1
|
Chen YH, Chou WH, Yie JC, Teng HC, Wu YL, Wu CY. Influence of Catheter-Incision Congruency in Epidural Analgesia on Postcesarean Pain Management: A Single-Blinded Randomized Controlled Trial. J Pers Med 2021; 11:jpm11111099. [PMID: 34834451 PMCID: PMC8619661 DOI: 10.3390/jpm11111099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/20/2021] [Accepted: 10/26/2021] [Indexed: 11/17/2022] Open
Abstract
Patient-controlled epidural analgesia (PCEA) or epidural morphine may alleviate postcesarean pain; however, conventional lumbar epidural insertion is catheter–incision incongruent for cesarean delivery. Methods: In total, 189 women who underwent cesarean delivery were randomly divided into four groups (low thoracic PCEA, lumbar PCEA, low thoracic morphine, and lumbar morphine groups) for postcesarean pain management. Pain intensities, including static pain, dynamic pain, and uterine cramp, were measured using a 100 mm visual analog scale (VAS). The proportion of participants who experienced dynamic wound pain with a VAS score of >33 mm was evaluated as the primary outcome. Adverse effects, including lower extremity blockade, pruritus, postoperative nausea and vomiting, sedation, and time of first passage of flatulence, were evaluated. Results: The low thoracic PCEA group had the lowest proportion of participants reporting dynamic pain at 6 h after spinal anesthesia (low thoracic PCEA, 28.8%; lumbar PCEA, 69.4%; low thoracic morphine, 67.3%; lumbar morphine group, 73.9%; p < 0.001). The aforementioned group also reported the most favorable VAS scores for static, dynamic, and uterine cramp pain during the first 24 h after surgery. Adverse effect profiles were similar among the four groups, but a higher proportion of participants in the lumbar PCEA group (approximately 20% more than in the other three groups) reported prolonged postoperative lower extremity motor blockade (p = 0.005). In addition, the first passage of flatulence after surgery reported by the low thoracic PCEA group was approximately 8 h earlier than that of the two morphine groups (p < 0.001). Conclusions: Epidural congruency is essential to PCEA for postcesarean pain. Low thoracic PCEA achieves favorable analgesic effects and may promote postoperative gastrointestinal recovery without additional adverse effects.
Collapse
Affiliation(s)
- Ying-Hsi Chen
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-H.C.); (W.-H.C.); (J.-C.Y.); (H.-C.T.)
| | - Wei-Han Chou
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-H.C.); (W.-H.C.); (J.-C.Y.); (H.-C.T.)
| | - Jr-Chi Yie
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-H.C.); (W.-H.C.); (J.-C.Y.); (H.-C.T.)
| | - Hsiao-Chun Teng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-H.C.); (W.-H.C.); (J.-C.Y.); (H.-C.T.)
| | - Yi-Luen Wu
- Department of Medical Education, National Taiwan University, Taipei 100, Taiwan;
| | - Chun-Yu Wu
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100, Taiwan; (Y.-H.C.); (W.-H.C.); (J.-C.Y.); (H.-C.T.)
- Correspondence: ; Tel.: +886-2-2356-2158; Fax: +886-2-2341-5736
| |
Collapse
|
2
|
Tangen KM, Leval R, Mehta AI, Linninger AA. Computational and In Vitro Experimental Investigation of Intrathecal Drug Distribution: Parametric Study of the Effect of Injection Volume, Cerebrospinal Fluid Pulsatility, and Drug Uptake. Anesth Analg 2017; 124:1686-1696. [PMID: 28431428 DOI: 10.1213/ane.0000000000002011] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Intrathecal drug delivery is an attractive option to circumvent the blood-brain barrier for pain management through its increased efficacy of pain relief, reduction in adverse side effects, and cost-effectiveness. Unfortunately, there are limited guidelines for physicians to choose infusion or drug pump settings to administer therapeutic doses to specific regions of the spine or the brain. Although empiric trialing of intrathecal drugs is critical to determine the sustained side effects, currently there is no inexpensive in vitro method to guide the selection of spinal drug delivery parameters. The goal of this study is to demonstrate current computational capabilities to predict drug biodistribution while varying 3 parameters: (1) infusion settings, (2) drug chemistry, and (3) subject-specific anatomy and cerebrospinal fluid dynamics. We will discuss strategies to systematically optimize these 3 parameters to administer drug molecules to targeted tissue locations in the central nervous system. METHODS We acquired anatomical data from magnetic resonance imaging (MRI) and velocity measurements in the spinal cerebrospinal fluid with CINE-MRI for 2 subjects. A bench-top surrogate of the subject-specific central nervous system was constructed to match measured anatomical dimensions and volumes. We generated a computational mesh for the bench-top model. Idealized simulations of tracer distribution were compared with bench-top measurements for validation. Using reconstructions from MRI data, we also introduced a subject-specific computer model for predicting drug spread for the human volunteer. RESULTS MRI velocity measurements at 3 spinal regions of interest reasonably matched the simulated flow fields in a subject-specific computer mesh. Comparison between the idealized spine computations and bench-top tracer distribution experiments demonstrate agreement of our drug transport predictions to this physical model. Simulated multibolus drug infusion theoretically localizes drug to the cervical and thoracic region. Continuous drug pump and single bolus injection were successful to target the lumbar spine in the simulations. The parenchyma might be targeted suitably by multiple boluses followed by a flush infusion. We present potential guidelines that take into account drug specific kinetics for tissue uptake, which influence the speed of drug dispersion in the model and potentially influence tissue targeting. CONCLUSIONS We present potential guidelines considering drug-specific kinetics of tissue uptake, which determine the speed of drug dispersion and influence tissue targeting. However, there are limitations to this analysis in that the parameters were obtained from an idealized healthy patient in a supine position. The proposed methodology could assist physicians to select clinical infusion parameters for their patients and provide guidance to optimize treatment algorithms. In silico optimization of intrathecal drug delivery therapies presents the first steps toward a possible care paradigm in the future that is specific to personalized patient anatomy and diseases.
Collapse
Affiliation(s)
- Kevin M Tangen
- From the Departments of *Bioengineering; and †Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | | | | | | |
Collapse
|
3
|
Ding H, Hayashida K, Suto T, Sukhtankar DD, Kimura M, Mendenhall V, Ko MC. Supraspinal actions of nociceptin/orphanin FQ, morphine and substance P in regulating pain and itch in non-human primates. Br J Pharmacol 2015; 172:3302-12. [PMID: 25752320 PMCID: PMC4500367 DOI: 10.1111/bph.13124] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 02/20/2015] [Accepted: 02/25/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Nociceptin/orphanin FQ (N/OFQ) peptide (NOP) receptor agonists display a promising analgesic profile in preclinical studies. However, supraspinal N/OFQ produced hyperalgesia in rodents and such effects have not been addressed in primates. Thus, the aim of this study was to investigate the effects of centrally administered ligands on regulating pain and itch in non-human primates. In particular, nociceptive thresholds affected by intracisternal N/OFQ were compared with those of morphine and substance P, known to provide analgesia and mediate hyperalgesia, respectively, in humans. EXPERIMENTAL APPROACH Intrathecal catheters were installed to allow intracisternal and lumbar intrathecal administration in awake and unanaesthetized rhesus monkeys. Nociceptive responses were measured using the warm water tail-withdrawal assay. Itch scratching responses were scored from videotapes recording behavioural activities of monkeys in their home cages. Antagonist studies were conducted to validate the receptor mechanisms underlying intracisternally elicited behavioural responses. KEY RESULTS Intracisternal morphine (100 nmol) elicited more head scratches than those after intrathecal morphine. Distinct dermatomal scratching locations between the two routes suggest a corresponding activation of supraspinal and spinal μ receptors. Unlike intracisternal substance P, which induced hyperalgesia, intracisternal N/OFQ (100 nmol) produced antinociceptive effects mediated by NOP receptors. Neither peptide increased scratching responses. CONCLUSIONS AND IMPLICATIONS Taken together, these results demonstrated differential actions of ligands in the primate supraspinal region in regulating pain and itch. This study not only improves scientific understanding of the N/OFQ-NOP receptor system in pain processing but also supports the therapeutic potential of NOP-related ligands as analgesics.
Collapse
Affiliation(s)
- H Ding
- Department of Physiology and Pharmacology, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - K Hayashida
- Department of Anesthesiology, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - T Suto
- Department of Anesthesiology, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - D D Sukhtankar
- Department of Physiology and Pharmacology, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - M Kimura
- Department of Anesthesiology, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - V Mendenhall
- Preclinical Translational Services, Wake Forest University School of MedicineWinston-Salem, NC, USA
| | - M C Ko
- Department of Physiology and Pharmacology, Wake Forest University School of MedicineWinston-Salem, NC, USA
- Department of Dermatology, Wake Forest University School of MedicineWinston-Salem, NC, USA
- Center for Comparative Medicine Research, Wake Forest University School of MedicineWinston-Salem, NC, USA
| |
Collapse
|
4
|
Bujedo BM. Current evidence for spinal opioid selection in postoperative pain. Korean J Pain 2014; 27:200-9. [PMID: 25031805 PMCID: PMC4099232 DOI: 10.3344/kjp.2014.27.3.200] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/01/2014] [Accepted: 04/16/2014] [Indexed: 11/21/2022] Open
Abstract
Background Spinal opioid administration is an excellent option to separate the desirable analgesic effects of opioids from their expected dose-limiting side effects to improve postoperative analgesia. Therefore, physicians must better identify either specific opioids or adequate doses and routes of administration that result in a mainly spinal site of action rather than a cerebral analgesic one. Methods The purpose of this topical review is to describe current available clinical evidence to determine what opioids reach high enough concentrations to produce spinally selective analgesia when given by epidural or intrathecal routes and also to make recommendations regarding their rational and safety use for the best management of postoperative pain. To this end, a search of Medline/Embase was conducted to identify all articles published up to December 2013 on this topic. Results Recent advances in spinal opioid bioavailability, based on both animals and humans trials support the theory that spinal opioid bioavailability is inversely proportional to the drug lipid solubility, which is higher in hydrophilic opioids like morphine, diamorphine and hydromorphone than lipophilic ones like alfentanil, fentanyl and sufentanil. Conclusions Results obtained from meta-analyses of RTCs is considered to be the 'highest' level and support their use. However, it's a fact that meta-analyses based on studies about treatment of postoperative pain should explore clinical surgery heterogeneity to improve patient's outcome. This observation forces physicians to use of a specific procedure surgical-based practical guideline. A vigilance protocol is also needed to achieve a good postoperative analgesia in terms of efficacy and security.
Collapse
Affiliation(s)
- Borja Mugabure Bujedo
- Department of Anaesthesiology, Critical Care and Pain Medicine, Donostia University Hospital, San Sebastián, Spain
| |
Collapse
|
5
|
Ginosar Y, Riley ET, Angst MS. Analgesic and sympatholytic effects of low-dose intrathecal clonidine compared with bupivacaine: a dose-response study in female volunteers. Br J Anaesth 2013; 111:256-63. [PMID: 23533254 DOI: 10.1093/bja/aet027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A wide range of doses has been suggested for intrathecal clonidine, but no dose-ranging study has examined analgesic effects below 100 µg. The primary aim of this volunteer study was to assess the dose vs analgesic effect relationship for doses of intrathecal clonidine below 100 µg. METHODS After IRB approval and signed informed consent, 11 healthy female volunteers participated in this randomized, double-blinded, cross-over study using a dose-ranging sparse-sampling technique. Participants received intrathecal clonidine (doses 0-100 µg; n=10) and intrathecal bupivacaine (doses 0-8.8 mg; n=9) on separate study days. At baseline, 30, and 60 min from drug administration, experimental heat pain tolerance was assessed at both a lumbar and a cranial dermatome. Heat and cold perception thresholds were assessed at the same time intervals. Heart rate (HR), arterial pressure, and forearm-finger and toe-leg cutaneous temperature gradients (Tfinger-arm and Ttoe-leg) were used as measures of sympatholysis. RESULTS Both intrathecal clonidine and bupivacaine caused significant, dose-dependent analgesic effects at the leg but not the head. Significant analgesia to experimental heat pain was detected above 25 µg clonidine and 3 mg bupivacaine. Administration of bupivacaine but not clonidine resulted in a significant dose-related decrease in HR and Ttoe-leg; neither drug caused dose-related sympatholytic effects in the doses used. CONCLUSIONS After 50 µg clonidine or 5 mg bupivacaine, the heat pain tolerance increased by ∼1°C, similar to the analgesic effect of 5 mg epidural morphine or 30 µg epidural fentanyl in previous studies using this experimental heat pain model. Our results provide additional data for rational dose selection of intrathecal clonidine.
Collapse
Affiliation(s)
- Y Ginosar
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.
| | | | | |
Collapse
|
6
|
Chu LF, D'Arcy N, Brady C, Zamora AK, Young CA, Kim JE, Clemenson AM, Angst MS, Clark DJ. Analgesic tolerance without demonstrable opioid-induced hyperalgesia: a double-blinded, randomized, placebo-controlled trial of sustained-release morphine for treatment of chronic nonradicular low-back pain. Pain 2012; 153:1583-1592. [PMID: 22704854 DOI: 10.1016/j.pain.2012.02.028] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/24/2012] [Accepted: 02/24/2012] [Indexed: 10/28/2022]
Abstract
Although often successful in acute settings, long-term use of opioid pain medications may be accompanied by waning levels of analgesic response not readily attributable to advancing underlying disease, necessitating dose escalation to attain pain relief. Analgesic tolerance, and more recently opioid-induced hyperalgesia, have been invoked to explain such declines in opioid effectiveness over time. Because both phenomena result in inadequate analgesia, they are difficult to distinguish in a clinical setting. Patients with otherwise uncomplicated low-back pain were titrated to comfort or dose-limiting side effects in a prospective, randomized, double-blind, placebo-controlled clinical trial using sustained-release morphine or weight-matched placebo capsules for 1 month. A total of 103 patients completed the study, with an average end titration dose of 78 mg morphine/d. After 1 month, the morphine-treated patients developed tolerance to the analgesic effects of remifentanil, but did not develop opioid-induced hyperalgesia. On average, these patients experienced a 42% reduction in analgesic potency. The morphine-treated patients experienced clinically relevant improvements in pain relief, as shown by a 44% reduction in average visual analogue scale pain levels and a 31% improvement in functional ability. The differences in visual analogue scale pain levels (P = .003) and self-reported disability (P = .03) between both treatment groups were statistically significant. After 1 month of oral morphine therapy, patients with chronic low-back pain developed tolerance but not opioid-induced hyperalgesia. Improvements in pain and functional ability were observed.
Collapse
Affiliation(s)
- Larry F Chu
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Modulation of remifentanil-induced postinfusion hyperalgesia by the β-blocker propranolol in humans. Pain 2012; 153:974-981. [DOI: 10.1016/j.pain.2012.01.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 01/07/2012] [Accepted: 01/12/2012] [Indexed: 11/21/2022]
|
8
|
Effect of a Preemptive Femoral Nerve Block on Cytokine Release and Hyperalgesia in Experimentally Inflamed Skin of Human Volunteers. Reg Anesth Pain Med 2010; 35:514-9. [DOI: 10.1097/aap.0b013e3181faa107] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|
9
|
Case reports: management of intractable upper extremity pain with continuous subarachnoid block at the low cervical level without impairment of upper extremity function. Anesth Analg 2010; 110:1721-4. [PMID: 20375298 DOI: 10.1213/ane.0b013e3181da8ee0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a case of continuous subarachnoid block for the treatment of refractory cancer pain in the shoulder and upper extremity on the right side of the patient. The catheter tip was placed in the subarachnoid space close to the nerve roots on the right side at the height of C5 corresponding to the painful region. Until the patient died, his pain was controlled with infusions of bupivacaine (30-58.7 mg/d) and morphine (2-19.6 mg/d) for 120 days during which upper extremity function was not disturbed and respiratory function and performance status were improved. This case suggests continuous subarachnoid block at the low cervical level is useful for refractory cancer pain in the shoulder and upper extremity.
Collapse
|
10
|
Ambros B, Steagall PVM, Mantovani F, Gilbert P, Duke-Novakovski T. Antinociceptive effects of epidural administration of hydromorphone in conscious cats. Am J Vet Res 2009; 70:1187-92. [DOI: 10.2460/ajvr.70.10.1187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
11
|
Angst MS, Chu LF, Tingle MS, Shafer SL, Clark DJ, Drover DR. No evidence for the development of acute tolerance to analgesic, respiratory depressant and sedative opioid effects in humans. Pain 2009; 142:17-26. [DOI: 10.1016/j.pain.2008.11.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 10/24/2008] [Accepted: 11/03/2008] [Indexed: 10/21/2022]
|
12
|
Raj PP, Chado HN, Angst M, Heavner J, Dotson R, Brandstater ME, Johnson B, Parris W, Finch P, Shahani B, Dhand U, Mekhail N, Daoud E, Hendler N, Somerville J, Wallace M, Panchal S, Glusman S, Jay GW, Palliyath S, Longton W, Irving G. Painless Electrodiagnostic Current Perception Threshold and Pain Tolerance Threshold Values in CRPS Subjects and Healthy Controls: A Multicenter Study. Pain Pract 2008. [DOI: 10.1111/j.1533-2500.2001.01007.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- P. Prithvi Raj
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | | | | | - James Heavner
- Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Rose Dotson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Murray E. Brandstater
- Department of Physical Medicine & Rehabilitation, Loma Linda University, Loma Linda, California
| | | | | | | | | | - Upinder Dhand
- University of Illinois at Chicago, Chicago, Illinois
| | - Nagy Mekhail
- Cleveland Clinic Pain Management Center, Cleveland, Ohio
| | - Emad Daoud
- Cleveland Clinic Pain Management Center, Cleveland, Ohio
| | | | | | - Mark Wallace
- University of California Medical Center, San Diego, California
| | - Sunil Panchal
- Critical Care Medicine and Oncology, Johns Hopkins University, Baltimore, Maryland
| | - Silvio Glusman
- The Pain Management Center Cook County Hospital, Chicago, Illinois
| | - Gary W. Jay
- Headache and Neurological Rehabilitation Institute of Colorado, Northglenn, Colorado
| | - Sarala Palliyath
- Department of Neurology, New Orleans VAMC, New Orleans, Louisiana
| | - William Longton
- Department of Anesthesia, Stanford University, Palo Alto, California
| | - Gordon Irving
- University Center for Pain Medicine, University of Texas, Houston, Texas
| |
Collapse
|
13
|
Cytokine profile in human skin in response to experimental inflammation, noxious stimulation, and administration of a COX-inhibitor: a microdialysis study. Pain 2008; 139:15-27. [PMID: 18396374 DOI: 10.1016/j.pain.2008.02.028] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2007] [Revised: 01/12/2008] [Accepted: 02/25/2008] [Indexed: 11/20/2022]
Abstract
Animal studies have documented a critical role for cytokines in cell signaling events underlying inflammation and pain associated with tissue injury. While clinical reports indicate an important role of cytokines in inflammatory pain, methodological limitations have made systematic human studies difficult. This study examined the utility of a human in vivo bioassay combining microdialysis with multiplex immunoassay techniques for measuring cytokine arrays in tissue. The first experiment measured cytokines in interstitial fluid collected from non-inflamed and experimentally inflamed skin (UVB). The effects of noxious heat on cytokine release were also assessed. The second experiment examined whether anti-hyperalgesic effects of the COX-inhibitor ibuprofen were associated with decreased tissue levels of the pro-inflammatory cytokines IL-1 beta and IL-6. In the first experiment, inflammation significantly increased IL-1 beta, IL-6, IL-8, IL-10, G-CSF, and MIP-1 beta. Noxious heat but not experimental inflammation significantly increased IL-7 and IL-13. In the second experiment, an oral dose of 400 and 800 mg ibuprofen produced similar anti-hyperalgesic effects suggesting a ceiling effect. Tissue levels of IL-1 beta and IL-6 were not affected after the 400mg dose but decreased significantly (44+/-32% and 38+/-13%) after the 800 mg dose. These results support the utility of explored method for tracking cytokines in human tissue and suggest that anti-hyperalgesic and anti-inflammatory effects of ibuprofen are at least partially dissociated. The data further suggest that high clinical doses of ibuprofen exert anti-inflammatory effects by down-regulating tissue cytokine levels. Explored human bioassay is a promising tool for studying the pathology and pharmacology of inflammatory and chronic pain conditions.
Collapse
|
14
|
Raj PP, Chado HN, Angst M, Heavner J, Dotson R, Brandstater ME, Johnson B, Parris W, Finch P, Shahani B, Dhand U, Mekhail N, Daoud E, Hendler N, Somerville J, Wallace M, Panchal S, Glusman S, Jay GW, Palliyath S, Longton W, Irving G. Painless electrodiagnostic current perception threshold and pain tolerance threshold values in CRPS subjects and healthy controls: a multicenter study. Pain Pract 2007; 1:53-60. [PMID: 17129284 DOI: 10.1046/j.1533-2500.2001.01007.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The purpose of this study is to evaluate both painless and painful sensory transmission in patients with Complex Regional Pain Syndrome (CRPS) using the automated electrodiagnostic sensory Nerve Conduction Threshold (sNCT) test. This test generates reliable, painless Current Perception Threshold (CPT) and atraumatic Pain Tolerance Threshold (PTT) measures. Standardized CPT and PTT measures using constant alternating current sinusoid waveform stimulus at 3 different frequencies 5 Hz, 250 Hz, and 2 kHz (Neurometer CPT/C Neurotron, Inc. Baltimore, MD) were obtained from CRPS subjects at a distal phalange of the affected extremity and at an ipsilateral asymptomatic control site. Matched sites were tested on healthy subjects. Detection sensitivities for an abnormal PTT and CPT test were calculated based on specificity of 90% as determined from data obtained from healthy controls. A Spearman rank correlation was used to test for a significant association between presence of allodynia and an abnormal PTT or CPT at any frequency tested. Thirty-six CRPS subjects and 57 healthy controls were tested. The highest detection sensitivity of the PTT test from symptomatic test sites was 63% for the finger and 71% for the toe. PTT abnormalities were also detected, to a lesser degree, at the asymptomatic control site (41% finger control site, 16% toe control site). The highest CPT detection sensitivity at the symptomatic site was 37% for the finger site and 53% for the toe site. CPT abnormalities were also detected at the asymptomatic control site (29% finger control site, 37% toe control site). Eighty-six percent of the CRPS subjects had either a PTT or CPT abnormality at any frequency at the symptomatic site. There was a significant correlation between presence of allodynia and presence of an abnormal CPT and PTT, respectively (P < .01). The correlation coefficient was lower for CPT than for PTT, ie, 0.34 versus 0.6 for the finger and 0.48 versus 0.67 for the toe, respectively. In studied CRPS patients an abnormal PTT was detected with higher sensitivity than an abnormal CPT. Assessing PTT may become a useful electrodiagnostic quantitative sensory test for diagnosing and following the course of neuropathic pain conditions.
Collapse
Affiliation(s)
- P P Raj
- Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Fichna J, Janecka A, Costentin J, Do Rego JC. The endomorphin system and its evolving neurophysiological role. Pharmacol Rev 2007; 59:88-123. [PMID: 17329549 DOI: 10.1124/pr.59.1.3] [Citation(s) in RCA: 180] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Endomorphin-1 (Tyr-Pro-Trp-Phe-NH2) and endomorphin-2 (Tyr-Pro-Phe-Phe-NH2) are two endogenous opioid peptides with high affinity and remarkable selectivity for the mu-opioid receptor. The neuroanatomical distribution of endomorphins reflects their potential endogenous role in many major physiological processes, which include perception of pain, responses related to stress, and complex functions such as reward, arousal, and vigilance, as well as autonomic, cognitive, neuroendocrine, and limbic homeostasis. In this review we discuss the biological effects of endomorphin-1 and endomorphin-2 in relation to their distribution in the central and peripheral nervous systems. We describe the relationship between these two mu-opioid receptor-selective peptides and endogenous neurohormones and neurotransmitters. We also evaluate the role of endomorphins from the physiological point of view and report selectively on the most important findings in their pharmacology.
Collapse
Affiliation(s)
- Jakub Fichna
- Laboratory of Experimental Neuropsychopharmacology, CNRS FRE 2735, IFRMP 23, Faculty of Medicine & Pharmacy, University of Rouen, 22, Boulevard Gambetta, 76183 Rouen cedex, France
| | | | | | | |
Collapse
|
16
|
Carvalho B, Angst MS, Fuller AJ, Lin E, Mathusamy AD, Riley ET. Experimental Heat Pain for Detecting Pregnancy-Induced Analgesia in Humans. Anesth Analg 2006; 103:1283-7. [PMID: 17056970 DOI: 10.1213/01.ane.0000239224.48719.28] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Animal studies suggest that increased circulating estrogen and progesterone, and activation of the endorphin system cause prenancy-induced antinociceptive effects. Human studies have provided inconsistent results and have often lacked a nonpregnant control group. In this study, we compared sensitivity to experimental heat and cold pain in pregnant and nonpregnant women. Nineteen healthy nonpregnant female volunteers and 20 pregnant women at term were enrolled. Pain threshold and tolerance were examined using experimental heat-induced pain and cold pressor pain models. Subjects were evaluated pre- and 1-2 days post-delivery (pregnant), or on consecutive days (nonpregnant). Heat pain tolerance was significantly increased in the pregnant women during pre and postdelivery when compared with nonpregnant controls (50.0 +/- 1.0 vs 49.0 +/- 1.2 and 50.1 +/- 0.7 vs 49.2 +/- 1.2 degrees C; mean +/- sd). However, pain induced by the cold pressor test was endured for a similar amount of time by both study groups. Pregnancy-induced analgesic effects at term can be detected in a model of experimental heat pain. These effects persist during the first 24-48 h after delivery. Experimental heat pain is a suitable modality for further characterizing the phenomenon of pregnancy-induced analgesia in humans.
Collapse
Affiliation(s)
- Brendan Carvalho
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | | | | | | | | | | |
Collapse
|
17
|
Staahl C, Christrup LL, Andersen SD, Arendt-Nielsen L, Drewes AM. A comparative study of oxycodone and morphine in a multi-modal, tissue-differentiated experimental pain model. Pain 2006; 123:28-36. [PMID: 16600508 DOI: 10.1016/j.pain.2006.02.006] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Revised: 11/28/2005] [Accepted: 02/03/2006] [Indexed: 12/24/2022]
Abstract
Visceral pain can be difficult to treat with classical mu-opioid agonists and it has been suggested to use opioids with distinct pharmacological profiles. In animal experiments, oxycodone has shown different effects compared to morphine, and clinical observations have shown that oxycodone may occasionally be superior to, e.g., morphine in the treatment of visceral pain. In the current study, we randomised 24 healthy subjects to treatment with either morphine (30 mg), oxycodone (15 mg) or placebo in a crossover study. The experimental pain model involved multi-modal (mechanical, thermal and electrical) pain tests in the skin, muscles and viscera. The pain tests were carried out at baseline and 30, 60 and 90 min after oral administration of the drugs. The model showed effect of the two opioids compared to placebo on all stimulus modalities in all three types of tissues (all P values <0.001). Both opioids attenuated the sensory response mainly to painful stimulations. Morphine and oxycodone were equipotent in pain modulation of the skin and muscles, but oxycodone had superior analgesic effect to both morphine and placebo on the mechanical (P<0.001) and thermal (P<0.001) stimulations of the oesophagus. In conclusion, the multi-modal and tissue-differentiated pain model could link findings from animal experiments to clinical findings. A different pharmacological profile of oxycodone compared to that of morphine was shown, and thus oxycodone may be a useful alternative to morphine in the treatment of visceral pain syndromes.
Collapse
Affiliation(s)
- Camilla Staahl
- Center for Visceral Biomechanics and Pain, Department of Gastroenterology, University Hospital Aalborg, Denmark.
| | | | | | | | | |
Collapse
|
18
|
Pennefather SH, Gilby S, Danecki A, Russell GN. The changing practice of thoracic epidural analgesia in the United Kingdom: 1997-2004. Anaesthesia 2006; 61:363-9. [PMID: 16548957 DOI: 10.1111/j.1365-2044.2006.04549.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The clinical governance framework and medico-legal climate in the United Kingdom has changed significantly in the past 7 years. We used a postal questionnaire to survey thoracic epidural practice in the United Kingdom in 1997 and repeated this survey in 2004. The response rate to both surveys was 59-60%. There has been considerable change in respect of taking specific consent for thoracic epidural analgesia (24% in 1997, 74% in 2004), awake epidural cannulation (40% in 1997, 84% in 2004), availability of an acute pain service (47% in 1997, 95% in 2004) and HDU-only nursing of patients (63% in 1997, 30% in 2004). Of the 2004 respondents, < 1% used the newer, less toxic local anaesthetics, 49% would consider inserting a thoracic epidural in patients receiving clopidogrel, and 34% would consider inserting a thoracic epidural in patients receiving both aspirin and clopidogrel. A central register of thoracic epidural complications would assist in further developing practice.
Collapse
Affiliation(s)
- S H Pennefather
- Consultant, Department of Anaesthesia, Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE.
| | | | | | | |
Collapse
|
19
|
Abstract
Despite many medical advances, the incidence of postoperative nausea and vomiting (PONV) and postdischarge nausea and vomit-ing (PDNV) remains high. Sequelae such as dehydration, wound dehiscence, bleeding and others, contributed to increased healthcare costs and patient dissatisfaction. This article reviews the literature regarding the anatomy of emesis, the predictors of PONV and various treatments.
Collapse
Affiliation(s)
- Karen Stanley Williams
- Department of Anesthesiology and Critical Care, George Washington University Medical Center, 900 23rd Street, N.W., Washington DC 20037, USA.
| |
Collapse
|
20
|
Grach M, Massalha W, Pud D, Adler R, Eisenberg E. Can coadministration of oxycodone and morphine produce analgesic synergy in humans? An experimental cold pain study. Br J Clin Pharmacol 2004; 58:235-42. [PMID: 15327582 PMCID: PMC1884562 DOI: 10.1111/j.1365-2125.2004.02141.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS The coadministration of subantinociceptive doses of oxycodone with morphine has recently been shown to result in a synergistic antinociceptive effect in rats. The present study was aimed to investigate the possibility that coadministration of morphine and oxycodone can produce a similar synergistic effect in humans exposed to an experimental model of cold pressor test (CPT). METHODS The enriched enrollment design was used to exclude 'stoic' and 'placebo responders' in a single-blind fashion. 'Nonstoic', placebo 'nonresponder' female volunteers (n = 30) were randomly assigned to receive 0.5 mg kg(-1) oral morphine sulphate, 0.5 mg kg(-1) oral oxycodone hydrochloride, and the combination of 0.25 mg kg(-1) morphine sulphate with 0.25 mg kg(-1) oxycodone hydrochloride, 1 week apart from each other, in a double-blind crossover design. Latency to pain onset (threshold), pain intensity (VAS), and pain tolerance (time until removal of the hand from the water) were measured six times over a 3-h period, subsequent to the administration of each medication, and were used to assess their antinociceptive effect. RESULTS The combination produced a significantly higher effect on latency to pain onset than that of morphine alone [difference in mean postbaseline value 2.2; 95% confidence interval (CI) 0.48, 3.9; P = 0.01] but the effect was nonsignificantly smaller that that of oxycodone alone. Similarly, the effect of the combination on pain tolerance was significantly larger than that of morphine alone (combination difference 8.4; 95% CI 2.5, 14.3; P = 0.007), whereas oxycodone alone caused a nonsignificantly larger effect than that of the combination treatment. Comparisons of pain magnitude failed to show any significant differences between the three treatments. CONCLUSIONS These results indicate that at the doses tested, morphine and oxycodone do not produce synergistic antinociceptive effects in healthy humans exposed to the CPT.
Collapse
Affiliation(s)
| | | | - Dorit Pud
- Haifa Pain Research GroupHaifa, Israel
- Faculty of Social Welfare and Health Studies University of HaifaHaifa, Israel
| | - Rivka Adler
- Haifa Pain Research GroupHaifa, Israel
- Pain Relief Unit, Rambam Medical CentreHaifa, Israel
| | - Elon Eisenberg
- Technion–Israel Institute of TechnologyHaifa, Israel
- Haifa Pain Research GroupHaifa, Israel
- Pain Relief Unit, Rambam Medical CentreHaifa, Israel
| |
Collapse
|
21
|
Supraspinal and spinal cord opioid receptors are responsible for antinociception following intrathecal morphine injections. Eur J Anaesthesiol 2004. [DOI: 10.1097/00003643-200403000-00003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Tambeli CH, Quang P, Levine JD, Gear RW. Contribution of spinal inhibitory receptors in heterosegmental antinociception induced by noxious stimulation. Eur J Neurosci 2004; 18:2999-3006. [PMID: 14656295 DOI: 10.1111/j.1460-9568.2003.03031.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Noxious (i.e. painful) stimulation in the rat induces profound heterosegmental antinociception as demonstrated by the ability of either thermal stimulation (50 degrees C water) or subdermal capsaicin injection in the hindpaw to attenuate the nociceptive trigeminal jaw-opening reflex. Importantly, noxious stimulus-induced antinociception (NSIA) is mediated by endogenous opioids (as well as other neurotransmitters) in nucleus accumbens, as indicated by the ability of intra-accumbens administration of mu- or delta-opioid receptor antagonists to block NSIA. Although noxious peripheral stimulation is known to release excitatory neurotransmitters such as glutamate at the level of the spinal cord, the present study was designed to test the hypothesis that NSIA depends on further activation of spinal inhibitory receptors. This hypothesis was based on findings that inhibition of spinal processing (e.g. intrathecal local anaesthetic administration) also produces heterosegmental antinociception mediated by endogenous opioids in nucleus accumbens. Thus, to reconcile the paradoxical findings that both spinal excitation and inhibition appear to activate the same nucleus accumbens opioid-mediated antinociceptive mechanism, we investigated whether spinal administration of antagonists for inhibitory receptors would block the antinociceptive effect of subdermal capsaicin. We report that spinal administration of selective antagonists for mu-opioid (Cys2, Tyr3, Orn5, Pen7amide), kappa-opioid (nor-binaltorphimine), GABA-A (bicuculline), GABA-B (CGP 35348) and glycine (strychnine) receptors significantly reduced NSIA. The selective delta-opioid receptor antagonist naltrindole had no significant effect. These results, together with our previous findings, suggest that peripheral noxious stimuli release endogenous opioids, GABA and glycine in the spinal cord which, in turn, inhibit tonic pronociceptive spinal activity to produce heterosegmental antinociception mediated in nucleus accumbens.
Collapse
MESH Headings
- Animals
- Bicuculline/pharmacology
- Capsaicin/pharmacology
- Dose-Response Relationship, Drug
- Drug Interactions
- Electrodes, Implanted
- Electromyography
- GABA Antagonists
- Glycine Agents/pharmacology
- Male
- Models, Neurological
- Narcotic Antagonists/pharmacology
- Neural Inhibition/physiology
- Nucleus Accumbens/physiopathology
- Organophosphorus Compounds/pharmacokinetics
- Pain/chemically induced
- Pain/physiopathology
- Pain Measurement/methods
- Physical Stimulation
- Rats
- Rats, Sprague-Dawley
- Receptors, Opioid, kappa/antagonists & inhibitors
- Receptors, Opioid, kappa/drug effects
- Receptors, Opioid, mu/antagonists & inhibitors
- Receptors, Opioid, mu/drug effects
- Spinal Cord/drug effects
- Spinal Cord/physiopathology
- Strychnine/pharmacology
Collapse
Affiliation(s)
- C H Tambeli
- Department of Oral and Maxillofacial Surgery, Room C-522, Box 0440, University of California at San Francisco, San Francisco, CA 94143-0440, USA
| | | | | | | |
Collapse
|
23
|
Curatolo M, Petersen-Felix S, Arendt-Nielsen L. Assessment of regional analgesia in clinical practice and research. Br Med Bull 2004; 71:61-76. [PMID: 15684246 DOI: 10.1093/bmb/ldh035] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Assessment of pain and sensory function during regional analgesia contributes to a better understanding of the mechanisms underlying the action of drugs and techniques, and provides information on the effectiveness of regional analgesia in daily practice. Sensory tests only partially mimic clinical pain, mainly because they are artificial and reproduce only a part of the complex experience of pain. Therefore information gained by sensory tests should not be uncritically generalized to clinical pain conditions. Studies using experimental pain models are not in competition with studies performed under clinical conditions, but complement them. In order to mirror clinical pain, experimental models ideally stimulate muscles and viscera, induce peripheral and central sensitization, and evoke temporal and spatial summation. These methods are available, but are underused. Test modalities used in clinical practice have limited validity. In recent years almost no research has been performed to develop better test modalities that are suitable for daily practice.
Collapse
Affiliation(s)
- Michele Curatolo
- Department of Anaesthesiology, Division of Pain Therapy Inselspital, 3010 Berne, Switzerland.
| | | | | |
Collapse
|
24
|
Ginosar Y, Riley ET, Angst MS. The site of action of epidural fentanyl in humans: the difference between infusion and bolus administration. Anesth Analg 2003; 97:1428-1438. [PMID: 14570661 DOI: 10.1213/01.ane.0000081793.60059.10] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Most published studies suggesting that epidural fentanyl acts predominantly at spinal sites administered the drug as a bolus injection, whereas most studies suggesting that it acts predominantly at supraspinal sites administered the drug as an infusion. In this study we tested the hypothesis that the mode of administration (bolus versus infusion) of epidural fentanyl determines its site of action. Ten healthy volunteers were enrolled in this randomized, double-blinded, cross-over study. On separate study days fentanyl was administered into the epidural space as a bolus (0.03 mg followed by 0.1 mg 210 min later) and as an infusion (0.03 mg/h followed by 0.1 mg/hr 210 min later for 200 min). Using a thermal and electrical experimental pain model, the heat ( degrees C) and electrical current (mA) causing maximum tolerable pain were assessed repetitively over a period of 420 min. The analgesic efficacy measures were obtained at a lumbar and a cranial dermatome. Plasma fentanyl concentrations were determined throughout the study. Epidural bolus administration of fentanyl resulted in segmental analgesia (leg > head), whereas the epidural infusion of fentanyl produced nonsegmental analgesia (leg = head). There was a significant linear relationship between the analgesic effect and the plasma concentration of fentanyl for the epidural infusion but not for the epidural bolus administration of fentanyl. These findings support our hypothesis and might explain the apparent conflict in the literature regarding the site of action of epidural fentanyl. IMPLICATIONS In an experimental pain study in volunteers, epidural fentanyl caused segmental analgesia when administered as a bolus and nonsegmental systemic analgesia when administered as a continuous infusion. This finding may help resolve the long-standing controversy surrounding the site of action of epidural fentanyl.
Collapse
Affiliation(s)
- Yehuda Ginosar
- *Department of Anesthesia, Stanford University, Stanford, California, and the †Department of Anesthesiology and Critical Care Medicine, Hebrew University Hadassah School of Medicine, Jerusalem, Israel
| | | | | |
Collapse
|
25
|
Gustorff B, Hoerauf KH, Lierz P, Kress HG. Comparison of different quantitative sensory testing methods during remifentanil infusion in volunteers. Br J Anaesth 2003; 91:203-8. [PMID: 12878618 DOI: 10.1093/bja/aeg161] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aim of this study was to compare thermal and current sensory testing stimuli with respect to opioid responsiveness. METHODS Eighteen healthy volunteers were randomized in a placebo-controlled, double-blind crossover study to receive an infusion of remifentanil 0.08 micro g kg(-1) min(-1) or saline for 40 min. Test procedures included determination of pain perception thresholds (PPT) and pain tolerance thresholds (PTT) to heat, cold, and current at 5, 250 and 2000 Hz, at baseline and at the end of the infusion. RESULTS Both current at 5 Hz (PPT 3.69 (SD 2.48) mA vs 2.01 (1.52) mA; PTT 6.42 (2.79) mA vs 3.63 (2.31) mA; P<0.001) and 250 Hz (PPT 4.31 (2.42) mA vs 2.89 (1.57) mA; PTT 7.08 (2.68) mA vs 4.81 (2.42) mA; P<0.001) and heat (PPT 47.4 (2.7) degrees C vs 45.2 (3) degrees C; PTT 51.1 (1.8) degrees C vs 49.7 (1.8) degrees C; P<0.05) detected a significant analgesic effect of remifentanil compared with placebo. No analgesic effect was shown on cold or current at 2000 Hz. The magnitude of responsiveness of current stimuli at 5 Hz and 250 Hz was superior to heat stimuli. CONCLUSION Both current (5 and 250 Hz) and heat sensory testing detected a significant analgesic effect of a remifentanil infusion compared with saline. There was more response to current testing.
Collapse
Affiliation(s)
- B Gustorff
- Department of Anaesthesia and General Intensive Care Medicine (B), University of Vienna, Währinger-Gürtel 18-20, A-1090 Vienna, Austria.
| | | | | | | |
Collapse
|
26
|
Eichenberger U, Giani C, Petersen-Felix S, Graven-Nielsen T, Arendt-Nielsen L, Curatolo M. Lumbar epidural fentanyl: segmental spread and effect on temporal summation and muscle pain. Br J Anaesth 2003; 90:467-73. [PMID: 12644419 DOI: 10.1093/bja/aeg100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite extensive use, different aspects of the pharmacological action of epidural fentanyl have not been clarified. We applied a multi-modal sensory test procedure to investigate the effect of epidural fentanyl on segmental spread, temporal summation (as a measure for short-lasting central hyperexcitability) and muscle pain. METHODS Thirty patients received either placebo, 50 or 100 micro g single dose of fentanyl epidurally (L2-3), in a randomized, double-blind fashion. Heat pain tolerance thresholds at eight dermatomes from S1 to fifth cranial nerve (assessment of segmental spread), pain threshold to transcutaneous repeated electrical stimulation of the sural nerve (assessment of temporal summation) and pain intensity after injection of hypertonic saline into the tibialis anterior muscle (assessment of muscle pain) were recorded. RESULTS Fentanyl 100 micro g, but not 50 micro g, produced analgesia to heat stimulation only at L2. Surprisingly, no effect at S1 was detected. Both fentanyl doses significantly increased temporal summation threshold and decreased muscle pain intensity. CONCLUSIONS The findings suggest that a single lumbar epidural dose of fentanyl should be injected at the spinal interspace corresponding to the dermatomal site of pain. Increased effect on L2 compared with S1 suggests that drug effect on spinal nerve roots and binding to opioid receptors on the dorsal root ganglia may be more important than traditionally believed for the segmental effect of epidurally injected fentanyl. Epidural fentanyl increases temporal summation threshold and could therefore contribute to prevention and treatment of central hypersensitivity states. I.M. injection of hypertonic saline is a sensitive technique for detecting the analgesic action of epidural opioids.
Collapse
Affiliation(s)
- U Eichenberger
- Department of Anaesthesiology, Division of Pain Therapy, University of Bern, Inselspital, CH-3010 Bern, Switzerland.
| | | | | | | | | | | |
Collapse
|
27
|
Koo M, Sabaté A, Dalmau A, Camprubi I. Sevoflurane requirements during coloproctologic surgery: difference between two different epidural regimens. J Clin Anesth 2003; 15:97-102. [PMID: 12719047 DOI: 10.1016/s0952-8180(02)00509-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE To examine the influence of epidural morphine on the end-tidal sevoflurane concentration titrated to maintain bispectral index (BIS) values between 40 and 50. DESIGN Prospective, double-blinded clinical trial. SETTINGS Anesthesia department of a university hospital. PATIENTS 40 ASA physical status I, II, and III patients scheduled for elective coloproctological surgery. INTERVENTIONS Patients were randomized to receive via a thoracic epidural catheter either a) bupivacaine 0.25% (10 mL) and saline 0.9% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% (5 mL/hr) or b) bupivacaine 0.25% (10 mL) and morphine 0.1% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% plus morphine 0.025% (5 mL/hr). Anesthesia was induced with propofol, fentanyl 2 microg kg(-1) and atracurium and maintained with sevoflurane and nitrous oxide in oxygen. Sevoflurane level was titrated to maintain a BIS value between 40 and 50. After extubation, patients were asked about the presence of pain. MAIN RESULTS There was no significant difference between groups of end-tidal sevoflurane concentrations at identical BIS values and hemodynamic values at any time in the study. However, the morphine group had a lower pain score level at extubation than did the plain bupivacaine group (no pain on movement, 79% vs. 31.5%, p < 0.01). CONCLUSIONS Adding morphine to the bupivacaine epidural solution did not reduce sevoflurane requirements but did provide high-quality postoperative analgesia, mainly just after tracheal extubation.
Collapse
Affiliation(s)
- Maylin Koo
- Department of Anesthesiology, Ciutat Sanitària i Universitària de Bellvitge, Hospital Princeps d'Espanya, Feixa Llarga s/n. l'Hospitalet de Llobregat, 08907 Barcelona, Spain.
| | | | | | | |
Collapse
|
28
|
Lötsch J, Angst MS. The mu-opioid agonist remifentanil attenuates hyperalgesia evoked by blunt and punctuated stimuli with different potency: a pharmacological evaluation of the freeze lesion in humans. Pain 2003; 102:151-61. [PMID: 12620606 DOI: 10.1016/s0304-3959(02)00349-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Experimental pain models inducing hyperalgesia, i.e. an increased sensitivity to noxious stimuli often present in clinical pain, are important tools for studying antinociceptive drug profiles. The correct interpretation of results obtained in these models necessitates their mechanistic understanding. This study evaluated the freeze lesion, an experimental model of hyperalgesia, in humans. Twelve healthy subjects were tested with mechanical (brush, punctuated and blunt) and electrical (5, 250, and 2000 Hz sine wave current) stimuli before and after freezing the skin, and during a computer-controlled infusion of the mu-opioid agonist remifentanil targeting five different plasma concentrations between 0 and 6 ng/ml in a two-staged, single occasion, randomized, and double blind study design. Pharmacodynamic modeling techniques were used to describe the effect of freezing and drug administration on the mechanical and electrical pain thresholds. Freezing the skin resulted in hyperalgesia to blunt and punctuated stimuli and lowered the respective pain threshold by 29 and 73%. Hyperalgesia to brushing or electrical stimuli was not detected. Remifentanil attenuated hyperalgesia to blunt stimuli about twice as potently as hyperalgesia to punctuated stimuli, as indicated by a significantly steeper linear relationship between the remifentanil plasma concentration and the increase of the pain threshold to blunt stimuli. Remifentanil attenuated electrical pain with greater potency for low frequency stimulation. The potency difference of remifentanil suggests that different neuronal mechanisms mediate hyperalgesia to blunt and punctuated stimulation. Absence of brush-evoked and electrical hyperalgesia is compatible with the view that mechanical hyperalgesia to blunt and punctuated stimulation of the freeze lesion is predominantly caused by a peripheral mechanism.
Collapse
Affiliation(s)
- Jörn Lötsch
- Department of Clinical Pharmacology, pharmazentrum frankfurt, Johann Wolfgang Goethe-University, Theodor Stern Kai 7, D-60590 Frankfurt, Germany
| | | |
Collapse
|
29
|
Arendt-Nielsen L, Sumikura H. From pain research to pain treatment: role of human pain models. J NIPPON MED SCH 2002; 69:514-24. [PMID: 12646983 DOI: 10.1272/jnms.69.514] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
There is no objective measure of pain; we can however measure different aspects of the pain perception. Earlier experimental pain models often only involved induction of cutaneous pain. Recently new experimental models have been developed eliciting deep muscle and visceral pain that may more closely resemble the clinical pain condition. It is imperative to use multi-modal and multi-structure pain induction and assessment techniques, as a simple model cannot describe the very complex and multi-factorial aspects of clinical pain. The importance of peripheral and central hyperexcitability for acute and chronic pain has been demonstrated in animals and to some extent in humans. But in spite of our immense knowledge we still do not know how to prevent and treat this hyperexcitability. Our understanding of nociceptive mechanisms involved in acute and chronic pain and the effects of anaesthetic drugs or combinations of drugs on these mechanisms in humans may also be expanded with experimental human models. This knowledge can then help us to develop and test therapeutic regimes in patients with acute and chronic pain.
Collapse
Affiliation(s)
- Lars Arendt-Nielsen
- Center for Sensory-Motor Interaction, Laboratory for Experimental Pain Research, University of Aalborg, Denmark.
| | | |
Collapse
|
30
|
Repeated Failure of Epidural Analgesia. Reg Anesth Pain Med 2002. [DOI: 10.1097/00115550-200209000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
31
|
Troncy E, Junot S, Keroack S, Sammut V, Pibarot P, Genevois JP, Cuvelliez S. Results of preemptive epidural administration of morphine with or without bupivacaine in dogs and cats undergoing surgery: 265 cases (1997-1999). J Am Vet Med Assoc 2002; 221:666-72. [PMID: 12216906 DOI: 10.2460/javma.2002.221.666] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine prevalence of adverse effects associated with epidural administration of morphine with or without bupivacaine in dogs and cats undergoing surgery and evaluate effects of epidural administration of morphine on postoperative pain severity. DESIGN Retrospective study. ANIMALS 242 dogs and 23 cats. PROCEDURE Morphine with or without bupivacaine was administered prior to surgery with a Tuohy needle, spinal needle, or epidural catheter. In 18 dogs that underwent surgery twice, results of preemptive epidural administration of morphine with or without bupivacaine were compared with results of systemic administration of oxymorphone and ketoprofen. RESULTS The delivered fraction of isoflurane was significantly lower in animals given morphine and bupivacaine than in animals given morphine alone. Analgesia was of significantly longer duration in dogs given morphine and bupivacaine than in dogs given morphine alone. During anesthesia, mild respiratory and cardiovascular depression was reported. Seven dogs and 2 cats had urine retention, and 2 dogs developed pruritus. Six dogs vomited when a second dose of morphine was given epidurally the day after surgery. Eight of 72 dogs had delayed hair growth. In 18 dogs that underwent surgery twice, the delivered fraction of isoflurane was significantly lower and the duration of analgesia was significantly longer when morphine with or without bupivacaine was given epidurally than when oxymorphone and ketoprofen were given. CONCLUSIONS AND CLINICAL RELEVANCE Results suggest that preemptive epidural administration of morphine with or without bupivacaine is a safe and effective method of inducing long-lasting analgesia in dogs and cats and is superior to standard management of postoperative pain with repeated injection of oxymorphone and ketoprofen.
Collapse
MESH Headings
- Analgesia, Epidural/adverse effects
- Analgesia, Epidural/veterinary
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Anesthetics, Local/pharmacology
- Animals
- Bupivacaine/administration & dosage
- Bupivacaine/adverse effects
- Cats/physiology
- Cats/surgery
- Dogs/physiology
- Dogs/surgery
- Female
- Injections, Epidural/veterinary
- Ketoprofen
- Male
- Morphine/administration & dosage
- Morphine/adverse effects
- Oxymorphone
- Pain Measurement/veterinary
- Pain, Postoperative/prevention & control
- Pain, Postoperative/veterinary
- Retrospective Studies
- Safety
- Time Factors
- Treatment Outcome
Collapse
Affiliation(s)
- Eric Troncy
- Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | | | | | | | | | | | | |
Collapse
|
32
|
Gustorff B, Nahlik G, Hoerauf KH, Kress HG. The absence of acute tolerance during remifentanil infusion in volunteers. Anesth Analg 2002; 94:1223-8, table of contents. [PMID: 11973194 DOI: 10.1097/00000539-200205000-00032] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED The development of acute opioid tolerance in humans remains controversial. We tested the hypothesis that continuous remifentanil infusion leads to rapid development of opioid tolerance. Twenty healthy male volunteers were enrolled onto a randomized, placebo-controlled, double-blinded, cross-over design study to receive a 3 h continuous infusion of remifentanil (0.08 microg x kg(-1) x min(-1)) or saline. Test procedures included determination of pain perception thresholds and pain tolerance thresholds to heat and cold and neuroselective sine wave constant current at 5 Hz and 250 Hz. Test procedures were performed at baseline and then repeated at 25, 55, 85, 115, and 160 min (heat/cold) and at 35, 65, 95, 125, and 170 min (electrical current) during infusion. No significant decrease of the pain threshold devolutions between 55 and 180 min after the start of infusion of remifentanil could be detected. In conclusion, no development of acute opioid tolerance was observed during constant remifentanil infusion of 3 h in volunteers. IMPLICATIONS The opioid remifentanil was applied to 20 volunteers at a constant concentration for 3 h while pain thresholds to temperature and current were repeatedly assessed. Our aim was to study whether thresholds decrease over time because of the rapid development of opioid tolerance. No development of rapid opioid tolerance was observed.
Collapse
Affiliation(s)
- Burkhard Gustorff
- Department of Anesthesia, Vienna General Hospital, University of Vienna, Austria.
| | | | | | | |
Collapse
|
33
|
Abstract
This paper is the twenty-third installment of the annual review of research concerning the opiate system. It summarizes papers published during 2000 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; learning, memory, and reward; eating and drinking; alcohol and other drugs of abuse; sexual activity, pregnancy, and development; mental illness and mood; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; gastrointestinal, renal, and hepatic function; cardiovascular responses; respiration and thermoregulation; and immunological responses.
Collapse
Affiliation(s)
- A L Vaccarino
- Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA.
| | | |
Collapse
|
34
|
|