Mioclonías positivas y negativas en paciente con enfermedad renal crónica / Positive and negative myoclonus in a patient with end stage renal disease

Introducción: Las mioclonías son contracciones musculares paroxísticas de corta duración o pérdida abrupta del tono muscular, denominadas mioclonías positivas y negativas, respectivamente. Se presenta un caso clínico de mioclonías positivas y negativas generalizadas y se pretende describir los múltiples mecanismos fisiopatológicos y etiologías que lo desencadenan. Presentación del caso: Hombre de 35 años, con diabetes mellitus tipo 1 complicada con enfermedad renal diabética en hemodiálisis, desarrolló una bacteriemia asociada a catéter por Staphylococcus aureus y presentó mioclonías positivas y negativas. Se identificaron como posibles desencadenantes la uremia, la infección y los fármacos con potencial promioclónico; el hallazgo incidental de una lesión isquémica en núcleo caudado no explicaba la semiología encontrada en el paciente. Se hizo el control y retiro de todos los factores promioclónicos enunciados, junto a manejo farmacológico con levetiracetam, y con ello se logró el control de los síntomas. Discusión: Los pacientes con enfermedad renal crónica son susceptibles a la acumulación de productos tóxicos de tipo guanidinas, que tienen potencial para producir mioclonías. Además, las infecciones, el uso de fármacos con potencial promioclónico y lesiones estructurales como las isquemias corticales son etiologías que deben considerarse en el diagnóstico diferencial. El mayor impacto en los síntomas se observa con el control del factor desencadenante, y, en caso de persistir, la terapia farmacológica proporciona buenos resultados. Conclusión: Las mioclonías son trastornos del movimiento relativamente comunes en la enfermedad renal crónica. La identificación del desencadenante es crucial para su manejo junto al uso de fármacos con actividad antimioclónica.

Introduction: Myoclonus are paroxysmal muscle contractions of short duration or abrupt loss of muscle tone, called positive and negative myoclonus respectively. A clinical case of generalized positive and negative myoclonus is presented and the aim is to describe the multiple pathophysiological mechanisms and etiologies that trigger it. Case presentation: A 35-year-old man with type 1 diabetes mellitus complicated by diabetic kidney disease on hemodialysis developed catheter-associated bacteremia due to Staphylococcus aureus and presented positive and negative myoclonus. Uremia, infection, and drugs with pro-myoclonic potential were identified as possible triggers; The incidental finding of an ischemic lesion in the caudate nucleus did not explain the semiology found in the patient. The control and removal of all the pro-myoclonic factors mentioned was carried out, along with pharmacological management with levetiracetam, thus achieving control of the symptoms. Discussion: Patients with chronic kidney disease are susceptible to the accumulation of guanidine-type toxic products, which have the potential to produce myoclonus. Furthermore, infections, the use of drugs with pro-myoclonic potential and structural lesions such as cortical ischemia are etiologies that should be considered in the differential diagnosis. The greatest impact on symptoms is observed with the control of the triggering factor and if it persists, pharmacological therapy provides good results. Conclusion: Myoclonus are relatively common movement disorders in chronic kidney disease. Identification of the trigger is crucial for its management along with the use of drugs with anti-myoclonic activity.

Avaliação do manejo médico no atendimento de cefaleia na sala de urgência e emergência do Hospital Regional de Barbacena - MG / Evaluation of medical management in the treatment of headache in the urgency and emergency room of the Hospital Regional de Barbacena - MG

Introdução: O manejo da cefaleia nas salas de urgência e emergência deve ser baseada em uma anamnese detalhada para que o diagnóstico e tratamento sejam adequados, entretanto não é o que se encontra nos atendimentos. Objetivo: Avaliar o manejo do atendimento das cefaleias em uma sala de Urgência e Emergência. Métodos: Estudo de corte transversal retrospectivo, realizado através da análise de dados de 1317 prontuários eletrônicos de pacientes com queixa de cefaleia que procuraram o serviço de emergência do Hospital Regional de Barbacena durante o período de 01 de janeiro de 2017 a 30 de junho de 2019. Os diagnósticos relatados nos prontuários foram classificados de acordo com os critérios da Classificação Internacional das Cefaleias (ICHD-3). Os dados foram submetidos à análise estatísticas, pelo teste de qui-quadrado. Considerou-se diferenças estatisticamente significativas aquelas cujo valor p≤0,05. Resultados: Do total de prontuários, três foram excluídos, sendo analisados 1314. Entre os prontuários analisados, 73,21% apresentaram diagnósticos iniciais eram cefaleia, 16,67% migrânea e 10,12% cefaleia do tipo tensão. Já no diagnóstico final, cefaleia correspondeu a 59,67%, migrânea a 17,95% e cefaleia do tipo tensão a 8,52%. Em relação ao tratamento, foi receitado opioides para 43,99% dos pacientes e para o restante foram prescritos medicamentos não opioides. Conclusão: O trabalho sugeriu falha no manejo da cefaleia nas salas de urgência e emergência, provavelmente pela limitação do conhecimento dos profissionais de saúde acerca da dor de cabeça. O que acarretou no grande número de diagnósticos inespecíficos e inadequada abordagem terapêutica.

Introduction: Detailed clinical evaluation should be the basis for the proper management of headaches in emergency rooms, in order to allow adequate diagnosis and treatment. However, this is not usually observed on clinical rounds. Objective: To evaluate the management of headache consultations in an emergency rooms. Methods: This is a cross-section study was performed analyzing data from 1,317 electronic medical records of patients with headache complaints who sought treatment at the Barbacena City Regional Hospital's between January 1, 2017, and June 20, 2019. Medical records were classified according to the International Classification of Headache Disorders (ICHD-3). The data collected were statistically analyzed using chi-square tests. The study considered a p-value≤0.05 to define statistically significant differences. Results: Three medical records were excluded and 1,314 were analyzed. Among the medical records analyzed, 73.21% of initial diagnoses were classified as headache, 16.67% as migraine, and 10.12% as tension-type headache. Headache corresponded to 59.76% of final diagnoses, migraine to 17.95%, and tension-type headache to 8.52%. Regarding the treatment, 43.99% of patients were prescribed opioids for the remaining were prescribed nonopioid medications. Conclusion: The study suggests that the management of headaches is inadequate in emergency rooms, probably due to limited knowledge of health professionals about headache. This resulted in a large number of nonspecific diagnoses and inadequate therapeutic approaches.

Prescripción de analgésicos no opioides en un Servicio de Ortopedia / Prescription of non-opioid analgesics in an Orthopedics Service

Introducción: El dolor asociado a las alteraciones del sistema musculoesquelético debe ser tratado frecuentemente por los especialistas en Ortopedia. Los analgésicos no opioides se ubican dentro de los fármacos que más se prescriben en este Servicio, aunque no siempre de modo adecuado, según los principios de la prescripción racional. Objetivo: Caracterizar el uso de analgésicos no opioides en el servicio de Ortopedia del Hospital Dr. Salvador Allende. Material y Métodos: Estudio descriptivo de utilización de medicamentos del tipo prescripción-indicación y esquema terapéutico. Se revisaron las historias clínicas de 70 pacientes ingresados en el Servicio de Ortopedia del Hospital Dr. Salvador Allende, durante el período comprendido desde septiembre de 2018 hasta enero de 2019. Resultados: Predominó el sexo femenino y la media de edad de 71,3 años en los pacientes estudiados con una desviación estándar de 22.2 años. Los analgésicos más prescritos fueron dipirona, diclofenaco y paracetamol, en indicaciones aprobadas donde destacaron las fracturas, la celulitis y la seudoartrosis. En la totalidad de los casos, las dosis empleadas fueron adecuadas, no así los intervalos de administración ni la duración del tratamiento. Conclusiones: Es alentador el predominio de la prescripción de analgésicos no opioides con buena relación beneficio-riesgo. No obstante, la presencia de prescripciones irracionales en cuanto a intervalos de administración y duración del tratamiento, indica un déficit en la práctica de la terapéutica analgésica que no debe ser ignorado(AU)

Introduction: The pain associated with alterations of the musculoskeletal system should be frequently treated by the specialist in Orthopedics. Non-opioid analgesics are the most prescribed drugs in this medical service although they are not always used appropriately according to the principles of national prescription. Objective: To characterize the use of non-opioid analgesics in the orthopedics service of the Dr. Salvador Allende Hospital. Material and Methods: A descriptive study of the use of prescription-indication medications and therapeutic scheme was conducted. Medical records of 70 patients admitted to the orthopedics service of the Dr. Salvador Allende Hospital during the period between September 2018 and January 2019 were reviewed. Results: The female sex and a mean age of 71.3 years with standard deviation of 22,2 years predominated in the study. The most frequently used analgesics, which were indicated in the treatment of fractures, cellulitis and pseudarthrosis, were dipyrone, diclofenac and paracetamol. In all cases, the doses used were adequate, but not the administration intervals or the duration of treatment. Conclusions: The predominance of the prescription of non-opioid analgesics with a good benefit-risk ratio is encouraging. However, the presence of irrational prescriptions regarding administration intervals and duration of treatment indicates a deficit in analgesic therapy that should not be ignored(AU)

Representações sociais de pessoas com câncer em cuidados paliativos sobre a morfina / Social representations of people with cancer in palliative care on morphine

INTRODUÇÃO: A dor se apresenta como sintoma frequente nas pessoas com câncer, e os opioides são os fármacos de escolha para o seu alívio. Dentre eles tem-se a morfina, que é um dos mais utilizados. OBJETIVOS: Descrever as representações sociais de pessoas com câncer em cuidados paliativos sobre a morfina; Analisar tais representações e suas implicações para a adesão ou não a esse opioide no tratamento/alívio da dor do câncer; Propor estratégias de cuidados afinadas às representações das pessoas com câncer que requerem o uso de morfina. MÉTODO: Pesquisa com abordagem qualitativa, do tipo descritiva e exploratória, realizada em uma instituição pública hospitalar. Os participantes foram pessoas com câncer atendidas no Ambulatório. Critérios de inclusão: maiores de 18 anos, com índice ≥ 50% na Escala de Karnofsky (KPS) e prescrição analgésica de morfina. Critérios de exclusão: presença de dor de moderada a intensa no momento da coleta de dados; e aqueles com comprometimento verbal, cognitivo e/ou psiquiátrico. Os dados foram coletados por questionário e entrevista semiestruturada. Os dados do questionário foram analisados por estatística descritiva simples e percentual, e aos conteúdos verbais aplicou-se a análise de conteúdo do tipo lexical, com o uso do software Alceste. Projeto aprovado pelos Comitês de Ética em Pesquisa da instituição proponente e cooperante, com pareceres no 3.296.128 e no 3.453.968, respectivamente. Todos os participantes assinaram o Termo de Consentimento Livre e Esclarecido. RESULTADOS: A média de idade foi de 54,7 anos; sexo feminino (69,7%); predomínio da religião evangélica (60,6%); 81,8% afirmaram seguir corretamente a prescrição da morfina; na Escala de Karnofsky, 45,5% apresentaram índice de 60%, evidenciando a necessidade de assistência ocasional, mas com capacidade de trabalhar; a intensidade da dor pela escala visual analógica variou entre leve (grau 1) e moderada (grau 4), ambas com 21,2% de respostas. O processamento dos dados no Alceste gerou dois blocos, o primeiro com a Classe 1, que expressa a representação medicamentosa do tratamento com a morfina e os fatores associados a esse tratamento; o segundo foi composto pelas Classes 2 e 3 e expressam as relações sociais envolvidas no contexto do tratamento, o vínculo da pessoa que usa morfina com o mundo que a cerca, bem como a relação estabelecida com esse medicamento, o conhecimento sobre a morfina e as atitudes adotadas diante desse uso. Houve ambiguidade nas representações da morfina, colocando-a entre a dor e o temor, pois a indicam como um importante recurso para alívio/tratamento da dor do câncer, mas sinalizam que também pode trazer repercussões negativas associadas aos seus efeitos. CONSIDERAÇÕES FINAIS: Apesar de haver aderência dos pacientes à morfina, a opiofobia ainda precisa ser combatida por meio de estratégias que façam circular informações que possam reconstruir representações sobre a morfina e seu uso terapêutico. A educação terapêutica por meio da atuação de equipe multidisciplinar se destaca como uma boa estratégia de difusão de informações seguras sobre o uso de opioides.

INTRODUCTION: Pain is a frequent symptom in people with cancer, and opioids are the drug of choice for its relief, including morphine, which is one of the most used. OBJECTIVES: To describe the social representations of people with cancer in palliative care about morphine; To analyze such representations and their implications for adherence or not to this opioid in the cancer pain treatment/relief; To propose care strategies related to the representations of people with cancer that require the use of morphine. METHOD: Descriptive and exploratory research with a qualitative approach, carried out in a public hospital. The participants were people with cancer treated at the clinic. Inclusion criteria: over 18 years old, with an index ≥ 50% on the Karnofsky Scale (KPS) and morphine as an analgesic medication prescribed. Exclusion criteria: presence of moderate to severe pain at the time of data collection; and those with verbal, cognitive and/or psychiatric impairment. Data was collected by questionnaire and semi-structured interview. The questionnaire data were analyzed using simple and percentage descriptive statistics, and the verbal content was analyzed using lexical content with the Alceste software. Project approved by the Research Ethics Committees of the proposing and cooperating institution, with opinions No. 3,296,128 and 3,453,968, respectively. All participants signed the Free and Informed Consent Form. RESULTS: The average age was 54.7 years; female gender (69.7%); prevalence of the evangelical religion (60.6%); 81.8% said they correctly followed the prescription of morphine; on the Karnofsky Scale, 45.5% had an index of 60% showing the need for occasional assistance, but with the ability to work; pain intensity by visual analog scale ranged from mild (grade 1) to moderate (grade 4), both with 21.2% responses. The data processing at Alceste generated two blocks, the first with class 1, which expresses the drug representation of the treatment with morphine and the factors associated with that treatment; the second was composed of Classes 2 and 3 and expresses the social relationships involved in the context of the treatment, the bond of the person who uses morphine with the world around her, as well as the relationship established with this medicine, the knowledge about the morphine and the attitudes towards the use of the medicine. There was ambiguity in the representations of morphine, placing it between pain and fear, as they indicate it as an important resource to relieve/treat cancer pain, but it can also bring negative repercussions associated with its effects. FINAL CONSIDERATIONS: Despite patient adherence to morphine, opiophobia still needs to be fought through strategies that spread information that can reconstruct representations about morphine and its therapeutic use. Therapeutic education through the work of a multidisciplinary team stands out as a good strategy to disseminate safe information about the use of opioids.

INTRODUCCIÓN: El dolor es un síntoma frecuente en las personas con cáncer y los opioides son los fármacos de elección para su alivio; entre ellos está la morfina, que es uno de los más utilizados. OBJETIVOS: Describir las representaciones sociales de las personas con cáncer en cuidados paliativos sobre la morfina; analizar tales representaciones y sus implicaciones para la adherencia o no a este opioide en el tratamiento / alivio del dolor producido por el cáncer; Proponer estrategias de cuidados en sintonía con las representaciones de las personas con cáncer que requieren el uso de morfina. MÉTODO: Investigación con enfoque cualitativo, descriptivo y exploratorio, realizada en un hospital público. Los participantes fueron personas con cáncer tratadas en modalidad ambulatorial. Criterios de inclusión: mayores de 18 años, con índice ≥ 50% en la Escala de Karnofsky (KPS) y prescripción analgésica de morfina. Criterios de exclusión: presencia de dolor de moderado a intenso en el momento de la recogida de datos; y aquellos con comprometimiento verbal, cognitivo y/o psiquiátrico. Datos recogidos mediante cuestionario y entrevista semiestructurada. Los datos del cuestionario se analizaron mediante estadística descriptiva simple y porcentual y el contenido verbal fue sometido a análisis de contenido de tipo lexical, utilizándose el software Alceste. Proyecto aprobado por los Comités de Ética en Investigación de la institución proponente y cooperante, con dictámenes núm. 3.296.128 y 3.453.968, respectivamente. Todos los participantes firmaron una declaración de Consentimiento Libre e Informado. RESULTADOS: La edad promedio fue de 54,7 años; sexo femenino (69,7%); predominio de la religión evangélica (60,6%). El 81,8% afirmó que seguía correctamente la prescripción de morfina. En la Escala de Karnofsky, el 45,5% presentó un índice del 60%, lo que indica la necesidad de asistencia ocasional, pero con capacidad para trabajar. La intensidad del dolor, según la escala visual analógica (EVA), varió de leve (grado 1) a moderado (grado 4), ambos con 21,2% de respuestas. El procesamiento de datos en el software Alceste generó dos bloques: el primero con la Clase 1, que expresa la representación farmacológica del tratamiento con morfina y los factores asociados a ese tratamiento; el segundo estaba compuesto por las Clases 2 y 3 y expresa las relaciones sociales involucradas en el contexto del tratamiento, el vínculo de la persona que usa morfina con el mundo que la rodea, así como la relación que establece con ese medicamento, el conocimiento sobre la morfina y las actitudes adoptadas con respecto a su uso. Hubo ambigüedad en las representaciones de la morfina, pues se la situó entre el dolor y el miedo: los participantes la señalaron como un recurso importante para el alivio/tratamiento del dolor oncológico, pero también mencionaron la posibilidad de repercusiones negativas asociadas a sus efectos. CONSIDERACIONES FINALES: A pesar de la adherencia de los pacientes a la morfina, la opiofobia aún debe combatirse mediante estrategias que hagan circular información que permita la reconstrucción de las representaciones sobre la morfina y su uso terapéutico. La educación terapéutica mediante la actuación de un equipo multidisciplinario descolla como una buena estrategia para difundir información segura sobre el uso de opioides.

The Support in Opioid Introduction Period for Outpatients with Cancer by Palliative Care Staffs

Introduction: Our palliative care staff began the support activity in opioid introduction for outpatients with cancer at Komaki City Hospital in March 2018, because it was difficult to make them understand about proper use of opioid analgesics and misinterpretation about abuse at the time of opioid introduction in outpatient settings. This study aimed to evaluate the effects of the activity (patient education on pain control, telephone follow up, and assessment of the symptom). Method: Outpatients with cancer receiving strong opioids for pain relief from January 2017 to March 2019 were eligible. We retrospectively investigated the difference of the variables between baseline and after the activity as follows; the ratios of prescribing immediate-release opioids, antiemetics, and laxatives when opioids were prescribed and side effects due to opioid analgesics appeared. Results: The study included 122 patients. The prescribing ratios of immediate-release opioids antiemetics and laxatives all increased from 90.7 to 98.5%, from 63.0 to 70.6%, and from 61.1 to 70.6%, respectively. The side effect incidence due to opioids with STAS-J 2 or more decreased from 12 (22.2%) to 9 (13.2%). Discussion: The activity could contribute to the provision of drug treatments and counselling needed for opioid therapy.

RODEXKE. Infiltración con ropivacaína, dexmedetomidina y ketorolac en cirugía espinal: Una estrategia para disminuir el consumo de opioides / RODEXKE. Infiltration with ropivacaine, dexmedetomidine, and ketorolac in spinal surgery: A strategy to decrease opioid consumption

Objetivos: Evaluar la efectividad de la infiltración del sitio quirúrgico, con ropivacaína, dexmedetomidina y ketorolac, en pacientes sometidos a instrumentación transpedicular dorsolumbar con técnica mini invasiva, en cuanto al consumo de opioides durante la internación. Materiales y métodos: Se recolectaron en forma retrospectiva los datos prospectivos de las historias clínicas de pacientes con una instrumentación con tornillos transpediculares percutáneos operados entre Junio del 2016 y Diciembre del 2018. 32 pacientes cumplieron con los criterios de selección. Se infiltró en el momento del cierre quirúrgico con una solución preparada con 150 mg de ropivacaína, 0,7 mcg/kg de dexmedetomidina y 60 mg de ketorolac, disuelto en solución fisiológica estéril para completar 40ml (Grupo M) y se la comparó con pacientes en los cuales solo se infiltró con 150mg de ropivacaína (Grupo E). Resultados: El consumo de equivalentes de morfina durante las primeras 72hs postoperatorias presentó en el grupo M una mediana de 0mg, y el grupo E, una mediana de 9,5mg (RIQ de 13,35), con una p<0,000. Por el contrario el consumo de morfina en la sala de recuperación presentó una mediana de 0mg (RIQ de 2) para el grupo M, y de 2mg (RIQ de 5) para el grupo E, sin encontrarse una diferencia significativa, p=0,132. Conclusión: Los resultados obtenidos en la comparación del consumo de opioides durante las primeras 72hs de la internación permite inferir que esta combinación de fármacos es superior respecto a la infiltración estándar con ropivacaína, independientemente de la estrategia analgésica utilizada durante el tiempo quirúrgico.

Objectives: To assess the effectiveness of a surgical site infiltration with ropivacaine, dexmedetomidine and ketorolac, in reducing opioid consumption in patients with a transpedicular dorsolumbar instrumentation using a minimally invasive technique. Materials y methods: We retrospectively collected data from patient's charts from June of 2016 to December of 2018. 32 patients with minimally invasive transpedicular dorsolumbar instrumentation, who met all criteria, were included in the analysis. During wound closure a mixture of 150mg of ropivacaine, 0,7mcg/kg of dexmedetomidine and 60mg of ketorolac, diluted in normal saline to achieve 40ml was injected (Group M). We compared them with patients in whom only 150mg of ropivacaine and saline where injected in the surgical site (Group E). Results: Morphine equivalents use during the first 72 hours postoperative had a median of 0mg for group M, and of 9,5mg (IQR of 13.35), with a p<0,000. On the contrary, morphine use during post anesthesia care unit stance had a median of 0mg (IQR of 2) for group M and of 2mg (IQR of 5) for group E, without a statistically significant difference, p=0,132. Conclusion: The result of the analysis of opioid consumption during the first 72 hours postoperative allows concluding that the infiltration of these 3 drugs together its superior to the standard infiltration with ropivacaine, independently of the analgesic strategy used during the surgery.

A case of idiopathic edema after opioid abuse cessation: can failed aldosterone escape be implicated?

Edema is a recognized complication of ongoing heavy opioid use, regardless of the means of delivery or the specifics of the drug in question. The mechanism responsible remains incompletely understood. Hypotheses currently offered include increased Anti-Diuretic Hormone (ADH) secretion, histamine-mediated permeability changes, independent opioid-receptor mediated fluid retention and an exacerbation of pre-existing vascular compromise. Authors report a case of a 39yr old lady in whom edema emerged 7 months after cessation of opioid abuse. All secondary causes of edema were excluded by an exhaustive battery of investigations. The edema failed to recede with loop diuretics, and resolved only on institution of spironolactone, on which she maintained improvement. This case study reinforces hypotheses of ADH likely mediating opioid associated edema and suggests that aldosterone receptor antagonists are probably a superior class of drugs in opioid-associated edema. It also suggests that the physiological changes caused by opioid use that are responsible for edema are likely stable and persist well beyond the period of actual use. Reformed opioid abusers who never received OST are a huge population whose unique physiological status is likely to yield valuable insights into not just the pathology of opioid-abuse related edema, but the pathology of opioid use as a whole.

Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico / Effectiveness of neurolytic sympathetic plexus block in a descriptive case series of patients with oncological pain / Efetividade do bloqueio neurolítico simpático abdominal em uma série descritiva de casos em pacientes com dor oncológica

Introducción. El dolor es el principal síntoma que se presenta en el 40% de los pacientes oncológicos en tratamiento y en entre el 80% y el 85% de pacientes con la enfermedad avanzada. Dentro de las herramientas farmacológicas, los opioides son una opción con los consecuentes efectos secundarios, momento en el cual los procedimientos intervencionistas adquieren su importancia. El objetivo del artículo es mostrar el impacto sobre el control del dolor y la calidad de vida en paciente con dolor oncológico abdominal sometido a bloqueo celíaco o hipogástrica en un periodo de 3 meses, con el fin de generar conocimiento del tema en el área de la salud. Metodología. Se realizó una serie descriptiva de casos en un período de 3 meses. Se incluyeron 34 pacientes adultos con dolor abdominal de origen oncológico, con propuesta de bloqueo neurolítico de plexos celíacos o hipogástrico superior como método de control del dolor y se realizó un análisis de las variables en el programa estadístico IBM SPSS Versión 19. Resultados. Se encontró alivio del dolor en el 79.4% de los pacientes intervenidos al poco tiempo del procedimiento y de 33.3% a los 3 meses. No se encontró significante mejoría en la calidad de vida evaluada con el cuestionario SF-36. Conclusiones. Se encontró en este estudio que pacientes con índice de Karnofsky <50 tuvieron alta tasa de mortalidad posterior al bloqueo. La técnica de fenolización más radiofrecuencia podrían tener mejor respuesta terapéutica. Son necesarios más estudios para evaluar posibles asociaciones. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Introduction. Pain is the main symptom that occurs in 40% of cancer patients undergoing treatment and between 80% and 85% of patients with advanced cancer. Out of the pharmacological tools, opioids are an option with secondary effects, which makes interventional procedures important. The objective of the article is to demonstrate the impact of celiac or hypogastric plexus block in a three-month period on the pain control and quality of life of patients with abdominal oncological pain in order to generate knowledge of this topic in the healthcare sector. Methodology. A descriptive case series was conducted in a three-month period. Thirtyfour adult patients with oncological abdominal pain with proposed celiac or superior hypogastric plexus block as a method of pain control were included and an analysis was conducted of the variables in the statistical program IBM SPSS Version 19. Results. Pain relief was found in 79.4% of the treated patients shortly after the procedure and in 33.3% of the treated patients after 3 months. No significant improvement was evidenced in the quality of life evaluated with the SF-36 questionnaire. Conclussions. The study found that patients with a Karnofsky performance score of < 50 had a high mortality rate after the block. The technique of phenolization and radiofrequency could have a better therapeutic response. More studies are needed to assess possible associations. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Introdução. A dor é o principal sintoma que ocorre em 40% dos pacientes oncológicos em tratamento e entre 80% e 85% dos pacientes com a doença avançada. Dentro das ferramentas farmacológicas, os opióides são uma opção com consequentes efeitos colaterais, momento em que os procedimentos intervencionistas se tornam importantes. Objetivo. O objetivo do artigo é mostrar o impacto no controle da dor e na qualidade de vida em pacientes com dor oncológica abdominal submetido a bloqueio celíaco ou do plexo hipogástrico em um período de 3 meses, a fim de gerar conhecimento sobre o assunto na área da saúde. Métodos. Foi feita uma série descritiva de casos durante um período de 3 meses. Foram incluídos 34 pacientes adultos com dor abdominal de origem oncológica, com proposta de bloqueio neurolítico do plexo celíaco ou hipogástrico superior como método de controle da dor e a análise das variáveis foi realizada no programa SPSS statistic 19 IBM. Resultados. Observou-se alívio da dor em 79.4% dos pacientes operados logo após o procedimento e em 33.3% 3 meses depois. Não houve melhora significativa na qualidade de vida avaliada com o questionário SF-36. Discussão. Encontrou-se neste estudo que pacientes com índice de Karnofsky > 50 apresentaram alta taxa de mortalidade após o bloqueio. A técnica de fenolização e a radiofrequência poderiam ter melhor resposta terapêutica. Mais estudos são necessários para avaliar possíveis associações. Cómo citar. Jaimes J, Leotau MA, Rangel GW, Miranda N, García-Salazar N, Rangel-Vera JA. Efectividad del bloqueo neurolítico simpático abdominal en una serie de casos descriptiva en pacientes con dolor oncológico. MedUNAB. 2019;22(3):330-340. doi: 10.29375/01237047.3337

Relationship between Cancer Pain Self-management and Pain in Outpatients with Advanced Cancer Taking Opioid Analgesics

Purpose: To clarify the relationship between cancer pain self-management and pain in outpatients with advanced cancer taking opioid analgesics. Methods: 56 patients were surveyed using a questionnaire, which included items on cancer pain self-management deductively extracted from previous studies and items from the Japanese version of the Brief Pain Inventory. Results: Among patients self-managing their cancer pain, scores for “facilitation of around-the-clock opioid analgesics compliance” were significantly lower than scores for “interference with life”. Scores for “enduring end-of-dose failure pain” were significantly higher than scores for “severe pain”, “average pain”, and “interference with life”. Scores for “use of rescue doses when pain occurs” were significantly higher than scores for “sleep”. Scores for “methods to relieve pain other than analgesics” were significantly higher than scores for “mood”. Conclusions: The present study suggested that pain relief should be based on the use of opioid analgesics, and indicated the importance in pain relief of pain treatment that ensures good sleep and support for achieving self-management including holistic care.

Two Cases of Opioid-Induced Hyperalgesia in Cancer Patients Treated with Opioids for Pain Management / 한국호스피스완화의료학회지

Opioids are important drugs for the management of severe cancer pain without a ceiling effect. However, opioid administration leads to dose-limiting complications including drowsiness, hallucinations, delirium, respiratory depression, cognitive impairment, seizure, myoclonus, and hyperalgesia. Opioid-induced hyperalgesia (OIH) is a paradoxical phenomenon as opioid exposure increases pain sensitivity. Reducing or stopping opioids, opioid rotation, or co-administration of N-methyl-D-aspartate (NMDA) antagonists have been suggested for the management of OIH. In this study, we report two clinical cases of successful management of OIH in cancer pain patients that were treated with opioids.

Tratamiento opioide del dolor mixto en pacientes pediátricos asistidos por el equipo de Cuidados Paliativos: Cinco años de experiencia / Opioid treatment for mixed pain in pediatric patients assisted by the Palliative Care team: Five years of experience

Introducción: El dolor se define como una experiencia sensorial y emocional desagradable, relacionada con daño tisular actual o potencial. Según su mecanismo fisiopatológico, se clasifica en dolor nociceptivo, neuropático y mixto. Cuando su intensidad es de moderada a grave, se debe administrar un opioide potente, y la morfina es el fármaco de elección. Si resulta ineficaz o aparecen efectos adversos intolerables, se recomienda la rotación de opioide. Nuestro objetivo fue describir el tratamiento farmacológico del dolor mixto en los pacientes asistidos por el equipo de Cuidados Paliativos del Hospital General de Niños Pedro de Elizalde entre agosto de 2011 y septiembre de 2015. Se incluyeron 72 pacientes, con edad media de 10,1 años y la enfermedad de base más frecuente fue patología oncológica. El opioide de inicio fue morfina en 57 casos; 48 recibieron fármacos adyuvantes. La rotación de opioides ocurrió en la mitad de los casos y la más frecuente fue de morfina a metadona.

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Depending on its pathophysiological mechanism, it may be classified into nociceptive, neuropathic, and mixed pain. If pain is moderate to severe, a strong opioid should be administered and, when this is the case, morphine is the drug of choice. If morphine is ineffective or causes intolerable adverse effects, opioid rotation is recommended. Our objective was to describe the drug management for mixed pain used in patients assisted by the Palliative Care team of Hospital General de Niños Pedro de Elizalde between August 2011 and September 2015. A total of 72 patients were included. Their mean age was 10.1 years, and the most common underlying disease was cancer. The initial opioid was morphine in 57 cases; 48 patients received adjuvant drugs. Opioid rotation was indicated in half of cases, and the most common switch was from morphine to methadone.

Successful Treatment with Transdermal Buprenorphine Patch in Opioid-Dependent Cancer Patients: Case Series / 한국호스피스완화의료학회지

Opioid aberrant behavior is an emerging problem as strong opioid is increasingly used to alleviate cancer pain in patients with cancer. Although the treatment of opioid addiction and physical dependence for non-cancer pain is well known, few studies have been conducted with cancer patients, particularly in the Korean population. Presented here are ten cases of cancer patients who were physically dependent on strong opioid and successfully treated with a partial mu-opioid receptor agonist, buprenorphine. This is the first report showing the efficacy of transdermal buprenorphine as a treatment for physical dependence on opioid medication in cancer patients.

Designing the ideal perioperative pain management plan starts with multimodal analgesia / 대한마취과학회지

Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.

Patrones de prescripción de metadona entre médicos colombianos especialistas en manejo del dolor / Methadone Prescription Patterns among Pain Physicians in Colombia

Introducción: el dolor crónico es una enfermedad con graves consecuencias para personas, médicos y sistemas de salud. Una de las estrategias de manejo es el uso prolongado de opioides, y dentro de los disponibles en Colombia se encuentra la metadona, con características farmacológicas únicas y asociación con aumento de mortalidad por sobredosis y complicaciones cardiovasculares. La adecuada prescripción y seguimiento de metadona se relaciona con complicaciones similares al manejo con otros opioides. Objetivo: describir los patrones de prescripción de metadona entre médicos colombianos especialistas en manejo de dolor y comparar estos patrones de prescripción con las recomendaciones mayormente aceptadas por la comunidad científica internacional. Materiales y métodos: se utilizó una encuesta electrónica estructurada aplicada entre médicos especialistas en dolor identificados a través de las principales agremiaciones y programas de formación nacionales. Resultados: los encuestados que respondieron son mayoritariamente experimentados anestesiólogos, con entrenamiento universitario clínico y que trabajan en hospitales universitarios. La mayoría de ellos percibe como efectivo el manejo a largo plazo con opioides para el control analgésico y la mejoría funcional, a pesar de la falta de respaldo empírico. La mayoría no aplica las herramientas recomendadas por guías de práctica clínica, aunque las conocen. Conclusiones: se debe mejorar la educación de prescriptores de metadona para mejorar la seguridad de los pacientes. Se infiere pobre aplicabilidad de herramientas recomendadas por guías de práctica clínica en el medio colombiano. Los resultados de la presente encuesta no son fácilmente generalizables.

Background: Chronic pain is a disease with serious consequences for people, physicians, and health care systems. Chronic opioid usage is one of this therapy strategy. Methadone is among the available opioids in Colombia and it is characterized by unique pharmacological properties and increased mortality reports because of overdose and cardiovascular complications. Appropriate monitoring and prescribing patterns of methadone are associated with complications similar to chronic management with other opioids. Aim: To describe methadone prescribing patterns among Colombian pain physicians and compare them to the accepted recommendations by the international scientific community. Materials and Methods: An electronic structured survey was applied to pain specialist physicians identified through major pain study associations and national training programs. Results: Respondents of the survey are mostly experienced university certified physicians and anesthesiologists with clinical training working at university hospitals. Most of them perceive chronic opioid therapy as an effective strategy for pain relief and functional outcomes despite the lack of empirical support. Most of them know clinical practice guidelines but are not applying them despite this matter. Conclusions: We must enhance education for prescribers in order to improve patient safety. The recommended clinical practice guidelines are poorly applied by Colombian doctors. The results of this study must be cautiously assessed.

Survey of the Period of Tapering of a Strong Opioid Analgesic for Oral Mucositis Resulting from Concomitant Chemoradiotherapy for Head and Neck Cancer after the End of Treatment

Severe pain from mucositis resulting from concomitant chemoradiotherapy (CCRT) is commonly treated with opioid analgesics. However, the period of use of opioid analgesics differs among individuals. We performed a retrospective cohort study of 46 patients who were treated with long-term opioid analgesics after CCRT for head and neck cancer. Among these patients, opioid analgesics were used for a median of 30 days. A comparative study was conducted between patients with long-term use of strong opioid analgesic drugs and those with short-term use. A significantly prolonged use of opioid analgesic agent was associated with cetuximab use (TPF vs. S-1 vs. Cmab, 35.0 vs. 44.1 vs. 180.7, p≤0.001). There were no psychiatric symptoms such as dependence and delirium. When patient background and chemotherapy selection are known, the possibility of severe oropharyngeal mucositis and the potential need for long-term opioid analgesics can be evaluated. Consideration of reduction or discontinuation according to pain after the end of treatment is important.

Factors Influencing Pain Medication Preference for Breakthrough Cancer Patients and Their Application to Treatments: Survey on Physicians / 한국호스피스완화의료학회지

PURPOSE: The purpose of this study was to assess the factors influencing the rescue medication decisions for breakthrough cancer patients and evaluate treatments using the factors. METHODS: Based on the results of an online survey conducted by the Korean Society of Hospice and Palliative Care from September 2014 through December 2014, we assessed the level of agreement on nine factors influencing rescue medication preference. The same factors were used to evaluate oral transmucosal fentanyl lozenge, oral oxycodone and intravenous morphine. RESULTS: Agreed by 77 physicians, a rapid onset of action was the most important factor for their decision of rescue medication. Other important factors were easy administration, strong efficacy, predictable efficacy and less adverse effects. Participants agreed that intravenous morphine produced a rapid onset of action and strong and predictable efficacy and cited difficulty of administration and adverse effects as negative factors. Oral oxycodone was desirable in terms of easy administration and less adverse effects. However, its onset of action was slower than intravenous morphine. While many agreed to easy administration of oral transmucosal fentanyl lozenge, the level of agreement was low for strength and predictability of its efficacy, long-term durability and sleep improvement. CONCLUSION: Rapid onset of action is one of the important factors that influence physicians' selection of rescue medication. Physicians' assessment of rescue medication differed by medication.

Can oliceridine (TRV130), an ideal novel µ receptor G protein pathway selective (µ-GPS) modulator, provide analgesia without opioid-related adverse reactions?

All drugs have both favorable therapeutic and untoward adverse effects. Conventional opioid analgesics possess both analgesia and adverse reactions, such as nausea, vomiting, and respiratory depression. The opioid ligand binds to µ opioid receptor and non-selectively activates two intracellular signaling pathways: the G protein pathway induce analgesia, while the β-arrestin pathway is responsible for the opioid-related adverse reactions. An ideal opioid should activate the G protein pathway while deactivating the β-arrestin pathway. Oliceridine (TRV130) has a novel characteristic mechanism on the action of the µ receptor G protein pathway selective (µ-GPS) modulation. Even though adverse reactions (ADRs) are significantly attenuated, while the analgesic effect is augmented, the some residual ADRs persist. Consequently, a G protein biased µ opioid ligand, oliceridine, improves the therapeutic index owing to increased analgesia with decreased adverse events. This review article provides a brief history, mechanism of action, pharmacokinetics, pharmacodynamics, and ADRs of oliceridine.

Intravenous lidocaine infusions for 48 hours in open colorectal surgery: a prospective, randomized, double-blinded, placebo-controlled trial / 대한마취과학회지

BACKGROUND: Although intravenous (i.v.) lidocaine is used as a perioperative analgesic in abdominal surgery, evidence of efficacy is limited. The infusion dose and duration remain unclear. This study aimed to investigate the effect of a longer low-dose 48-hour infusion regimen on these outcomes. METHODS: Fifty-eight adults undergoing elective open colorectal surgery were randomized into the lidocaine group (1.5 mg/kg bolus followed by 1 mg/kg/h infusion for 48 hours) and control group. After surgery, patients were given a fentanyl patient-controlled analgesia machine and time to first bowel movement (primary outcome) and flatus were recorded. Postoperative pain scores and fentanyl consumption were assessed for 72 hours. RESULTS: There was no significant difference in time to first bowel movement (80.1 ± 42.2 vs. 82.5 ± 40.4 hours; P = 0.830), time to first flatus (64.7 ± 38.5 vs. 70.0 ± 31.2 hours; P = 0.568), length of hospital stay (9 [8–13] vs. 11 [9–14) days; P = 0.531], nor postoperative pain scores in the lidocaine vs. control groups. Cumulative opioid consumption was significantly lower in the lidocaine vs. the control group from 24 hours onwards. At 72 hours, cumulative opioid consumption (µg fentanyl) in the lidocaine group (1,570 [825–3,587]) was over 40% lower than in the placebo group (2,730 [1,778–5,327]; P = 0.039). CONCLUSIONS: A 48-hour low-dose i.v. lidocaine infusion does not significantly speed the return of bowel function in patients undergoing elective open colorectal surgery. It was associated with reduced postoperative opioid consumption, but not with earlier hospital discharge, or lower pain scores.

Concurrent Use of Nefopam vs. Ketorolac with Opioid Analgesic for Post-operative Pain Management

OBJECTIVE: To compare the analgesic effects and adverse drug reactions (ADRs) of fentanyl intravenous patient-controlled analgesia (ivPCA) with nefopam, a centrally acting analgesic agent with demonstrated opioid sparing activity, as compared to ketorolac in a tertiary teaching hospital. METHODS: A retrospective evaluation of electronic medical records was conducted on patient records including either nefopam or ketorolac with opioid ivPCA for post-operative pain management in general surgery department from January to December 2014. The status of pain control and ADRs were collected. RESULTS: Out of 6,330 general surgery cases, nefopam was given in 153 prescriptions (6.9%) and ketorolac in 81 prescriptions (3.6%). The level of pain control was not different between two groups (70.9% vs. 75.3%; p = 0.51), but ADRs were more frequently reported in nefopam group (9.8% vs. 2.5%; p < 0.05). New ADRs of hot flushes (n = 1) and paresthesia in hands (n = 1) were reported in nefopam group and they were unlisted in the approved package insert. No serious ADRs were reported in both groups. CONCLUSION: Our findings presented that nefopam showed a similar analgesic effect and higher ADR rates compared to ketorolac as an adjuvant to fentanyl iv PCA for postoperative pain management in general surgery patients in South Korea.

Conocimiento y experiencias de estudiantes de enfermería en la administración de principales opioides en el tratamiento del dolor / Knowledge and experiences of nursing students in the administration of major opioids in the treatment of pain

Los opioides constituyen fármacos que cumplen un papel fundamental en el manejo del dolor, pueden producir efectos adversos, conocerlos permite su prevención y tratamiento. La enfermería actúa en el final del proceso de la terapia medicamentosa, aumentando su responsabilidad en evidenciar e impedir fallos. El objetivo fue determinar el conocimiento y experiencias de estudiantes de enfermería en la administración de opioides en el tratamiento del dolor. Estudio observacional descriptivo, transverso. Se aplicó un cuestionario organizado en: características demográficas, conocimientos sobre opioides y dolor y experiencia en la administración de opioides. La muestra conformaron 202 estudiantes de enfermería, Instituto Dr. Andrés Barbero-Universidad Nacional de Asunción. Se destaca el conocimiento global sobre opioides de 37,6% (76), mientras que 62,4% (126) desconocía el tema. Los aspectos más conocidos: concepto de analgésicos, analgésicos opioides y dolor, clasificación del dolor, acciones de enfermería en presencia del dolor, principal clase farmacológica que se emplea en el tratamiento agudo del dolor, los ítems relacionados a la morfina superaron el 60% de conocimiento. Los porcentajes por debajo del 60% fueron concepto de nociceptores, clasificación de opioides y grupo de opioides. Se constató que 14,87% tuvo experiencia en la administración de opioides, de los cuales 43,3% (13) tenía conocimiento global acerca de los opioides y 56,7% (17) no conocía. Se concluye que solo un poco más de la cuarta parte de los estudiantes conocían de la administración de principales opioides en el tratamiento del dolor, sin embargo, no existe asociación significativa entre los que conocen y administran.

Opioids are drugs that play a fundamental role in the management of pain, they canproduce adverse effects, and knowing them allows prevention and treatment. Nursingacts at the end of the drug therapy process, increasing its responsibility to evidenceand prevent failures. The objective was to determine the knowledge and experiencesof nursing students in the administration of opioids in the treatment of pain. This wasa descriptive, transverse observational study. An organized questionnaire was appliedin: demographic characteristics, knowledge about opioids and pain and experience inthe administration of opioids. The sample consisted of 202 nursing students from theDr. Andrés Barbero Institute-National University of Asunción. The overall knowledgeabout opioids was 37.6% (76), while 62.4% (126) did not know about them . Themost well-known aspects were: concept of analgesics, opioid analgesics and pain,classification of pain, nursing actions in the presence of pain, the mainpharmacological class used in the acute treatment of pain, the morphine-related items exceeded 60% of knowledge. The percentages below 60% were concept ofnociceptors, opioid classification and opioid group. It was found that 14.87% hadexperience in the administration of opioids, of which 43.3% (13) had global knowledgeabout opioids and 56.7% (17) did not know them. It is concluded that only a littlemore than a quarter of the students knew about the administration of principal opioidsin the treatment of pain, however, there was no significant association between thosewho know and administer.