Estudio CRONO: prevalencia del dolor irruptivo en pacientes con dolor crónico no oncológico en Andalucía, España / CRONO study: prevalence of breakthrough pain in patients with non-cancer chronic pain in Andalusia, Spain

Objetivo: El objetivo de este estudio es evaluar la prevalencia de dolor irruptivo (DI) en pacientes ambulatorios con dolor crónico de origen no oncológico y caracterizar la fisiopatología, localización, intensidad y frecuencia de los episodios de DI. Material y métodos: Estudio observacional, prospectivo y no intervencionista realizado en 16 unidades de dolor ambulatorias de hospitales de Andalucía y Ceuta. Se preguntó a los pacientes consecutivos elegibles si experimentan DI definido como "una exacerbación transitoria del dolor que ocurre espontáneamente, o en relación con un desencadenante predecible o impredecible específico, a pesar del dolor de base estable y controlado". En cada día de la encuesta, los dos primeros pacientes que confirmaron DI fueron preguntados sobre las características clínicas de su PTP (etiología, inicio, intensidad, frecuencia y tratamiento). Resultados: Se realizó un cribaje a un total de 3209 pacientes con dolor crónico no oncológico para identificar a 1118 pacientes con DI, lo que representó una prevalencia del 36 %. Se obtuvieron las características del DI de 350 pacientes: la intensidad media fue de 8,3 (± 1,4) en una Escala Analógica Visual (EVA), con una media de 2 episodios/24 horas (rango 1-5/24 h). El mecanismo del dolor fue mixto en 149 (42,6 %), neuropático en 91 (26 %) y nociceptivo en 72 (20,6 %) de los pacientes. Se encontró correlación positiva entre una mayor intensidad de DI con el nivel de dolor basal (r = 0,243, p < 0,001), y el número de crisis diarias de DI (r = 0,123, p = 0,003), ambas estadísticamente significativas. El 78 % de los pacientes estaba en tratamiento con opioides. Los más frecuentes fueron el citrato de fentanilo (52,6 %) y el tramadol (17,4 %). Conclusiones: La tasa de prevalencia del DI en pacientes con dolor crónico no oncológico es superior a un tercio de los pacientes atendidos en las unidades ambulatorias de dolor hospitalario en España. El DI provoca niveles reducidos de funcionalidad, trastornos psicológicos y un aumento del gasto asistencial. La clave del tratamiento es la individualización

Objective: The aim of this study was to evaluate the prevalence of breakthrough pain (BTP) in ambulatory patients with non-cancer chronic pain in Spain and to characterize physiopathology, location, intensity and frequency of BTP episodes. Methods: Prospective, non-interventional, observational study conducted in 16 pain units of hospitals of Andalusia and Ceuta. Eligible consecutive patients were are asked if they experience BTP defined as "a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite stable and controlled background pain". At each survey day, the first two patients reporting BTP were further interrogated on the clinical characteristics of their BTP (etiology, onset, intensity, frequency and treatment). Results: A total of 3,209 patients with non-cancer chronic pain were screened to identify 1,118 patients with BTP, which represented a prevalence of 36 %. BTP characteristics were retrieved from 350 patients: mean BTP intensity was 8.3 (± 1.4) on a Visual Analogue Scale (VAS), with a mean of 2 episodes/24 hour (range 1-5/24 h). Pain mechanism was mixed in 149 (42.6 %), neuropathic in 91 (26 %) and nociceptive in 72 in (20.6 %) of patients. Significant correlation was found between BTP intensity and both higher background pain (r = 0.243, p < 0.001), and daily BTP episodes frequency (r = 0.123, p = 0.003). 78 % of the patients were on opioid treatment. The most frequent were fentanyl citrate (52.6 %) and tramadol (17.4 %). Conclusions: The prevalence rate of BTP in patients with chronic non-oncologic pain is higher than one-third of the patients seen in outpatient hospital pain units in Spain. BTP causes reduced levels of functionality, psychological disorders, and an increase in health care expenditure. Individualization is the key to treatment

[Relationship between laryngoscopy degree and intubation difficulty]. / Relación entre el grado de largingoscopia y de dificultad de intubación.

OBJECTIVES: To determine the relation between difficult intubation and grade of direct laryngoscopy, as well as the factors that influence them, and prognosis. PATIENTS AND METHOD: In 1,336 patients receiving general anesthesia, seven airway measurements were made to reflect degree of difficulty and predictive value of presurgical tests on direct laryngoscopy and intubation. RESULTS: The incidences of difficult laryngoscopic and intubation procedures were 1.4 and 3.0%, respectively. Difficult intubation was more frequent in women and in patients between 40 and 65 years of age (p < 0.05). In 105 intubations (64.8%) performed with moderate difficulty (use of a stylette, external laryngeal pressure or two tries) and 17 (41.5%) performed with difficulty (three or more tries), the laryngoscopic procedure was graded as easy (Cormack-Lehane grade I-II). In these cases (easy laryngoscopy with moderate/difficult intubation), the causes recorded were size of endotracheal tube in comparison with the laryngeal opening (n = 11); anterior glotis (n = 36); insufficient relaxation (n = 31); disease in or beyond the vocal cords (n = 29); or undetermined (n = 15). In the easy intubation cases, the laryngoscopic procedures were grade III in 2.9%. Intubation was difficult in 16.3% (n = 39) of patients presenting some type of abnormality upon examination of the airway (p < 0.05). The airway characteristic that best predicted laryngoscopic difficulty was extension of the lower neck to 90 degrees (relative risk of 4.46), mouth opening less than 3.5 cm (3.92), presence of two airway abnormalities (4.25) and presence of three or more abnormalities (5.39) (p < 0.01). CONCLUSION: The fact that cases of easy laryngoscopy coincide with difficult intubation suggests that, to the degree of intubation difficulty must be added extrinsic factors (individual skill, maneuvers performed, instrumentation, relaxation of the laryngeal musculature and others) that are hard to standardize and reflect when predicting an intubation by the grade of difficulty in laryngoscopy.