Paliativna oskrba ob koncu življenja, v katerem se pojavijo znaki pričetka umiranja s pešanjem vitalnih organov in se končajo s smrtjo, je pomemben del celostne paliativne oskrbe. Včasih, ob izredno ...težkih refraktarnih simptomih napredovale bolezni, je lahko primerna tudi paliativna sedacija. Paliativna sedacija je medicinski postopek, kjer je potrebno strogo upoštevati protokol izvedbe, in slediti etično moralnim vidikom in nikakor prekoračiti črte evtanazije. Paliativno sedacijo je potrebno skrbno načrtovati, se pogovoriti z bolnikom, svojci in s celotnim timom, ki bolnika oskrbuje (zdravniki in negovalno osebje), ga ustrezno dokumentirati in nadzorovati. Pomemben je multidisciplinarni pristop, ko vsak od vključenih zdravnikov specialistov in negovalnega osebja osvetli svoj vidik. V prispevku smo opisali klinični primer bolnice, ki se je zaradi refraktarnega simptoma sprva odločila za paliativno sedacijo, kasneje pa je svojo odločitev spremenila. Pri opisanem primeru s standardnimi učinkovinami sprva nismo uspeli doseči ustrezne globine paliativne sedacije, zato smo se odločili uporabiti deksmedetomidin. Z deksmedetomidinom smo dosegli plitvo sedacijo, ki je bolnici olajšala trpljenje do te mere, da se je tudi odločila za prekinitev paliativne sedacije. Deksmedetomidin je učinkovita in varna učinkovina, ki si išče svoje mesto tudi v paliativni medicini. V literaturi so objavljeni samo posamezni prikazi kliničnih primerov in pregledov področja, ni pa še objavljene randomizirane raziskave. V prihodnosti se taka raziskava načrtuje.
The objective of this study was to evaluate the severity of acute pain and side effects in breast cancer patients postoperatively treated with two regimens of tramadol with paracetamol in a ...prospective double-blind study. Altogether 117 breast cancer patients who had axillary lymphadenectomy were randomized into two analgesic study groups and the analgesic treatment lasted 4 weeks. Stronger analgesia group received every 8 h 75/650 mg of tramadol with paracetamol, while weaker analgesia group received every 8 h 37.5/325 mg of tramadol with paracetamol. Patients with the higher dose of tramadol had less pain during the 1st and 4th week than patients with the lower dose. Frequency of nausea, vomiting, lymphedema or range of shoulder movement was not significantly different between the two groups of patients. Constipation was significantly more common in the group with stronger analgesia during the 2nd week in comparison to patients with weaker analgesia. The patients who were on 75/650 mg of tramadol with paracetamol had less pain in comparison to patients who were on 37.5/325 mg. Side effects were mild, but common in both groups of patients.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Purpose
The aim of this study was to compare the rate of chronic adverse effects after a weaker and stronger postoperative analgesia.
Methods
A prospective double-blind randomized study included 117 ...breast cancer patients receiving tramadol for pain relief for 4 weeks after an axillary lymphadenectomy from 2015 to 2018. Patients with a larger dose received 75/650 mg of tramadol with paracetamol every 8 h and a group with a lower dose received 37.5/325 mg of tramadol with paracetamol every 8 h from the 2nd to the 29th postoperative day. 1 year after surgery, patients were evaluated for the presence of neuropathic pain, chronic pain, arm symptoms and lymphedema.
Results
There was a trend for a lower rate of neuropathic pain after stronger analgesia in comparison to weaker analgesia (
p
= 0.059). Chronic pain was present in 18% of patients 1 year after the lymphadenectomy. There was no difference in the rate of chronic pain after stronger and weaker postoperative analgesia. Patients had less arm symptoms after a stronger analgesia than after a weaker analgesia (
p
= 0.02). Furthermore, there was a trend for a lower rate of lymphedema of the forearm after a stronger analgesia than after a lower analgesia (
p
= 0.078).
Conclusions
The patients who received a stronger postoperative analgesia had less arm symptoms and a better quality of life in comparison to patients who received a weaker analgesia. The patients who received a stronger postoperative analgesia had a statistical trend for less neuropathic pain in comparison to patients who received a weaker analgesia.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Each case of unwanted event in health practice that ends with death or a heavy injury quickly becomes main topic of public discussion about the quality of health service. Due to use of unclear ...terminology there is a false common perception about doctors’ responsibility. Such perception also puts unnecessary pressure on all actors in different official procedures. The mentioned perception is partly also generated by inadequate actions of health providers in unwanted events. Health providers mostly do not have an adequate system of organizational, legal, informational and personal actions in case of unwanted events. The article shows how such a system could be used for risk management in the case of unwanted events.
Each case of unwanted event in health practice that ends with death or a heavy injury quickly becomes main topic of public discussion about the quality of health service. Due to use of unclear ...terminology there is a false common perception about doctors’ responsibility. Such perception also puts unnecessary pressure on all actors in different official procedures. The mentioned perception is partly also generated by inadequate actions of health providers in unwanted events. Health providers mostly do not have an adequate system of organizational, legal, informational and personal actions in case of unwanted events. The article shows how such a system could be used for risk management in the case of unwanted events.
Each case of unwanted event in health practice that ends with death or a heavy injury quickly becomes main topic of public discussion about the quality of health service. Due to use of unclear ...terminology there is a false common perception about doctors’ responsibility. Such perception also puts unnecessary pressure on all actors in different official procedures. The mentioned perception is partly also generated by inadequate actions of health providers in unwanted events. Health providers mostly do not have an adequate system of organizational, legal, informational and personal actions in case of unwanted events. The article shows how such a system could be used for risk management in the case of unwanted events.
Debelost je kronična bolezen, za katero je značilno čezmerno kopičenje maščevja v telesu. Debeli bolniki imajo pogosto številne pridružene bolezni ter anatomske in presnovne spremembe, ki so povezane ...z večjim tveganjem za zaplete v perioperativnem obdobju. Debelost tako pomembno vpliva na izbiro anestezijske tehnike in zahteva multidisciplinarni pristop. V prispevku predstavljamo primer 60-letne bolnice z rakom na debelem črevesu in indeksom telesne mase (ITM) 48,1 kg/m2. Perioperativno smo jo obravnavali v skladu s protokolom za hitro okrevanje po kirurškem posegu (angl. Enhanced Recovery After Surgery, ERAS). Pred kirurškim posegom smo ocenili morebitna tveganja in jih upoštevali pri vodenju anestezije med kirurškim posegom. Po posegu smo bolnico obravnavali v enoti intenzivne terapije (EIT). V prispevku se osredotočamo na anesteziološke vidike perioperativnega vodenja. Čeprav je debelost nedvomno pomemben dejavnik tveganja kirurškega zdravljenja, pa v novejših raziskavah poročajo tudi o ugodnih vplivih debelosti z manjšo perioperativno obolevnostjo in smrtnostjo. Gre za t. i. paradoks debelosti, saj čezmerna telesna masa velja za zaščitni dejavnik, ki varuje pred zapleti kirurškega zdravljenja, kar smo potrdili tudi v našem primeru. Hkrati smo opredelili kritične točke pri anesteziji morbidno debelega bolnika in tista področja, na katerih lahko anesteziologi – ob upoštevanju protokola ERAS – pomembno prispevamo k bolnikovemu čim hitrejšemu okrevanju.
Debelost je kronična bolezen, za katero je značilno čezmerno kopičenje maščevja v telesu. Debeli bolniki imajo pogosto številne pridružene bolezni ter anatomske in presnovne spremembe, ki so povezane ...z večjim tveganjem za zaplete v perioperativnem obdobju. Debelost tako pomembno vpliva na izbiro anestezijske tehnike in zahteva multidisciplinarni pristop. V prispevku predstavljamo primer 60-letne bolnice z rakom na debelem črevesu in indeksom telesne mase (ITM) 48,1 kg/m2. Perioperativno smo jo obravnavali v skladu s protokolom za hitro okrevanje po kirurškem posegu (angl. Enhanced Recovery After Surgery, ERAS). Pred kirurškim posegom smo ocenili morebitna tveganja in jih upoštevali pri vodenju anestezije med kirurškim posegom. Po posegu smo bolnico obravnavali v enoti intenzivne terapije (EIT). V prispevku se osredotočamo na anesteziološke vidike perioperativnega vodenja. Čeprav je debelost nedvomno pomemben dejavnik tveganja kirurškega zdravljenja, pa v novejših raziskavah poročajo tudi o ugodnih vplivih debelosti z manjšo perioperativno obolevnostjo in smrtnostjo. Gre za t. i. paradoks debelosti, saj čezmerna telesna masa velja za zaščitni dejavnik, ki varuje pred zapleti kirurškega zdravljenja, kar smo potrdili tudi v našem primeru. Hkrati smo opredelili kritične točke pri anesteziji morbidno debelega bolnika in tista področja, na katerih lahko anesteziologi – ob upoštevanju protokola ERAS – pomembno prispevamo k bolnikovemu čim hitrejšemu okrevanju.
Tramadol is an opioid analgesic often used for pain management after breast cancer surgery. Its analgesic activity is due to the activation of the μ-opioid receptor, encoded by the
gene. This study ...investigated the association of genetic variability in
and its regulatory miRNA genes with outcomes of tramadol/paracetamol treatment after breast cancer surgery with axillary lymphadenectomy.
The study included 113 breast cancer patients after breast cancer surgery with axillary lymphadenectomy treated with either 75/650 mg or 37.5/325 mg of tramadol with paracetamol for pain relief within the randomized clinical trial KCT 04/2015-DORETAonko/si at the Institute of Oncology Ljubljana. All patients were genotyped for
rs1799971 and rs677830,
rs1011784, and
rs2296616 using competitive allele-specific PCR. The association of genetic factors with acute and chronic pain as well as adverse effects of tramadol treatment was evaluated using logistic regression, Fisher's exact test, and Mann-Whitney test.
The investigated
related polymorphisms were not associated with acute pain assessed with the VAS scale within four weeks after surgery (all P > 0.05). Carriers of at least one polymorphic
rs1799971 allele had a higher risk of constipation in the first four weeks after surgery compared to non-carriers (OR = 4.5, 95% CI = 1.6-12.64, P = 0.004). Carriers of at least one polymorphic
rs677830 allele had a higher risk of constipation after third week of tramadol treatment (OR = 3.11, 95% CI = 1.08-8.89, P = 0.035). Furthermore, carriers of two polymorphic
rs1011784 alleles had a higher risk of nausea after 28 days of tramadol treatment (OR = 7.35, 95% CI = 1.27-42.6, P = 0.026), while heterozygotes for
rs2296616 allele had a lower risk of nausea after 21 days of tramadol treatment (OR = 0.21, 95% CI = 0.05-0.87, P = 0.031). In carriers of two polymorphic
rs2296616 alleles, chronic pain was significantly more common than in carriers of two wild-type alleles (P = 0.004). Carriers of at least one polymorphic
rs1011784 allele experienced more neuropathic pain after adjustment for tramadol dose (OR = 2.85, 95% CI = 1.07-7.59, P = 0.036), while carriers of at least one polymorphic
rs677830 allele experienced less neuropathic pain compared to carriers of two wild-type alleles (OR = 0.38, 95% CI = 0.15-0.99, P = 0.047).
Genetic variability of
and genes coding for miRNAs that could affect
expression may be associated with adverse effects of tramadol/paracetamol treatment as well as with chronic and neuropathic pain after breast cancer surgery with axillary lymphadenectomy.
Informed consent is legal institute that was introduced in the research area to prevent possible abuses in human research. Almost a century later it was introduced also in general medicine outside ...the research area. It’s a basic human right to decide about own body and thus also about possible interventions in such body. Fore decisions the quality information is necessary. Co-deciding on the type of medical treatment would result also in better result of such treatment (the patient would be more interested to cooperate in the treatment process). The present practice is that informed consent is mere a part of bureaucratic doctor-patient relation as a mode to prevent possible lawsuits. Taking into account other negative impacts on the patient (sc. nocebo effect) there is a serious question whether informed consent is adequate and fruitful. The submission posts some proposals that improve doctor-patient relationship and give patient real possibility to decide alone how and to what extent he/she would execute his/hers rights as a patient regarding medical treatments.
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