyl patch (TDFP) and to evaluate the efficacy and safety of TDFP in the treatment of cancer pain. METHODS: Sixty cancer patients whose pain had been stabilized with oral morphine for at least 48 hours (morphine phase) were switched to TDFP using standard conversion chart for fentanyl dosage. TDFP were replaced every 72 hours for 9 days (fentanyl phase). Assessment of pain, nausea, vomiting, pruritus and somnolence were recorded as visual analogue scale (VAS). RESULTS: Patients' pain assessment and side effects were not significantly different during both phases. But ten patients reported some skin reactions to the patch, such as erythema, itching, and papules. CONCLUSIONS: TDFP were well tolerated and provided pain relief in cancer patients equivalent to that achieved with oral morphine.

Neurolytic Blockade of the Ganglion Impar for Relief of Cancer-Related Perianal Pain: A case report / 대한마취과학회지

The perineum refers to the anatomical area immediately below the pelvis, and is comprised of diverse anatomic and somatic innervation. Although various interventions have been proposed for the management of intractable cancer-related perineal pain, their efficacy are limited because the target of nerve blocks has focused on somatic rather than sympathetic components. Recently, blockade of the ganglion impar has been introduced as an alternative means of managing intractable neoplastic perineal pain of sympathetic origin. We successfully treated a patient who had suffered from cancer-related intractable perineal pain with ganglion impar block.