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Dos Santos Fernandes H, Lima Filho PEP, Gouvêa ÁL, Espada EB. Continuous peripheral nerve block for upper limb ischemic pain: a case report. Braz J Anesthesiol 2021; 71:451-453. [PMID: 34229863 PMCID: PMC9373551 DOI: 10.1016/j.bjane.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 10/18/2020] [Indexed: 11/19/2022] Open
Abstract
Peripheral Arterial Obstructive Disease (PAOD) may course with severe ischemic pain. In low-income health systems, patients may wait for vascular surgery. Continuous peripheral nerve block may be an effective alternative, with fewer side effects, in this scenario. A female patient with acute arterial obstruction of upper limb evolving with severe ischemic pain. She was submitted to a continuous infraclavicular brachial plexus block, which led to a satisfying pain control until the amputation surgery. The early postoperative period evolved with good pain management. This approach may be effective and safe as an analgesia option for ischemic pain.
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Affiliation(s)
- Hermann Dos Santos Fernandes
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesia, São Paulo, SP, Brazil.
| | - Pedro E P Lima Filho
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesia, São Paulo, SP, Brazil
| | - Áquila L Gouvêa
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesia, São Paulo, SP, Brazil
| | - Eloisa B Espada
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Anestesia, São Paulo, SP, Brazil
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Jiang X, Yuan Y, Ma Y, Zhong M, Du C, Boey J, Armstrong DG, Deng W, Duan X. Pain Management in People with Diabetes-Related Chronic Limb-Threatening Ischemia. J Diabetes Res 2021; 2021:6699292. [PMID: 34046505 PMCID: PMC8128546 DOI: 10.1155/2021/6699292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 12/24/2022] Open
Abstract
Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.
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Affiliation(s)
- Xiaoyan Jiang
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yi Yuan
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Yu Ma
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Miao Zhong
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Chenzhen Du
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Johnson Boey
- Department of Podiatry, National University of Hospital Singapore, Singapore 169608
| | - David G. Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, CA 90033, USA
| | - Wuquan Deng
- Department of Endocrinology, Diabetic Foot Center, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing 400014, China
| | - Xiaodong Duan
- Department of Rehabilitation, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
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Fernandes HDS, Ximenes JLS, Taguchi PK, Espada EB, Gouvêa ÁL, Vieira JE, Ashmawi HA. Continuous peripheral nerve block for in-patients with lower limb ischemic pain. Clinics (Sao Paulo) 2021; 76:e2805. [PMID: 35116081 PMCID: PMC8128081 DOI: 10.6061/clinics/2021/e2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Demonstrate that continuous peripheral nerve block (CPNB) may be an alternative with adequate analgesia and a lower incidence of side effects for ischemic pain due peripheral obstructive arterial disease (POAD). METHODS Retrospective cohort study with 21 patients with POAD, Fontaine IV graded, with foot pain. Patients were submitted to continuous sciatic nerve block (CSNB), through a perineural catheter. Primary outcomes were pain intensity (by numerical rating scale) and opioid consumption (in oral morphine equivalents). RESULTS During CSNB, pain scores markedly decreased in comparison to the pre-block period. CONCLUSIONS CPNB may be a good option for ischemic pain treatment in in-patients, as it provides effective pain control with fewer adverse effects.
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Affiliation(s)
- Hermann dos Santos Fernandes
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding authors. E-mail: /
| | - Jorge Luiz Saraiva Ximenes
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paloma Kiyomi Taguchi
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Eloisa Bonetti Espada
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Áquila Lopes Gouvêa
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Joaquim Edson Vieira
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Hazem Adel Ashmawi
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Accessibility of axonal G protein coupled mu-opioid receptors requires conceptual changes of axonal membrane targeting for pain modulation. J Control Release 2017; 268:352-363. [PMID: 29054370 DOI: 10.1016/j.jconrel.2017.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 10/07/2017] [Accepted: 10/13/2017] [Indexed: 12/19/2022]
Abstract
The mechanisms of axonal trafficking and membrane targeting are well established for sodium channels, which are the principle targets for perineurally applied local anaesthetics. However, they have not been thoroughly investigated for G protein coupled receptors such as mu-opioid receptors (MOR). Focusing on these axonal mechanisms, we found that axonal MOR functionality is quite distinct in two different pain states, i.e. hindpaw inflammation and nerve injury. We observed axonal membrane MOR binding and functional G protein coupling exclusively at sites of CCI nerve injury. Moreover at these axonal membrane sites, MOR exhibited extensive co-localization with the membrane proteins SNAP and Na/K-ATPase as well as NGF-dependent enhanced lipid rafts and L1CAM anchoring proteins. Silencing endogenous L1CAM with intrathecal L1CAM specific siRNA, disrupting lipid rafts with the perineurial cholesterol-sequestering agent MβCD, as well as suppressing NGF receptor activation with the perineurial NGF receptor inhibitor K252a abrogated MOR axonal membrane integration, functional coupling, and agonist-elicited antinociception at sites of nerve injury. These findings suggest that local conceptual changes resulting from nerve injury are required for the establishment of functional axonal membrane MOR. Axonal integration and subsequent accessibility of functionally coupled MOR are of great relevance particularly for patients suffering from severe pain due to nerve injury or tumour infiltration.
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Kirksey MA, Haskins SC, Cheng J, Liu SS. Local Anesthetic Peripheral Nerve Block Adjuvants for Prolongation of Analgesia: A Systematic Qualitative Review. PLoS One 2015; 10:e0137312. [PMID: 26355598 PMCID: PMC4565585 DOI: 10.1371/journal.pone.0137312] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/14/2015] [Indexed: 12/13/2022] Open
Abstract
Background The use of peripheral nerve blocks for anesthesia and postoperative analgesia has increased significantly in recent years. Adjuvants are frequently added to local anesthetics to prolong analgesia following peripheral nerve blockade. Numerous randomized controlled trials and meta-analyses have examined the pros and cons of the use of various individual adjuvants. Objectives To systematically review adjuvant-related randomized controlled trials and meta-analyses and provide clinical recommendations for the use of adjuvants in peripheral nerve blocks. Methods Randomized controlled trials and meta-analyses that were published between 1990 and 2014 were included in the initial bibliographic search, which was conducted using Medline/PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Only studies that were published in English and listed block analgesic duration as an outcome were included. Trials that had already been published in the identified meta-analyses and included adjuvants not in widespread use and published without an Investigational New Drug application or equivalent status were excluded. Results Sixty one novel clinical trials and meta-analyses were identified and included in this review. The clinical trials reported analgesic duration data for the following adjuvants: buprenorphine (6), morphine (6), fentanyl (10), epinephrine (3), clonidine (7), dexmedetomidine (7), dexamethasone (7), tramadol (8), and magnesium (4). Studies of perineural buprenorphine, clonidine, dexamethasone, dexmedetomidine, and magnesium most consistently demonstrated prolongation of peripheral nerve blocks. Conclusions Buprenorphine, clonidine, dexamethasone, magnesium, and dexmedetomidine are promising agents for use in prolongation of local anesthetic peripheral nerve blocks, and further studies of safety and efficacy are merited. However, caution is recommended with use of any perineural adjuvant, as none have Food and Drug Administration approval, and concerns for side effects and potential toxicity persist.
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Affiliation(s)
- Meghan A Kirksey
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Stephen C Haskins
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
| | - Jennifer Cheng
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America
| | - Spencer S Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York, United States of America; Department of Anesthesiology, Weill College of Medicine at Cornell University, New York, New York, United States of America
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Abstract
Regional anesthesia has become invaluable for the treatment of pain during and after a wide range of surgical procedures. However, its benefits in the nonsurgical setting have been less well studied. Regional anesthesia is an appealing modality for critically ill patients, providing focused and sustained pain control with beneficial systemic effect profiles. Indications for regional anesthesia in this patient group are not limited to surgical and postsurgical analgesia but expand to the management of trauma-related issues, medical conditions, and painful procedures at the bedside. Patients in the critical care unit present special challenges to the regional anesthesiologist, including coagulopathies, infections, immunocompromised states, sedation- and ventilation-associated problems, and factors potentially increasing the risk for systemic toxicity. This review is intended to evaluate the role of regional anesthesia in critically ill patients, to discuss potential benefits, and to provide a summary of the published evidence on the subject.
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Chung MK, Cho YS, Bae YC, Lee J, Zhang X, Ro JY. Peripheral G protein-coupled inwardly rectifying potassium channels are involved in δ-opioid receptor-mediated anti-hyperalgesia in rat masseter muscle. Eur J Pain 2013; 18:29-38. [PMID: 23740773 DOI: 10.1002/j.1532-2149.2013.00343.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although the efficacy of peripherally administered opioid has been demonstrated in preclinical and clinical studies, the underlying mechanisms of its anti-hyperalgesic effects are poorly understood. G protein-coupled inwardly rectifying potassium (GIRK) channels are linked to opioid receptors in the brain. However, the role of peripheral GIRK channels in analgesia induced by peripherally administered opioid, especially in trigeminal system, is not clear. METHODS Expression of GIRK subunits in rat trigeminal ganglia (TG) was examined with reverse transcription-polymerase chain reaction, Western blot and immunohistochemistry. Chemical profiles of GIRK-expressing neurons in TG were further characterized. Behavioural and Fos experiments were performed to examine the functional involvement of GIRK channels in δ-opioid receptor (DOR)-mediated anti-hyperalgesia under an acute myositis condition. RESULTS TG expressed mRNA and proteins for GIRK1 and GIRK2 subunits. Majority of GIRK1- and GIRK2-expressing neurons were non-peptidergic afferents. Inhibition of peripheral GIRK using Tertiapin-Q (TPQ) attenuated antinociceptive effects of peripherally administered DOR agonist, [D-Pen(2), D-Pen(6) ]-enkephalin (DPDPE), on mechanical hypersensitivity in masseter muscle. Furthermore, TPQ attenuated the suppressive effects of peripheral DPDPE on neuronal activation in the subnucleus caudalis of the trigeminal nucleus (Vc) following masseteric injection of capsaicin. CONCLUSIONS Our data indicate that peripheral DOR agonist-induced suppression of mechanical hypersensitivity in the masseter muscle involves the activity of peripheral GIRK channels. These results could provide a rationale for developing a novel therapeutic approach using peripheral GIRK channel openers to mimic or supplement the effects of peripheral opioid agonist.
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Affiliation(s)
- M-K Chung
- Department of Neural and Pain Sciences, University of Maryland School of Dentistry, Baltimore, USA
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Saloman JL, Niu KY, Ro JY. Activation of peripheral delta-opioid receptors leads to anti-hyperalgesic responses in the masseter muscle of male and female rats. Neuroscience 2011; 190:379-85. [PMID: 21664434 DOI: 10.1016/j.neuroscience.2011.05.062] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 11/18/2022]
Abstract
In this project, we examined peripheral δ-opioid receptor (DOR)-mediated anti-hyperalgesic responses in the context of an acute orofacial muscle pain condition in both male and female rats. We also investigated whether the ATP-sensitive K+ channel (KATP), a downstream target of OR signaling, contributes to DOR-mediated anti-hyperalgesic responses. Local pretreatment of the masseter with a DOR agonist, [D-Pen², D-Pen⁶]-enkephalin (DPDPE), dose-dependently attenuated capsaicin-induced mechanical hypersensitivity in both male and female rats. However, there were sex differences in the potency of local DPDPE in that a 10-fold higher dose of DPDPE was required in female rats to produce the level of anti-hyperalgesia achieved in male rats. The sex differences in the DPDPE effect may not be fully explained by DOR expression level since there was no significant sex difference in DOR mRNA levels in trigeminal ganglia (TG). Finally, pretreatment of the masseter with the KATP antagonist, glibenclamide, significantly blocked the effects of DPDPE in male rats suggesting that the peripheral DOR effect is mediated by the KATP. These studies revealed novel information about sex differences with regards to peripherally localized DOR-mediated anti-hyperalgesia under an orofacial muscle pain condition.
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Affiliation(s)
- J L Saloman
- Program in Neuroscience, Department of Neural and Pain Sciences, University of Maryland Baltimore School of Dentistry, 650 W. Baltimore Street, Baltimore, MD 21201, USA
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Eisenberg E, Vielvoye-Kerkmeer APE, van Mansom I, Roelofs EG, Stevens AM. Nurses’ Knowledge about Pain Management with Opioids for Dying Patients United Kingdom Nursing Perspective. J Pain Palliat Care Pharmacother 2010. [DOI: 10.3109/15360288.2010.503729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Elon Eisenberg
- Dr. Ans P. E. Vielvoye-Kerkmeer is pain consultant and anaesthesiologist, Dr. Inge van Mansom is an old age and palliative care specialist, and Dr. Els G. Roelofs is a general practitioner and palliative care specialist, WWZ Sint Elisabeth Gasthuishof, Leiden, The Netherlands. Anna-Marie Stevens is a Macmillan nurse consultant in cancer palliative care at The Royal Marsden NHS Foundation Trust, London, UK
| | - Ans P. E. Vielvoye-Kerkmeer
- Dr. Ans P. E. Vielvoye-Kerkmeer is pain consultant and anaesthesiologist, Dr. Inge van Mansom is an old age and palliative care specialist, and Dr. Els G. Roelofs is a general practitioner and palliative care specialist, WWZ Sint Elisabeth Gasthuishof, Leiden, The Netherlands. Anna-Marie Stevens is a Macmillan nurse consultant in cancer palliative care at The Royal Marsden NHS Foundation Trust, London, UK
| | - Inge van Mansom
- Dr. Ans P. E. Vielvoye-Kerkmeer is pain consultant and anaesthesiologist, Dr. Inge van Mansom is an old age and palliative care specialist, and Dr. Els G. Roelofs is a general practitioner and palliative care specialist, WWZ Sint Elisabeth Gasthuishof, Leiden, The Netherlands. Anna-Marie Stevens is a Macmillan nurse consultant in cancer palliative care at The Royal Marsden NHS Foundation Trust, London, UK
| | - Els G. Roelofs
- Dr. Ans P. E. Vielvoye-Kerkmeer is pain consultant and anaesthesiologist, Dr. Inge van Mansom is an old age and palliative care specialist, and Dr. Els G. Roelofs is a general practitioner and palliative care specialist, WWZ Sint Elisabeth Gasthuishof, Leiden, The Netherlands. Anna-Marie Stevens is a Macmillan nurse consultant in cancer palliative care at The Royal Marsden NHS Foundation Trust, London, UK
| | - Ann-Marie Stevens
- Dr. Ans P. E. Vielvoye-Kerkmeer is pain consultant and anaesthesiologist, Dr. Inge van Mansom is an old age and palliative care specialist, and Dr. Els G. Roelofs is a general practitioner and palliative care specialist, WWZ Sint Elisabeth Gasthuishof, Leiden, The Netherlands. Anna-Marie Stevens is a Macmillan nurse consultant in cancer palliative care at The Royal Marsden NHS Foundation Trust, London, UK
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