Carlo Reale

Learning curves of the Airtraq and the Macintosh laryngoscopes for tracheal intubation by novice laryngoscopists: a clinical study.

BACKGROUND:The curved laryngoscope blade described by Macintosh in 1943 remains the most widely used device to facilitate tracheal intubation. The Airtraq laryngoscope is a new, single-use device for tracheal intubation. Several studies compared the use of Airtraq and Macintosh laryngoscopes in simulated intubation scenarios on manikins. We evaluated learning and performance of tracheal intubation by novice laryngoscopists using the Airtraq or Macintosh laryngoscopes in a randomized controlled clinical trial. METHODS:One hundred eight consecutive patients scheduled for surgical procedures requiring tracheal intubation were enrolled. Patients were randomly allocated to undergo tracheal intubation using a Macintosh (n = 54) or an Airtraq (n = 54) laryngoscope. Tracheal intubation was performed by first-year residents who had no prior experience with the use of either laryngoscope. Primary end points were duration of tracheal intubation and intubation difficulty scale score for both devices. RESULTS:Eighteen residents participated in the protocol; 9 were allocated to each study group. Each participant performed at least 6 tracheal intubations with the same device. We observed a more rapid skill acquisition with the Airtraq than with the Macintosh laryngoscope, as demonstrated by the shorter duration of intubation with the Airtraq laryngoscope. Data analysis with the Student t test revealed a significant difference between the groups (P < 0.001). CONCLUSION:The Airtraq laryngoscope facilitates a more rapid learning curve compared with the Macintosh laryngoscope when used in a clinical setting by novice laryngoscopists. The Airtraq laryngoscope was judged easier to use by novice users.

Italian Oncological Pain Survey (IOPS) A Multicentre Italian Study of Breakthrough Pain Performed in Different Settings

Objective:A survey of breakthrough pain (BTP) was performed in five palliative care units (PCU), seven oncology departments (ONC), and nine pain clinics (OPC). Methods:A standard algorithm was used to confirm the diagnosis of BTP of patients refereed to different settings. Results:1,412 evaluable cancer patients were enrolled. 53.9% were males and the mean age was 63.7±13.1 years. The mean intensity of background pain was 2.8±0.73. Patients reported 2.4±1.1 BTP episodes/day with a mean intensity of 7.37±1.28. 80.6% patients reported that the BTP had a significant negative impact in everyday life. The majority of patients reported a fast onset of BTP, which was predictable in 50.7% of cases, while BTP with a gradual onset (>10 min) was less predictable (29%) (P=0.001). PCU patients were older, had lower Karnofsky levels, a lower number of BTP episodes/day, a slow onset of BTP onset, and a less predictable BTP. Cancer diagnosis was performed a mean of 23.5 months (SD±32.8) before the assessment. The mean duration of background pain was 3.5 months (SD±3.5), and the mean duration of any analgesic treatment was 2.5 months (SD±3). BTP started a mean of 2.2 months (SD±1.9) before the assessment. Characteristics of BTP were influenced by the course of disease, as well as the duration of background pain and initiation of BTP. Most patients took rapid onset opioids and were satisfied with the treatment. BTP diagnosis was prevalently made by ONC and OPC physicians, and rarely by GPs. Conclusion:This survey performed by an Italian observatory expert review group, has confirmed that the BTP represents a clinically relevant condition with a negative impact on the patient’s quality of life. BTP was detected in all settings involved. A number of factors are associated with the BTP. Also factors regarding the course of disease and setting of care have been assessed. This information may help in stratifying patients or predicting the risk of development of BTP with specific characteristics.

Knowledge of residual curarization: an Italian survey

Background: The use of neuromuscular blocking agents (NMBAs) is widespread in anesthetic practice; little is known about the current use of these drugs in Italy. This survey was conducted to obtain information about the most commonly used clinical tests and the train‐of‐four (TOF) ratios that are considered as being reliable for assessing recovery from neuromuscular blockade at the end of anesthesia and the estimated occurrence rates of post‐operative paralysis in Italian hospitals.

Breakthrough Pain in Patients Referred to Pain Clinics: The Italian Pain Network Retrospective Study

IntroductionDespite breakthrough pain (BTP) being one of the most severe forms of pain, there are no definitive data on its prevalence.MethodsThe authors performed a retrospective survey of the prevalence of BTP in consecutive patients in four Italian pain clinics, subsequent to application of an Italian law mandating detailed clinical records on pain characteristics, treatment, and results. Mean pain intensity was assessed with a numerical rating scale from 0 to 10.ResultsThe authors analyzed records of 1,401 patients (58% women, 33.1% patients with cancer). Transient episodes of severe pain or BTP were referred by 790 patients (56.4%), including 58.2% of the men (342 of 588) and 55.1% of the women (448 of 813). Among the 464 patients with cancer, 70.3% reported daily exacerbation of pain. The mean BTP intensity was 8.31 ± 1.58 and 31.1% of patients reported experiencing three episodes per day.ConclusionDespite some limitations of the study, the authors show that transient episodes of severe pain or BTP are significantly present both in cancer and other diseases, and that many patients are not yet receiving appropriate opioid therapy. The authors need validated tools at international level for the diagnosis and treatment of BTP in patients with cancer and for transitory and patients with severe non-cancer pain. A survey at national level is needed to estimate the prevalence of BTP in different settings, to plan specific medical education.

Standard Therapy with Opioids in Chronic Pain Management

AbstractObjective: Moderate to severe pain is commonly experienced by cancer and non-cancer patients. Although opioids are generally the most important drugs in chronic pain management, their use in Italy remains low. We designed a prospective open trial to assess the efficacy and safety of a standard therapy clinically available for a large range of patients. Methods: A total of 172 consecutive patients (89 women and 83 men) with chronic pain (daily mean visual analogue scale (VAS) score > 4) that was not adequately managed by their existing pain regimen were enrolled to receive an immediate release (IR) dose of morphine: 30 mg/day (opioid-naive patients) or 60 mg/day (non-naive patients) for 5 days. After this period (start therapy), all patients were switched to slow release (SR) opioid therapy for 30 days (steady therapy). Each breakthrough pain (BTP) episode was treated with a single dose of IR morphine (20% of the daily dose) during all study periods. Results: Daily VAS score was reduced from 7.4 ± 1.3 at baseline to 3.8 ± 1.5 (p < 0.0001) after 30 days of steady therapy in cancer and non-cancer patients. Fewer patients reported BTP events by study end (55% of patients with BTP at basal time had no BTP at last follow up), and the number of daily BTP events experienced by patients was reduced by therapy to 1–2 per day in 75% of patients reporting BTP. Further, the time delay to reach pain relief following administration of a rescue dose of IR morphine was 15 minutes or less in 52.1% of patients at study end. The standard therapy was well tolerated and fewer adverse effects were recorded at the end of the study period compared with baseline, with the exception of constipation, which showed a moderate increase (from 18.2% to 25.0%). Conclusion: Start therapy with IR morphine followed by conversion to SR opioid therapy could be implemented as a standard therapy to manage moderate to severe chronic pain in patients with cancer or non-cancer pain. ORamorph® in TIBER study (ORTIBER).

Effects of Opioid Rotation in Chronic Pain Patients: ORTIBARN Study

AbstractBackground: Opioid rotation is currently the subject of considerable debate for two reasons: firstly as a strategy for pain treatment, and secondly because of the difficulty in determining equianalgesic doses. Switching from one slow-release (SR) opioid analgesic to another raises a number of critical issues, and there are no widespread studies that support a standard protocol. Initiation of opioid therapy must consider gradual dose titration of the drug until the minimum effective and maximum tolerated dosage for each patient is found. Objective: This study aimed to evaluate the effects of SR opioid rotation after a stabilization period with normal-release (NR) morphine (‘start therapy’) in patients with cancer or non-cancer pain not controlled with their current SR opioid. Methods: This is a multicentre, open-label, prospective study. A total of 326 consecutive patients were enrolled who were affected by chronic cancer or non-cancer pain that was not controlled by an SR opioid administered as either monotherapy or in combination with other analgesic drugs. Following start therapy with oral NR morphine at a dosage of 5 mg or 10 mg every 4 hours, rotation to an SR opioid of a different type from that previously administered was carried out. Results: After about 3 days of start therapy with NR morphine, rotation to an SR opioid allowed a significant decrease of both baseline pain and daily episodes of breakthrough pain. No significant difference was detected between dosages and type of opioid administered, both prior to and after the start therapy period with NR morphine. Conclusions: Rotation to another opioid preceded by a brief period of opioid receptor resetting by start therapy with NR morphine allows a good level of pain control and avoids rotation to inappropriate opioid dosages or combinations analgesics.

435 ASSOCIATION OF HYDROMORPHONE AND PREGABALIN IN PHANTOM LIMB PAIN

Background and Aims: The effects of estrogens on pain perception remain controversial. To investigate this GSK1522814A, a selective estrogen receptor beta ligand, was tested in rat models of inflammatory and acute pain. Mechanisms by which estrogens modulate pain remain unknown, however Smith et al. (2006; J. Neurosci 26: 5777) reported that estradiol influences opioid neurotransmission. To explore this further, GSK1522814A was dosed in the presence of the opioid antagonist naloxone, in both paradigms. Methods: Using rats previously dosed with CFA (100ml, intraplantar), weight bearing differences between hind limbs were measured before and after the administration of GSK1522814A (0.1–1mg/kg, p.o.) when administered alone, and in the presence of naloxone (1mg/kg, s.c.). In naïve rats, paw withdrawal thresholds to a mechanical stimulus were taken before and after the administration of GSK1522814A (1–10mg/kg, p.o.) when administered alone, and in the presence of naloxone (1mg/kg, s.c.). Results: GSK1522814A significantly reversed CFA-induced inflammatory pain at all doses (p < 0.001). In a separate study, a reversal of 87±13% at 1mg/kg was inhibited by naloxone to 4±10%. GSK1522814A (3+10mg/kg) also produced an anti-nociceptive response in naïve rats (p < 0.001). In a separate study, pre/postdose paw withdrawal threshold difference of ~125 g in rats dosed with GSK1522814A (3mg/kg) was reduced to ~15 g by naloxone. Conclusions: These results suggest that estrogens are involved in inflammatory pain and anti-nociception in rats via modulation of the endogenous opioid system. 435 ASSOCIATION OF HYDROMORPHONE AND PREGABALIN IN PHANTOM LIMB PAIN F. Cannata*, R. Bortone, G. Lunghi, M. Grio, P. Favaro, S. Del Monte, F. Debach, A. Canneti, M. Luzi, P. Di Marco, C. Reale. University “La Sapienza” Rome Dipartment of Anaesthesiology, Critical care and pain therapy, Rome, Italy