WHO Three-step Ladder Research Articles

Neurolisis del plexo celíaco: una revisión sistemática

Introducción: La mayoría de los pacientes con cáncer desarrollarán dolor crónico. El tratamiento tradicional sigue la escalera de tres pasos de la OMS para el alivio del dolor por cáncer. Sin embargo, este tratamiento tiende a ser ineficaz con el tiempo. A medida que la enfermedad progresa, se necesitan dosis más altas de opioides para lograr un control óptimo del dolor, aumentar los efectos adversos relacionados con ellos y afectar la calidad de vida. La neurólisis del plexo celíaco (CPN) es um método alternativo de analgesia que puede ser extremadamente útil para esos pacientes. Objetivo: El objetivo de este trabajo es evaluar la efectividad de la CPN en el control del dolor crónico y revisar su técnica. Métodos: Las bases de datos PUBMED, MEDLINE y LILACS se utilizaron para realizar una revisión sistemática, utilizando el impacto como criterio de selección. Los veintiún artículos que seleccionamos se organizaron en una tabla para el análisis estadístico. Resultados: La mayoría de los estudios concluyeron que la CPN es un método efectivo para el control del dolor crónico en la parte superior del abdomen y disminuye el consumo de opioides, aunque su efectividad depende del tiempo de administración y la progresión de la enfermedad. Discusión: la CPN es un procedimiento quirúrgico que destruye las fibras neurales del plexo celíaco, responsable de la inervación sensible de las vísceras abdominales superiores. Como resultado, las vías aferentes del dolor visceral se bloquean, disminuyendo el dolor. Los pacientes que sufren de dolor crónico originado en la parte superior del abdomen debido a cáncer pancreático, pancreatitis crónica, cáncer gástrico, cáncer hepático metastásico, cáncer biliar, cáncer es-ofágico u otras patologías que involucran las vísceras abdominales superiores pueden beneficiarse del procedimiento. Múltiples enfoques están disponibles; los posteriores están asociados con menos daño de los órganos viscerales y complicaciones neurológicas. Los enfoques guiados por imágenes que utilizan tomografía computarizada están relacionados con mejores resultados. Las complicaciones son raras, se pueden encontrar complicaciones graves en menos del 2% de los pacientes. Conclusión: Los médicos deben considerar la CPN como un posible método de control del dolor para pacientes con dolor crónico originado em las vísceras abdominales superiores. Aunque el impacto en las escalas de mortalidad y dolor puede ser comparable al tratamiento analgésico convencional, este procedimiento es preferible a los pacientes debido a la menor cantidad de efectos secundarios y la disminución en el consumo de opioides.

Tumorschmerztherapie

Pain belongs to the most prevalent symptoms that require patients with urological tumours to seek medical help. The treatment of cancer pain requires standardized guidelines that are best reflected by the WHO's three-step ladder of cancer pain relief. This implies an individualized approach, a detailed history taking of underlying pain and thorough clinical examination, as well as a consistent and forceful therapy of constant and breakthrough pain episodes, using pharmacological substances and non-pharmacological techniques. This requires the choice of the correct drug, an application "by the clock", an individualized dose titration, and the use of co-analgesics. For constant "background" pain, slow release substances are needed, whilst fast acting pain medication is given on demand for breakthrough pain episodes. Besides symptomatic analgesic therapy, cancer pain therapy may also comprise tumor specific treatment modalities, whenever appropriate and requested by the patient. This comprises radiation therapy, e.g. for bone or soft tissue processes or brain metastases, as well as radionuclide techniques, surgical procedures, chemotherapy, new substances or antihormonal therapy. Furthermore, pain is considered a multimodal experience that requires the consideration of psychical and social factors. This chapter describes the different facets of cancer pain, its epidemiology, pathophysiology, diagnostics and therapeutic principles.

Prevalence of opioid adverse events in chronic non-malignant pain: systematic review of randomised trials of oral opioids

Adverse events of opioids may restrict their use in non-cancer pain. Analysis of the incidence of common adverse events in trials conducted in non-cancer pain has usually been limited to opioids used to treat severe pain according to the WHO three-step ladder. To examine the incidence of common adverse events of opioids in non-cancer pain, a systematic review and meta-analysis of information from randomised trials of all opioids in non-cancer pain was undertaken. Studies used were published randomised trials of oral opioid in non-cancer pain, with placebo or active comparator. Thirty-four trials with 5,546 patients were included with 4,212 patients contributing some information on opioid adverse events. Most opioids used (accounting for 90% of patients) were for treating moderate rather than severe pain. Including trials without a placebo increased the amount of information available by 1.4 times. Because of clinical heterogeneity in condition, opioid, opioid dose, duration, and use of titration, only broad results could be calculated. Use of any oral opioid produced higher rates of adverse events than did placebo. Dry mouth (affecting 25% of patients), nausea (21%), and constipation (15%) were the most common adverse events. A substantial proportion of patients on opioids (22%) withdrew because of adverse events. Because most trials were short, less than four weeks, and because few titrated the dose, these results have limited applicability to longer-term use of opioids in clinical practice. Suggestions for improved studies are made.

Pain management in cancer cervix

Cancer of the cervix uteri is a common cause of pain among women. On the physical realm, the cancer may cause somatic [soft tissue and bone], visceral and neuropathic pain [lumbosacral plexopathy]. Radiotherapy and chemotherapy may cause neuropathy too. Psychological, social and cultural factors modify the pain. Evaluation of the individual type of pain and a patient-centred approach are fundamental requirements for rational management. Disease modifying treatment like radiotherapy and chemotherapy must be considered when applicable. Pain control is usually achieved by the use of WHO three-step ladder, remembering that possible association of renal dysfunction would necessitate caution in the use of NSAIDs and opioids. Side effects must be anticipated, prevented when possible, and aggressively treated; nausea and vomiting may already be present, and constipation can worsen pain when there is a pelvic mass. Pain emergencies can be treated by quick titration with intravenous morphine bolus doses. Neuropathic pain may warrant the use of usual adjuvants, with particular reference to cortico-steroids and the NMDA antagonist, ketamine. In intractable pain, many neurolytic procedures are tried, but a solid evidence base to justify their use is lacking. Continuous epidural analgesia with local anaesthetic and opioid may be needed when drug therapy fails, and desperate situations may warrant interventions such as neurolysis. Such physical measures for pain relief must be combined with psychosocial support and adequate explanations to the patient and the family.

Indonesia: Status of cancer pain and palliative care

Indonesia is a large archipelago with an estimated 203,000-365,400 new cancer cases a year. Most cases present in the advanced stage. Pain is the chief complaint in 89% of the patients of the palliative care unit at Dr. Soetomo hospital. The program is a community-based, family-oriented, and culturally adapted home care, widely applicable throughout the country. The service and medication should be affordable, simple, and available. The WHO three-step ladder has been adopted as the method of choice in cancer pain relief. Facilities supportive for the program are the existing health-care delivery system and non-formal support system (Indonesian Cancer Foundation and Organization for Family Welfare Promotion, PKK). The chief constraints for program implementation are the geographical and population problems, lack of resources and funding for the training of health-care workers, and limited availability of oral morphine.