Articles: palliative-care.
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A review of 15 patients, who underwent 34 CO2 laser bronchoscopic procedures, over a 2-year period, is presented. All had malignancies of the tracheobronchial tree and underwent laser surgery to palliate breathlessness or haemoptysis. ⋯ One quarter of the patients required repeat procedures and there were two deaths in the early post-operative period. The indications for such surgery, the technique and its limitations, and the palliation obtained are discussed.
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Critically ill cancer patients may present special problems. Often these patients are terminally ill and mortality in a critical care unit devoted to cancer patients is higher than in other units. Sedation becomes paramount in the treatment of these patients. ⋯ Nerve blocks, primarily intercostal for chest trauma, were used in the past, but the requirement for frequent reinjection has made them less desirable. Recently thoracic paravertebral block has been used successfully for 9 to 10 hour pain relief with chest trauma. With this armamentarium of techniques and drugs, the critical care physicians should be able to go a long way to relieve pain and suffering of patients in the ICU.
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J. Thorac. Cardiovasc. Surg. · Jan 1988
Systemic-pulmonary polytetrafluoroethylene shunts in palliative operations for congenital heart disease. Revival of the central shunt.
The concept of central shunting in smaller children with the Waterston shunt was initially well accepted. It has been abandoned because of the difficult estimation of lumen size, preferential flow to the right side, and difficulty in the take-down of the shunt. We have replaced the Waterston shunt with a short segment of polytetrafluoroethylene between the ascending aorta and the main pulmonary artery. ⋯ We have modified our technique so that (1) graft length is less than 0.5 cm and both ends are beveled, (2) the aortotomy is fashioned with a punch, (3) the center of the polytetrafluoroethylene graft is never clamped, (4) heparin is given during the construction of the shunt, and (5) aspirin (10 mg/kg/day) is administered daily. Patency ranges from 1 to 4 years. We conclude that the polytetrafluoroethylene shunt provides excellent palliation and that the central shunt, in the smaller child and infant, offers the benefits of shunting without distortion of the peripheral pulmonary arteries.
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Pain is a complex somato psychic experience that requires a multimodality approach to treatment. Pharmacologically, pain in cancer can be divided into opioid non-responsive, opioid partially responsive, opioid responsive (but do not use opioids) and opioid responsive (do use opioids). Three concepts govern the use of analgesics in opioid responsive pains: 'by the mouth', 'by the clock' and 'by the ladder'. ⋯ Useful alternative strong opioids include phenazocine, hydromorphone and buprenorphine. A number of controversial issues are discussed. These include the oral to parenteral potency ratio of morphine; the main site of metabolism of morphine; the relative merits of morphine and diamorphine; the risk of respiratory depression; the development of tolerance; and the risk of addiction.