Assessing and treating pain in the newborn

OBJECTIVES: To update information about available neonatal pain assessment and pain relief methods.METHOD: Medical literature review of the past 10 years, including textbooks, general reviews, systematic reviews, prospective, randomized controlled studies, retrospective works and case studies. Literature was reviewed based on the author clinical and scientific experience regarding pain evaluation and treatment.RESULTS: Lack of verbal expression of pain is one of the major impediments to adequate pain relief in the neonatal period. Nowadays, several valid pain assessment tools are available, including the analysis of the neonate facial features and multidimensional tools, as NIPS, CRIES, and PIPP. Non-pharmacological pain relief can be achieved by non-nutritive suction and suction of dextrose water. Neonatal analgesia, in general, includes de the use of paracetamol, opioids and local anesthetics. Opioids remain the main resource for acute pain treatment in the neonatal intensive care unit. Sedatives are important agents to decrease patient activity and restlessness, but they do not relieve pain.CONCLUSION: Based on medical, ethical, and humanitarian grounds, neonatal pain should be considered and treated.

Predicting surgical outcome for pain relief and return to work.

BACKGROUND: We evaluated a new psychological test (Paindex) for identifying and quantifying psychological factors associated with poor surgical outcome, and predicting the degree of pain relief and return to work. METHOD: This test was administered to 120 randomly selected patients before carpal tunnel and laminectomy surgeries. RESULTS: This test correctly predicted the probability of pain relief and return to work in 46 of the 50 laminectomy patients (92%), and 63 of the 70 carpal tunnel patients (90%). The overall test sensitivity was 86% and the specificity 94%. CONCLUSION: These findings indicate that this can be a useful adjunctive test for identifying psychological problems that could have a bearing on the decision to operate and then problems that could occur after surgery, particularly in cases where the extent and degree of pain and disability are judged to be considerably in excess of the objective medical findings.

Surgery for chronic pancreatitis--extended pancreaticojejunostomy.

BACKGROUND/AIMS: The role of Frey's operation as extended pancreatic duct drainage operation was evaluated in patients with chronic pancreatitis. METHODOLOGY: 206 patients with chronic pancreatitis were surgically treated, evaluated and followed for a minimum period of 6 months, in order to ascertain the status of pancreatic function and pain relief for both pancreatic duct drainage operations, including Frey's operation, and pancreatectomy. RESULTS: pain relief was established in 62 out of 86 patients (72.1%) undergoing pancreas duct drainage operation, in 51 out of 65 patients (78.5%) undergoing pancreatectomy. Fourteen out of 16 patients undergoing standard pancreaticojejunostomy with either persistent or alleviated pain had impacted calculi or pseudocysts in the pancreatic head and uncinate process preoperatively. Seventeen patients (16.3%) maintained normal glucose tolerance. Improvement was noted in 15 patients (14.4%) and in 27 patients the condition worsened (26.0%). The 10 years survival ratio in patients with diabetes mellitus preoperatively was 67.5% significantly lower than in patients without diabetes mellitus, 81.3% (p = 0.0029). Frey's operation was performed in 11 patients, providing satisfactory pain relief and preserving pancreatic exocrine and endocrine function. CONCLUSIONS: Frey's procedure should be considered as a new standard procedure in patients with pancreatic head complications and ductal dilatation in chronic pancreatitis.

(221) percutaneous vertebroplasty: minimally invasive procedure for vertebral fracture.

Objective: Vertebral fracture is a common health problem. Percutaneous Vertebroplasty (PVP) is a minimally invasive procedure done to provide pain relief and stabilization. This study examined the results of a case series of persons with vertebral fractures. Method: Eighteen cases (16 women, 2 men; 53-89 year old: mean age 74.68 years) with mid and low back pain were evaluated and vertebral fractures were confirmed with MR Imaging. Seventeen patients had osteoporotic and one patient had metastatic fracture. PVPs using polymethylmethacrylate were performed under fluoroscopic guidance by transpedicular approach between April 1999 to October 2000 at an outpatient surgery center. A semi-structured evaluation of response to PVP was conducted immediately, at 3 days and after 3 weeks. Results: PVP were done for 27 vertebral levels (17 Thoracic and 10 Lumber). Prior to procedure pain levels on numeric scale (0-10) ranged from 5 to 10 with a mean of 9.15. On short term follow up at 3rd post-procedure day, four patients has less then 50% pain relief while 14 patients reported 50% to 100% relief with mean of 78%. On long term follow up 15 patients reported 50% to 100% pain relief with mean of 72.66%. No complications were reported during intra as well as post-operative period. Conclusion: PVP is a minimally invasive procedure for the treatment of vertebral fracture with promising results. It provides significant pain relief with the potential for improving functional outcome.

Biochemistry of pain relief with intracerebral stimulation. Few facts and many hypotheses.

On the basis of data obtained from subprimates subjected to acute pain stimuli, it has been hypothesized that the suppression of chronic pain in man during stimulation in the periventricular region involves endogenous opioid mechanisms. However, there is at present no direct and unequivocal proof that the pain relief in man is necessarily and entirely dependent upon such mechanisms. There exist several putative substances with opiate-like properties but they are difficult to identify. The assay methods lack specificity and cross-reactions are common. There are only a few studies published on the influence of intracerebral stimulation in man on the CSF-content of opioid substances; the changes observed are inconsistent, and data are only given on patients having satisfactory pain relief. Furthermore, measurements have been made only during the course of a few hours and nothing is reported on the relationship between the changing concentrations of the substance and the level of pain. The observation that Naloxone may reverse the effect of intracerebral stimulation has become the keystone in postulating common mechanisms for stimulation-produced pain relief and morphine analgesia. The fact, that Naloxone is sometime ineffective or has to be used in huge, and unphysiological, doses is generally disregarded. There are a number of substances which may serve as neurotransmittors in pain transmission and pain inhibition but their mode of action in the generation and suppression of chronic pain is entirely unknown. Data collected from various European clinics covering more than 200 patients subjected to intracerebral stimulation show that the outcome of this treatment is highly unpredictable. Intracerebral stimulation as a clinically useful treatment of chronic pain can not be further developed unless hard data on its biochemical background in man are provided.

Motor cortex stimulation as treatment of trigeminal neuropathic pain.

A report is given on first experiences with motor cortex stimulation in 10 patients with different forms of neuropathic pain. Three of them had central pain as sequelae of cerebrovascular disease. In none of them did the stimulation provide pain relief. Two patients had pain from peripheral nerve injuries. One did not respond, but the other obtained about 50% pain relief. The remaining 5 patients with trigeminal neuropathy experienced definite pain relief varying between 60 and 90%. During test stimulation most patients had one or two short-lasting generalized seizures. But no one had any motor effects after permanent implantation. Motor cortex stimulation appears to be a new and promising possibility of pain treatment, especially in cases with trigeminal neuropathy, but many problems have yet to be solved, before a clear indication could be given.

Ductal drainage or resection for chronic pancreatitis.

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunosotomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.

Temporary external pedicular fixation versus definitive bony fusion: a prospective comparative study on pain relief and function.

Temporary external pedicular fixation is used as a prognostic instrument when treating degenerative conditions with spinal fusion. We studied the validity of the method and whether a functional test could improve the prognostic value of such fixation. Twenty-six patients with long-standing lumbar pain had an external temporary fixation. Pain levels were registered before fixation on a visual analogue scale at rest, as a mean for the previous week, and at seven different standardized activities. Walking capacity and walking speed for a standardized distance were also measured. Identical evaluations were then repeated during the external fixation and 1 year after definitive fusion. Based on the outcome of the temporary fixation, 20 patients were recommended for definitive surgical fusion. In six cases, the option of fusion surgery was rejected due to an unfavourable pain response or insufficient pain relief during the test fixation period, and this group was not further followed within the study. One year after surgery, 14 of 20 patients reported a good outcome. Solid bony fusion assessed by conventional radiography was seen in 19 patients. One patient with a poor clinical outcome had a pseudarthrosis. The mean values for pain level at rest, during last week and at the seven different activities in the functional test tended to decrease after fusion compared to the situation with temporary external fixation. In no activity did the external fixator overestimate the mean positive pain-relieving effect after definitive fusion. The walking capacity significantly increased, while the walking speed did not alter at the three different measurements. We conclude that with a good outcome ratio of 14 patients out of 19 having a solid fusion, the external frame improved patient selection and can be used as a valid prognostic instrument. The pain relief and function after definitive fusion can not be quantified by the external fixation, probably due to the fact that the stabilisation with an external frame is partial. The value of the functional test design presented is moderate, and an outcome evaluation comprising pain relief at rest and mean pain level during a week in fixation seems adequate.

Near-total pancreatectomy for chronic pancreatitis.

Eighty-seven patients underwent distal subtotal or near-total (80% to 95%) pancreatectomy (NTP) during a 25-year period for management of intractable pain resulting from chronic pancreatitis. Alcoholism affected the majority of patients and 20% of cases were idiopathic in origin. Ten patients (12%) exhibited insulin-requiring diabetes before operation. The perioperative mortality rate was 3.4%. Significant improvement or complete pain relief was achieved in 75% of patients while 14% remained narcotic dependent. Forty-four patients (51%) required insulin postoperatively, with an average insulin requirement of 35 U per day. Thirty late deaths occurred 2 to 15 years after operation, 12 (40%) of which were related to complications of pancreatic insufficiency or persistent alcoholism. Five patients (8.5%) required completion pancreatectomy 6 months to 4 years after NTP for complications relating to persistent pancreatitis. NTP provides effective pain relief in the majority of patients with chronic pancreatitis. While this procedure can be performed with a low operative mortality rate, the high incidence of endocrine and exocrine insufficiency after operation may contribute to late deaths. Consequently, this procedure should be performed only when the underlying disease has functionally destroyed the pancreas or when lesser procedures have failed to provide adequate pain relief.

Family reports of cancer pain, pain relief, and prescription access.

PURPOSE: The authors 1) describe family caregiver reports of degree of pain, pain relief, and prescription access in persons with advanced cancer during the last 4 weeks of life and 2) test for differences according to geographic location and care setting. DESCRIPTION OF STUDY: A randomized, stratified sample of 375 caregivers was produced from a list of all state residents who died of cancer in 1994. Written informed consent was received from 170 family caregivers (46%) who were then interviewed by telephone. Caregiver responses regarding pain intensity, pain relief, prescription access, and care setting were analyzed. RESULTS: Eighty-six percent (n = 147) of caregivers reported that pain was a problem, and 61% (n = 103) recalled a great deal to quite a bit of pain compared with 25% (n = 44) who recalled some or little pain. The mean degree of pain was 2.23 (SD +/- 1.32) on a scale of 1 (a great deal) to 5 (no pain). Of 140 caregivers reporting pain relief data, 46% (n = 64) reported that interventions either stopped the pain or that pain became much better, whereas 54% (n = 76) reported that interventions made the pain a little better, had no effect, or made it worse. The overall mean of pain relief was 2.62 (SD +/-.87) on a scale of 1 (usually stopped the pain) to 5 (made it worse). Greater degrees of pain were associated with reports of less pain relief (r = -19; P =.02). No differences in pain or pain relief were found across county type or patient care setting. Caregivers in the institution-only group (n = 18) recalled lower degrees of pain and the home-only group (n = 61) reported the most pain relief. Many in this latter group were served by hospice and home health nurses, and only 4% of the entire sample were served by physicians alone. Notably, 12% (n = 21) of the sample reported problems filling prescriptions. Of these, half had difficulty obtaining medicine because it was "not available." A total of 48 problems with prescription access were found that were distributed evenly across county types and patient care settings. CLINICAL IMPLICATIONS: Findings suggest that caregiver reports about the degree of pain or the effectiveness of pain interventions do not vary by residence or care setting at the end of life. pain relief is moderate at best. Health professionals in all patient care settings should routinely address the issue of obtaining and paying for prescriptions, and local cancer pain task forces should be formed to advocate for better pain relief. An additional solution is to equip families with problem-solving skills specific to cancer pain.