Download Update 11 - Update in Anaesthesia - WFSA

Update in Anaesthesia 93Strong opioidsby injection,localanesthesia, andNSAIDs(early)Weakopioids bymouth andminoranalgesics(as paindecreases)Aspirin,acetaminophen/paracetamol, andNSAIDs(chronic)Figure 1. The WFSA acute pain treatment ladderPatients with PLP may suffer from an exacerbation of theirpain during regional anesthesia, but this problem subsides asthe block wears off 14 . If this problem occurs duringan operation on an amputee, it does not usually respond toopioids, but lignocaine, diazepam, or thiopentone have beensuccessful 17 .Rehabilitation. Rehabilitation starts from day 1 withpassive movement and active mobilization on crutches as soonas possible. In the case of lower limb amputation, restorationof function requires a prosthesis to regain mobility and makecrutches unnecessary 18 . All too often PLP prohibits use of aprosthesis and creates a vicious circle of depression,isolation, and continued suffering. Psychological rehabilitationand recovery of self-esteem are dependent on social reintegration19 .If you give someone a leg - you are giving him hands.—Jacques MeynadierThe use of a prosthesis is vital to the rehabilitationprocess. Because of continued bone growth, prostheses forchildren need to be refitted every six months. Skin breakdowncaused by growing bone may make reamputation necessary.Phantom Limb PainIncidence and characteristics. It is helpful to distinguishbetween painless phantom sensations, stump pain, and pain inthe amputated parts of the body as there are implications forpathophysiology, outcome, and treatment 20 . Few studies havelooked at traumatic amputees and most trials are in elderlyarteriopaths, but the reason for amputation does not seem toinfluence the long-term complication rate. Military casualtiessuffer the same type and frequency of problem as civilians 21 .Phantom sensations are experiences of the missing limb asthough it were still present. Like PLP, they can start at the timeof operation or much later. They can vary from vivid sensationsmoving in a complex fashion, to a vague and fixedawareness of fingers or toes attached to the stump (“telescoping”).Stump pain is pain felt in the stump only and not theabsent limb. Phantom limb pain occurs commonly both inchildren 22,23 and in adults 20,23–25 . Patients may not mention it forfear of being ridiculed.PLP varies greatly in frequency and intensity 21 . Emotionaland autonomic influences can provoke or reduce it. The pain isgenerally felt in the more distal part of the amputated limb(toes, fingers) and has been described by Jensen et al. 20 aseither exteroceptive (stabbing, burning) or proprioceptive(squeezing, cramp-like) in nature. It can be continuous orintermittent, and its intensity may be mild to excruciating.Phantom sensations, stump pain, and PLP are closely associated.PLP usually is less severe in amputees without phantomsensations or stump pain 24,25 . It seems to be less likely if the initialamputation is treated actively and a prosthesis promptly used 26 .A recent survey in 590 ex-servicemen found that PLPpersisted in 47% of the amputees, disappeared in 16%, andrequired treatment in 55%. In this survey PLP was so severe(VAS 8.7) in 25% that they sought pain consultation. A large,older military survey found nearly identical figures 25 .Predisposing factors. Age, site of amputation, or preamputationpain intensity seem not to influence the persistenceof late (>6 months) PLP 20,23–25,27 . No conclusive data linkthe type of anesthetic used during amputation and theincidence of PLP.Despite earlier claims 28,29 , a well-controlled, randomizedtrial did not show a reduction in the incidence of PLP bypreemptive epidural analgesia 30 . This question is important aspreamputation epidural analgesia is not without risk. Thestudy did, however, show that active pain control decreasedthe incidence and severity of chronic pain problems.Treatment. Treatments must reflect solid clinical experienceor experimental evidence. No single form of treatmentclaims success 19 .Recently it has been suggested that transcutaneouselectrical nerve stimulation (TENS), paracetamol (with orwithout a weak opioid), and nonsteroidal anti-inflammatorydrugs (NSAIDs) are more effective for PLP than injections,“centrally acting” analgesics like tricyclics or anticonvulsants,and strong opioids 24 . Simpler methods of pain relief appear tobe more effective and are more accessible in countries withlandmine problems. Clinical experience 31 and that of thevoluntary agency Douleur Sans Frontières in the developingworld suggests that neurolytic blockade of neuromas mayreduce stump pain and that TENS can reduce PLP 32 .Evidence for efficacy of second-line therapies for PLPusually is based on small numbers and limited follow-up 33–39 .These treatments include calcitonin, beta-blockers, neuroleptics,injection of local anesthetic drugs into the contralateralside, neurosurgery, and central stimulation. Other treatmentmethods may have been tried unsuccessfully and not reported,or not published owing to negative results.There is increased interest in the use of NMDA antagonistsin chronic pain conditions even though side effects limittheir current use. They may also have a place in the preemptivemanagement of postamputation pain problems. The wide useof ketamine in developing countries may yield data about therole of this NMDA antagonist to reduce PLP 40,41 .Sympathetic blockade has been used diagnostically andtherapeutically. However, neurolytic block normally requiresradiologic control and its effect gradually wears off 42 .DiscussionThose who produce and use armaments rarely consider theirlong-term effects upon health. From a military point of viewlandmines continue to be considered an effective weapon, dueto their low cost and deterrent capabilities.