Chiara Angeletti

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.

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.

Pain and Natural Disaster

The treatment for pain in emergency medicine is a matter of increasing interest. Available data indicate that in both normal conditions and during major‐emergencies, the majority of healthcare providers are culturally and professionally unprepared to adequately treat acute pain conditions. In case of natural disasters, opioid drugs are often unavailable. Moreover, no guidelines or validated protocols provide adequate indications for the treatment for pain in case of massive emergencies. Training of the medical and nursing staff, in both formal and continuing, or on‐the‐job education is needed to adequately face a devastating emergency. Unfortunately, there is an inadequate level of training among healthcare professionals, even in highly seismic areas, and the source of aid is frequently limited, especially in the immediate aftermath of a disaster to those already present at the scene. Pain inadequately treated may modify the characteristics of the pain itself. Pain is no longer considered just a symptom, but itself becomes an autonomous pathology heavily influencing the social life and psycho‐social aspects of a person. In the disastrous situation following an earthquake, an inadequate treatment of pain was the major violation of the psycho‐physical integrity of individuals and a severe violation of their rights, as human beings and patients.

GlideScope and Frova Introducer for Difficult Airway Management.

The introduction into clinical practice of new tools for intubation as videolaringoscopia has dramatically improved the success rate of intubation and the work of anesthesiologists in what is considered the most delicate maneuver. Nevertheless intubation difficulties may also be encountered with good anatomical visualization of glottic structures in videolaringoscopia. To overcome the obstacles that may occur both in a difficult provided intubation such as those unexpected, associated endotracheal introducer able to facilitate the passage of the endotracheal tube through the vocal cords into the trachea may be useful. We report 4 cases of difficult intubation planned and unplanned and completed successfully using the GlideScope videolaryngoscope associated with endotracheal Frova introducer.

Intravenous naloxone plus transdermal buprenorphine in cancer pain associated with intractable cholestatic pruritus.

To the Editor: The complex and unpredictable series of symptoms that comes with the terminal stage of neoplastic disease significantly compromises patients’ quality of life, and poses harsh therapeutic challenges for clinicians. Good control of severe cancer-related cholestatic pruritus seems to be hard to achieve and pruritus still undermines the remaining physical and relational capabilities of seriously ill cancer patients. Its pathogenesis remains substantially unknown and its treatment mostly empirical. An increased central opioidergic tone seems to be an important component of cholestatic pruritus, with hyperactivity of the serotoninergic system playing a primary role. These elements were the basis for the therapeutic choice successfully applied in the following clinical case.

Hemodynamic Changes during Hepatic Vascular Exclusion: Use of Intraoperative Transesophageal Echocardiography a Case Series

The aim of this clinical observation was to compare intraoperative transesophageal echocardiography (TEE) and pulmonary artery catheterization (PAC) during hepatic vascular exclusion (HEV). Five non-cirrhotic patients to undergo HVE for major liver resection have been observed. Hemodynamic parameters: pulmonary arterial wedge pressure (PCWP), cardiac index (CI), cardiac output (CO), and systemic vascular resistance (SVR) have been monitored by PAC. Left ventricular end-diastolic area (LVEDA), left ventricular end-systolic area (LVESA), left ventricular end-diastolic pressure (LVEDP), cardiac index (CI), cardiac output (CO), and fractional area changes (FAC) have been monitored by TEE. Hemodynamic variables were assessed before clamping (𝑇0), at 5 and 30 minutes after clamping (𝑇1, 𝑇2) and 15 minutes after unclamping (𝑇3). No significant difference between PCWP and LVEDP was found. LVEDP significantly decreased at 𝑇1 and 𝑇2 compared to 𝑇0 (𝑃<0.001); PCWP showed the same trend. A correlation was found between SV and LVEDP (𝑅2=0.755, 𝑃<0.001) as well as CI (𝑅2=0.630, 𝑃<0.001). Data confirm that intraoperative TEE may be a reliable method for hemodynamic monitoring during major liver resections.