Saturday, December 27, 2014
sympathectomy leads to fluctuation of vasoconstriction alternated with vasodilation in an unstable fashion. Following sympathectomy the involved extremity shows regional hyper - and hypothermia
"To quote Nashold, referring to sympathectomy, "Ill- advised surgery may tend to magnify the entire symptom complex"(38). Sympathectomy is aimed at achieving vasodilation. The neurovascular instability (vacillation and instability of vasoconstrictive function), leads to fluctuation of vasoconstriction alternated with vasodilation in an unstable fashion (39). Following sympathectomy the involved extremity shows regional hyper - and hypothermia in contrast, the blood flow and skin temperature on the non- sympathectomized side are significantly lower after exposure to a cold environment (39). This phenomenon may explain the reason for spread of CRPS. In the first four weeks after sympathectomy, the Laser Doppler flow study shows an increased of blood flow and hyperthermia in the extremity (40). Then, after four weeks, the skin temperature and vascular perfusion slowly decrease and a high amplitude vasomotor constriction develops reversing any beneficial effect of surgery (39). According to Bonica , "about a dozen patients with reflex sympathetic dystrophy (RSD) in whom I have carried out preoperative diagnostic sympathetic block with complete pain relief, sympathectomy produced either partial or no relief (40)"
Thursday, December 25, 2014
Despite the simplicity and rapidity of the procedure, some patients experience intense, in some cases persistent, postoperative pain
Jornal Brasileiro de Pneumologia - The incidence of residual pneumothorax after video-assisted sympathectomy with and without pleural drainage and its effect on postoperative pain:
"Anteroposterior chest X-ray in the orthostatic position, while inhaling, was absolutely normal in 18 patients (32.1%), and residual pneumothorax was detected in 17 patients (30.4%). When the patients were separated into two groups (those who had received drainage and those who had not), 25.9% (7 patients) and 34.4% (10 patients), respectively, presented residual pneumothorax, with no difference between the two groups (p = 0.48) (Figure 1).
The additional alterations were laminar atelectasis and emphysema of the subcutaneous cellular tissue.
Chest X-rays in the orthostatic position, while exhaling, revealed residual pneumothorax in 39.3% (22 patients) and was absolutely normal in 25% (14 patients). On the same X-rays, when patients were analyzed separately, residual pneumothorax was seen in 33.3% of the patients who had received drainage (9 patients) and in 44.8% (13 patients) of those who had not, with no difference between the two groups (p = 0.37) (Figure 1).
The low-dose computed tomography scans of the chest detected residual pneumothorax in 76.8% (43 patients). In the patients submitted to postoperative drainage, this rate was 70.3% (19 patients), compared with 82.7% (24 patients) in those without pleural drainage, with no difference between the two groups (p = 0.27) (Figure 1). Therefore, the overall rate of occult pneumothorax (only visible through tomography), revealed on anteroposterior X-rays was 35.7% (20 patients): 48.2% while patients were inhaling and 41.1% while patients were exhaling. The VAS score in the PACU ranged from 0 to 10, with a mean of 2.16 ± 0.35.
Regarding characteristics, 44.6% of the patients reported chest pain upon breathing and 32.1% reported retrosternal pain. The same evaluation performed in the infirmary, during the immediate postoperative period, ranged from 0 to 10, with a mean of 3.75 ± 0.30, being 69.6% of chest pain upon breathing and 78.6% of retrosternal pain. On postoperative day 7, according to VAS, pain ranged from 0 to 10, with a mean of 2.05 ± 0.31; regarding characteristics, it was continuous in 32.1% of the cases, and retrosternal in 26.8%. On postoperative day 28, pain ranged from 0 to 3, with a mean of 0.17 ± 0.08, 7.1% of mechanical rhythm and 5.4% upper posterior."
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-37132008000300003&lng=en&nrm=iso&tlng=en
"Anteroposterior chest X-ray in the orthostatic position, while inhaling, was absolutely normal in 18 patients (32.1%), and residual pneumothorax was detected in 17 patients (30.4%). When the patients were separated into two groups (those who had received drainage and those who had not), 25.9% (7 patients) and 34.4% (10 patients), respectively, presented residual pneumothorax, with no difference between the two groups (p = 0.48) (Figure 1).
The additional alterations were laminar atelectasis and emphysema of the subcutaneous cellular tissue.
Chest X-rays in the orthostatic position, while exhaling, revealed residual pneumothorax in 39.3% (22 patients) and was absolutely normal in 25% (14 patients). On the same X-rays, when patients were analyzed separately, residual pneumothorax was seen in 33.3% of the patients who had received drainage (9 patients) and in 44.8% (13 patients) of those who had not, with no difference between the two groups (p = 0.37) (Figure 1).
The low-dose computed tomography scans of the chest detected residual pneumothorax in 76.8% (43 patients). In the patients submitted to postoperative drainage, this rate was 70.3% (19 patients), compared with 82.7% (24 patients) in those without pleural drainage, with no difference between the two groups (p = 0.27) (Figure 1). Therefore, the overall rate of occult pneumothorax (only visible through tomography), revealed on anteroposterior X-rays was 35.7% (20 patients): 48.2% while patients were inhaling and 41.1% while patients were exhaling. The VAS score in the PACU ranged from 0 to 10, with a mean of 2.16 ± 0.35.
Regarding characteristics, 44.6% of the patients reported chest pain upon breathing and 32.1% reported retrosternal pain. The same evaluation performed in the infirmary, during the immediate postoperative period, ranged from 0 to 10, with a mean of 3.75 ± 0.30, being 69.6% of chest pain upon breathing and 78.6% of retrosternal pain. On postoperative day 7, according to VAS, pain ranged from 0 to 10, with a mean of 2.05 ± 0.31; regarding characteristics, it was continuous in 32.1% of the cases, and retrosternal in 26.8%. On postoperative day 28, pain ranged from 0 to 3, with a mean of 0.17 ± 0.08, 7.1% of mechanical rhythm and 5.4% upper posterior."
Jornal Brasileiro de Pneumologia
Print version ISSN 1806-3713
J. bras. pneumol. vol.34 no.3 São Paulo Mar. 2008
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1806-37132008000300003&lng=en&nrm=iso&tlng=en
Wednesday, December 24, 2014
Our data confirmed that sympathectomy in patients with EPH results in a disturbance of bronchomotor tone and cardiac function.
Our study was composed of patients affected by EH, and thus having a dysfunction of sympathetic activity. The observed respiratory and clinical effects would probably not be observed in healthy individuals.
(ii) The cardio-respiratory effects were observed 6 months after operation. However, a longer postoperative period would be required to determine if they are long-term effects.
(iii) The number of patients was too limited, thus our results should be corroborated by larger studies.
CONCLUSION
Our data confirmed that sympathectomy in patients with EPH results in a disturbance of bronchomotor tone and cardiac function.
(ii) The cardio-respiratory effects were observed 6 months after operation. However, a longer postoperative period would be required to determine if they are long-term effects.
(iii) The number of patients was too limited, thus our results should be corroborated by larger studies.
CONCLUSION
Our data confirmed that sympathectomy in patients with EPH results in a disturbance of bronchomotor tone and cardiac function.
Eur J Cardiothorac Surg (2012)doi: 10.1093/ejcts/ezs071
Scientists have created a device that can beat arthritis agony - vagus nerve stimulation for arthritis and other disorders
Scientists have created a device that can beat arthritis agony | Health | Life & Style | Daily Express: "Tiny pacemaker-style devices embedded in the necks of patients with chronic rheumatoid arthritis "hacked" into their nervous systems.
The implant fires bursts of electrical impulses into a key nerve that relays brain signals to the body's vital organs.
Scientists, conducting a groundbreaking trial of the implant, say more than half found their condition dramatically improved.
More than 400,000 patients in the UK are affected by the debilitating disease. Now researchers believe the same technique, which can eliminate the need for a daily cocktail of drugs, could reverse conditions like asthma, obesity and diabetes.
The findings, revealed to Sky News, will be published in the new year.
We may be able to achieve remission in 20 to 30 per cent of patients
Paul-Peter Tak, Rheumatologist Professor
More than half the 20 patients taking part in tests at the Academic Medical Centre in Amsterdam have shown significant improvement.
Rheumatologist Professor Paul-Peter Tak said even for those unaffected by the most modern medicines, they saw an improvement.
"We may be able to achieve remission in 20 to 30 per cent of patients - a huge step forward in the treatment of rheumatoid arthritis," he added.
Doctors hope the implant could be widely used within a decade, but concede they do not yet fully understand how it has such a powerful effect. It stimulates the vagus nerve, which connects the brain to major organs.
By firing impulses for just three minutes a day, scientists were able to reduce the activity of the spleen, a key organ in the immune system.
Within a matter of days, the organ produced fewer chemicals and other immune cells that cause the abnormal inflammation in the joints of people with rheumatoid arthritis.
Kris Famm, who is leading the research, said: "I hope that in 10 to 20 years if you or I had diabetes, we would go to the doctor and there is an option for this sort of device."
Patient Monique Robroek was in so much pain she struggled to walk across a room, despite taking the strongest possible arthritis drugs.
She had an implant fitted under her skin a year ago and has now stopped taking medication and is pain free.
"I have my normal life back," she said. "Within six weeks I felt no pain. It is like magic.""
'via Blog this'
The implant fires bursts of electrical impulses into a key nerve that relays brain signals to the body's vital organs.
Scientists, conducting a groundbreaking trial of the implant, say more than half found their condition dramatically improved.
More than 400,000 patients in the UK are affected by the debilitating disease. Now researchers believe the same technique, which can eliminate the need for a daily cocktail of drugs, could reverse conditions like asthma, obesity and diabetes.
The findings, revealed to Sky News, will be published in the new year.
We may be able to achieve remission in 20 to 30 per cent of patients
Paul-Peter Tak, Rheumatologist Professor
More than half the 20 patients taking part in tests at the Academic Medical Centre in Amsterdam have shown significant improvement.
Rheumatologist Professor Paul-Peter Tak said even for those unaffected by the most modern medicines, they saw an improvement.
"We may be able to achieve remission in 20 to 30 per cent of patients - a huge step forward in the treatment of rheumatoid arthritis," he added.
Doctors hope the implant could be widely used within a decade, but concede they do not yet fully understand how it has such a powerful effect. It stimulates the vagus nerve, which connects the brain to major organs.
By firing impulses for just three minutes a day, scientists were able to reduce the activity of the spleen, a key organ in the immune system.
Within a matter of days, the organ produced fewer chemicals and other immune cells that cause the abnormal inflammation in the joints of people with rheumatoid arthritis.
Kris Famm, who is leading the research, said: "I hope that in 10 to 20 years if you or I had diabetes, we would go to the doctor and there is an option for this sort of device."
Patient Monique Robroek was in so much pain she struggled to walk across a room, despite taking the strongest possible arthritis drugs.
She had an implant fitted under her skin a year ago and has now stopped taking medication and is pain free.
"I have my normal life back," she said. "Within six weeks I felt no pain. It is like magic.""
'via Blog this'
Monday, December 22, 2014
Acute pain following needlescope-VATS (nVATS) sympathectomy
"...recently Sihoe et al. [10] have reported that pre-emptive wound infiltration with a local anaesthetic reduces the postoperative wound pain following needlescope-VATS (nVATS) sympathectomy for palmar hyperhidrosis. The concept of pre-emptive analgesia has gained popularity following
experimental work, demonstrating that early control of pain can alter its subsequent evolution as well as the recognition that nociception produces important physiological responses, even in adequately anaesthetised individuals, and the understanding that for many individuals the minimisation of pain can improve clinical outcomes [11].
The pre-emptive analgesia is based on the intuitive idea that if pain is treated before the injury occurs, the nociceptive system will perceive less pain than if analgesia is given after the injury has already occurred. The preoperative administration of analgesic will modify the afferent nociceptive barrage from the site of injury, thus preventing the development of central sensitisation and hyperalgesia [12].
Thus, we have focussed on this argument in the aim of the present study, which is to determine whether pre-emptive local analgesia (PLA) has an effect to reduce acute postoperative pain following standard-VATS (s-VATS) sympathectomy, in view of n-VATS being considered less painful
than the s-VATS procedure [4,5]."
http://ejcts.oxfordjournals.org/content/37/3/588.full.pdf+html
European Journal of Cardio-thoracic Surgery 37 (2010) 588—593
Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy
Alfonso Fiorelli, Giovanni Vicidomini, Paolo Laperuta, Luigi Busiello,
Anna Perrone, Filomena Napolitano, Gaetana Messina, Mario Santini*
Thoracic Surgery Unit, Second University of Naples, Naples, Italy
Received 28 March 2009; received in revised form 21 July 2009; accepted 31 July 2009; Available online 12 September 2009
experimental work, demonstrating that early control of pain can alter its subsequent evolution as well as the recognition that nociception produces important physiological responses, even in adequately anaesthetised individuals, and the understanding that for many individuals the minimisation of pain can improve clinical outcomes [11].
The pre-emptive analgesia is based on the intuitive idea that if pain is treated before the injury occurs, the nociceptive system will perceive less pain than if analgesia is given after the injury has already occurred. The preoperative administration of analgesic will modify the afferent nociceptive barrage from the site of injury, thus preventing the development of central sensitisation and hyperalgesia [12].
Thus, we have focussed on this argument in the aim of the present study, which is to determine whether pre-emptive local analgesia (PLA) has an effect to reduce acute postoperative pain following standard-VATS (s-VATS) sympathectomy, in view of n-VATS being considered less painful
than the s-VATS procedure [4,5]."
http://ejcts.oxfordjournals.org/content/37/3/588.full.pdf+html
European Journal of Cardio-thoracic Surgery 37 (2010) 588—593
Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy
Alfonso Fiorelli, Giovanni Vicidomini, Paolo Laperuta, Luigi Busiello,
Anna Perrone, Filomena Napolitano, Gaetana Messina, Mario Santini*
Thoracic Surgery Unit, Second University of Naples, Naples, Italy
Received 28 March 2009; received in revised form 21 July 2009; accepted 31 July 2009; Available online 12 September 2009
"sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation"
Patients with palmar hyperhidrosis have been reported to have a much
more complex dysfunction of autonomic nervous system, involving compensatory high parasympathetic activity as well as sympathetic overactivity (13, 14), suggesting that sympathicotomy initially induces a sympathovagal imbalance with a parasympathetic predominance, and that this is restored on a long-term basis (14). Therefore, thoracic sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation.
The reduction of finger skin temperature on the non-denervated side may be due to either a decrease in the cross-
inhibitory effect or the abnormal control of the inhibitory fibers by the sudomotor center (6).
Vasoconstrictor neurons have been found to be largely under the inhibitory control of various afferent
input systems from the body surface, whereas sudomotor neurons are predominantly under excitatory
control (15). The basic neuronal network for this reciprocal organization is probably located in the spinal level (15). Therefore, the reduction in the contralateral skin temperature may be explained by cross-inhibitory control of various afferent in the spinal cord.
In particular, our study showed that, following bilateral T3 sympathicotomy, the skin temperatures on
the hands increased whereas the skin temperatures on the feet decreased. These findings suggest a
cross-inhibitory control between the upper and lower extremities. However, the pattern of skin
temperature reduction on the feet differed from that on the contralateral hand. The skin temperature on
the feet did not decrease after right T3 sympathicotomy but decreased significantly after bilateral T3
sympathicotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/
more complex dysfunction of autonomic nervous system, involving compensatory high parasympathetic activity as well as sympathetic overactivity (13, 14), suggesting that sympathicotomy initially induces a sympathovagal imbalance with a parasympathetic predominance, and that this is restored on a long-term basis (14). Therefore, thoracic sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation.
The reduction of finger skin temperature on the non-denervated side may be due to either a decrease in the cross-
inhibitory effect or the abnormal control of the inhibitory fibers by the sudomotor center (6).
Vasoconstrictor neurons have been found to be largely under the inhibitory control of various afferent
input systems from the body surface, whereas sudomotor neurons are predominantly under excitatory
control (15). The basic neuronal network for this reciprocal organization is probably located in the spinal level (15). Therefore, the reduction in the contralateral skin temperature may be explained by cross-inhibitory control of various afferent in the spinal cord.
In particular, our study showed that, following bilateral T3 sympathicotomy, the skin temperatures on
the hands increased whereas the skin temperatures on the feet decreased. These findings suggest a
cross-inhibitory control between the upper and lower extremities. However, the pattern of skin
temperature reduction on the feet differed from that on the contralateral hand. The skin temperature on
the feet did not decrease after right T3 sympathicotomy but decreased significantly after bilateral T3
sympathicotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/
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