Dolor por cáncer/Cancer pain

Avances recientes en el tratamiento del dolor por cáncer 
Recent advances in cancer pain management.
Wilson J, Stack C, Hester J.
F1000Prime Rep. 2014 Feb 3;6:10. eCollection 2014.
Pain is the most feared symptom of cancer. New oncological cancer treatments are improving survival, but advanced cancer presents challenges that have not been seen before, often with pain that is very difficult to manage because of a recurrent tumour that is invading the central nervous system. In some of the older interventional techniques of destroying nerve pathways, expertise has diminished or has been deemed unnecessary with the development of specialist palliative care. Not all pain is managed adequately with the analgesic ladder. Knowledge of pain mechanisms, careful assessment and selection of the right technique at the right time will enhance cancer pain management. New techniques include intrathecal drug therapy, vertebroplasty, cordotomy, ultra-sound guided nerve blocks, neuromodulation and advances in drug therapies. 

Bloqueo lumbar paravertebral como método de tratamiento del dolor en cuidado paliativo  
Lumbar paravertebral blockade as intractable pain management method in palliative care.
Zaporowska-Stachowiak I1, Kotlinska-Lemieszek A, Kowalski G, Kosicka K, Hoffmann K, Główka F, Luczak J.
Onco Targets Ther. 2013 Sep 3;6:1187-96. doi: 10.2147/OTT.S43057. eCollection 2013.
Optimal symptoms control in advanced cancer disease, with refractory to conventional pain treatment, needs an interventional procedure. This paper presents coadministration of local anesthetic (LA) via paravertebral blockade (PVB) as the alternative to an unsuccessful subcutaneous fentanyl paincontrol in a 71-year old cancer patient with pathological fracture of femoral neck, bone metastases, and contraindications to morphine. Bupivacaine in continuous infusion (0.25%, 5 mL * hour(-1)) or in boluses (10 mL of 0.125%-0.5% solution), used for lumbar PVB, resulted in pain relief, decreased demand for opioids, and led to better social interactions. The factors contributing to an increased risk of systemic toxicity from LA in the patient were: renal impairment; heart failure; hypoalbuminemia; hypocalcemia; and a complex therapy with possible drug-drug interactions. These factors were taken into consideration during treatment. Bupivacaine’s side effects were absent. Coadministered drugs could mask LA’s toxicity. Elevated plasma α1-acid glycoprotein levels were a protective factor. To evaluate the benefit-risk ratio of the PVB treatment in boluses and in constant infusion, bupivacaine serum levels were determined and the drug plasma half-lives were calculated. Bupivacaine’s elimination was slower when administered in constant infusion than in boluses (t½ = 7.80 hours versus 2.64 hours). Total drug serum concentrations remained within the safe ranges during the whole treatment course (22.9-927.4 ng mL(-1)). In the case presented, lumbar PVB with bupivacaine in boluses (≤ 137.5 mg * 24 hours(-1)) was an easy to perform, safe, effective method for pain control. Bupivacaine in continuous infusion (≤150 mg * 12 hours(-1)) had an acceptable risk-benefits ratio, but was ineffective.
KEYWORDS:bone metastases, bupivacaine, intractable pain, opioid ineffectiveness


El uso a largo plazo de catéteres para bloqueo nervioso en pacientes pediátricos con fracturas patológicas relacionadas con el cáncer. 
Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures.
Burgoyne LL, Pereiras LA, Bertani LA, Kaddoum RN, Neel M, Faughnan LG, Anghelescu DL.
Anaesth Intensive Care. 2012 Jul;40(4):710-3.
We report three cases of children with osteosarcoma and pathologic fractures treated with long-term continuous nerve blocks for preoperative paincontrol. One patient with a left distal femoral diaphysis fracture had a femoral continuous nerve block catheter for 41 days without complications. Another with a fractured left proximal femoral shaft had three femoral continuous nerve block catheters for 33, 26 and 22 days respectively. The third patient, whose right proximal humerus was fractured, had a brachial plexus continuous nerve block catheter for 36 days without complication. In our experience, prolonged use of continuous nerve block is safe and effective in children with pathologic fractures for preoperative pain control.


Anestesiología y Medicina del Dolor

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