RESUMO
OBJECTIVE: The aim of this retrospective cohort study was to analyze responses to intravenous (IV) phenytoin (PHT) for trigeminal neuralgia (TN) crisis in a group of patients treated at our institution. BACKGROUND: TN is one of the most common causes of facial pain. Its treatment relies on preventive therapy with either carbamazepine or oxcarbazepine. During severe pain episodes, patients may be unable to eat, drink, or even swallow oral medication, requiring in-hospital treatment. There is scarce evidence to support IV medication use for TN, making management of this condition difficult. METHODS: We reviewed clinical records of patients with TN crisis consulting the emergency department at a tertiary neurological referral center in Buenos Aires, Argentina, treated with IV PHT as analgesic strategy, and with at least 1-month posttreatment follow-up. Demographic features, magnetic resonance imaging findings, and therapeutic management were analyzed. RESULTS: Thirty-nine patients with TN were included, 18 (46.2%) receiving IV PHT more than once (total number of infusions administered, 65). Immediate pain relief was observed in 89.2% (58/65) and 15.4% (10/65) presented side effects. CONCLUSIONS: We recommend IV PHT as acute rescue treatment in TN crisis.
Assuntos
Avaliação de Resultados em Cuidados de Saúde , Fenitoína/farmacologia , Neuralgia do Trigêmeo/tratamento farmacológico , Bloqueadores do Canal de Sódio Disparado por Voltagem/farmacologia , Doença Aguda , Adulto , Idoso , Feminino , Seguimentos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Fenitoína/administração & dosagem , Fenitoína/efeitos adversos , Estudos Retrospectivos , Centros de Atenção Terciária , Bloqueadores do Canal de Sódio Disparado por Voltagem/administração & dosagem , Bloqueadores do Canal de Sódio Disparado por Voltagem/efeitos adversosRESUMO
BACKGROUND: Intravenous lidocaine infusion has been clearly demonstrated as effective for pain in randomized controlled trials, but the belief that cardiac monitoring is required for safe administration is a barrier to access in the palliative care setting. There are also multiple infusion protocols reported in the literature. We have been administering lidocaine infusions for severe cancer pain at the BC Cancer Agency (BCCA) since 2003, without electrocardiographic (ECG) monitoring. Our simple protocol is for 5 mg/kg to be infused over 1 hour, with the option for subsequent doses to be increased if necessary, up to a maximum of 10 mg/kg. Our aim with this study is to share 11 years of our experience with this protocol. METHODS: This is a retrospective case series. Records of patients who received at least one lidocaine infusion for pain between 2003 and 2013 at the BCCA were reviewed. The primary end points were the documentation of clinical benefit and adverse effects. RESULTS: A total of 122 lidocaine infusions were administered in 51 individual patients. Twenty-five (49%) had a major response, 12 (23.5%) had a minor response, and 14 (27.5%) were considered nonresponders. Twenty-two (43.1%) patients were noted to have some adverse effect during at least one of the infusions, but only 1 (1.9%) patient had the infusion permanently discontinued. The most common side effects were drowsiness (30.7%), perioral numbness (13.4%), nausea (5.7%), and minor fluctuations of blood pressure (3.8%). CONCLUSIONS: This case series demonstrates that our protocol of infusional lidocaine can be beneficial to patients with cancer with severe opioid-refractory pain, and can safely be administered with close observation and vital sign monitoring, without ECG monitoring. Lidocaine infusion is a useful option to consider when other pain treatments have not been successful. Although only approximately half of patients will respond well, there is little harm to be expected from a trial of lidocaine infusion and responders can be repeatedly treated. This treatment could be delivered in palliative care units, hospices, or even patients' homes, providing suitable nursing supervision can be provided.