Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewDrug combinations in pain treatment: a review of the published evidence and a method for finding the optimal combination.
The evidence of the usefulness of drug combinations in pain management is reviewed and the problem of finding the optimal combination is presented. For post-operative pain, adding a non-steroidal anti-inflammatory drug (NSAID) or paracetamol to intravenous morphine is beneficial. Adding ketamine to intravenous morphine may be advantageous, but ketamine has a narrow therapeutic window. ⋯ Adding NSAIDs or ketamine to opioids may be useful in cancer pain. Because of the enormous number of possible combinations, randomized controlled trials may fail to test the optimal combination. A stepwise optimization model that has been applied in clinical investigations is presented.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewSteroid injections: effect on pain of spinal origin.
Pain originating from the spine is a common clinical problem that is often difficult to manage. This chapter considers the evidence supporting the use of corticosteroid injections for pain of spinal origin. Clinical problems considered in this review are radicular pain, zygapophyseal joint pain, discogenic pain and non-specific pain from the cervical, lumbar and thoracic spine. ⋯ Intradiscal and intra-articular injections in both lumbar and cervical spines have not been shown to be effective. Sacroiliitis responds well to intra-articular corticosteroids. There is insufficient evidence to support the use of atlanto-axial or atlanto-occipital joint injections.
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Systemic administration of analgesic drugs is still the most widely used method for providing pain relief in acute painful situations. Opioids may be selected on the basis of their physicochemical characteristics and their diffusion index to the brain. But in clinical practice, their very steep concentration-analgesic effect relationship remains a critical aspect of opioid therapy. ⋯ CSIs may be beneficial in patients in whom post-operative bleeding is a major surgical risk as the effects of NSAIDs on coagulation may last for days. Finally, low-dose ketamine infusions remain a worthwhile addition to opioid therapy. Analgesic concentrations of ketamine are 1/5th to 1/10th the anaesthetic concentration and exert significant inhibition on N-methyl-d-aspartate (NMDA) receptor activation.
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Best Pract Res Clin Anaesthesiol · Dec 2002
ReviewEffect of post-operative analgesia on patient morbidity.
The pathophysiology that commonly follows surgery results in detrimental physiological effects and may be associated with post-operative mortality and morbidity. The use of post-operative epidural analgesia, but not systemic opioids, may attenuate some of these adverse physiological effects and result in a decrease in patient-related morbidity post-operatively. Randomized trials suggest that the perioperative use of epidural analgesia may facilitate return of gastrointestinal function, attenuate hypercoagulable events and diminish post-operative pulmonary complications. A multimodal approach incorporating the use of epidural analgesia to control perioperative pathophysiology will facilitate the patient's recovery.
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Diagnostic blocks are used to obtain information about the source of a patient's pain. As such they differ in principle and in practice from regional anaesthetic blocks. In order to be valid, diagnostic blocks must be precise and target-specific. ⋯ This warns that sympathetic blocks must be controlled in each and every case lest false conclusions be drawn about the response. Medial branch blocks of the lumbar and of the cervical dorsal rami have been extensively investigated in order to establish their validity, diagnostic utility and therapeutic utility. They provide an example and benchmark for how diagnostic blocks can and should be validated.