Articles: pain-clinics.
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Postoperative pain can intensify the sympathoadrenergic reaction, which is commonly seen after surgery, and thus possibly pave the way for certain complications, such as coronary ischemia, bronchopneumonia, intestinal stasis, thromboembolism, infection, sepsis, and metabolic disturbances. Investigations of cardiovascular, respiratory, gastrointestinal, metabolic, and immunologic function indicate that high-quality pain relief can diminish postoperative organ impairment and failure. Some aspects of the improvements attributed to the quality of analgesia, such as prevention of tachycardia and hypertension, attenuation of hyperglycemia and catabolism, improvement of gastrointestinal motility and cellular immunity cannot be definitely distinguished from the effects of sympathetic blockade due to epidural analgesia with local anesthetics, however. ⋯ Some studies indicate that better analgesia is advantageous for the patient, especially with respect to postoperative complications, hospital stay, long-term well being, and costs. In other clinical trials incorporating more patients, however, this hypothesis had to be rejected. At present, therefore, we cannot state that effective pain relief influences postoperative morbidity and mortality.
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Up to 70% of cancer patients in the terminal phase of their disease complain of moderate or severe pain. Pain therapy in these patients follows the analgesic ladder of the WHO. Many cancer patients will need a strong opioid to get sufficient pain relief. ⋯ The transdermal application of a strong opioid may be an alternative, especially for patients with cancer of the head and neck or in the gastrointestinal tract. Because of the pharmacokinetic laziness of the system the use of Fentanyl-TTS should be limited to patients with stable tumor pain. In these patients Fentanyl-TTS might be valuabe on step III of the analgesic ladder of the WHO or as an alternative to invasive methods when it is impossible to administer oral opioids.
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PCAO (patient-controlled analgesia in outpatients) is a new treatment concept designed to overcome chronic or acute pain of cancer patients. From 1989 to 1992, a total of with tumour pain 204 patients were treated in the pain clinics of Fürth in cooperation with the Department of Radiation at the University Hospital in Regensburg. In 90 of these patients adequate oral medication was impossible because of problems in swallowing or blockage of the gastrointestinal tract, and subcutaneous opioid infusion over 24 h was therefore instituted. ⋯ PCAO for treatment of cancer patients at home yields freedom from of pain around the clock, independence, and quality of life with active personal involvement. The most important thing is that the patient can sleep during the night, as can the doctor, the nurse and relatives, as they do not need to give injections during the night. This new method of treating the pain of cancer patients at home in advanced disease is also well accepted by social security authorities, as it reduces the costs dramatically.
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Animal experiments have unequivocally demonstrated peripheral antinociceptive effects of opioids in inflamed tissue. Exogenous mu-, delta- und kappa-agonists can produce such effects. Opioid receptors are present on peripheral terminals of primary afferent neurons and their endogenous ligands are produced and contained in resident immune cells within the inflamed tissue. ⋯ A small number of clinical studies has examined the peripheral analgesic effects of opioids. Their results are equivocal so far. In view of the predominant role of the inflammatory process in the manifestation of peripheral opioid effects, the postoperative situation seems to be particularly worthwhile to study.
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In the pain treatment of patients with incurable head and neck tumors it may be difficult to provide adequate oral drug therapy in the advanced stages. In these cases continuous subcutaneous application of morphine by means of external infusors is an alternative. An example of the method of continuous subcutaneous application of analgesics in pain therapy is shown in a patient suffering from a chondrosarcoma of the maxilla. ⋯ Because of growing tumor infiltration, we progressively increased the morphine dosage. Nevertheless, continous subcutaneous application of droperidol, dexamethasone and clonidine was also needed to achieve much better analgesia. The technical simplicity of this safe and effective treatment make it suitable for outpatient care in tumor clinics.