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Isola del Giglio, Italy

Mercadante S.,Anesthesia and Intensive Care Unit
Current Pain and Headache Reports | Year: 2011

Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity on a baseline pain of moderate intensity in patients on regularly administered analgesic treatment. This review provides updated information about the classification, assessment, and treatment of BTcP, with special emphasis on the use of opioids. Due to its slow onset to effect, oral opioids cannot be considered an efficacious treatment of BTcP. More recently, different technologies have been developed to provide fast pain relief with potent opioid drugs, such as fentanyl, delivered by noninvasive routes. Transmucosal, buccal, sublingual, and intranasal fentanyl have been shown to provide rapid analgesia in comparison with oral morphine or placebo and are available for clinical use in most countries. All the studies performed with these delivery systems have recommended that these drugs should be administered to opioid-tolerant patients receiving doses of oral morphine equivalents of at least 60 mg. The need of titrating opioid doses for BTcP has been commonly recommended in all the controlled studies, but never has been substantiated in appropriate studies. © 2011 Springer Science+Business Media, LLC.


Mercadante S.,Anesthesia and Intensive Care Unit | Mercadante S.,University of Palermo
Critical Reviews in Oncology/Hematology | Year: 2011

Breakthrough cancer pain (BTcP) has been defined as a transitory increase in pain intensity on a baseline pain of moderate intensity in patients on analgesic treatment regularly administered. This review provides updated information about the use of opioids for the treatment of BTcP, with special emphasis on the use of new rapid onset opioids (ROOs). Due to its slow onset to effect oral opioids cannot be considered an efficacious treatment for BTcP. Parenteral opioids may provide rapid onset of analgesia, but not always available particularly at home. Different technologies have been developed to provide fast pain relief with potent opioid drugs such fentanyl, delivered by non-invasive routes. Transmucosal administration of lipophilic substances has gained a growing popularity in the last years, due to the rapid effect clinically observable 10-15. min after drug administration, obtainable in non-invasive forms. Fentanyl is a potent and strongly lipophilic drug, which matches the characteristics to favour the passage through the mucosa and then across the blood-brain barrier to provide fast analgesia. Transmucosal, buccal, sublingual, and intranasal fentanyl showed their efficacy in comparison with oral morphine or placebo and are available for clinical use in most countries. All the studies performed with ROOs have recommended that these drugs should be administered to opioid-tolerant patients receiving doses of oral morphine equivalents of at least 60 mg. The choice of the dose of ROO to be prescribed as needed remains controversial. The need of titrating opioid doses for BTcP has been commonly recommended in all the controlled studies, but has never been substantiated in appropriate studies. © 2010 Elsevier Ireland Ltd.


Bonacchi M.,University of Florence | Harmelin G.,University of Florence | Peris A.,Anesthesia and Intensive Care Unit | Sani G.,University of Florence
Journal of Thoracic and Cardiovascular Surgery | Year: 2011

Background: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used in refractory acute respiratory distress syndrome where lung recovery is the primary goal. For its achievement, adequate extracorporeal blood flow and a maximal separation between oxygenated (inflow) and deoxygenated (outflow) blood flow are essential for reducing the recirculation phenomenon. We introduce the χ-configuration, a new cannulation strategy for VV-ECMO. Patients and Methods: We report our experience with 30 VV-ECMO consecutive patients: in 16 patients (group NS) we applied the χ-configuration, which consists of a particular right atrial cannula arrangement and a self-made modified inflow cannula, consisting of an outflow multihole venous cannula that was inserted percutaneously through the right femoral vein, into the right atrium, just below on the superior vena cava, and a self-made modified curved inflow cannula (inserted percutaneously through the right internal jugular vein) that, in its terminal segment, permitted the tip to be positioned close to the tricuspid valve. In 14 patients (group C) we applied the standard femoro-jugular VV-ECMO 2-cannula setting. In both groups, efficacy of blood oxygenation was obtained by gas-blood analysis, by blood samples obtained at arterial, central venous, and pulmonary artery lines, and by ECMO inflow and outflow lines. The recirculation fraction was obtained by a specific bedside formula. Results: No differences were noted between groups regarding the pre-ECMO patient characteristics. No complications during cannulation were recorded. In group NS, on-ECMO time, post-ECMO mechanical ventilation time, and ECMO overall results were significantly better than in group C. During high-flow VV-ECMO, pulmonary and systemic arterial oxygen saturation and arterial oxygen tension were significantly higher in group NS, and blood recirculation fraction was significantly lower. Conclusions: Our data indicate that χ-configuration can be safe, feasible, and more effective than conventional VV-ECMO. It permits near complete drainage of the desaturated blood and a preferential oxygenated blood inflow toward the tricuspid valve, resulting in a significant reduction of recirculation, thereby improving the patient's oxygenation. Our innovative strategy reduces on-ECMO and post-ECMO mechanical ventilation time, gives a faster and better pulmonary recovery, improves survival, and can reduce hospital costs. © 2011 by The American Association for Thoracic Surgery.


Mercadante S.,Anesthesia and Intensive Care Unit
Surgical Oncology | Year: 2010

Postoperative pain is often underestimated in elderly patients, based on considerations of the limited function of kidney and liver with advancing age or presumed high threshold of pain sensation. Achieving adequate pain management for the older patient is complicated by comorbid diseases, increased risk of adverse drug reactions, and physician factors such as inadequate training and reluctance to prescribe opioid medications. Anticholinergic load has been related to impaired cognitive and physical function. Older patients are more likely than younger patients to have impaired physical status. Cognitive problems frequently observed may make evaluation of pain difficult. Patient-controlled analgesia (PCA) permits analgesic titration according to the patient's own needs and greatly reduces the risk of overdose because of increased individual sensitivity to analgesic drugs. The success of such a technique depends on close evaluation of all preoperative and intraoperative factors that can cause or contribute to acute delirium. In the present paper we review the literature on this pivotal field. © 2009 Published by Elsevier Ltd.


Mercadante S.,Anesthesia and Intensive Care Unit | Mercadante S.,University of Palermo
Current Opinion in Supportive and Palliative Care | Year: 2013

Purpose of review Cancer pain management is in continuous innovation and new data are available that could change the therapeutical approach and guidelines. Recent findings There are different fields of research that produce new data and interesting findings. The principal data regard the factors influencing the analgesic response, breakthrough cancer pain management, opioid switching, and pharmacogenetics. Summary The findings reported in this review provide new ideas to be developed in further studies to confirm or not confirm some suggestive data. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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