Surjya Prasad Upadhyay

Prevalence and Characteristics of Breakthrough Pain in Patients with Head and Neck Cancer: A Cross-Sectional Study

BACKGROUND Approximately one half to two thirds of patients with cancer-related pain experience breakthrough pain (BTP) in their daily activities. OBJECTIVE This is the first report to determine the prevalence and characteristics of BTP experienced by patients with head and neck cancer. METHODS This was a prospective cross-sectional study conducted in patients with head and neck cancer on stable doses of opioid (morphine) for at least 1 week. This study was designed as a cross-sectional study using a series of breakthrough pain questionnaires (BPQ). RESULTS Prevalence of BTP in our study was 48% (average of 3.85 episodes per day) of which more than 50% of episodes were of gradual onset but with severe intensity. Incident pain was predominate (50%) followed by spontaneous (25%) and end of dose failure (20%) and in 5% the nature of pain was unknown or mixed. Unlike other studies the onset of BTP in this present study with head and neck cancer was more gradual and lasted longer than 30 minutes. CONCLUSIONS Patients with head and neck cancer do suffer a lot because of the high incidence of BTP (48%). The majority of patients suffering from BTP are not satisfied at all with the measures taken for their BTP. The majority of patients in India have head and neck cancer; we must approach this matter as a challenge and new technique and therapy should be introduced for the benefit of these patients.

Successful treatment of an intractable postherpetic neuralgia (PHN) using peripheral nerve field stimulation (PNFS).

Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome that arises as a sequel of herpes zoaster eruption. The treatment of postherpetic neuralgia is medically challenging and often frustrating in some situation as the exact mechanism of neuralgia is poorly understood and multiple and complex pathophysiology is postulated requiring poly pharmacy, which itself leads to many side effects. Here, we present a successful management of supra-orbital PHN using peripheral nerve field stimulation (PNFS), which was refractory to the commonly used pharmacological treatment. After successful trial stimulation, permanent stimulator was placed successfully, patient medication were tapered off within 2 weeks. At present, patient is in 8-week poststimulation with excellent pain relief, without any side effect.

Intrathecal Drug Delivery System (IDDS) for Cancer Pain Management: A Review and Updates

Cancer pain remains undertreated and a significant number of patients with cancer pain die from severe untreated pain. With increasing survival rate in cancer, the prevalence of cancer pain is also increasing in number. Though majority of patients with cancer pain can be effectively treated with conventional medical management, still a significant portion of patients required some form of interventional pain management techniques. Among the interventional techniques, intrathecal drug delivery is increasingly used in cancer pain management. Our objective of this article is to review literatures and clinical studies on intrathecal drug delivery system (IDDS) in cancer pain management and to provide updates on its use, precautions, contraindications, side effects and its management, socioeconomic consideration, and management of IDDS in difficult or uncommon situations.

Psychosocial Concerns in Patients With Advanced Cancer: An Observational Study at Regional Cancer Centre, India

Introduction: The diagnosis and treatment of cancer is associated with substantial physical, psychological, and social morbidity. The objective of this study was to identify the prevalence of psychosocial concerns in the patients with advanced cancer admitted to our institute. Materials and Methods: A total of 100 patients admitted to the inpatient palliative care unit of our institute were enrolled in this study. A descriptive questionnaire that dealt with the patient’s psychological acceptance of the disease and emotional distress that accompanies the diagnosis was prepared. Patient’s social and spiritual needs were addressed, and the future concerns that the patient is preoccupied with were discussed on a one-on-one basis with the patient himself or herself. Results: It was found that a majority of patients, though aware of their diagnosis, were not aware of the disease prognosis. There was a generalized anxiety regarding the treatment of the disease and fear of suffering. Most patients preferred to keep the revelation of the diagnosis to those close to them and not reveal it publicly. Financial drain out of resources was a major concern. Future concerns about their own fitness, the settlement of their children, and the family’s well-being were seen commonly in almost all the patients. Conclusions: Attention to psychosocial and spiritual health needs of patients with cancer is an integral part of an effective palliation, though they are less commonly expressed but are strongly felt by patients with cancer. It is therefore recommended that all clinicians and health care providers should address psychosocial health needs as a part of their routine practice.

Oral Morphine Overdose in a Cancer Patient Antagonized by Prolonged Naloxone Infusion

An 80-year-old male was diagnosed with carcinoma in the lung with multiple bony metastases and had been prescribed pain medications as per World Health Organization analgesic ladder guidelines. However, he was not getting adequate pain relief and there were difficulties in titration of the morphine doses on an outpatient basis. Therefore, he was hospitalized for dose titration of oral morphine and was coprescribed amitriptyline and ranitidine. During the titration of the analgesic dose, he developed severe symptoms of morphine overdose. He was immediately treated with intravenous naloxone. After prolonged infusion of naloxone, he achieved his baseline vital parameters without any permanent sequel to the overdose event. This case report describes the possible causes of oral morphine overdose in the elderly and its successful treatment. To prevent such complications, one has to be very cautious of other factors such as drug interactions, particularly in the elderly.

Rupture in Polycystic Kidney Disease Presented as Generalized Peritonitis with Severe Sepsis: A Rare Case Report

Recurrent upper urinary tract (renal) infections have been reported to be frequent in patients with autosomal dominant polycystic kidney disease and often difficult to treat. Female preference and enteric organism predominance suggest that these renal infections are acquired to retrograde from the lower urinary tract. We encountered a rare case of bilateral polycystic kidneys with spontaneous intraperitoneal rupture of multiple infected renal cysts causing generalized peritonitis leading to severe sepsis with multiorgan failure. The patient is successfully managed with nephrectomy followed by prolonged supportive care in intensive care unit.

Role of Intravenous Dexmedetomidine in Prolonging Postoperative Analgesia and Quality of Block Following Spinal Anaesthesia. A SystemicReview and Update

Intravenous dexmedetomidine is been increasingly used in perioperative setting including as an adjunct to local anaesthetic in various regional techniques with an intent either to improve the block quality, to increase the duration of block or to provide sedation and patient comfort during the periblock period. Intravenous dexmedetomidine when used just before or after spinal anaesthesia has many desirable effects such as adequate sedation and patient comfort, longer sensory-motor blockade, prolong postoperative analgesia and reduces post-anaesthesia shivering. A systemic review was done to evaluate and provide update on the use of intravenous dexmedetomidine as an adjunct for spinal anaesthesia. The optimal dose or method of administration of intravenous dexmedetomidine under spinal anaesthesia has not been defined yet. Current literatures suggest a ceiling effect on prolonging post-spinal analgesia after 0.5 mcg/kg boluses. With increasing the dose beyond 0.5 mcg/kg resulted in unwanted side effects notably bradycardia and excessive sedation. Further study with diverse population is needed to define the optimal dose of intravenous dexmedetomidine.

Unilateral Giant Varicocele Mimicking Inguinal Hernia Resulting from Portosystemic Shunt without Evidence of Portal Hypertension: An Unusual Case Report

Isolated giant varicocele has been reported with portal hypertension that results in abnormal communication between portal venous system and testicular vein venous system resulting in retrograde backflow of blood into the testicular venous system which leads to varicosity of the pampiniform plexuses. 65-year-old male with no past medical or surgical history presented to us with soft inguinoscrotal swelling that disappears on lying down mimicking inguinal hernia. Clinical examination revealed soft inguionoscrotal swelling that disappears on pressure. Ultrasonography revealed varicosity of pampiniform plexus, and CT angiography to trace the extent of the varicosity revealed abnormal communication of right testicular vein with superior mesenteric vein. There was no evidence of any portal hypertension; the cause of the portosystemic shunt remains obscure, and it might be a salvage pathway for increasing portal pressure. The case is noteworthy for its rare presentation and abnormal communication with portal venous system in the absence of evidence of portal hypertension.

Use of Epidural Steroid as an Adjuvant in Neuropathic Cancer Pain Management: A Case Report

The complexity of pain and pain care is such that there may come a point in the treatment of a patient with pain when a simple approach to management is no longer possible. The proverbial analgesic ladder can be rapidly overtaken when attempting palliative management of long-term or severe end-of-life pain. Epidural steroid injection is frequently used procedure in chronic back pain of neuropathic origin in nonmalignant cases. This case report implicates the use of epidural steroid for the management of severe neuropathic symptoms including allodynia and hyperalgesia in the setting of cancer pain and palliative care.

A Practical Guide to Sedation and Analgesia in Paediatric Intensive Care Unit (ICU)

All critically ill children have the right to adequate relief of their pain Correctable physical and environmental factors causing discomfort should be addressed using non-pharmacologic interventions before the initiation of pharmacologic interventions. The choice of sedative-analgesic agent and its initial dose are selected on the basis of several factors such as cause of the distress, desire depth and duration of therapy, clinical condition, potential drug interactions and pharmacokinetic modifying variables. Analgosedation: prioritize the use of analgesia first and then sedation should be the norm while starting sedative-analgesic and reverse to be followed in the weaning process. The level of sedation should be regularly assessed and documented using a sedation assessment scale, wherever possible using a validated scoring system such as the COMFORT scale Once the primary cause of ICU admission is treated, the sedative requirement should fall. Attempt should be made to reduce the level of sedation which require an individualised approach based on clinical condition, drug used for sedation-analgesia, total dose and duration of therapy. During reduction or withdrawal of sedative-analgesic, children should be closely observed for development of withdrawal symptoms. *Corresponding author: Dr. Surjya Prasad Upadhyay, Specialist Anaesthesiology, NMC Hospital Dubai, Investment Park, Dubai, UAE, E-mail: run77in@yahoo.com Citation: Upadhyay, S.P., et al. A Practical Guide to Sedation and Analgesia in Paediatric Intensive Care Unit (ICU). (2017) J Anesth Surg 4(1): 16. A Practical Guide to Sedation and Analgesia in Paediatric Intensive Care Unit (ICU) Surjya Prasad Upadhyay1*, Anand Tripathy1, Sameer kapoor2, Piyush N Mallick3 Received date: December 26, 2016 Accepted date: January 10, 2017 Published date: January 16, 2017 DOI: 10.15436/2377-1364.17.061 Upadhyay, S.P., et al. ed need for sedation without proper monitoring and frequent re-evaluation that may contribute to adverse outcomes and complications[5]. Both under-sedation and over sedation have the potential to lead to agitated patients with compromised short-term safety issues and impact on duration of ventilation and length of stay (LOS)[6,7]. Contrary to earlier belief that as long as they were properly sedated, children in ICU were unaware of what was happening to them; new evidences are emerging that they, like adults, children can suffer from disturbing memories of their ICU course, which can affect their longer-term psychological recovery. The consequences of both under sedation and over-sedation are potentially amplified in the critically ill child in the paediatric ICU due to the developing brain[8].