Alessandra Ciccozzi

Clonidine for treatment of postoperative pain: a dose-finding study.

The aim of this double‐blind randomized study was to evaluate the optimal intravenous dose of Clonidine administrated during the peri‐operative period, after lumbar hemilaminectomy for herniated disk repair. The ‘optimal intravenous dose’ was defined as that providing minimal analgesic request, stable haemodynamic profile and a minimal sedation score during 12 h after extubation. Eighty adult patients, ASA physical status I–II, undergoing lumbar hemilaminectomy for herniated disk (L4‐L5, L5‐S1) were included in the study. All the patients were randomly assigned to one of four study groups (A, B, C, D), 20 patients each. The same standardized general anaesthesia was performed for each group. Thirty minutes before the end of surgery, group A, B and C patients received three different loading doses of intravenous Clonidine (5 μg/kg, 3 μg/kg, 2 μg/kg respectively), followed by the same infusion of intravenous Clonidine (0.3 μg/kg per hour). Group D patients received a bolus dose and a continuous infusion of NaCl 0.9%. In the recovery unit, postoperative pain was treated by a patient‐controlled analgesia device, containing morphine. Pain relief was evaluated by the total morphine requirement during the postoperative period. Systolic blood pressure (SBP), heart rate and sedation were also noted during the first 12 h postoperatively. Intravenous Clonidine decreased morphine requirements in a dose‐dependent manner. Group A, B, C and D patients requested 5 ± 2, 11 ± 3, 19 ± 4 and 29 ± 8 doses of morphine respectively. Clonidine also affected SBP in a dose‐related manner. Group A, B and C patients had an SBP decrease respectively of 26 ± 3%, 7 ± 4% and 2 ± 2% compared with basic values while, at the same time, in group D patients no SBP variation was registered. In conclusion, this study demonstrates that, when sedation and analgesic effect of Clonidine is required, 3 μg/kg bolus dose followed by a continuous infusion of 0.3 μg/kg per hour has to be considered the optimal intravenous dose. The higher dose of intravenous Clonidine (5 μg/kg) produced better analgesia but the degree of hypotension and sedation was more severe and longer lasting; it required ephedrine administration and careful monitoring of the patient. On the other hand, the bolus of intravenous Clonidine 2 μg/kg (group C) was less effective in terms of pain relief but with similar side‐effects to the 3 μg/kg dosage (group B).

Improved Cancer Pain Treatment Using Combined Fentanyl‐TTS and Tramadol

▪ Abstract:  The aim of the study was to facilitate dose escalation of strong opioids. In this randomized open‐label study the influence of tramadol on dose adjustment of transdermal fentanyl in advanced cancer pain control was prospectively evaluated. Seventy patients affected by intractable cancer disease with visual analog scale (VAS) score >3 were enrolled. Thirty‐five patients were treated conventionally with increasing transdermal fentanyl dosage as required (group F) and 35 patients received oral tramadol added to their transdermal fentanyl before each increment of the transdermal opioid dosage (group T). Pain control was equally satisfactory in the two groups. VAS scores at baseline (T: 4.36 ± 1.53; F: 4.51 ± 1.36; n.s.) and at the end of the study (T: 1.8 ± 1.6; F: 1.6 ± 1.5; n.s.) did not differ. However, in the tramadol group this level of pain control was achieved with much slower dose escalation of fentanyl. The mean application time of the fentanyl‐Transdermal Therapeutic System patch for each dosage (25, 50, 75 μg/hour) was significantly greater in patients receiving tramadol. No patient in group T escalated to the 100 μg/hour patch, while in 12 patients of group F the 100 μg/hour patch was applied after a 75 μg/hour patch mean application period of 18.6 ± 4.7 days. The number of fentanyl‐TTS dosage changes was significantly lower in group T (1.2 ± 0.4 vs. 2.3 ± 0.5; P < 0.05). The mean total duration of treatment in group T, was 37.1 ± 11.6 days. The amount of fentanyl used at study end was 56.6 ± 11.2 μg/hour plus 141.1 ± 151.9 mg tramadol per day (median: 200 mg/day) in group T patients compared with 84.1 ± 12.2 μg/hour in group F patients (P < 0.05). The combination of a strong opioid with a weak opioid to treat severe cancer pain allowed a more gradual increase of analgesic delivery than was possible using fentanyl‐TTS alone, minimizing periods of under‐ and overdosing. In addition, it considerably slowed the pace of fentanyl dose escalation. In conclusion, this TTS fentanyl‐tramadol analgesic protocol provides a useful alternative to the usual treatment of cancer pain with fentanyl‐TTS alone, especially in case of quick progression of disease and pain. ▪

Intra-articular buprenorphine after knee arthroscopy: A randomised, prospective, double-blind study

Background: Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra‐articular administration of buprenorphine after knee arthroscopy.

Transdermal Buprenorphine for Central Neuropathic Pain: Clinical Reports

Transdermal buprenorphine is an effective analgesic for a variety of pain conditions. Traditionally, neuropathic pain is treated with medications such as tricyclic antidepressants or anticonvulsants, with opioid medications as second or third‐line agents. We present two different painful conditions of presumed neuropathic origin, with complex etiopathogenesis, which were successfully treated with buprenorphine. The results of treatment of these neuropathic pain syndromes with buprenorphine are encouraging, suggesting that it might represent a valid alternative to standard approaches for central neuropathic pain.

Low Back Pain in a Natural Disaster

Low back pain is usually self‐limited. The transition from acute to chronic LBP is influenced by physical and psychological factors. Identification of all contributing factors, in a mass emergency setting, differentiating primary and secondary life‐threatening forms of LBP, is the best approach for success. Aims of the present report were to estimate the prevalence of LBP in population afferent to four advanced medical presidiums (AMPs) during postseismic emergency period and to evaluate frequency of use, types of pain killers administered to patients and short‐term efficacy of them.

Haemodynamic effects of intravenous clonidine on propofol or thiopental induction

The study evaluated the effects of premedication with intravenous clonidine on thiopental or propofol requirements for induction and haemodynamic changes associated with both induction and endotracheal intubation. Clonidine administered intravenously before induction of anaesthesia reduced propofol or thiopental requirements. The association of clonidine and propofol caused, after injection of the induction drug, a decrease in mean arterial pressure which was significantly greater than with thiopental. Moreover, a major haemodynamic stability was registered before and after laryngoscopy in the clonidine‐thiopental group. These findings might contraindicate the clonidine‐propofol combination in patients with cardiovascular disease.

High dose of buprenorphine in terminally ill patient with liver failure: Efficacy and tolerability

Pain in terminally ill patients with cancer can be often hard to manage, due to the unpredictable kinetics of drugs caused by progressive kidney and liver dysfunction. Plasma concentrations of active metabolites-also a cause of dangerous side effects--could be difficult to estimate. This case report holds the idea that buprenorphine, a partial agonist of m-receptors, even at high dosage, may be effective and safe to use in terminally ill patients with significant liver and kidney impairment.

Bradykinin B2 receptor antagonist off label use in short-term prophylaxis in hereditary angioedema.

Hereditary angioedema type I (HAE-C1-INH) is an inherited disorder characterized by repeated severe angioedema attacks mostly triggered by traumas, emotional stress, increased estrogen levels or surgical procedures, in particular, odontostomatological interventions. Icatibant, a bradykinin B2 receptor antagonist, has been approved for treatment of HAE attacks. In this paper we describe the “off label” administration of icatibant as short-term prophylaxis of dental extraction in a patient with HAE with the aim of preventing perioperative angioedema attacks. The drug showed an effective and safe profile. Thus, a short-term prophylaxis of angioedema attacks in patients with HAE may be arranged on a multidisciplinary basis, according to the clinical history of each single patients.

Duloxetine and Pregabalin for Pain Management in Multiple Rheumatic Diseases Associated with Fibromyalgia

The fibromyalgia syndrome (FMS) is characterized by chronic and widespread musculoskeletal pain and soreness accompanied by sleep disorders, chronic fatigue and affective disorders. FMS is often associated with other forms of immuno‐rheumatic diseases. Although FMS pathophysiology is still not fully understood, a number of neuroendocrine, neurotransmission and neurosensitive disorders might generate a mechanism for the elicitation of pain by “central sensitization,” which is common to many other painful conditions. The present case describes the success of a therapeutic scheme, which associates two different pharmacological classes, anticonvulsants and new‐generation antidepressants, when FMS complicates a rare pathology called Cogans syndrome. The association of two drugs might noticeably affect the molecular mechanisms of difficult pain, thus solving painful conditions of multifactorial origin.

Regional anaesthesia techniques for carotid surgery: the state of art

PurposeThis review will analyse some aspects of regional anaesthesia (RA) for carotid endarterectomy (CEA), a surgical procedure which requires a strict monitoring of patient’s status. RA remains an important tool for the anaesthesiologist. Some debates remain about type and definition of regional anaesthesia, efficacy and safety of the different cervical block techniques, the right dose, concentration and volume of local anaesthetic, the use of adjuvants, the new perspectives: ultrasonography, the future directions.MethodsA literature search was performed for journal articles in English language in the PubMed Embase and in The Cochrane Library database, from January 2000 to December 2013. The electronic search strategy contained the following medical subject headings and free text terms: local anaesthesia versus general anaesthesia for endarterectomy, superficial and deep cervical block, complications of cervical nerve block, ultrasound guidance of superficial and deep cervical plexus block.ConclusionsThe gold standard for RA will be achieved after overcoming a number of limitations by a more extensive use of ultrasonography, by combining general and regional anaesthesia, including conscious anaesthesia, by defining the appropriate volume, concentration and dosage of local agents and by addition of adjuvants.RiassuntoObiettivoLa presente rewiew analizza alcune problematiche riguardanti l’anestesia regionale (AR) nella chirurgia della carotide, endoarterectomia carotidea (EAC) procedura chirurgica che richiede un attento monitoraggio dello stato neurologico e clinico del paziente. L’AR continua ad essere una metodica, alternativa all’anestesia generale (AG), importante per l’anestesista. Permangono, tuttavia, alcuni punti di discussione sul tipo e la definizione della AR, sull’efficacia e la sicurezza delle differenti tecniche di blocco del plesso cervicale, sul dosaggio, la concentrazione ed il volume di anestetico locale più appropriati, sull’uso di farmaci adiuvanti, sulle nuove prospettive: l’ultrasonografia e le sue future applicazioni in questo ambito.MetodiE’ stata eseguita una ricerca bibliografica sui principali database, Pubmed Embase e The Cochrane Library dal gennaio 2000 al dicembre 2013. Sono stati utilizzati nella ricerca elettronica le seguenti parole chiave ed associazioni di termini medici: anestesia locale versus anestesia generale nell’endoarterectomia carotidea, blocco del plesso cervicale superficiale e profondo, complicanze del blocco nervoso cervicale, blocco del plesso cervicale profondo e superficiale ecoguidato.ConclusioniIl gold standard, nell’esecuzione dell’AR, per interventi di EAC, sarà possibile solo superando alcune limitazioni legate alle tecniche anestesiologiche tradizionali. Ciò sarà ottenuto grazie ad un uso più appropriato e specifico dell’ultrasonografia, in questo ambito, ad una sempre maggiore integrazione di tecniche regionali con l’anestesia generale, includendo in quest’ultima anche la cosiddetta “conscious anaesthesia”, ad una precisa definizione del volume, della concentrazione e del dosaggio di AL più appropriati ed all’aggiunta di farmaci adiuvanti alla soluzione anestetica.