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Recent Review articles |
References & Useful Resources |
Acute Pain review slides - updated! |
Research |
Information for patients |
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Westmead Hospital
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This site provides current information about acute pain management.
See also the Westmead Anaesthesia Blog for recent journal articles.
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Recent Review articles |
References & Useful Resources |
Acute Pain review slides - updated! |
Research |
Information for patients |
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Latest News:
Acute Pain management: Scientific Evidence: 2e (Dec 2005)
This excellent, evidence based guideline is available as a pdf file from the ANZCA website (www.anzca.edu.au)
It has been endorsed by Australian and International pain management organisations. Highly recommended.
New Review of Acute Pain Management
Here is a recent comprehensive review document from the Institute for Clinical Systems Improvement. This is a collaborative group based in Minesota, USA and includes the Mayo Clinic.The full document is available here
Consensus statement on intraspinal drugs in cancer pain
This article in the Journal of Pain and Symptom Management (June issue) helps provide some guidance in this difficult area
Reports of renal impairment with Parecoxib
Therapeutic Goods Administration has published a warning about case reports of renal impairment following Parecoxib.
Although Parecoxib is a COX 2 inhibitor it still has a risk of causing renal dysfunction. This is more likely with multiple dosing and the presence of risk factors such as diabetic nephropathy and coadministration of significant drugs (eg ACE inhibitors). see the TGA/ADRAC warning here.
Intrathecal Midazolam for Pain relief (Anesthesia & Analgesia June 2004)
This has been talked about for a few years - now Colin Goodchild has published his clinical results. Fortunately this issue also has a review of toxicology to help address the concerns about neurotoxicity. For those new to the controversy start by reading the editorial. No doubt the future letters to the editor will be entertaining.
BJA (Jan 04)
Ballantyne, J. C.. “Does epidural analgesia improve surgical outcome?” Br. J. Anaesth. 92(1): 4-6.
Death - no; Pain relief and minor morbidity - yes.
This editorial helps to resolve the discrepancy between recent RCTs of epidural analgesia (eg MASTER Study, Park/VA study), and meta-analyses/older RCTs (eg Yeager etc). It makes the point that modern patient care, in the best hospitals, may not be significantly improved by the addition of epidural analgesia when considering rare events like death. However, she reaffirms that pain relief after thoracic or upper abdominal analgesia is improved by epidural analgesia (see also JAMA pain issue for recent supporting evidence) and that minor morbidity (ileus, altelecasis,) and patient satisfaction is improved by epidural analgesia.
Anesthesia and Analgesia (Jan 2004)
Has a study of Rofecoxib as a supplement to PCA morphine after surgery. The findings demonstrate its benefit.
The accompanying editorial reviews the state of COX-2 inhibitors for postop-analgesia.
The main recommendations are that COX-2 inhibitors provide:
"1) decrease postoperative pain (even in patients using PCA),
2) decrease opioid requirements by 20%–50%, and
3) provide greater patient satisfaction compared with placebo.
Nevertheless, the primary advantage of COX-2 inhibitors compared with NSAIDs is their lack of effect on platelet function and bleeding and hence the opportunity for pre- and perioperative administration".
It covers other issues including the possible CNS site of action of these drugs by inhibiting central sensitivity. Its is a good short review. Click here for full content, otherwise see (Kharasch, E. D. (2004). “Perioperative COX-2 Inhibitors: Knowledge and Challenges.” Anesth Analg 98(1): 1-3.)See also other info on COX-2s below on this page
The Lancet (December 6) has had a recent series on Anaesthesia. The article on 'Postoperative Care' by Kehlet and Dahl, covers recent issues in acute pain. It is concise and worth reading. Click here for abstract
Opioid rotation in Cancer Pain. This important concept is reviewed by Russell Portenoy In the Journal of Clinical Oncology
JAMA theme issue on Pain (Nov 12)
This is an excellent issue that has articles covering all aspects of pain. Especially notable is a meta-analysis of the effectiveness of epidural analgesia compared to parenteral opioids. The conclusion being "Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids". There are many other valuable articles. Highly recommended.
click here for table of contentsAnesthesia & Analgesia - June 2003
Epidural Insertion in Anesthetized Adults: Will Your Patients Thank You?
In this editorial they raise the old concern and urges caution.Cyclooxygenase-2 Inhibitors Noor M. Gajraj
Yes, a review article on this was expected. Here it is, but strangely nothing on parecoxib (apart from valdecoxib) click here
Anesthesiology June 2003
Charles B. Berde, MD, Ph.D.; Timothy J. Brennan, MD, Ph.D.; Srinivasa N. Raja, MD
David C. Warltier, M.D., Ph.D., Editor; Emmanuel Marret, M.D.; Antoine Flahault, M.D., Ph.D.; Charles-Marc Samama, M.D., Ph.D.; Francis Bonnet, M.D.
A systematic review of seven prospective, randomized, controlled trials demonstrated that the use of nonsteroidal antiinflammatory drugs after tonsillectomy increased the risk of re-operation for hemostasis.
News about Ketamine
More interesting information continues to appear about this old drug.
Sveticic, G., A.
Gentilini, et al. (2003). "Combinations of morphine with ketamine for patient-controlled
analgesia: a new optimization method." Anesthesiology May 98(5): 1195-205.
CONCLUSIONS: Using a novel method to analyze drug combinations, the study
supports combinations of morphine with ketamine in a ratio of 1:1 and a
lockout interval of 8 min for postoperative PCA following spine and hip
surgery.
This sounds to good
to be true - from the March issue of Anesthesia and Analgesia this study
appeared.
"A Single Small Dose of Postoperative Ketamine Provides Rapid and Sustained
Improvement in Morphine Analgesia in the Presence of Morphine-Resistant
Pain."
Avi A. Weinbroum. Anesth
Analg 2003;96 789-79
A small-dose ketamine and morphine regimen interrupted severe postoperative
pain that was not relieved previously by morphine. Ketamine reduced morphine
consumption and provided rapid and sustained improvement in morphine analgesia
and in subjective feelings of well-being, without unacceptable side effects.
The dose of morphine was 15 mcg/kg and ketamine was 250mcg/kg. This was
better than a single larger dose of morphine (30mcg/kg)
Good short review of Spinal analgesia for cancer pain Kedlaya. “Epidural and intrathecal analgesia for cancer pain.”
Best practice & research. Clinical anaesthesiology. 16.4 (2002): 651-65.
Yes, there is even
more on the MASTER study, and also the Veteran
affairs coop (Park Ann Surg Oct 2001) epidural study. In an editorial
in the February issue of Anesthesia and Analgesia, Oscar de Leon-Casasola
reviews the apparent disagreement between meta-analyses and large RCTs.
He is particularly concerned that that the details of management of epidural
patients in the MASTER study are not published and that lack of strict management
may have significantly limited the benefit of epidural analgesia. For more
see the full editorial here. It will
be interesting to see if a response follows from the authors of the MASTER
study
More on the MASTER
study (!). An editorial by Paul Myles (investigator in the MASTER study)
and others in the Medical Journal of Australia gives qualified support for
epidural analgesia. It states that epidurals provide benefit with less respiratory
complications and less pain. Expresses concern for the rare risks of epidural
abscess or nerve injury - but neglects risks of non-epidural alternatives
i.e. respiratory depression. more>>
Want to know everything
about epidural drugs? Then read this review article by Suellen Walker et
al. It is a 'magnum opus' from Anesthesia and Analgesia. It covers all the
combinations of drugs for spinal analgesia ("analgesic chemotherapy"); not
only postoperative pain, also chronic and cancer pain. Highly recommended.
Walker, S. M., L. C. Goudas, et al. (2002). "Combination spinal analgesic
chemotherapy: a systematic review." Anesth Analg 95(3): 674-715.
Does an Acute Pain
Service actually improve patient outcome? Read this systematic review
by Kehlet's group. Appears that APSs are worthwhile, but more study is needed.
How safe is regional
anesthesia? Read this prospective survey
of 150,000 patients from France. Very relevant
Parecoxib (Dynastat) See this new page which has a summary of all studies of this new analgesic (COX-2 inhibitor). It is also worth reading the BMJ editorial on COX-2 inhibitors below and the PowerPoint slide show in the meetings section
Acute Pain -
The BJA education issue; July 2001
This has everything in one spot. The table of contents is here.
Full contents requires a subscription.
The
COX-2 controversy: are they really better or just clever marketing??.
Read this excellent review article from the Canadian Medical Journal by
a clinical pharmacologist. click
here for full text
Here are some full text articles from the journal 'Pain"
Translational
issues and NMDA
Here are review articles from the Lancet's series on pain
in 1999
Links to the full
10 articles from the Lancet - This includes reviews of pathophysiology
of pain; highly recommended!
Management of Cancer Pain
This is a large review article that was prepared for the US Government's AHRQInvestigators: Leonidas Goudas, M.D., Ph.D., Daniel B. Carr, MD, Rina Bloch, M.D, and others Overview
Pain related to cancer affects the lives of large numbers of patients and their families. The topic of cancer-related pain was selected by the Agency for Healthcare Research and Quality (AHRQ) in response to a request from the American Pain Society. In framing this request, the American Pain Society observed that a significant amount of scientific evidence had been published on this topic since the 1994 release of the clinical practice guideline Management of Cancer Pain. This evidence report, however, is a literature synthesis and not a clinical practice guideline or a survey of current practice. It is intended to provide background information and summaries of evidence for use by varied groups, including primary care practitioners, nurses, pharmacists, physical therapists, specialists in oncology, pain treatment, or other disciplines, as well as policy makers. We reviewed the published literature on the epidemiology of cancer pain and its relief and also summarized predominantly randomized controlled trials so as to gauge the efficacy of major treatments.
The Report can be downloaded as a zipped file at: http://www.ahrq.gov/clinic/evrptfiles.htm#cancer pain.
Other notable items
Niemi, G. and H. Breivik (2002). "Epinephrine markedly improves thoracic epidural analgesia produced by a small-dose infusion of ropivacaine, fentanyl, and epinephrine after major thoracic or abdominal surgery: a randomized, double-blinded crossover study with and without epinephrine." Anesth Analg 94(6): 1598-605, table of contents. Here is something old but effective - just add adrenaline 2mcg/ml to a postop epidural infusion. This cheap and easy addition improved pain relief with coughing, increased dermatomal coverage and reduced nausea. Read the abstract here
Howell, C. J., T. Dean, et al. (2002). "Randomised study of long term outcome after epidural versus non- epidural analgesia during labour." BMJ 325(7360): 357. This RCT of women having epidurals for labour or not, found that the incidence of long term backache did not differ between the groups and was otherwise common (i.e. childbirth itself was associated with backache). This is important information for patients to know when when deciding to have an epidural or another type of analgesia. The abstract is here; the full article in pdf is here
Epidural Analgesia Enhances Functional Exercise Capacity and Health-related Quality of Life after Colonic Surgery: Results of a Randomized Trial. Franco Carli Anesthesiology 2002; 97:533-4.
This study assessed functional capacity after PCA or epidural analgesia. The conclusion was - "epidural analgesia had a positive impact on out-of-bed mobilization, bowel function, and intake of food, with long-lasting effects on exercise capacity and health-related quality of life". see abstractAre COX 2 inhibitors better than traditional NSAIDs? Are you planning to switch to Parecoxib (Dynastat)? Then read this editorial on the topic from the BMJ. You can view it in pdf format here.
The MASTER Study was published on April 13th 2002 in The Lancet. This long awaited study is an RCT of epidural v conventional analgesia in high risk patients having major abdominal surgery. It found that the epidural group had a lower risk of respiratory failure and better analgesia. The risk of death was low in both groups and not significantly different (but study size was probably not sufficient for this uncommon event - read discussion section in paper). Here is the link to the page on the Lancet website or you can view the abstract here. Good comments to read in the letters from such authorities as Kehlet and Van Aiken
Park, et al. (2001). "Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study." Ann Surg 234(4): 560-9;
An interesting RCT of epidural analgesia (but only morphine - no local) or not. Looked at different surgical types and found only a benefit for aortic surgery. This was due to a lower incidence of death, AMI, CVA and respiratory failure. Notably they did not otherwise select for high medical risk like the MASTER study. Abstract is hereDo Orthopaedic Surgeons still try to stop you prescribing NSAIDs for analgesia? If so then read this evidence based review from Oxford.
Norris Study. A rigorous RCT examining GA v Epidural for abdominal aortic aneurysm surgery. Caution should exercised as there were only 40 patients in each group, so this study probably underpowered
Publication of the Westmead Cardiac epidural study in February 2002 issue of Anesthesia and Analgesia
Review of non-opioid analgesics for day stay surgery Anesth Analg 2002 94: 577-585
About the Westmead Acute Pain Service
The Acute Pain Service (APS) manages pain for patients after major surgery, trauma, acute medical conditions and advanced cancer pain.
The APS is recognised for training in the Faculty of Pain Medicine, ANZCA and commenced operation in January 1992.
The staff comprises an anaesthetic consultant, a registrar (24h) and nursing staff (7 days).
Created September 18 2001, Last update Monday May 14, 2007 ,
content and design copyright 2001-2003, all rights reserved
