Regional anesthesia and pain medicine
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Although there is considerable information about the mechanisms through which injury stimuli produce acute pain, recent studies indicate that there are significant long-term consequences of persistent injury. Pain is exacerbated, in part, because of a reorganization of spinal cord circuitry in the setting of persistent injury. This review describes our studies of the contribution of the primary afferent neurotransmitter, substance P (SP), to these changes. ⋯ Taken together, these studies emphasize that persistent pain should be considered a disease state of the nervous system, not merely a symptom of some other disease conditions. In the setting of persistent injury, the nervous system undergoes dramatic changes that exacerbate and prolong the pain condition. Our studies underscore the importance of preventing the long-term changes that result from persistent injury.
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Despite unprecedented interest in understanding pain mechanisms and pain management, a significant number of patients continue to experience unacceptable pain after surgery. Recent surveys show that there has been no apparent improvement since an early study in 1952 (15). It is increasingly clear that the solution to the problems of postoperative pain management lies not so much in the development of new techniques but in developing an organization to exploit existing expertise. ⋯ All senior anesthesiologists (section chiefs) working in the operating room are part of this APS. The means of providing satisfactory analgesia are already present in most hospitals. Careful planning and a multidisciplinary approach to pain management will ensure that resources are optimally utilized, and the quality of pain management is consistently maintained.
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Reg Anesth Pain Med · Jan 1999
ReviewNeuraxial techniques for cancer pain: an opinion about unresolved therapeutic dilemmas.
Epidural and intrathecal techniques are well established for minimizing cancer pain. However, several issues remain unresolved. ⋯ A subcutaneous tunnelling and fixation of the catheter, bacterial filters, minimum changes of tubings, weekly exit site care, site protection, and monitoring for any signs of infection are suggested for advanced cancer patients. Areas still needing clarification include the optimum use of spinal adjuvants, the appropriate spinal morphine-bupivacaine ratio, methods to improve spinal opioid responsiveness, and long-term catheter management during home-care programs.