SUMMARY The rationale for using multimodal analgesia after any major surgery is achievement of a... more SUMMARY The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.
Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstra... more Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstrated that it is associated with poor survival owing to cancer progression. Immunotherapy, especially NK cell transfer therapy, is an attractive alternative because current methodologies to isolate, generate, and expand NK cells have shown good safety profiles in current active investigations. We believe that the use of NK cell transfer therapy in the context of postoperative minimal residual disease deserves significant investigation.
Carotid artery ballooning and stenting is a percutaneous interventional therapy for the treatment... more Carotid artery ballooning and stenting is a percutaneous interventional therapy for the treatment of patients with atherosclerotic occlusive disease of the carotid artery. Patients with severe comorbidities are usually considered candidates for this procedure. The carotid artery stenting can be done under either general or strict local anesthesia, or alternatively by using a combination of intravenous sedation and local anesthesia. Dexmedetomidine is a selective alpha-adrenergic agent that has both sedative and analgesic properties but lacks a depressive effect on respiratory drive. This article describes the case of a patient with severe chronic obstructive pulmonary disease and severe carotid stenosis, who underwent carotid stenting under monitored anesthesia care with dexmedetomidine. Only one episode of bradycardia and hypotension was observed, and this was successfully treated with glycopyrrolate.
It is not uncommon for anesthesiologists to encounter cancer patients who have received chemother... more It is not uncommon for anesthesiologists to encounter cancer patients who have received chemotherapy agents known to cause cardiovascular toxicities such as heart failure, systemic hypertension and thromboembolic events. Anthracyclines have been for several decades the most studied agents because of their known cardiovascular effects and relatively high incidence of heart failure. However, cancer patients are currently treated with newer chemotherapeutics such as imatinib, sunitinib, trastuzumab and bevacizumab that are also responsible of causing cardiovascular toxicities. The type of cardiotoxicity associated with these newer agents (type II cardiotoxicity) appears to be different in terms of pathogenesis to that caused by anthracyclines (type I cardiotoxicity). Thus, anesthesiologist needs to be aware of the clinical features of each type of cardiac toxicity. This review will summarize the current clinical evidence on cardiovascular toxicity induced by chemotherapeutic agents and...
We present two patients with chemotherapy-induced painful neuropathy that had been poorly control... more We present two patients with chemotherapy-induced painful neuropathy that had been poorly controlled with medications but successfully treated with spinal cord stimulation (SCS). A trial period of SCS provided effective pain relief in both patients who subsequently underwent permanent stimulator implantation. Psychophysical tests were performed before and after the implantation of trial and permanent stimulators. SCS improved pain scores and facilitated a reduction of medications. Both patients reported improved gait and one of them also reported an increase in leg flexibility. Psychophysical tests demonstrated an improvement in touch and sharpness detection thresholds. In summary, SCS offers a therapeutic option for patients with chemotherapy-induced peripheral neuropathy who have poor pain relief with standard medical treatment.
Recently we demonstrated the effect of fenoldopam on ischemia/reperfusion (I/R) induced NFkappaB ... more Recently we demonstrated the effect of fenoldopam on ischemia/reperfusion (I/R) induced NFkappaB mediated pro-inflammatory signal transduction. However, the effect of fenoldopam on I/R-induced apoptosis is not known. We utilized a rat model of acute ischemic nephropathy to test the hypothesis that fenoldopam attenuates I/R-induced apoptosis. Sprague-Dawley rats were anesthetized by intraperitoneal administration of 50 mg/kg urethane and randomly allocated into 4 groups (n=6 each): (1) sham-operated, (2) sham operation with infusion of 0.1 microg/kg/min fenoldopam, (3) unilateral renal ischemia followed by 4 h of reperfusion, and (4) I/R with fenoldopam infusion. Kidney samples were fixed and paraffin-embedded to measure apoptosis. Data were compared between groups using ANOVA with Bonferroni correction. RNA was extracted from each left kidney to probe cDNA microarray and measure gene expression as percent of positive control. Compared to the control group, I/R significantly (P < 0.001) induced apoptosis in both the cortex and medulla. Similarly, microarray analysis revealed that IR induced 73 apoptosis-related genes. Treatment with fenoldopam significantly reduced (P < 0.001) I/R-induced apoptosis both in the cortex and medulla and attenuated all 73 I/R-induced apoptosis-related genes. Data from this rat model of ischemic nephropathy suggest that fenoldopam may attenuate I/R-induced apoptosis and apoptosis-related gene transcription.
Taxol produces neuropathic pain with three distinct zones of involvement in the extremities. Most... more Taxol produces neuropathic pain with three distinct zones of involvement in the extremities. Most distally is an area of on-going pain and proximal to this is a zone of sensory disturbance but not overt pain. These two areas were confined in all but one case to the glabrous skin of the hands and/or feet. More proximal is an area not recognized by the patients as involved with pain or sensory disturbance yet wherein quantitative sensory tests nevertheless reveal altered sensibility. Impairment of perception to light touch, normally conveyed by myelinated fibers, was dramatically altered in all three areas, being approximately 50-fold greater than normal in areas of pain and sensory disturbance as well as in areas of skin perceived by the patients as not affected. Impairment of perception to sharpness, normally conveyed by small myelinated fibers, was most pronounced in areas of on-going pain, intermediate in areas of sensory disturbance and near baseline in more proximal skin of chemotherapy patients. In contrast to mechanical sensibility, thermal thresholds for warm and heat pain detection were normal throughout. Finally, chemotherapy patients showed paradoxical burning pain to skin cooling that was most pronounced in proximal areas of skin thought to be unaffected by the patients, intermediate in the border zone of altered sensibility and least pronounced in areas of on-going pain. These data suggest that taxol produces a neuropathy characterized by pronounced impairment of function in A-beta myelinated fibers, intermediate impairment of A-delta myelinated fibers, and a relative sparing of C-fibers.
SUMMARY The rationale for using multimodal analgesia after any major surgery is achievement of a... more SUMMARY The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.
Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstra... more Immune suppression after oncologic surgery is a common phenomenon. Several studies have demonstrated that it is associated with poor survival owing to cancer progression. Immunotherapy, especially NK cell transfer therapy, is an attractive alternative because current methodologies to isolate, generate, and expand NK cells have shown good safety profiles in current active investigations. We believe that the use of NK cell transfer therapy in the context of postoperative minimal residual disease deserves significant investigation.
Carotid artery ballooning and stenting is a percutaneous interventional therapy for the treatment... more Carotid artery ballooning and stenting is a percutaneous interventional therapy for the treatment of patients with atherosclerotic occlusive disease of the carotid artery. Patients with severe comorbidities are usually considered candidates for this procedure. The carotid artery stenting can be done under either general or strict local anesthesia, or alternatively by using a combination of intravenous sedation and local anesthesia. Dexmedetomidine is a selective alpha-adrenergic agent that has both sedative and analgesic properties but lacks a depressive effect on respiratory drive. This article describes the case of a patient with severe chronic obstructive pulmonary disease and severe carotid stenosis, who underwent carotid stenting under monitored anesthesia care with dexmedetomidine. Only one episode of bradycardia and hypotension was observed, and this was successfully treated with glycopyrrolate.
It is not uncommon for anesthesiologists to encounter cancer patients who have received chemother... more It is not uncommon for anesthesiologists to encounter cancer patients who have received chemotherapy agents known to cause cardiovascular toxicities such as heart failure, systemic hypertension and thromboembolic events. Anthracyclines have been for several decades the most studied agents because of their known cardiovascular effects and relatively high incidence of heart failure. However, cancer patients are currently treated with newer chemotherapeutics such as imatinib, sunitinib, trastuzumab and bevacizumab that are also responsible of causing cardiovascular toxicities. The type of cardiotoxicity associated with these newer agents (type II cardiotoxicity) appears to be different in terms of pathogenesis to that caused by anthracyclines (type I cardiotoxicity). Thus, anesthesiologist needs to be aware of the clinical features of each type of cardiac toxicity. This review will summarize the current clinical evidence on cardiovascular toxicity induced by chemotherapeutic agents and...
We present two patients with chemotherapy-induced painful neuropathy that had been poorly control... more We present two patients with chemotherapy-induced painful neuropathy that had been poorly controlled with medications but successfully treated with spinal cord stimulation (SCS). A trial period of SCS provided effective pain relief in both patients who subsequently underwent permanent stimulator implantation. Psychophysical tests were performed before and after the implantation of trial and permanent stimulators. SCS improved pain scores and facilitated a reduction of medications. Both patients reported improved gait and one of them also reported an increase in leg flexibility. Psychophysical tests demonstrated an improvement in touch and sharpness detection thresholds. In summary, SCS offers a therapeutic option for patients with chemotherapy-induced peripheral neuropathy who have poor pain relief with standard medical treatment.
Recently we demonstrated the effect of fenoldopam on ischemia/reperfusion (I/R) induced NFkappaB ... more Recently we demonstrated the effect of fenoldopam on ischemia/reperfusion (I/R) induced NFkappaB mediated pro-inflammatory signal transduction. However, the effect of fenoldopam on I/R-induced apoptosis is not known. We utilized a rat model of acute ischemic nephropathy to test the hypothesis that fenoldopam attenuates I/R-induced apoptosis. Sprague-Dawley rats were anesthetized by intraperitoneal administration of 50 mg/kg urethane and randomly allocated into 4 groups (n=6 each): (1) sham-operated, (2) sham operation with infusion of 0.1 microg/kg/min fenoldopam, (3) unilateral renal ischemia followed by 4 h of reperfusion, and (4) I/R with fenoldopam infusion. Kidney samples were fixed and paraffin-embedded to measure apoptosis. Data were compared between groups using ANOVA with Bonferroni correction. RNA was extracted from each left kidney to probe cDNA microarray and measure gene expression as percent of positive control. Compared to the control group, I/R significantly (P < 0.001) induced apoptosis in both the cortex and medulla. Similarly, microarray analysis revealed that IR induced 73 apoptosis-related genes. Treatment with fenoldopam significantly reduced (P < 0.001) I/R-induced apoptosis both in the cortex and medulla and attenuated all 73 I/R-induced apoptosis-related genes. Data from this rat model of ischemic nephropathy suggest that fenoldopam may attenuate I/R-induced apoptosis and apoptosis-related gene transcription.
Taxol produces neuropathic pain with three distinct zones of involvement in the extremities. Most... more Taxol produces neuropathic pain with three distinct zones of involvement in the extremities. Most distally is an area of on-going pain and proximal to this is a zone of sensory disturbance but not overt pain. These two areas were confined in all but one case to the glabrous skin of the hands and/or feet. More proximal is an area not recognized by the patients as involved with pain or sensory disturbance yet wherein quantitative sensory tests nevertheless reveal altered sensibility. Impairment of perception to light touch, normally conveyed by myelinated fibers, was dramatically altered in all three areas, being approximately 50-fold greater than normal in areas of pain and sensory disturbance as well as in areas of skin perceived by the patients as not affected. Impairment of perception to sharpness, normally conveyed by small myelinated fibers, was most pronounced in areas of on-going pain, intermediate in areas of sensory disturbance and near baseline in more proximal skin of chemotherapy patients. In contrast to mechanical sensibility, thermal thresholds for warm and heat pain detection were normal throughout. Finally, chemotherapy patients showed paradoxical burning pain to skin cooling that was most pronounced in proximal areas of skin thought to be unaffected by the patients, intermediate in the border zone of altered sensibility and least pronounced in areas of on-going pain. These data suggest that taxol produces a neuropathy characterized by pronounced impairment of function in A-beta myelinated fibers, intermediate impairment of A-delta myelinated fibers, and a relative sparing of C-fibers.
Uploads
Papers by Juan Cata