Comparison of the hemodynamic response of dexmedetomidine versus additional intravenous lidocaine with propofol during tracheal intubation: a randomized controlled study.

BACKGROUND: Laryngoscopy and tracheal intubation are strong stimuli that cause a reflex increase in blood pressure (BP), heart rate (HR), and serum catecholamine level. These can lead to myocardial infarction or cerebrovascular accidents. The purpose of this study is to compare the efficacy of dexmedetomidine and lidocaine combined with propofol in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation. METHODS: This study was a randomized controlled study and adhered to the CONSORT guidelines. One-hundred and six patients undergoing elective general anesthesia with endotracheal intubation were divided randomly into two groups. Group D received dexmedetomidine (1 µg kg- 1) before induction. Group LP received lidocaine (1.5 mg kg- 1) before induction with additional propofol (0.5 mg kg- 1) before laryngoscopy. The primary endpoint was hemodynamic including systolic (S) BP, diastolic (D) BP, mean arterial blood pressure (MAP) and HR measured before and after induction and ≤ 10 min after intubation. Secondary outcome was complications/adverse effects. RESULTS: After induction, the mean SBP, DBP, MAP and HR decreased significantly from baseline in both groups except for mean HR in group LP at 1 min. Differences in mean values of SBP, DBP, and MAP were significantly lower in group D after intubation at 4-10 min (P <  0.05). Group LP had a non-inferior effect in blunting BP at all time points except 1 and 2 min after induction, and 2 min after intubation. The mean difference in HR in group D was significantly lower than that in group LP at all time points (P <  0.001). Group D had significantly more episodes of bradycardia (18.87% vs. 0%, P = 0.001) and hypotension (52.83% vs. 15.09%, P < 0.001) than did group LP. CONCLUSION: Lidocaine (1.5 mg kg- 1) with additional propofol (0.5 mg kg- 1) had a non-inferior effect compared with dexmedetomidine (1 µg kg- 1) in attenuating the hemodynamic response following laryngoscopy and endotracheal intubation, and had fewer adverse effects. TRIAL REGISTRATION: Thai Clinical Trial Registry, ( TRTC20190206002 ). Retrospectively registered 4 February 2019.

Analgesic efficacy of nefopam for cancer pain: a randomized controlled study.

Background: Nefopam is a non-opioid, non-steroidal, central acting drug used effectively for postoperative pain. The efficacy of nefopam for cancer pain remains unclear. We aimed to evaluate the analgesic efficacy of nefopam for cancer pain in a randomized controlled trial. Methods: Patients with moderate to severe cancer pain (n=40) were randomly divided into two groups. The nefopam group (n=20) received three 20 mg doses of nefopam every 8 hours. The placebo group (n=20) received normal saline. Intravenous patient-controlled analgesia with morphine was given for breakthrough pain for 48 hours. The primary outcome was significant pain reduction. Secondary outcomes were morphine consumption over 48 hours and incidence of side effects. Results: The nefopam group showed pain reduction at 12 hours (65% of patients), 24 hours (80%), 36 hours (85%), and 48 hours (65%). The placebo group showed pain reduction at 12 hours (70%), 24 hours (75%), 36 hours (80%), and 48 hours (60%). However, there were no statistically significant differences between the groups (p>0.05). The median dosage of morphine consumption in 48 hours was lower in the nefopam group (25.5 mg) compared with the placebo group (37 mg), but this was not statistically significant (p=0.499). There were no statistically significant differences in blood pressure and heart rate between the groups. Side effects in both groups were comparable. Conclusions: At dosage of 60 mg in 24 hours, nefopam did not provide significant pain reduction in moderate to severe cancer pain patients. However, there was a trend of reduced opioid consumption. Further studies with larger sample sizes, longer duration, or higher doses of nefopam are warranted. Registration: Thai Clinical Trail Registry (TCTR) ID TCTR20181016001; registered on 12 October 2018.

Factors influencing non-adherence to opioids in cancer patients: a mixed-methods cross-sectional study.

Background: Strong opioids are mainly utilized to attenuate pain in cancer patients. Adherence to analgesic drugs significantly promotes adequate pain management and improves quality of life. We aimed to identify the factors influencing non-adherence to strong opioids in cancer patients. Methods: A descriptive, cross-sectional, two-phased, mixed methods design was conducted prospectively to evaluate a cohort of 101 cancer patients who are currently prescribed strong opioids from a pain clinic in Thailand between January and March 2018. Participants were asked to complete a questionnaire that included the following sections: general characteristics; the Medication Taking Behavior in Thai (MTB-Thai) for assessing adherence to medications; and factors influencing nonadherence, which were analyzed using multivariate logistic regression. In addition, face-to-face in depth interviews were conducted with patients showing non-adherence to strong opioids (MTB-Thai score ≤21) and analyzed using thematic content analysis.  Results: Of 101 cancer pain patients that completed the questionnaire, 39.6% showed non-adherence to strong opioids. Illness understanding (P=0.047) and the use of more than three types of pain medication (P=0.032) were significant factors influencing non-adherence. Qualitative analysis indicated that fear of long-term outcomes, opioid side effects, ineffective pain control, attempts to make the regimen more acceptable, poor understanding, and non-acceptance of disease related to non-adherence. Conclusion: Non-adherence to opioids for cancer patients is a common problem. Awareness of patient factors, medication-related factors, and illness-related factors will provide the knowledge and adequate advice that may enhance adherence to medications.

Cooled radiofrequency denervation for treatment of sacroiliac joint pain: two-year results from 20 cases.

BACKGROUND: Sacroiliac joint pain is a common cause of chronic low back pain. Different techniques for radiofrequency denervation of the sacroiliac joint have been used to treat this condition. However, results have been inconsistent because the variable sensory supply to the sacroiliac joint is difficult to disrupt completely using conventional radiofrequency. Cooled radiofrequency is a novel technique that uses internally cooled radiofrequency probes to enlarge lesion size, thereby increasing the chance of completely denervating the sacroiliac joint. The objective of this study was to evaluate the efficacy of cooled radiofrequency denervation using the SInergy™ cooled radiofrequency system for sacroiliac joint pain. METHODS: The charts of 20 patients with chronic sacroiliac joint pain who had undergone denervation using the SInergy™ cooled radiofrequency system were reviewed at two years following the procedure. Outcome measures included the Numeric Rating Scale for pain intensity, Patient Global Impression of Change, and Global Perceived Effect for patient satisfaction. RESULTS: Fifteen of 20 patients showed a significant reduction in pain (a decrease of at least three points on the Numeric Rating Scale). Mean Numeric Rating Scale for pain decreased from 7.4 ± 1.4 to 3.1 ± 2.5, mean Patient Global Impression of Change was "improved" (1.4 ± 1.5), and Global Perceived Effect was reported to be positive in 16 patients at two years following the procedure. CONCLUSION: Cooled radiofrequency denervation showed long-term efficacy for up to two years in the treatment of sacroiliac joint pain.

Thoracic epidural-general analgesia in scoliosis surgery.

STUDY OBJECTIVE: To evaluate the efficacy of thoracic epidural analgesia (TEA) in scoliosis surgery. DESIGN: Descriptive clinical study. SETTING: University hospital. PATIENTS: 15 ASA physical status I, II, and III patients undergoing thoracolumbar scoliosis correction. INTERVENTIONS: TEA was performed at three to 5 cm cephalad to the incision, and 5 to 10 mL of 0.125% - 0.2% levobupivacaine was given initially. Then, 5 to 10 mL of levobupivacaine was infused hourly throughout the operation. General anesthesia (GA) was induced with thiopental sodium (5 mg/kg) and fentanyl (one µg/kg) and was maintained with 0.2% sevoflurane and 50% nitrous oxide in oxygen. Intraoperative epidural morphine (two to three mg) was administered, and 0.1% levobupivacaine with morphine (0.04 to 0.08 mg/mL) was infused at two to 4 mL/hr for postoperative analgesia. MEASUREMENTS: Adequacy of anesthesia, postanesthetic recovery and analgesia, adverse effects, and patient satisfaction were recorded. MAIN RESULTS: 20% of patients underwent more than 10 levels of correction, and 53% had coexisting morbid diseases. All had adequate anesthesia. Immediately in the Postanesthesia Care Unit (PACU), 67% of patients reached an Aldrete score of 10, and 40% were fully awake and oriented. All patients were arousable to command and able to flex their hips and knees. None had intraoperative recall. 73% reported no pain in the PACU or 6 hours postoperatively. No serious adverse effects occurred. 80% of patients rated their satisfaction as "good". CONCLUSIONS: Preincisional application of TEA with light GA may be used effectively in thoracolumbar scoliosis surgery.

Intrathecal analgesia in patients with cancer pain--an audit in a tertiary institution.

INTRODUCTION: Cancer pain is one of the most frequently encountered pain syndromes. With the application of the World Health Organization analgesic ladder, adequate analgesia is achieved in 75% to 90% of patients. The remaining patients suffer from intractable pain requiring intrathecal analgesia. The aim of this study was to retrospectively analyse the pain intensity before and after intrathecal analgesia and review the complications associated with the implantation and the care of the intrathecal device. MATERIALS AND METHODS: We reviewed medical records of all cancer patients whose pain were managed by intrathecal catheter implants in our centre from February 2005 to August 2008. The pain intensity, medication and complications related to intrathecal catheter insertion or drug delivery were reviewed at the time before starting the intrathecal analgesia (T0) and time of discharge from the hospital/time prior to death during their stay in the hospital (Tdsc). RESULTS: Twenty-nine patients were included. Out of these 29 patients, 86.2% had metastatic cancer. The most common indication was poor pain control. Pain intensity was reduced significantly at the time of discharge from hospital (P < 0.001). The number of patients with side effects from opioids decreased after intrathecal treatment. We found 4 patients with short-term catheter complications e.g. kinked or displaced catheter and catheter-related infection. CONCLUSION: Intractable cancer pain could be managed effectively by intrathecal analgesia with a significant decrease in pain intensity and reduced opioid-related side effects. The side effects due to intrathecal opioids and complications from intrathecal catheter were minimal.

Thoracic epidural anesthesia (TEA) with 0.2% ropivacaine in combination with ipsilateral brachial plexus block (BPB) for modified radical mastectomy (MRM).

BACKGROUND: Breast cancer is the 2nd most common tumors in Thai women. Until now, oncologic breast surgeries are typically performed by general anesthesia (GA). However, GA cannot provide adequate postoperative pain control and routine use of parenteral opioids aggravate postoperative sedation, nausea, emesis, impaired oxygenation and depressed ventilation. Thoracic epidural anesthesia (TEA) is one of the regional anesthetic techniques that can be done by using a low dose of local anesthetic in combination with ipsilateral brachial plexus block (BPB) for axillary node dissection. TEA can provide a better pain relief without potential paralysis of respiratory muscle and sedation. MATERIAL AND METHOD: Fifty ASA PS I-III patients undergoing MRM were randomly assigned to two study groups of 25 patients each. In the TEA group, an epidural catheter was inserted at T4 to T5, and 10-15 ml of 0.2% ropivacaine was injected, then interscalene BPB was done with 8 ml of 0.2% ropivacaine. Anesthesia was maintained with 5-10 ml of 0.2% ropivacaine per hour. GA was induced with 1 microg/kg of fentanyl followed by 1.5-2 mg/kg of propofol and was maintained with sevoflurane and 70% N2O in oxygen. The authors evaluated the adequacy of anesthesia, surgical condition, postanesthetic recovery, postanesthetic analgesia and patients' satisfaction. RESULTS: The demographic data was similar in both groups. The number of patients immediately arrived at PACU with a sedation score of 1 was significantly greater in TEA group (p = 0.003) while the number of patients with an Aldrete score of 10 was greater but not statistically significant (p = 0.25). The verbal rating scale and analgesic requirement were significantly lower in the TEA group (p < 0.001 and p = 0.002 respectively). Patients' satisfaction was greater with TEA than with GA (p = 0.014). Surgical condition was similar in both groups. CONCLUSION: The present study shows that TEA combined with BPB by using a low dose of 0.2% ropivacaine is a safe and reliable alternative technique for MRM. It can provide not only effective anesthesia but also better postoperative pain relief faster anesthetic recovery and greater patient satisfaction than those of the GA technique.