Current management of breakthrough cancer pain according to physicians from pain units in Spain.

PURPOSE: Current evidence suggests the need to improve the management of breakthrough cancer pain (BTcP). For this reason, we aimed to assess the opinion of a panel of experts composed exclusively of physicians from pain units, who play a major role in BTcP diagnosis and treatment, regarding the key aspects of BTcP management. METHODS: An ad hoc questionnaire was developed to collect real-world data on the management of BTcP. The questionnaire had 5 parts: (a) organizational aspects of pain units (n = 12), (b) definition and diagnosis (n = 3), (c) screening (n = 3), (d) treatment (n = 8), and (e) follow-up (n = 7). RESULTS: A total of 89 pain-unit physicians from 13 different Spanish regions were polled. Most of them agreed on the traditional definition of BTcP (78.9%) and the key features of BTcP (92.1%). However, only 30.3% of participants used the Davies' algorithm for BTcP diagnosis. Respondents preferred to prescribe rapid-onset opioids [mean 77.0% (SD 26.7%)], and most recommended transmucosal fentanyl formulations as the first option for BTcP. There was also considerable agreement (77.5%) on the need for early follow-up (48-72 h) after treatment initiation. Finally, 65.2% of participants believed that more than 10% of their patients underused rapid-onset opioids. CONCLUSIONS: There was broad agreement among pain experts on many important areas of BTcP management, except for the diagnostic method. Pain-unit physicians suggest that rapid-onset opioids may be underused by BTcP patients in Spain, an important issue that need to be evaluated in future studies.

Documento de consenso sobre el uso de la combinación paracetamol/tramadol en pacientes con dolor moderado-intenso / Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain

OBJETIVOS: Desarrollar recomendaciones sobre el uso de la combinación paracetamol/tramadol (P/T) en pacientes con dolor moderado-intenso, basadas en la mejor evidencia y experiencia. MÉTODOS: Se siguió la metodología de grupos nominales y Delphi apoyados por una revisión sistemática de la literatura (RSL). Se seleccionó un panel multidisciplinar de 12 expertos en el manejo del dolor. En la primera reunión de grupo nominal se definió el objetivo, alcance, usuarios, apartados del documento de consenso, así como recomendaciones generales preliminares. Para la RSL se definieron los criterios de inclusión y exclusión, y las estrategias de búsqueda. Dos revisores seleccionaron y analizaron los artículos. Esta evidencia se discutió en una segunda reunión de grupo nominal y se generaron las recomendaciones definitivas. Para cada recomendación, el nivel de evidencia y el grado de recomendación se clasificaron según el modelo de Oxford, y el grado de acuerdo por técnica Delphi. Se definió acuerdo si al menos el 70% de los participantes contestaron ≥ 7 en cada recomendación (1 = total desacuerdo a 10 = total acuerdo). RESULTADOS: Se generaron 20 recomendaciones que cubren aspectos generales, como la evaluación del dolor, y específicos del manejo de P/T. Estos últimos abarcan la indicación de la combinación P/T (perfil de paciente, dosificación, pauta, formulaciones), gestión del riesgo (contraindicaciones, precauciones, interacciones, uso concomitante con otras medicaciones, seguimiento, situaciones especiales) y la educación del paciente. CONCLUSIONES: Estas recomendaciones pretenden resolver algunos interrogantes clínicos habituales y facilitar la toma de decisiones respecto al uso de la combinación P/T en pacientes con dolor moderado-intenso

OBJECTIVES: To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience. METHODS: The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥ 7 for each recommendation (1 = total disagreement to 10 = total agreement). RESULTS: A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education. CONCLUSIONS: These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain

[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]. / Documento de consenso sobre el uso de la combinación paracetamol/tramadol en pacientes con dolor moderado-intenso.

OBJECTIVES: To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience. METHODS: The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement). RESULTS: A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education. CONCLUSIONS: These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.

Electroacupuntura en un caso de neuralgia postherpética con afectación de la rama oftálmica del V par craneal / Electroacupuncture in a case of postherpetic neuralgia with involvement of the ophthalmic branch of the trigeminal nerve

Neuralgia postherpética: cuadro de dolor neuropático crónico que aparece como complicación de una infección por el virus de la varicela zóster. La clínica se caracteriza por un dolor intenso y episódico. El tratamiento de elección es farmacológico, pero en un porcentaje de pacientes no se consigue una adecuada respuesta terapéutica, bien por intolerancia a los fármacos bien por inadecuado control del dolor. Se presenta el caso clínico de una paciente con una neuralgia postherpética que afecta a la rama oftálmica izquierda del V par craneal, en la cual no conseguimos un adecuado manejo del cuadro doloroso tras probar diferentes pautas farmacológicas. Ante esta situación, se inició sesiones de electroacupuntura combinadas con fármacos. Se obtuvo una mejoría progresiva de las crisis dolorosas en intensidad y frecuencia, lo que permitió la supresión del tratamiento farmacológico. Alternativa terapéutica a pacientes que no toleran los tratamientos farmacológicos para su dolor neuropático o cuando éstos son ineficaces (AU)

Postherpetic neuralgia consists of chronic neuropathic pain that appears as a complication of varicella-zoster virus infection and is characterized by intense and episodic pain. The treatment of choice is pharmacological but adequate therapeutic response is not always achieved, either due to drug intolerance or to inadequate pain control. Were port the case of a woman with postherpetic neuralgia affecting the left ophthalmic branch of the trigeminal nerve, in whom distinct drug treatments failed to achieve adequate pain control. Given this situation, electro-acupuncture sessions were started, combined with pharmacological therapy. The frequency and intensity of the pain exacerbations progressively diminished, allowing drug treatment to be discontinued. Electroacupuncture can constitute a therapeutic alternative in patients with drug intolerance or inadequate control of neuropathic pain with pharmacological treatment (AU)

Los conceptos de anestesia y profundidad anestésica / No disponible

Existen múltiples definiciones del concepto anestesia general y no hay acuerdo unánime sobre cuáles son los elementos comunes que conforman la anestesia general. Esto se debe en parte al conocimiento incompleto del funcionamiento del sistema nervioso, que condiciona que se ignoren múltiples aspectos sobre las acciones celulares de los fármacos anestésicos. Estos conceptos son básicos si queremos describir con precisión el concepto de profundidad anestésica, especialmente importante al existir en la clínica diversos sistemas de monitorización de dicha profundidad. En esta revisión llegaremos a una definición pragmática de la anestesia, como un estado reversible, inducido farmacológicamente, caracterizado por inconsciencia e inmovilidad del paciente, que provoca amnesia, con el objetivo de permitir y facilitar actos médicos potencialmente lesivos o desagradables, dentro del contexto de un acto anestésico en el que se intentan disminuirá demás los efectos adversos del acto médico y restaurar la homeostasis (AU)

There are multiple definitions of the concept of general anaesthesia, and there is no unanimous agreement on what are the common elements that comprise general anaesthesia. This is partly due to incomplete knowledge of the functioning of the nervous system which conditions that many aspects on the cellular actions of anaesthetic drugs are ignored. These concepts are basic if we want to describe accurately the concept of depth of anaesthesia, especially important as there are various systems available for monitoring such depth. In this review we will come to a pragmatic definition of anaesthesia, as a reversible state, pharmacologically induced, characterized by unconsciousness and immobility of the patient, which causes amnesia, to enable and facilitate potentially harmful or unpleasant medical acts, within the context of an anaesthetic act in which reducing the adverse effects of the medical act and restoring homeostasis are also pursued (AU)

[Intraoperative control of mean arterial pressure and heart rate with alfentanyl with fuzzy logic]. / Control intraoperatorio de la presión arterial media y frecuencia cardíaca por alfentanilo por medio de un controlador borroso.

OBJECTIVES: To describe a fuzzy logic controller that adjust alfentanil infusion during surgery based on changes in mean arterial pressure (MAP) and heart rate (HR). MATERIAL AND METHODS: We designed a fuzzy logic controller using if ... then ... conditions written in C language, to be executed by a 486 PC with a 66 Mhz CPU. The controller was used with eight ASA I-II patients undergoing gynecological surgery under anesthesia with propofol, alfentanil and ventilated with oxygen/air. MAP and HR were input every three minutes, after which the controller generated an infusion based on those figures. We performed a statistical study of alfentanil consumption time until extubation and time of hemodynamic stability. Relative error of MAP was calculated. RESULTS: The controller was used for a total of 373 min with the eight patients. MAP was 15% below the desired level for 2.14% (18 min) of that time and was 15% over the desired level for 5.6% (21 min) of the time. MAP held steady within the range of stability for the remaining 92.26% (334 min) of the time the controller was used. The relative error of MAP was 7.8 +/- 1.5%. Mean time until extubation was 7 min and 2 s. CONCLUSIONS: We believe the controller can be used to automate taks executed by experts. The controller was useful for stabilizing HR and MAP.

Control intraoperatorio de la presión arterial media y frecuencia cardíaca por alfentanilo por medio de un controlador borroso / Mean arterial pressure and heart rate with alfentanil controlled by fuzzy logic

Objetivos. El objetivo de este trabajo es describir un controlador borroso que ajusta la infusión de alfentanilo intraoperatoriamente basándose en la evolución de la presión arterial media (PAM) y frecuencia cardíaca (FC).Material y métodos. Hemos diseñado un controlador borroso con reglas condicionales "si... entonces...", escrito en lenguaje C y ejecutado en un PC 486 con una CPU de 66 Mhz. Se utilizó en 8 pacientes ASA I-II sometidas a cirugía ginecológica y anestesiadas con propofol, alfentanilo y ventiladas con oxígeno/aire. Cada 3 min los valores de presión arterial media (PAM) y frecuencia cardíaca (FC) eran introducidos en el controlador que generaba una infusión en función de la evolución de aquellos. Se aplicó un estudio estadístico descriptivo del consumo de alfentanilo, tiempo de extubación y tiempo de permanencia en una franja de estabilidad hemodinámica. Se calculó el error relativo de los valores de la PAM como índice de ejecución del controlador. Resultados. El tiempo de aplicación del controlador fue de 373 min repartidos entre las 8 pacientes. En un 2,14 por ciento de este tiempo (18 min) la PAM se encontró un 15 por ciento por debajo de la deseada, y en un 5,6 por ciento (21 min) por encima del 15 por ciento. El 92,26 por ciento restante (334 min) la PAM osciló dentro de la banda de estabilidad. El error relativo de la PAM fue del 7,8 ñ 1,5 por ciento. El tiempo medio de extubación fue de 7 min y 25 s. Conclusiones. Creemos que el controlador es aplicable en la automatización de tareas ejecutadas por expertos. El controlador fue útil en el mantenimiento de la FC y la PAM (AU)

No disponible

[Fuzzy logic and postoperative pain]. / Lógica borrosa y dolor postoperatorio.

OBJECTIVE: To apply a fuzzy logic expert control system for the treatment of postoperative pain in a clinical setting. MATERIAL AND METHODS: A system was designed consisting of a perfusion pump guided by a fuzzy logic computer interface to regulate the perfusion of alfentanil in accordance with the patient's pain response. The system was also equipped with a safety device that halted perfusion in case of desaturation, bradypnea or heart rate or blood pressure variations greater than 25%. The system was used in the first 90 minutes after surgery in a patient who underwent bilateral saphenectomy. RESULTS: All system functions worked properly, maintaining the target analgesic values (visual analog scale < or = 2) 77% of the time. CONCLUSION: It is possible to use fuzzy logic to obtain adequate treatment of postoperative pain.

[Design of an expert system for decision-making in an emergency situation]. / Diseño de un sistema experto para toma de decisiones en situación de urgencia.

OBJECTIVES: To study the clinical applicability of the expert system URGSANT as a help in making up decisions in emergencies. MATERIAL AND METHODS: URGSANT is an expert system implemented in INSIGT 2+ which is structured in a modular and hierarchical form. It contemplates 44 urgent situations relating to the central nervous system, hematopoietic, cardiovascular, respiratory, gastrointestinal, genitourinary, endocrinological, and miscellaneous group. Validation of the program was made by four anesthesiologists who evaluated the performance of the program in 25 emergency cases and in 25 other situations that were treated by other specialists. RESULTS: The rationale of the system was basically correct. In most cases the program was considered efficient or very efficient during the different clinical situations and only in one case its guidance was wrong. CONCLUSIONS: The URGSANT expert system is an efficient and useful method for the clinician during emergency situations.

[History of the introduction of ether anesthesia in Spain. A new contribution to its study]. / Historia de la introducción de la anestesia etérea en España. Una nueva contribución a su estudio.

Ether anesthesia was introduced in Spain on January 13, 1847. Dr. Diego de Argumosa y Obregón, from Madrid, was the first Spanish surgeon who operated with the help of sulphuric ether. Almost at the same time, by the end of January, the dentist Oliverio Machechan administered ether to 2 patients in whom he performed dental operations. Subsequently, ether was used in several parts of Spain: Barcelona, Pamplona, Motril, and by several Madrid surgeons through February and March. In Santiago de Compostela ether was also introduced very soon, and, on the basis of the data from the studies of Dr. José González Olivares (the surgeons who first tried it in that town), most authors dealing with this issue state that it was probably in Santiago de Compostela where these experiments were carried out simultaneously with those by Argumosa in Madrid or even before. We have in some occasions defended that thesis; however, we were not satisfied with it and we decided to reinvestigate the facts. We had access to other sources and we concluded that anesthetics were really used a very early phase in Santiago de Compostela, but in the case of ether it was later than Argumosa and Oliverio Machechan used it in Madrid and Mendoza in Barcelona. In the present article we analyze these facts in detail, with emphasis on those that we consider historically relevant and that had not been previously dealt with by any other author addressing these issues.