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Cuperus IE, Mathijssen IMJ, van Veelen MLC, Bouzariouh A, Stubelius I, Kölby L, Lundborg C, Das S, Johnson D, Wall SA, Larysz DF, Dowgierd K, Koszowska M, Schulz M, Gratopp A, Thomale UW, Zafra Vallejo V, Redondo Alamillos M, Ferreras Vega R, Apolito M, Vergnaud E, Paternoster G, Khonsari RH. A European multicenter outcome study on the different perioperative airway management policies following midface surgery in syndromic craniosynostosis: a proposal for a Standard Operating Procedure. Plast Reconstr Surg 2024:00006534-990000000-02238. [PMID: 38289904 DOI: 10.1097/prs.0000000000011317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Perioperative airway management following midface advancements in children with Apert and Crouzon/Pfeiffer syndrome can be challenging, and protocols often differ. This study examined airway management following midface advancements and postoperative respiratory complications. METHODS A multicenter, retrospective cohort study was performed to obtain information about the timing of extubation, perioperative airway management, and respiratory complications after monobloc / le Fort III procedures. RESULTS Ultimately, 275 patients (129 monobloc and 146 Le Fort III) were included; 62 received immediate extubation and 162 delayed extubation; 42 had long-term tracheostomies and nine perioperative short-term tracheostomies. Short-term tracheostomies were in most centers reserved for selected cases. Patients with delayed extubation remained intubated for three days (IQR 2 - 5). The rate of no or only oxygen support after extubation was comparable between patients with immediate and delayed extubation, 58/62 (94%) and 137/162 (85%) patients, respectively. However, patients with immediate extubation developed less postoperative pneumonia than those with delayed, 0/62 (0%) versus 24/161 (15%) (P = 0.001), respectively. Immediate extubation also appeared safe in moderate/severe OSA since 19/20 (95%) required either no or only oxygen support after extubation. The odds of developing intubation-related complications increased by 21% with every extra day of intubation. CONCLUSIONS Immediate extubation following midface advancements was found to be a safe option, as it was not associated with respiratory insufficiency but did lead to fewer complications. Immediate extubation should be considered routine management in patients with no/mild OSA and should be the aim in moderate/severe OSA after careful assessment.
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Affiliation(s)
- Iris E Cuperus
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Irene M J Mathijssen
- Department of Plastic and Reconstructive Surgery and Hand Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Anouar Bouzariouh
- Department of Anaesthesiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ingrid Stubelius
- Department of Anesthesiology and Intensive Care, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Kölby
- Department of Plastic Surgery, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Lundborg
- Department of Anesthesiology and Intensive Care, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sumit Das
- Department of Paediatric Anaesthesia, John Radcliffe Hospital, Oxford, United Kingdom
| | - David Johnson
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Steven A Wall
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Dawid F Larysz
- Department of Head and Neck Surgery for Children and Adolescents, Regional Specialized Children's Hospital Popowski, Olsztyn, Poland
- Department of Head and Neck Surgery for Children and Adolescents, University of Warmia and Mazury, Olsztyn, Poland
| | - Krzysztof Dowgierd
- Department of Head and Neck Surgery for Children and Adolescents, Regional Specialized Children's Hospital Popowski, Olsztyn, Poland
- Department of Head and Neck Surgery for Children and Adolescents, University of Warmia and Mazury, Olsztyn, Poland
| | - Małgorzata Koszowska
- Department of Head and Neck Surgery for Children and Adolescents, Regional Specialized Children's Hospital Popowski, Olsztyn, Poland
- Department of Head and Neck Surgery for Children and Adolescents, University of Warmia and Mazury, Olsztyn, Poland
| | - Matthias Schulz
- Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin, Germany
| | - Alexander Gratopp
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin Berlin, Germany
| | - Víctor Zafra Vallejo
- Department of Oral and Maxillofacial Surgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Marta Redondo Alamillos
- Department of Oral and Maxillofacial Surgery, University Hospital 12 de Octubre, Madrid, Spain
| | - Rubén Ferreras Vega
- Department of Anaesthesiology, University Hospital 12 de Octubre, Madrid, Spain
| | - Michela Apolito
- Department of Maxillofacial Surgery and Plastic Surgery, Hôpital Necker-Enfants Malades, AP-HP; National Reference Center for Craniosynostosis and Craniofacial Malformations (CRANIOST); Faculty of Medicine, Paris Cité University, Paris, France
| | - Estelle Vergnaud
- Department of Pediatric and Obstetrical Anesthesiology and Reanimation, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Giovanna Paternoster
- Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, AP-HP; National Reference Center for Craniosynostosis and Craniofacial Malformations (CRANIOST), Paris, France
| | - Roman H Khonsari
- Department of Maxillofacial Surgery and Plastic Surgery, Hôpital Necker-Enfants Malades, AP-HP; National Reference Center for Craniosynostosis and Craniofacial Malformations (CRANIOST); Faculty of Medicine, Paris Cité University, Paris, France
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Eeg-Olofsson M, Pauli N, Hafsten L, Jacobsson J, Lundborg C, Brink M, Larsson H, Lindell E, Löwhagen K, Gisslén M, Bergquist H. TTCOV19: timing of tracheotomy in SARS-CoV-2-infected patients: a multicentre, single-blinded, randomized, controlled trial. Crit Care 2022; 26:142. [PMID: 35585614 PMCID: PMC9115544 DOI: 10.1186/s13054-022-04005-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/01/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Critically ill COVID-19 patients may develop acute respiratory distress syndrome and the need for respiratory support, including mechanical ventilation in the intensive care unit. Previous observational studies have suggested early tracheotomy to be advantageous. The aim of this parallel, multicentre, single-blinded, randomized controlled trial was to evaluate the optimal timing of tracheotomy. METHODS SARS-CoV-2-infected patients within the Region Västra Götaland of Sweden who needed intubation and mechanical respiratory support were included and randomly assigned to early tracheotomy (≤ 7 days after intubation) or late tracheotomy (≥ 10 days after intubation). The primary objective was to compare the total number of mechanical ventilation days between the groups. RESULTS One hundred fifty patients (mean age 65 years, 79% males) were included. Seventy-two patients were assigned to early tracheotomy, and 78 were assigned to late tracheotomy. One hundred two patients (68%) underwent tracheotomy of whom sixty-one underwent tracheotomy according to the protocol. The overall median number of days in mechanical ventilation was 18 (IQR 9; 28), but no significant difference was found between the two treatment regimens in the intention-to-treat analysis (between-group difference: - 1.5 days (95% CI - 5.7 to 2.8); p = 0.5). A significantly reduced number of mechanical ventilation days was found in the early tracheotomy group during the per-protocol analysis (between-group difference: - 8.0 days (95% CI - 13.8 to - 2.27); p = 0.0064). The overall correlation between the timing of tracheotomy and days of mechanical ventilation was significant (Spearman's correlation: 0.39, p < 0.0001). The total death rate during intensive care was 32.7%, but no significant differences were found between the groups regarding survival, complications or adverse events. CONCLUSIONS The potential superiority of early tracheotomy when compared to late tracheotomy in critically ill patients with COVID-19 was not confirmed by the present randomized controlled trial but is a strategy that should be considered in selected cases where the need for MV for more than 14 days cannot be ruled out. Trial registration NCT04412356 , registered 05/24/2020.
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Affiliation(s)
- Måns Eeg-Olofsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden.
| | - Nina Pauli
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
| | - Louise Hafsten
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
| | - Josephine Jacobsson
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Lundborg
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Brink
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Helen Larsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Region Västra Götaland, NU-Hospital Group, Head and Neck Surgery, Trollhättan, Sweden
| | - Ellen Lindell
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Region Västra Götaland, Södra Älvsborg Hospital, Boras, Sweden
| | - Karin Löwhagen
- Department of Anesthesia and Intensive Care Medicine, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Bergquist
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gröna stråket 5, 413 45, Gothenburg, Sweden
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Rutström E, Söndergaard S, Lundborg C, Ene K. Postoperative pain experience, pain treatment and recovery after lumbar fusion and fixation surgery. Int J Orthop Trauma Nurs 2019; 34:3-8. [PMID: 30846358 DOI: 10.1016/j.ijotn.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Eva Rutström
- The Sahlgrenska Academy at Gothenburg University, Institute of Health and Care Sciences, SE 413 46, Gothenburg, Sweden.
| | - Sören Söndergaard
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christopher Lundborg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Ene
- The Sahlgrenska Academy at Gothenburg University, Institute of Health and Care Sciences, SE 413 46, Gothenburg, Sweden
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Abstract
Despite great progress in our understanding and management of pain, undertreatment of postoperative pain is still a major problem. There are individual patient differences in terms of nociception and perception, as well as varying responses to pain management. Postoperative pain can impact on the length of hospital stay, mobilization after surgery, and patient satisfaction. --This report is adapted from paineurope 2015: Issue 1, ©Haymarket Medical Publications Ltd, and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, LTD and is distributed free of charge to healthcare professionals in Europe. Archival issues can be viewed via the website: www.paineurope.com at which health professionals can find links to the original articles and request copies of the quarterly publication and access additional pain education and pain management resources.
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Forshammar J, Jörneberg P, Björklund U, Westerlund A, Lundborg C, Biber B, Hansson E. Anti-inflammatory substances can influence some glial cell types but not others. Brain Res 2013; 1539:34-40. [DOI: 10.1016/j.brainres.2013.09.052] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 09/16/2013] [Accepted: 09/23/2013] [Indexed: 01/22/2023]
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Block L, Forshammar J, Westerlund A, Björklund U, Lundborg C, Biber B, Hansson E. Naloxone in ultralow concentration restores endomorphin-1-evoked Ca²⁺ signaling in lipopolysaccharide pretreated astrocytes. Neuroscience 2012; 205:1-9. [PMID: 22245502 DOI: 10.1016/j.neuroscience.2011.12.058] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 12/28/2011] [Indexed: 12/19/2022]
Abstract
Long-term pain is a disabling condition that affects thousands of people. Pain may be sustained for a long time even after the physiological trigger has resolved. Possible mechanisms for this phenomenon include low-grade inflammation in the CNS. Astrocytes respond to inflammatory stimuli and may play an important role as modulators of the inflammatory response in the nervous system. This study aimed first to assess how astrocytes in a primary culture behave when exposed to the endogenous μ-opioid receptor agonist endomorphin-1 (EM-1), in a concentration-dependent manner, concerning intracellular Ca²⁺ responses. EM-1 stimulated the μ-opioid receptor from 10⁻¹⁵ M up to 10⁻⁴ M with increasing intensity, usually reflected as one peak at low concentrations and two peaks at higher concentrations. Naloxone, pertussis toxin (PTX), or the μ-opioid receptor antagonists CTOP did not totally block the EM-1-evoked Ca²⁺ responses. However, a combination of ultralow concentration naloxone (10⁻¹² M) and PTX (100 ng/ml) totally blocked the EM-1-evoked Ca²⁺ responses. This suggests that ultralow (picomolar) concentrations of naloxone should block the μ-opioid receptor coupled G(s) protein, and that PTX should block the μ-opioid receptor coupled G(i/o) protein. The second aim was to investigate exposure of astrocytes with the inflammatory agent lipopolysaccharide (LPS). After 4 h of LPS incubation, the EM-1-evoked Ca²⁺ transients were attenuated, and after 24 h of LPS incubation, the EM-1-evoked Ca²⁺ transients were oscillated. To restore the EM-1-evoked Ca²⁺ transients, naloxone was assessed as a proposed anti-inflammatory substance. In ultralow picomolar concentration, naloxone demonstrated the ability to restore the Ca²⁺ transients.
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Affiliation(s)
- L Block
- Department of Anesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, SE 41345 Gothenburg, Sweden
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7
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Lundborg C, Westerlund A, Björklund U, Biber B, Hansson E. Ifenprodil restores GDNF-evoked Ca(2+) signalling and Na(+)/K(+) -ATPase expression in inflammation-pretreated astrocytes. J Neurochem 2011; 119:686-96. [PMID: 21883228 DOI: 10.1111/j.1471-4159.2011.07465.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Glial cell line-derived neurotrophic factor (GDNF) plays an important role in neuroinflammatory and neuropathic pain conditions. Astrocytes produce and secrete GDNF, which interacts with its receptors to induce Ca(2+) transients. This study aimed first to assess intracellular Ca(2+) responses of astrocytes in primary culture when exposed to the neuroprotective and anti-inflammatory peptide GDNF. Furthermore, incubation with the inflammatory inducers lipopolysaccharide (LPS), NMDA, or interleukin 1-β (IL-1β) attenuated the GDNF-induced Ca(2+) transients. The next aim was to try to restore the suppressed GDNF responses induced by inflammatory changes in the astrocytes with an anti-inflammatory substance. Ifenprodil, an NMDA receptor antagonist at the NR2B subunit, was tested. It was shown to restore the GDNF-evoked Ca(2+) transients and increased the Na(+)/K(+) -ATPase expression. Ifenprodil seems to be a potent anti-inflammatory substance for astrocytes which have been pre-activated by inflammatory stimuli.
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Affiliation(s)
- Christopher Lundborg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Forshammar J, Block L, Lundborg C, Biber B, Hansson E. Naloxone and ouabain in ultralow concentrations restore Na+/K+-ATPase and cytoskeleton in lipopolysaccharide-treated astrocytes. J Biol Chem 2011; 286:31586-97. [PMID: 21757727 DOI: 10.1074/jbc.m111.247767] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Astrocytes respond to inflammatory stimuli and may be important modulators of the inflammatory response in the nervous system. This study aimed first to assess how astrocytes in primary culture behave in response to inflammatory stimuli concerning intracellular Ca(2+) responses, expression of Toll-like receptor 4 (TLR4), Na(+)/K(+)-ATPase, actin filament organization, and expression of cytokines. In a cell culture model with lipopolysaccharide (LPS), astrocyte response was assessed first in the acute phase and then after incubation with LPS for 1-48 h. The concentration curve for LPS-stimulated Ca(2+) responses was bell-shaped, and the astrocytes expressed TLR4, which detects LPS and evokes intracellular Ca(2+) transients. After a long incubation with LPS, TLR4 was up-regulated, LPS-evoked Ca(2+) transients were expressed as oscillations, Na(+)/K(+)-ATPase was down-regulated, and the actin filaments were disorganized. Interleukin-1β (IL-1β) release was increased after 24 h in LPS. A second aim was to try to restore the LPS-induced changes in astrocytes with substances that may have dose-dependent anti-inflammatory properties. Naloxone and ouabain were tested separately in ultralow or high concentrations. Both substances evoked intracellular Ca(2+) transients for all of the concentrations from 10(-15) up to 10(-4) M. Neither substance blocked the TLR4-evoked Ca(2+) responses. Naloxone and ouabain prevented the LPS-induced down-regulation of Na(+)/K(+)-ATPase and restored the actin filaments. Ouabain, in addition, reduced the IL-1β release from reactive astrocytes. Notably, ultralow concentrations (10(-12) M) of naloxone and ouabain showed these qualities. Ouabain seems to be more potent in these effects of the two tested substances.
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Affiliation(s)
- Johan Forshammar
- Department of Clinical Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Per Dubbsgatan 14, 1tr, SE 413 45, Gothenburg, Sweden
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Lundborg C, Hahn-Zoric M, Biber B, Hansson E. Glial cell line-derived neurotrophic factor is increased in cerebrospinal fluid but decreased in blood during long-term pain. J Neuroimmunol 2010; 220:108-13. [PMID: 20129677 DOI: 10.1016/j.jneuroim.2010.01.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 01/12/2010] [Accepted: 01/13/2010] [Indexed: 01/14/2023]
Abstract
Glial cell line-derived neurotrophic factor (GDNF) is involved in inflammation and pain, roles which remain to be delineated clinically. We aimed to evaluate the role of central nervous and peripheral GDNF in long-term pain patients and in controls by analysing intrathecal and blood concentrations of GDNF. Simultaneous measurements of pro-inflammatory cytokines IL-1beta, TNF-alpha and IL-6, anti-inflammatory cytokine IL-10 and chemokine IL-8 served to define inflammatory responses. Generally, blood levels of GDNF were higher than corresponding intrathecal levels. Pain was associated with levels of GDNF that were increased intrathecally, but decreased in blood. IL-8 was uniformly higher in pain patients.
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Affiliation(s)
- Christopher Lundborg
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, 413 45 Gothenburg, Sweden.
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Abstract
BACKGROUND Severe pain in the head and neck is associated with a lowered quality of life and conventional pain therapy often does not provide adequate relief. The aims of this study were to investigate the efficacy, pain relief, benefits and adverse effects of intracisternal or high cervical (IHC) administration of bupivacaine in patients with severe pain in the head, neck and face regions. METHODS Between 1990 and 2005, 40 patients (age 27-84 years) were treated with continuous IHC infusions of bupivacaine for various non-cancer (n=15) or cancer-related (n=25) refractory pain conditions (duration 1 month-18 years) in the head, neck, mouth and shoulder regions. RESULTS Visual analogue scale scores and opioid requirements decreased markedly after the start of the treatment and remained lowered throughout the study. No tachyphylaxis for bupivacaine was observed. Major side effects were few and most often transient. Most patients showed unchanged or improved mobility. There was no mortality, neurological damage or other severe events attributable to procedures in the study protocol. CONCLUSION For patients with severe and refractory pain in areas innervated by cranial and upper cervical nerves, cervical high spinal analgesia can provide safe and effective analgesia.
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Affiliation(s)
- C Lundborg
- Department of Anesthesiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Dahm P, Lundborg C. [Pain relief directly in the CNS]. Lakartidningen 2008; 105:2683-2688. [PMID: 18846877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
MESH Headings
- Acute Disease
- Adult
- Analgesia, Epidural/adverse effects
- Analgesia, Epidural/methods
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/adverse effects
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/methods
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/adverse effects
- Catheters, Indwelling
- Chronic Disease
- Dura Mater
- Female
- Humans
- Infusion Pumps, Implantable/adverse effects
- Injections, Spinal
- Male
- Middle Aged
- Neuralgia/therapy
- Pain/etiology
- Pain Management
- Pain, Postoperative/therapy
- Patient Care Team
- Patient Selection
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Affiliation(s)
- Peter Dahm
- Sahlgrenska Universitetssjukhuset, Göteborg.
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Lambert G, Elam M, Friberg P, Lundborg C, Gao S, Bergquist J, Nitescu P. Acute response to intracisternal bupivacaine in patients with refractory pain of the head and neck. J Physiol 2006; 570:421-8. [PMID: 16254013 PMCID: PMC1464318 DOI: 10.1113/jphysiol.2005.095562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Continuous intracisternal infusion of bupivacaine for the management of intractable pain of the head and neck is effective in controlling pain in this patient group. With the catheter tip being located at the height of the C1 vertebral body, autonomic regulatory information may also be influenced by the infusion of bupivacaine. By combining direct sampling of cerebrospinal fluid (CSF), via a percutaneously placed catheter in the cisterna magna, with a noradrenaline and adrenaline isotope dilution method for examining sympathetic and adrenal medullary activity, we were able to quantify the release of brain neurotransmitters and examine efferent sympathetic nervous outflow in patients following intracisternal administration of bupivacaine. Despite severe pain, sympathetic and adrenal medullary activities were well within normal range (4.2 +/- 0.6 and 0.7 +/- 0.2 nmol min(-1), respectively, mean +/-S.E.M.). Intracisternal bupivacaine administration caused an almost instantaneous elevation in mean arterial blood pressure, increasing by 17 +/- 7 mmHg after 10 min (P < 0.01). Heart rate increased in parallel (17 +/- 5 beats min(-1)), and these changes coincided with an increase in sympathetic nervous activity, peaking with an approximately 50% increase over resting level 10 min after injection (P < 0.01). CSF levels of GABA were reduced following bupivacaine (P < 0.05). CSF catecholamines and serotonin, and EEG, remained unaffected. These results show that acutely administered bupivacaine in the cisterna magna of chronic pain sufferers leads to an activation of the sympathetic nervous system. The results suggest that the haemodynamic consequences occur as a result of interference with the neuronal circuitry in the brainstem. Although these effects are transient, they warrant caution at the induction of intracisternal local anaesthesia.
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Affiliation(s)
- Gavin Lambert
- Department of Clinical Physiology, Sahlgrenska Hospital, Göteborg, Sweden.
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Lundborg C. Clinical variation. GPs' knowledge and attitudes regarding treatment of UTI and asthma in Sweden. A randomized controlled educational trial on guideline implementation. Eur J Public Health 2000. [DOI: 10.1093/eurpub/10.4.241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Dahm P, Lundborg C, Janson M, Olegård C, Nitescu P. Comparison of 0.5% intrathecal bupivacaine with 0.5% intrathecal ropivacaine in the treatment of refractory cancer and noncancer pain conditions: results from a prospective, crossover, double-blind, randomized study. Reg Anesth Pain Med 2000; 25:480-7. [PMID: 11009233 DOI: 10.1053/rapm.2000.8574] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Intrathecal (IT) administration of bupivacaine (BUP) for treatment of "refractory" pain has sometimes been associated with unacceptable side effects. This study was undertaken to determine if IT-ropivacaine (ROP) can reduce the rate and intensity of these side effects e.g., urinary retention, paresthesia, and particularly, paresis with gait impairment. A prospective, crossover, double-blind, randomized study. METHODS Twenty-one patients were enrolled, 9 dropped out of the study, and data were analyzed from 12 patients. Patients were treated by insertion of IT tunneled nylon catheters, continuous infusion of 0.5% ROP followed by 0.5% BUP or 0.5% BUP followed by 0.5% ROP solutions from an external electronic pump. Each local anesthetic was infused for 7 days, and their order of infusion randomized. The comparative efficacy of the ROP and BUP IT infusions was assessed from the daily doses of IT ROP and IT BUP, oral and parenteral opioids, and daily scores of nonopioid analgetic and sedative drug consumption. Self-reported pain intensity (visual analogue scale [VAS] mean scores) and scores of Bromage relaxation, ambulation, nocturnal sleep pattern, rates of side-effects attributable to the IT drugs, the patients' assessment of the IT ROP v the IT BUP periods of the trial, and the comparative daily cost of IT ROP v IT BUP were recorded. RESULTS The daily doses of the local anesthetics used were 23% higher for ROP than for BUP. Further, the daily cost was approximately equals 3 times higher for ROP than for BUP. No other significant differences between IT ROP and IT BUP were found. CONCLUSION The results of this study do not support the hypothesis that IT infusion of 0.5% ROP has advantages over IT infusion of 0.5% BUP when administered for relief of "refractory" pain.
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Affiliation(s)
- P Dahm
- Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
The possible relationship between postsynaptic alpha2-adrenoceptor function, as assessed by growth hormone (GH) response to clonidine (CLON; 1.5 or 2.0 microg/kg i.v.), and psychopathology was investigated in 30 patients with alcohol-dependence in the early withdrawal period. Excluding patients with high baseline GH, 23 of the 26 patients had blunted GH responses to CLON and 57% moderate or severe depression at day 1 after the end of alcohol intake. After 1 week, the GH responses to CLON remained blunted in 20 of 21 retested patients, whereas the depression and anxiety remitted in all but two patients. The results do not support any relationship between postsynaptic alpha2-adrenoceptor function and symptoms of psychopathology in alcohol withdrawal.
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Affiliation(s)
- C Fahlke
- Department of Psychology, Göteborg, Sweden
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Lundborg C, Dahm P, Nitescu P, Appelgren L, Curelaru I. Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I). Acta Anaesthesiol Scand 1999; 43:667-78. [PMID: 10408823 DOI: 10.1034/j.1399-6576.1999.430613.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM To date, there is no reliable method for treating the severe pain and for modifying the natural evolution of CRPS-I. Therefore, we explored the effect of long-term IT bupivacaine infusion (with or without buprenorphine) on this syndrome. PATIENTS AND METHODS (a) PATIENTS two women and one man, 25, 31 and 42 years old, with CRPS-I of the lower (n=2) or upper (n=1) extremity lasting for 4 and 5 months, and 14 years. (b) INTERVENTIONS insertion of externalized IT catheters; IT infusion of buprenorphine 0.015 mg/ml and bupivacaine 4.75 mg/ml (n=1), or only bupivacaine 5 mg/ml (n=2) from external electronic pumps. RESULTS The IT treatment lasted for 172, 282 and 668 days. The mean/maximal daily doses of the IT bupivacaine were 39/66, 55/80 and 69/125 mg, respectively. The pain intensity decreased from VASmean =7+/-1 to VASmean =2+/-2. None of the patients had regression of allodynia, edema, and trophic disturbances in the affected extremities. In 2 patients, the IT treatment did not prevent spread of the disease to the opposite extremity or the occurrence of phantom pain and stump allodynia after amputation. The IT catheters were withdrawn as being no longer needed: in 2 patients 56 and 458 days after amputation of the involved extremity, and in another one before replacement of the IT bupivacaine infusion with epidural dorsal column stimulation (EDCS). After termination of the IT treatment, the patients were observed for 1437, 1575, and 2689 days (until September 1, 1998). At that date, all the patients were alive, and still affected by their CRPS-I, either in the amputation stump (n=2), and/or in the opposite or remote extremities (n=2); further, two were unemployed and one worked for 75% of the time. One of them was taking up to 1500 mg of slow-release morphine to cope with pain. CONCLUSION The IT pain treatment with bupivacaine (with or without buprenorphine) alleviated the "refractory" pain, but affected neither the associated symptoms and signs of the CRPS-I, nor its natural evolution. Thus, the IT treatment cannot be recommended in preference to other pain treatment regimens for CRPS-I.
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Affiliation(s)
- C Lundborg
- Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lundborg C, Nitescu P, Appelgren L, Curelaru I. [Refractory pain in the head-neck region. Intrathecal pain relief requires professional expertise]. Lakartidningen 1998; 95:174-6. [PMID: 9467288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- C Lundborg
- Smärtsektionen, Sahlgrenska Universitetssjukhuset/Sahlgrenska, Göteborg
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